ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.

org 423

2003 SAEM ANNUAL MEETING ABSTRACTS

The editors of Academic Emergency Medicine are pleased and privileged to present the Original Research Abstracts
from the Annual Meeting of the Society for Academic Emergency Medicine, May 29–June 1, 2003, Boston,
Massachusetts. The exciting trends of emergency medicine research are reflected in these brief summaries, as are
the talent, creativity, and enthusiasm of novice as well as more experienced academicians.
This year, 939 research abstracts were submitted and 451 were selected for presentation at the Meeting (not
including 53 Innovations in Emergency Medicine Education Exhibits, which were submitted separately). Each
abstract was independently reviewed by up to six designated topics experts who were blinded to the authors.
Final determination for scientific presentation was made by the Scientific Subcommittee, chaired by Jeff Kline, and
the SAEM Program Committee, chaired by Ellen Weber. The decision for presentation was based on the final
review score and the space available for presentation at the meeting.
We present these abstracts as they were received electronically from the authors, who are solely responsible for
their content. They appear as they were received; we have done only minimal proofreading of these abstracts. Any
questions you may have on their content should be directed to their authors. Presentation numbers precede the
abstract titles. An index of key words and authors begins on page 577.
On behalf of the membership of SAEM, the editorial board of AEM, and the leadership of our specialty, we
express our sincere gratitude to these academicians and the SAEM Program Committee for their continuing effort
to improve our patients’ care by advancing emergency medicine research and education.

001 OPALS Study Phase III: What Is the Impact of
Advanced Life Support on Out-of-hospital Cardiac
Arrest? Ian G Stiell, George A Wells, Daniel W Spaite, Lisa
Nesbitt, Donna Cousineau, Valerie J De Maio, Tony Campeau,
Eugene Dagnone, Graham Nichol, Brian J Field, Tammy Beaudoin,
David Brisson, for the OPALS Study Group; University of
Ottawa: Ottawa, Ontario, Canada, Queens University:
Kingston, Ontario, Canada, University of Western Ontario:
London, Ontario, Canada, Niagara Regional Base Hospital:
Niagara Falls, Ontario, Canada, Ontario Ministry of Health:
Toronto, Ontario, Canada, University of Arizona: Tucson, AZ
Objectives: The Ontario Prehospital Advanced Life Support
(OPALS) Study is designed to systematically evaluate the
effectiveness of EMS interventions for critically ill and
injured patients. OPALS Phase III tested the incremental
impact on out-of-hospital cardiac arrest survival of adding
an ALS program to a multicenter BLS-D EMS system that
had previously optimized defibrillation (Phase II JAMA
1999). Methods: This multicenter before-after controlled
clinical trial was conducted in 17 communities (population
20,000 to 750,000) and enrolled all adult out-of-hospital
cardiac arrest patients during the 12-month BLS-D rapid
defibrillation phase and the subsequent 36-month ALS
phase. Paramedics were fully trained to ALS standards
including endotracheal intubation and administration of IV
drugs. The primary outcome was survival to hospital dis-
charge. Chi-square and logistic regression analyses were
performed. Results: The 5,637 patients enrolled during the
BLS-D (N ¼ 1,391) and ALS (N ¼ 4,246) phases were well
matched and had these characteristics: mean age 69.2 (range
16–102), male 66.7%, witnessed 51.7%, bystander CPR
14.7%, initial rhythm VF/VT 32.3%, defibrillator at scene
\8 minutes 93.3%. During the ALS phase, success rates
were intubation 93.7% and IV insertion 89.0%. From the
BLS-D to the ALS phase, the admission rate increased
(10.9% vs 14.6%; P \.001) but survival did not change (5.0%
vs 5.1%; P ¼ .82) for all rhythms combined. Logistic
regression also found the odds ratio for ALS to be non-
significant (0.91; 95% CI 0.6–1.3). There was no survival
improvement for any subgroup including cases witnessed
by bystander (7.1% vs 6.8%; P ¼ .80) or by EMS (13.5% vs
16.6%; P ¼ .41); with rhythm VF/VT (12.9% vs 13.2%; P ¼
.87) or PEA (1.4% vs 2.4%; P ¼ .27). Conclusions: The
OPALS Study is the largest multicenter controlled trial of
out-of-hospital cardiac arrest. The addition of prehospital
ALS interventions did not improve patient survival in
a previously optimized rapid defibrillation EMS system.
002 A Randomized Controlled Trial of a Novel Anti-
arrhythmic Agent, RSD1235, in the Treatment of
Acute Atrial Fibrillation Denis Roy, Brian H Rowe, Ian G
Stiell, Garth Dickinson, Jacques Lee, Humberto Vidaillet, Denis
Phaneuf, Sheila Grant, Gregory N Beatch, Alan M Ezrin;
Montreal Heart Institute: Montreal, Quebec, Canada,
University of Alberta: Edmonton, Alberta, Canada,
University of Ottawa: Ottawa, Ontario, Canada, University
of Toronto: Toronto, Ontario, Canada, Marshfield Clinic and
St. Joseph’s Hospital: Marshfield, WI, Notre-Dame Hospital:
Montreal, Quebec, Canada, Cardiome Pharma: Vancouver,
British Columbia, Canada
Objectives: Acute atrial fibrillation (AF) is a common
emergency department (ED) arrhythmia, and cardioversion
agents are often ineffective and cause complications. This
study was designed to determine the efficacy and safety of
a novel anti-arrhythmic (RSD1235) for the termination of
recent onset AF. Methods: This was a phase II, multi-
centered, randomized, double-blind, step-dose placebo-
controlled, parallel group study. Patients in uncomplicated
AF (3 hr \ AF \ 72 hr) were randomized to one of two
RSD1235 dose groups compared to placebo (PLAC) for
termination of AF. The two RSD1235 groups were LOW (0.5
424
and 1 mg/kg) or HIGH (2 and 3 mg/kg) dose given by I.V.
infusion over 10 min. Safety was assessed by: the incidence of
adverse events (AEs); vital signs; ECG monitoring, laboratory
data and examination. The primary endpoint was termina-
tion of AF during a 10-min infusion or the following 30-min.
Secondary endpoints included number of patients in NSR 24
h post-infusion and time to conversion to NSR. Results:
56 patients were enrolled from 20 US and Canadian sites
during 2002; demographics were similar between groups
(61% males; age ¼ 61 years). HIGH dose showed significant
improvements over PLAC in: (1) termination of AF within 30-
min (61% vs. 5%; p ¼ 0.0003), (2) patients in NSR at 0.5 h post-
dose (56% vs. 5%; p ¼ 0.0008), (3) patients in NSR at 1 hour
post-dose (53% vs. 5%; p ¼ 0.0014), and (4) median time to
achieve NSR (14 minutes vs. 162 minutes; p ¼ 0.016). Five
patients had SAEs: 4 PLAC patients and one LOW patient.
All SAEs resolved and none were deemed related to drug.
Clinically significant abnormal ECG results were seen in
PLAC (7), LOW (4) and HIGH (3) dose patients. Conclusion:
RSD1235, a new atrial-specific, mixed Na/K channel block-
ing agent, appears to be efficacious and safe for patients with
acute AF. Further Phase III studies using wider inclusion
criteria and larger populations are required before this
promising drug can be approved in this setting.
003 Prophylaxis with Antibiotic-containing
Microspheres and LiquiVent Reduces Mortality in
a Rat Model of Ventilator-associated Pneumonia Eric W
Dickson, Gary V Doern, Leo Trevino, Michelle Mazzoni,
Stephen O Heard; UMASS Medical School: Worcester MA,
University of Iowa: Iowa City, IA; Alliance Pharmaceutical
Corporation: San Diego, CA
Background: Patients undergoing emergent endotracheal
intubation are at increased risk for developing pneumonia.
Despite numerous strategies investigated to reduce occur-
rence of ventilator associated pneumonia (VAP), the in-
cidence of VAP and its associated mortality remains high.
Objective: This investigation tests the hypothesis that pro-
phylactic treatment of the airways using a liquid perfluor-
ocarbon (LiquiVent; LV) to deliver spray-dried microspheres
(SDM) containing antibiotics would improve survival in a rat
model of descending gram-negative pneumonia. Methods:
Wistar rats (n ¼ 49) were randomized to receive prophylaxis
with: 1) nothing (controls), 2) intramuscular (IM) tobramycin
1 mg/kg, 3) intratracheal LV plus SDM shells (vehicle) 2.5
ml/kg, 4) intratracheal LV plus SDM shells (2.5 ml/kg) plus 1
mg/kg IM tobramycin or 5) intratracheal LV plus SDM (2.5
ml/kg) containing 1 mg/kg tobramycin. All interventions
were given 24 hours prior to a bacterial challenge with 108
colony forming units of intratracheal Klebsiella pneumoniae.
Mortality at 10 days was the sole outcome measure. Survival
in individual groups was compared against controls by
Fisher exact test with Bonferroni correction for multiple
comparisons. Results: All animals in the control group
succumbed to pneumonia within 10 days of bacterial
inoculation (0% survival). Prophylaxis with either 1 mg/kg
IM tobramycin, 2.5 ml/kg SDM vehicle or 2.5 ml/kg SDM
vehicle plus 1 mg/kg IM tobramycin provided no protection
from the bacterial challenge with no survivors in these
cohorts by day 10. This is in sharp contrast to the cohort
receiving pretreatment with tobramycin-containing SDM
delivered via LV, where 60% of the animals survived to
2003 SAEM ANNUAL MEETING ABSTRACTS
study completion (p \ .05). Conclusion: Prophylaxis with
SDM containing antibiotics delivered in low dose LV
provided significant protection in a rat model of descending
gram-negative pneumonia, supporting the hypothesis that
perfluorocarbon delivered intratracheal antimicrobials may
be useful in the prevention of VAP.
004 Effect of Pharmaceutical Representatives on
Prescribing Practices of an Emergency Medicine
Residency Kanwal Singh Gill, Eric Daniel Katz, Heather
Mahoney; Washington University School of Medicine:
St. Louis, MO
Objectives: Drug company sponsorship of medical events is
controversial and may influence physicians’ prescription
habits. Recent advances in computer databases encouraged
us to attempt to quantify the effect pharmaceutically funded
events (PFE) have on an EM residency’s prescribing habits.
Methods: A prospective study of ED medications and ED
discharge prescriptions at a busy, academic, inner city, level
I ED was conducted. PFE’s (weekly lunches and monthly
dinners) and medications were recorded. Prescriptions and
ED medications were acquired by tracking system database.
Each product’s usage during the 2 weeks before its PFE was
the control and was compared with usage for the following
2 weeks. Multiple drugs at one PFE were counted as in-
dependent PFE’s, as were multiple events for the same
drug. Wilcoxon matched-pair signed-rank test was used for
comparison. Results: Over 14 weeks, 13 drugs (1–3/PFE)
were tracked at 15 PFE’s. 5 drugs were presented at multiple
events for a total of n ¼ 22 PFE’s. These PFE’s increased
outpatient prescriptions 116% (23 vs. 52) from baseline (Z ¼

2.371, p \ 0.018). ED administration of advertised
medications increased by 33% (105 vs. 140) from baseline
(Z ¼
1.366, p \ 0.172). Gatifloxacin, loratidine, oxycodone-
SA and celecoxib showed the largest total increase in usage.
Of 8 medications that were not prescribed prior to the
funded event, 4 (50%) were prescribed at least once
following the visit and 4 (50%) were not prescribed during
the studied intervals. Conclusions: Pharmaceutical repre-
sentatives have a strong and rapid effect on the prescription
habits of residency physicians. ED administration of
advertised medications increased 33% while outpatient
prescription of recommended medications increased by
116%. The involved residents’ perception of the impact of
PFE’s will be presented, as will assessment of cost-efficacy.
005 Survival of Adult Liver Stem Cells in Rat Brain
after Asphyxial Cardiac Arrest Laurence M Katz,
Amanda Young, Jon Frank, William B Coleman, Yuanfan Wang,
Kyunam Park; University of North Carolina School of Medicine:
Chapel Hill, NC, St Mary Hospital: Seoul, South Korea
Objective: Stem cells have potential for replacing cells in
the brain irreversibly damaged by cerebral ischemia. This
exploratory study was designed to determine whether adult
liver stem cells could survive after implantation in rat brains.
We hypothesized that reperfusion from asphyxial cardiac
arrest would create a microenvironment in the brain that
would promote survival of adult liver stem cells. Methods:
The experimental study was approved by the Institutional
Animal Care and Use Committee. Adult male liver stem cells
were implanted in the hippocampal region of female rats with
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
no asphyxial cardiac arrest (n ¼ 4) or 1 hr after resuscitation
from asphyxial cardiac arrest (n ¼ 4). The implanted cells
were of male adult liver stem cell origin and transfected with
the bacterial gene that expressed beta-galactosidase (BGAL)
protein if viable. Rats were sacrificed 28 days after implan-
tation of adult liver stem cells. Sectioned brains were
histochemically stained for the presence of BGAL protein
and the evaluator was blinded to therapeutic intervention.
Cells expressing BGAL protein were isolated by laser capture
microscopy and the presence of the Y chromosome (the adult
male liver stem cell) in the female rat brains was confirmed by
PCR and western blots. Results: Adult liver stem cells were
present in 0 of 4 rats with no ischemia and in 4 of 4 rats
implanted with adult liver stem cells after resuscitation from
asphyxial cardiac arrest (Fisher exact p # 0.029). Conclusion:
Adult liver stem cells were viable in the rat brain 28 days after
resuscitation from asphyxial cardiac arrest.
006 Rosiglitazone Improves Endothelial Function
in Rabbits with Hypercholesterolemia by
Reducing Oxidative Stress and Preserving NO/cGMP
Signaling Ling Tao, Hui-Rong Liu, Erhe Gao, Bernard L
Lopez, Theodore A Christopher, Tiang-Li Yuan, Xin L Ma;
Thomas Jefferson University: Philadelphia, PA, Albert
Einstein Medical Center: Philadelphia, PA, GlaxoSmithKline
Pharmaceuticals: King of Prussia, PA
Objective: Peroxisome proliferator-activated receptors
(PPARs) activation has been reported to attenuate the
formation of atherosclerosis. This study was designed to
elucidate the effects of a PPARg agonist on endothelial cell
(EC) dysfunction, a prerequisite of atherosclerosis, in
hypercholesterolemic rabbit. Method: Male New Zealand
rabbits were assigned to one of the following groups: control
(C, normal diet); hypercholesterolemia (HC, 1% cholesterol
diet for 8 weeks); and HC treated with rosiglitazone (ROSI),
a PPARg agonist (4 mg/kg/day for the last 5 weeks). EC
function was determined by comparing vasorelaxation to
ACh, an EC-dependent, and acidified NaNO2, an EC-
independent vasodilator. The integrity of the NO/cGMP
pathway was determined by VASP phosphorylation
(pVASP). Expression of inducible NO synthase (iNOS) and
formation of peroxynitrite were determined by immunohis-
tochemistry. Data was analyzed with ANOVA. Results: HC
caused a significant EC dysfunction (maximal relaxation to
ACh: 61 6 10% vs. 86 6 12% in C, P\0.01) and reduced levels
of pVASP (31% of C). Treatment with ROSI improved EC
function (81 6 13%, P \ 0.01 vs. HC) and preserved the
integrity of NO/cGMP pathway as evidenced by increased
pVASP levels in aortic tissue (2.8-fold increase over HC).
There was no difference in vasorelaxation to acidified NaNO2
among the groups. In vitro incubation of rings from untreated
HC rabbits with SOD mimics (50 mM of MnTE-2-PyP5þ)
improved vasorelaxation to ACh (79 6 14%, P \ 0.01 vs. C).
Moreover, HC markedly increased iNOS expression and
peroxynitrite formation, which were attenuated by ROSI
treatment. Conclusion: Increased destruction of, rather than
decreased production of NO is responsible for HC-induced
EC dysfunction. Our study demonstrates that in vivo
treatment with a PPARg agonist improves EC function via
decreasing NO destruction and preserving the integrity of
NO/cGMP pathway, suggesting that PPAR agonists have
clinical benefits in patients with HC and EC dysfunction.
425
007 The Anti-apoptotic Effects of KW-3902, A Selective
Adenosine A1 Receptor Antagonist, in Hemorrhagic
Shock Rat Heart Erhe Gao, Bohdan Minczak, Qizhong Mo,
Xinliang Ma, Justin L Kaplan, Carl R Chudnofsky; Albert
Einstein Medical Center, Jefferson Health System: Philadelphia,
PA, Thomas Jefferson University: Philadelphia, PA
Background: We have previously demonstrated that ad-
ministration of A1 adenosine receptor (A1AdoR) antagonist
during hemorrhagic shock (HS) improves hemodynamics
and prolongs survival rate in the rat. Objectives: 1) To
determine whether HS may result in myocardial apoptotic
death; 2) If so, to determine the effect of AdoA1R antagonist
on HS induced apoptosis. Methods: SD rats were divided
into three groups, sham (n ¼ 8), KW-3902 (n ¼ 5), and drug
vehicle (n ¼ 6). After catheterization (femoral arterial, vein,
and carotid arterial), rats were subjected to 60 minutes of HS
by removing a sufficient quantity of blood to maintain
a mean arterial blood pressure of 40 6 5 mmHg. The
animals were then resuscitated with shed blood and 2 ml of
0.9% saline. In the sham group, rats underwent catheter
placement but no blood was withdrawn. At 30 minutes
prior to resuscitation, the rats were treated with KW-3902
(0.1 mg/kg, i.v.) or vehicle. Myocardial apoptosis was
determined by DNA ladder formation and TUNEL staining.
Serum level of TNFa was measured at baseline, 30 minutes
after HS and one hour after resuscitation. Data were
analyzed using ANOVA and Student t-test. Result: In the
vehicle treatment group, HS caused significant increase in
serum TNFa concentration (316.4 6 24.1 pg/ml, p \ 0.05 vs
baseline, 35.19 6 4.61 pg/ml) and cardiomyocyte apoptosis
as evidenced by DNA ladder formation and TUNEL
positive nuclear staining (10.1 6 0.27%, p \ 0.01 vs sham).
Administration of KW-3902 decreased myocardial apoptosis
(1.85 6 0.26%, p \ 0.01 vs vehicle), reduced serum TNFa
level (73.15 6 8.5 pg/ml, p \ 0.05 vs vehicle, 227.1 6 30.1
pg/ml) and improved cardiac functional recovery after
resuscitation. Conclusion: These data demonstrate that HS
causes significant myocardial apoptosis, which can be
inhibited by a selective A1AdoR antagonist. This protective
effect of A1AdoR antagonist may be due to the suppressing
of TNFa production in HS.
008 Platelet Responsiveness to Adenosine-mediated
Preconditioning Is Age-dependent Karin Przyklenk,
Peter Whittaker; University of Massachusetts Medical School:
Worcester, MA
Objective: Brief ‘preconditioning’ (PC) ischemia elicits 2
forms of cardioprotection: a well-described effect of PC on
cardiomyocytes, rendering them resistant to infarction, and
a poorly characterized, favorable effect of PC on platelets.
Specifically: PC attenuates platelet aggregation in models of
unstable angina and acute myocardial infarction, an effect
mediated by activation of adenosine (Ado) A2 receptors on
the platelets’ surface. However, as Ado receptor sensitivity
is purportedly age-related, the beneficial effects of PC on
platelet responsiveness may be compromised in aging
populations—the group in which coronary thrombosis is
most relevant. Methods: We tested this concept in vitro, in 2
species, using exogenous administration of the A2 agonist
CGS 21680 to stimulate A2 receptors and platelet aggrego-
metry as a surrogate index of thrombosis. Paired aliquots of
426
whole blood from adult vs old rabbits (6 months vs 4 years
of age) and rats (4 months vs 2 years of age) were treated
with CGS (10 mM) or vehicle, and platelet aggregation was
initiated by collagen, the exogenous stimulus most relevant
to in vivo thrombosis. For each species, maximum aggrega-
tion (ohms) was compared by 2-factor ANOVA (*p \ .05 vs
age-matched vehicle; **p \ .05 vs adult). Results: In adult
rabbits, maximum aggregation was, as expected, reduced by
30% in CGS-treated aliquots vs vehicle control. In contrast,
old rabbits were refractory to A2 receptor stimulation
(Table). Similar results were obtained in rats: maximal
aggregation decreased by 18 6 5% vs 1 6 5%** with CGS
treatment in adult vs old rats. Conclusion: Although
adenosine A2 receptor stimulation attenuates in vitro
platelet aggregation in adults, these favorable effects of
pharmacologic PC are not manifest in old animals.
Platelet aggregation in rabbit blood: absolute
values (ohms) and % difference vs vehicle
Vehicle CGS: 10 mM % Difference
Adult 19.3 6 1.5 13.6 6 1.4*
30 6 4%
Old 17.8 6 1.1 17.3 6 1.1
2 6 4%**
009 Induction of Hypothermia in Swine Using Cold
Saline vs Saline Slurry Terry L Vanden Hoek, Jason
P Alverado, Travis C Anderson, Benjamin C Abella, Danhong
Zhao, Craig Wardrip, Jeffrey E Franklin, Kenneth E Kasza,
Lance B Becker; University of Chicago: Chicago, IL, Argonne
National Laboratory: Argonne, IL
Objectives: Hypothermia induction after return of sponta-
neous circulation (ROSC) from sudden cardiac arrest may be
beneficial, but is difficult to achieve within a few hours using
surface cooling alone. We hypothesized that phase-change
microparticulate saline solutions (i.e. ‘‘slurry’’) up to 50% ice
by volume (which absorbs 70 kcal/cc of ice as it melts from
solid to liquid phases) could be engineered with high enough
fluidity to be given via intravenous tubing and induce
hypothermia within minutes. Ice slurry coolants of 30–50%
ice crystals which melt to produce 0.9% saline solution were
engineered and compared to ice-cold saline without ice.
Methods: Swine 30–50 kg were anesthetized, intubated with
a 7.5–8.0 mm ETT, and instrumented with 8–9 Fr catheters in
the femoral veins. Temperature probes were placed into the
left and right cerebral cortex to monitor core brain tempera-
tures. Slurry (50 ml/kg; n ¼ 4) vs. ice-cold saline (0–28C)
(50 ml/kg; n ¼ 4) was introduced via the femoral vein catheter
at a rate of 120 ml/min. Results: Core temperature of the brain
fell almost 38C to a nadir of 34.6 6 SE 0.28C within 20 minutes
of cold saline being administered, and fell almost 58C to
a nadir of 31.4 6 0.48C after slurry administration, a significant
difference (p \ 0.05) between groups, and different than the
non-cooled control animal with core brain temperature drop
of less than 0.58C. In addition, the cooling effect was main-
tained out to 40 additional minutes after the infusion was
complete, with core brain temperature at 34.9 6 0.28C at 1 hr
after saline was started vs. 32.7 6 0.78C after slurry ad-
ministration (p \ 0.05). Conclusions: We conclude that both
saline and saline slurry may be useful tools for intra-arrest
hypothermia induction—faster than surface cooling meth-
ods. In addition, saline slurry can achieve significantly more
cooling than cold saline with the same fluid volume given.
2003 SAEM ANNUAL MEETING ABSTRACTS
010 Accuracy of Emergency Medicine Performed
Compression Ultrasound for the Evaluation of
Deep Venous Thrombosis John P Fojtik, Neal Handly,
Thomas G Costantino; Drexel University College of Medicine:
Philadelphia, PA
Objectives: The use of lower extremity Doppler ultrasound
has become the accepted test of choice for diagnosing deep
venous thrombosis (DVT). Current vascular and radiology
vascular labs perform full lower extremity Doppler ultra-
sound mapping the entire deep venous system. We study
the use of limited lower extremity compression vascular
ultrasound and evaluate its accuracy within the emergency
department to diagnose DVT. Methods: This was a pro-
spective observational study of all lower extremity vascular
ultrasound studies performed by emergency physicians
(EP) at MCP and Hahnemann University Hospitals between
December 2001 and December 2002. All emergency physi-
cians performing the studies met or exceeded current ACEP
guidelines and had additional training with vascular ultra-
sound. All ultrasound scans were performed with linear
7.5–10 MHz probes. The EP study consisted of compression
ultrasound of the common femoral, superficial femoral and
popliteal veins at three distinct sites. Color flow Doppler
was implemented if the examiner had difficulty finding the
vessels. All studies were confirmed in the radiology
department with complete duplex ultrasound of the affected
extremity. Results: 91 patients were enrolled in the study,
and 24 were diagnosed with DVT. Emergency physician
performed compression ultrasound had a sensitivity of
96% (95% CI ¼ 0.87–1.0) and a specificity of 99% (95% CI ¼
0.95–1.0). The positive diagnostic likelihood ratio was 64.21
and the negative diagnostic likelihood ratio was 0.04.
Conclusion: Emergency physician performed limited com-
pression ultrasound can accurately diagnose lower extrem-
ity deep venous thrombosis.
011 Ultrasound Changes Emergency Physician
Management of Cellulitis Nael Hasan, Vivek S Tayal,
H James Norton; Carolinas Medical Center: Charlotte, NC
Objective: The role of ultrasound (US) in cases of soft-tissue
infection without obvious abscess has not been defined.
While the typical treatment involves antibiotics, there is
a subgroup of treatment failures caused by unsuspected
abscess. We hypothesized that sonographic evaluation
would change the emergency physician’s management of
patients with cellulitis. Methods: Prospective cohort study
in an urban emergency department of patients [18 years of
age with clinical signs of soft-tissue infection but without
obvious abscess. Perineal infections were excluded. Upon
identifying an eligible patient, the treating physician’s
pretest opinion regarding the need for further invasive
procedures was determined. Emergency physicians trained
in soft-tissue ultrasonography then performed US of the
infected area. The US results were revealed to the treating
physician, and the effect on the management plan was
recorded. Data was interpreted via chi-square testing.
Results: 58 patients were enrolled over 12 months. US
changed the management of patients with cellulitis in 20/58
(34.5%) [95% CI 22.3–46.7]. In the pretest subgroup felt likely
not to need further intervention (n ¼ 42), US changed the
management plan in 12/42 (28.6%), with 9 receiving
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
drainage and 3 receiving further diagnostics or specialist
consultation. In the pretest subgroup where further inter-
vention was felt likely (n ¼ 16), US changed the manage-
ment plan in 8/16 (50%), including 3 where drainage was no
longer felt necessary and 5 who had further diagnostic tests
or consultation. There was no difference between subgroups
in likelihood of US influencing management plan (12/42
vs. 8/16, p ¼ .125). Conclusion: Ultrasound significantly
changes emergency physician management of cellulitis.
Regardless of clinical perception, ultrasound provides in-
formation that can detect occult abscess as well as prevent
unneeded invasive procedures.
012 Doppler Ultrasound as a Non-invasive Means to
Determine Stroke Volume and Cardiac Output
Jack Siegel, Michael DePetro, Larry Fontanilla, Paul R
Sierzenski, Patty McGraw, Robert E O’Connor; Christiana
Care Health System: Newark, DE
Objectives: Pulmonary artery catheterization is a mainstay
of intensive care monitoring, yet poses risk to the patient.
We conducted this study to determine whether transcranial
Doppler (TCD) applied to the suprasternal notch, can be
used to estimate stroke volume (SV) and cardiac output
(CO). Methods: The study was conducted during 2002 at
a tertiary care teaching hospital. Patients with pulmonary
artery catheters in place were eligible for the study. The TCD
machine was used to obtain Doppler signals from the aorta,
by application of the probe over the suprasternal notch. A
depth of 8 to 11 cm will be searched with a Doppler sample
size of 10 square mm. Following measurement of SV and CO
by thermodilution technique, aortic flow velocity (AFV) in
cm/sec was measured using TCD. After AFV determina-
tion, SV and CO were then re-measured. Mean SV values
were compared with AFV using Pearson’s correlation co-
efficient Before and after measurements were analyzed using
the Mann-Whitney U-test. Results: A total of 20 patients
were enrolled. Mean age was 64 years. Mean SV was 73 ml.
pre-AFV (range 54–138) and 78 ml. post-AFV (range 61–122).
This difference was not significant. Mean AFV was 20 cm/sec
(range 10–31). There was a mean of 10 minutes from initial SV
measurement to AFV, and 7 minutes from AFV to second SV
measurement. Correlation between mean SV measurement
and AFV was 0.71. The mean ratio of SV/AFV was 4.6 (range
3.9–5.2). Conclusion: Use of TCD to measure AFV is a non-
invasive technique that provides a rough estimate of SV,
without exposing the patient to risks inherent with thermo-
dilution catheter insertion.
013 Resident Performed Compression Ultrasound for
the Evaluation of Proximal Lower Extremity Deep
Vein Thrombosis: Fast, Accurate, and Timely Timothy
B Jang, Gregory Polites, Martin Docherty, Chandra Aubin;
Barnes-Jewish Hospital: St. Louis, MO
Objectives: To prospectively examine if emergency medi-
cine residents could quickly perform accurate compression
ultrasonography (CUS) for the detection of proximal lower
extremity DVTs (PLEDVT) with minimal training. Methods:
A prospective, observational study using a convenience
sample of patients presenting with signs/symptoms of
PLEDVT. Vascular laboratory and department of radiology
427
studies were considered ‘‘gold standard.’’ Resident CUS
was done of the femoral vessels down to the popliteal fossa.
An area of incompressibility or thrombus was considered
‘‘positive’’. Results: 70 patients were enrolled and examined
by 8 residents without prior experience with DVT US. Their
average scan time was 11.7 minutes (95% CI, 9.4–14). The
average patient age was 54 years. EM resident CUS was
considered positive in 26 of the 70 patients. Confirmatory
testing was positive in 22 patients for PLEDVT. None of the
44 patients which were considered negative for PLEDVT by
EM-resident CUS were found to have PLEDVT by confir-
matory testing:
Test characteristic for PLEDVT
sensitivity 100% (95% CI, 81.5–100)
specificity 91.7% (95% CI, 79.1–97.3)
PPV 84.6% (95% CI, 64.3–95.0)
NPV 100% (95% CI, 90.0–100)
42 patients (60%) were evaluated ‘‘after hours.’’ 11 patients
were admitted and subsequently diagnosed with DVT by
diagnostic imaging done an average of 1385 minutes (95% CI,
850–1920) after EM resident-CUS. 13 patients were diagnosed
with DVT prior to being admitted (2 with distal peroneal vein
DVT). Their diagnostic imaging was obtained an average of
512 minutes (95% CI, 374–650) after EM resident-CUS. 23
patients were diagnosed as ‘‘without DVT’’ prior to dispo-
sition with an average time from EM resident-CUS to
diagnostic imaging of 388 minutes (95% CI, 221–555).
Conclusion: EM residents with limited US experience can
quickly perform CUS for the detection of PLEDVT with high
sensitivity. This leads to a significant decrease in time to
diagnostic imaging.
014 FAST vs FAST, AST, ALT and Urinalysis in Children
with Blunt Abdominal Trauma Antonio E Muñiz,
Sam Bartle, Robin L Foster, Chris Woleben, Steve R Liner;
Virginia Commonwealth University Health System:
Richmond, VA
Objectives: The aim of the study is to compare the
effectiveness of the focused assessment with sonography
for trauma (FAST) examination with and without the
addition of the AST, ALT and urinalysis in children
sustaining blunt abdominal trauma. Methods: Prospective
convenience sample with data collected on 95 children (\18
years-old) from 2/99 to 12/02. The ultrasounds were
performed by EM or PEM attendings and confirmed by
CT (98%) or OR findings (2%). Results: The median age was
11.3 6 5.4 [95% CI, 10.2, 12.4] with a range of 3 months-old
to 18 years-old. There were 57 (60%) males, with 47 (49.4%)
Caucasians, 45 (47.3%) African Americans, and 3 Hispanics.
The FAST was (þ) in 28 patients who had injuries identified
by CT scan. This resulted in a specificity (77.7%), specificity
(98.3%), PPV (96.5%), and NPV (87.8%). An elevated AST
([50 IU/L) and ALT ([75 IU/L) only identified 23 patients
with significant injuries with a sensitivity (63.8%), specificity
(88.1%), PPV (76.6%), NPV (81,2%). The urinalysis([5 rbc/
hpf) identified 19 patients with significant injuries with
a sensitivity (52.7%), specificity (84.7%), PPV (67.8%), NPV
(72.4%). There were 8 (þ) CT scans with negative FAST
examinations. Injuries in these patients included: duodenal
hematoma, adrenal hemorrhage, grade 1 and 3 liver
428 2003 SAEM ANNUAL MEETING ABSTRACTS

lacerations, grade 1 and 2 spleen lacerations, and small ACEP 2001 guideline of 25 exams is consistent with the
pelvic fluid from a pelvic fracture. With the addition of the learning curve suggested by our data, in contrast to the 400
urinalysis and AST/ALT to the FAST examination all exams recommended by others.
children with a positive CT scan would be identified. This
resulted in a sensitivity (100%), specificity (85.2%), PPV
(72.0%), NPV (100%). Conclusions: The FAST by itself is not 016 Validation of the TIMI Risk Score in the Emergency
adequate in screening children with blunt abdominal Department Chest Pain Patient Population
trauma. The addition of an AST, ALT and urinalysis in this Judd E Hollander, Charles V Pollack Jr, Frank D Sites, Peter
study identified all children with a positive CT scan of the Grossman, Geoffrey Duviner, Frances S Shofer; University of
abdomen. Further research should be conducted using Pennsylvania: Philadelphia, PA
a protocol of FAST, AST, ALT and urinalysis for children
with blunt abdominal trauma. Objective: The TIMI Risk Score was derived from ‘‘mega-
trials’’ of ACS patients with ECG changes or positive cardiac
markers. This 7-item tool risk stratifies these patients with
015 The Learning Curve for EP-performed Focused respect to 30-day outcomes. It is also recommended to help
Abdominal Sonography for Trauma (FAST) Exams guide treatment (aggressive vs conservative management;
in the Detection of Intraperitoneal Free Fluid Timothy B type of anticoagulation). However, it was derived in a group
Jang, Chandra Aubin, Sanford Sineff, Rosanne Naunheim; of patients that emergency physicians already consider high
Barnes-Jewish Hospital: St. Louis, MO risk and has never been assessed in an unselected ED chest
pain patient population. We assessed the utility of the TIMI
Background: No consensus or standard guidelines exist
Risk Score in an unselected ED chest pain patient popula-
regarding the training of EPs performing US. Various
tion. Study design: Prospective cohort study. Methods:
recommendations, including SAEM guidelines, have been
Consecutive ED CP pts were identified by trained research
made, but lack data to substantiate them. Objectives: To
assistants from 7/99 to 3/02. Data included demographics,
assess the learning curve of ‘‘novice’’ EPs in performing
medical/cardiac history, and components of the TIMI Risk
FAST exams for the detection of free fluid (FF) and
Score (age [65 yrs; known coronary stenosis 50% or more,
determine if 10 or 20 exams could be used as a minimum
ST segment deviation, 2 or more anginal events in prior 24
standard for training as previously suggested. Methods:
hours; aspirin in preceding 7 days and elevated CK-MB or
This was a retrospective study of patients who underwent
cTnI). Investigators followed the hospital course daily. The
EP-performed FAST exams prior to operative or department
main outcome was 30-day death, AMI, or revascularization.
of radiology evaluation. Operative findings were considered
Results: 4492 pts were enrolled (mean age, 52.3 6 16 yrs;
gold standard, followed by results of abdominal CT then
41% male; 70% African-American; 319 had a final diagnosis
abdominal US. Results: 1,318 patients were examined using
of AMI; follow-up obtained in 98%). The incidence of each
EP-performed FAST exams. 698 patients went on to receive
individual TIMI Risk factor was: age [65 yrs, 23%; known
gold standard evaluations and were included in this study.
coronary stenosis 50% or more, 6%; ST segment deviation,
67 EPs performed FAST exams during the study period,
15%; 2 or more anginal events in prior 24 hours, 28%; aspirin
averaging 19 FAST exams/EP (95% CI, 11–27). All EPs had
use in prior 7 days, 24%; and elevated markers, 11%. The
performed less than 3 FAST exams prior to the study except
incidence of 30-day death, AMI, revascularization (D/AMI/
for 1 attending who had 21 prior FAST exams. The results of
Revasc) according to number of risk factors is shown below:
EP-performed FAST exam for FF are shown below by level
of experience. # Risk Factors 30 day D/AMI/Revasc
0 1.6%
Exams #EPs Sensitivity Specificity
1 4.7%
0–10 37 88.1% (77.2–94.3) 97.7% (94.5–99.2) 2 12.1%
11–20 15 85.0% (61.1–96.0) 100% (94.4–100) 3 23.6%
21–30 5 82.4% (55.8–95.3) 94.4% (80.0–99.0) 4 46.8%
[ 31 10 94.8% (88.6–97.9) 98.6% (94.5–99.8) 5 69.1%
6/7 71.4%
Exams TP TN FP FN #pts
0–10 59 214 5 8 286 Conclusions: The TIMI Risk Score successfully risk stratifies
11–20 17 81 0 3 101 patients with chest pain at the time of initial ED evaluation.
21–30 14 34 2 3 53 This tool may assist triage and disposition of ED chest pain
[ 31 110 140 2 6 258 patients.
Chi-square analysis of the above data is shown below:
Comparison Groups x a 017 Cocaine Induced Myocardial Infarction Is Associated
with Reduced Microvascular Perfusion Jim Edward
0–10, 11–20, 21–30, [30 47.11 \0.0001
0–10 vs. [10 15.89 0.012
Weber, C Michael Gibson, Sabina A Murphy, Gregory L Larkin,
0–20 vs. [20 35.19 \0.0001 Judd E Hollander; University of Michigan: Ann Arbor, MI,
0–30 vs. [30 39.36 \0.0001 Harvard Medical School: Boston, MA, University of
Pennsylvania: Philadelphia, PA, University of Texas
Southwestern Medical Center: Dallas, TX
Conclusion: Previous suggestions that 10 exams could be
used as a minimum standard for the training or credential- Background: Epicardial flow is impaired with acute
ing of EPs performing FAST exams was not validated. The myocardial infarction (AMI) in both culprit and non-culprit
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
vessels, suggesting slowing attributable to resistance other
than stenosis. Slower global myocardial flow is related to
a higher incidence of adverse outcomes, including mortality.
Objective: To compare microvascular flow between cocaine
in myocardial infarction patients (CIMI) v patients (pts) who
received thrombolysis in myocardial infarction (TIMI), and
normal controls. Methods: Secondary analysis of prospec-
tively collected angiographic data. Pts with CIMI, TIMI, and
controls were matched for age, race, gender and risk factors.
Outcome measures included TIMI myocardial perfusion
grade 3 (TMPG 3), digital subtraction angiography (DSA)
blush brightness, and frames to first blush (FFB). Multi-
variate regression was used to adjust for demographic
variables. Chi-square was used for categorical variables
and Student’s t-test or Wilcoxon rank sum was used for
continuous variables. Results: 2,551 angiograms were
analyzed; (CIMI ¼ 57, TIMI ¼ 2,403, control ¼ 91). Both
CIMI and TIMI pts had impaired TMPG 3 when compared
to controls (40% and 26.6 & v 100%; p , 0.001 for both). CIMI
pts had less DSA and required more FFB than controls; (5.69
6 5.6 v 10.91 6 5.7; p \ 0.0001) and (70.3 6 36.9 v 50.8 6
20.3; p \ 0.0001) respectively. Conclusions: Although
microvascular perfusion was more impaired in TIMI v
CIMI pts, only 40% of CIMI pts had normal tissue level
perfusion. Compared to normal controls, CIMI pts had
dimmer myocardial perfusion on DSA, and a prolonged
time to fill the myocardium with dye. Significant myocardial
perfusion abnormalities appear to exist in pts with CIMI.
018 The Evaluation of Hyperlipidemia in Emergency
Department Patients with Possible Acute Coronary
Syndrome Andra L Blomkalns, Christopher J Lindsell,
Caroline E Eady, Elise M O’Connell, W Brian Gibler;
University of Cincinnati: Cincinnati, OH, Institute for Health
Policy and Health Services Research: Cincinnati, OH
Objective: Hyperlipidemia is a recognized risk factor for
coronary heart disease (CHD) and lipid status is often
unknown in emergency department (ED) patients. Public
health initiatives recommend risk factor identification while
recent NIH guidelines recommend drug therapy for patients
with severe hyperlipidemia and a 10-year Framingham risk
score of [20%. We hypothesize that a significant proportion
of ED patients with possible acute coronary syndrome (ACS)
would qualify for lipid reduction therapy. Methods: We
performed a prospective observational study of ED patients
presenting between April and November 2002. Patients with
symptoms consistent with possible ACS, having an ECG and
cardiac markers drawn, were studied. Only those patients
with unknown lipid status were included. The study
institution is a tertiary-care, urban teaching hospital with
86,000 ED visits per year. Six hour fasting lipid profiles were
obtained, along with assessment for other CHD risk factors.
NIH guidelines are used to determine whether patients
qualified for drug therapy (low density lipoproteins (LDL)
[¼ 130 mg/dL and known CHD or a 10-year Framingham
risk score of[20%). Results: 318 patients were enrolled in the
study, 53 patients have been excluded from analysis due to
missing data. The remaining 265 patients had a mean age of
46 (SE 0.89) years, 44% were male, and 35% were white.
Median lipid values for this population were LDL 108 mg/
dL and total cholesterol 181 mg/dL. Proportions of patients
with LDL [¼ 130 and [¼ 160 were 30.9% and 9.1%,
429
respectively. 38 patients (14.3%, 95%CI 10.6%–19.1%) quali-
fied for drug therapy according to NIH guidelines. Conclu-
sions: Hyperlipidemia requiring lipid lowering therapy is
present in a significant proportion of ED patients with
possible ACS. Our study suggests that lipid screening and
subsequent appropriate lipid lowering drug therapy should
be considered for ED patients with possible ACS.
019 Serum Markers of Coronary Pro-thrombotic State
Identify High-risk Patients Missed by Traditional
Myocardial Markers Hong K Kim, Christopher Faustin
Lori J Sokoll, Omar F Laturza, Gary B Green; Johns Hopkins
University: Baltimore, MD
Objectives: To determine the prognostic value of serum
testing for three candidate markers of coronary pro-throm-
botic state (p-selectin, vascular cell adhesion molecule
[VCAM] & intercellular adhesion molecule [ICAM]) among
ED patients with possible myocardial ischemia. Methods:
498 consecutively consenting patients with chest pain or
other symptoms of possible ischemia were prospectively
enrolled at two urban EDs. Exclusion criteria included non-
cardiac etiology by radiograph, direct trauma or bleeding
diathesis. Serum samples were subsequently tested for
p-selectin, VCAM, ICAM, CKMB, myoglobin, and troponin
I (cTnI). Adverse events (AE) occurring within 30 days
(death; MI; cardiac or respiratory arrest; arrhythmia; pulmo-
nary edema; conduction disturbance; hypotension; unstable
angina; repeat ED visit, admission or unscheduled clinic visit
for cardiac cause) were recorded by chart review, phone and
mail survey. Predictive values for AEs were calculated and
compared. Results: Complete data was obtained for 445
patients. 140 AEs occurred in 91 patients (20.5%) including 3
deaths (0.7%) and 19 MIs (4.3%). Of the 91 AE patients, the
traditional marker panel (CKMB, myoglobin and cTnI)
identified 85 (sensitivity ¼ 83.3% [79.9, 86.8]). Addition of
VCAM captured 4 out of the 6 otherwise missed AE patients
(sensitivity ¼ 94.4% [92.3, 96.5]). A 5-marker panel including
VCAM, ICAM and the traditional markers yielded maxi-
mum sensitivity (97.2% [95.7, 98.8]), identifying 90 of the 91
high-risk patients. However, as the specificities of the new
markers are low (VCAM ¼ 25.2%, ICAM ¼ 25.4%, p-selectin
¼ 42.8%), in our sample this improvement in sensitivity
would have required further evaluation of 167 additional
patients without subsequent AEs (false positives). Conclu-
sions: Each of the three candidate markers can identify some
high-risk patients otherwise missed by traditional markers.
However, poor specificity limits the clinical utility of existing
assays for these markers of coronary pro-thrombotic state.
020 The TIMI Risk Index Predicts In-hospital and
Long-term Mortality in Unselected Patients with
Myocardial Infarction Leonard Ilkhanoff, Christopher J
O’Donnell, Carlos A Camargo, David O’Halloran, Robert P
Giugliano, Donald M Lloyd-Jones; Massachusetts General
Hospital: Boston, MA
Objectives: The TIMI risk index [(heart rate 3 (age/
10)squared)/systolic blood pressure] is a predictor of
mortality at 30 days in patients (pts) with ST elevation MI
(STEMI). We sought to test whether this index could predict
in-hospital and longterm mortality in unselected pts with
STEMI and non-STEMI. Methods: We used a database of
430
consecutive unselected pts with MI admitted via the ED to an
urban academic hospital in 1991–92. The risk index was
calculated for each pt based on heart rate and blood pressure
at presentation to the ED. We used Cox models to assess the
risk of mortality by quintile of risk index, after adjustment for
potential confounders. Results: Of 566 pts with MI (mean age
68 6 12 years, 36% women), vital status was known for 100%
in-hospital, 90% at 1 year, and 77% at 10 years. Mortality rates
for these endpoints were 8%, 18% and 61%, respectively. The
mean risk index score was 29 6 16 (range 3–135). The table
shows mortality rates and multivariable-adjusted hazard
ratios (HR) by quintile. Mortality rates increased significantly
across quintiles at all endpoints (P-trend \ 0.01 for all).
Results were similar for pts with STEMI and non-STEMI.
Conclusions: The TIMI risk index is a strong, independent
predictor of short- and longterm mortality in ED pts
presenting with acute MI. Our results broaden the applica-
tion of this index to unselected pts with STEMI and non-
STEMI and extend its utility to longterm risk stratification.
In-Hospital 1-Year Adjusted HR 10-Year Adjusted
Quintile Rate Rate (95%CI) Rate HR (95%CI)
1 0% 3% 1.0 (ref) 28% 1.0 (ref)
2 2% 5% 1.4 (0.3–5.6) 42% 1.2 (0.8–1.9)
3 7% 15% 3.7 (1.1–12.8) 68% 2.4 (1.6–3.7)
4 12% 27% 6.1 (1.8–20.5) 78% 3.0 (2.0–4.6)
5 21% 40% 8.0 (2.4–26.7) 89% 4.3 (2.8–6.6)
*Adjusted for elevated creatinine, CHF at presentation, history
of CABG, revascularization during index hospitalization.
021 The Effect of Gender on Initial ECG Time for
Patients Who Presented to an Academic Emergency
Department with Chest Pain Kevin M Takakuwa, Frances S
Shofer, Judd E Hollander, Frank D Sites, Iris M Reyes;
University of Pennsylvania Health System: Philadelphia, PA
Objective: To determine whether gender affected initial
ECG time of patients who presented to an urban academic
emergency department (ED) with chest pain. Our hypoth-
esis was that there would be no differences between women
and men. Methods: This was a prospective cohort study of
all patients aged 24 and older who presented to our ED
between July 9, 1999 and October 23, 2000 with chest pain.
Structured data collection included demographics, history,
laboratory, ECG data, treatment provided, hospital course,
and 30-day followup. We divided all patients into three
groups based on final diagnosis 30 days post discharge to
home: those with acute myocardial infarction (AMI),
unstable angina (USA), and all others with chest pain
(CP). Data were analyzed using Wilcoxon Rank Sum tests.
Results: A total of 2,439 patients were studied: women
(55%), men (45%); blacks (68%), whites (29%), other (3%);
age 55 and older (49%), age 54 and younger (51%). For
patients with AMI, there was no significant time to initial
ECG difference between women and men (p ¼ 0.95). The
median ECG time was 14 min for women (n ¼ 123;
interquartile range (IQR) 1.0–49 min) and 18 min for men
(n ¼ 190; IQR 0.0–48 min). For patients with USA, there was
no significant difference between groups (p ¼ 0.28). The
median ECG time was 25 min for women (n ¼ 233; IQR 1.0–
69 min) and 20 min for men (n ¼ 299; IQR 4.0–53 min). There
was a significant gender difference for patients with CP (p \
2003 SAEM ANNUAL MEETING ABSTRACTS
0.0001). The median ECG time for women was significantly
longer at 44 min (n ¼ 980; IQR 9.0–96 min) compared to men
at 31 min (n ¼ 614; IQR 4.0–71 min). Conclusions: Overall
there was a gender difference in median time to ECG with
men getting faster initial ECGs than women. These effects
can be explained by patients with CP who do not have an
AMI or USA. We found no gender differences in initial time
to ECG for patients who did have a time sensitive acute
myocardial infarction or unstable angina.
022 Out-of-hospital Factors Associated with Serious
Abdominal or Thoracic Injury among Occupants
Involved in Motor Vehicle Crashes Craig D Newgard;
Oregon Health & Science University: Portland, OR
Objective: To assess motor vehicle crash (MVC) scene
variables routinely collected by out-of-hospital personnel
for association with serious abdominal (ABD) or thoracic
(THOR) injury, controlling for crash severity (deltaV), and to
address 3 scenarios: 1) same-side occupants involved in
lateral collisions, 2) drivers of vehicles with steering wheel
deformity, and 3) front-seat occupants exposed to air bag
deployment. Methods: Subjects [17 years included in the
National Accident Sampling System database (NASS),
a national probability sample of occupants involved in
MVCs over 7 years, were analyzed. Multiple imputation
was utilized to impute missing values. 14 variables were
assessed for association with ABD or THOR (Abbreviated
Injury Scale [2) using logistic regression. Analyses were
performed on all impact types and restricted to (separately)
lateral collisions, drivers, and front-seat occupants. Separate
models were assessed for each injury type. Clusters, strata,
and weights were integrated to account for the complex
sampling design of NASS. Results: 39,839 subjects were
included in the analysis. Factors associated with ABD and
THOR included: passenger space intrusion, rollover, Glas-
gow Coma Score, age, ejection, and entrapment. Restraints
were protective in all models. There was a strong, syner-
gistic association between same-side occupants involved in
lateral collisions and both injury types (interaction terms:
ABD OR 8.6, 95%CI 1.1–65, THOR OR 26, 95%CI 1.5–448).
Steering wheel deformity was associated with THOR (not
ABD) among drivers (OR 1.4 for each 5 cm increase in
deformity, 95%CI 1.2–1.8), and the effect was not modified
by driver air bag deployment (p ¼ 0.1616 for interaction).
Air bag deployment was not associated with either injury
type. Conclusions: Certain out-of-hospital variables have
a strong association with ABD and THOR. Same-side
occupants involved in lateral collisions and drivers of
vehicles with steering wheel deformity are at high risk for
such injuries.
023 Non-traumatic Prehospital Hypotension Predicts
Short-term Mortality Alan E Jones, Ian G Steill, Lisa
P Nesbitt, Daniel W Spaite, Nael Hasan, Thomas H Blackwell,
Jeffrey A Kline; Carolinas Medical Center: Charlotte, NC,
Ottawa Health Research Institute, University of Ottawa:
Ottawa, ON, Canada
Objective: Prehospital hypotension may signify need for
intensive resuscitation and rapid diagnosis upon ED arrival.
We hypothesized that prehospital hypotension confers risk
of short-term mortality. Methods: Multicenter study of
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org 431

ambulance-transported, non-trauma, non-CPR patients con- (N ¼ 3 EMS and N ¼ 4 ED). Of the PE arrests, 83% had at
ducted at two venues: 1. A Canadian prospective multi- least 2 of 3 components of the triad vs. 33% of the non-PE
center study of patients with respiratory distress from group (95% CI for difference 16–74%). Return of spontane-
1995–2000; 2. A case-control study of high-priority medical ous circulation occurred in 7/18 PE patients and 8/15
transports during 2001 in a US metropolitan EMS system. non-PE patients. Mortality was 100% in the PE group. No
Data at both venues were extracted from prospectively patient had an overt contraindication to fibrinolytic therapy.
recorded, standardized EMS run sheets by either a physician Analysis of the EMS cardiac arrest registry indicated that
or a paramedic. Data extraction and analyses at each venue 65% of patients age \71 coded as having prehospital PEA
were conducted independently. Exposure (cases) defined as: arrest were enrolled during the study period. Conclusions:
age [17, any SBP \100 mmHg during transport, and one or A CDR can be implemented in an urban EMS and ED
more of 15 predefined symptoms of circulatory insuffi- system to detect PE as most likely cause of cardiac arrest.
ciency. Non-exposure (controls) defined as: age [17, SBP Patients with PE are very likely to manifest 2 or 3 com-
[100 mmHg during entire transport, and more than 1 ponents of the clinical triad prior to PEA arrest.
symptom. Outcome variable: in-hospital or 30-day mortal-
ity. At the US venue, cases were pairwise matched with
a random sample of age-matched controls. Odds ratios (OR) 025 Predictors of Survival for Out-of-hospital
with bias-corrected 95% CIs were calculated from multivar- Respiratory Distress Patients in the OPALS
iate logistic regression. Results: Canadian venue: Out of Study Ian G Stiell, Valerie J De Maio, Lisa Nesbitt, Graham
7935 transports, 788 (10%) exposures and 7147 non- Nichol, David Brisson, Tammy Beaudoin,, for the OPALS Study
exposures were identified, ages 70 6 18 vs. 71 6 16 years Group; ; University of Ottawa: Ottawa, Ontario, Canada,
(p ¼ 0.07), respectively. Short term mortality after exposure Queens University: Kingston, Ontario, Canada, University of
was 27% vs 11% for non-exposures (OR ¼ 3.7, 95% CI 2.8 to Western Ontario: London, Ontario, Canada, Niagara Regional
4.9). US venue: Out of 3128 transports, 395 (13%) cases and Base Hospital: Niagara Falls, Ontario, Canada, Ontario
395 controls were identified, ages 66 6 18 vs. 66 6 10 years, Ministry of Health: Toronto, Ontario, Canada, University of
respectively. Short term mortality of cases was 29% vs 7% Arizona: Tucson, AZ
for controls (OR ¼ 2.9, 1.6 to 4.3). Other significant pre-
dictors of mortality were age, pulse rate, dyspnea and Objectives: We previously demonstrated that the addition
altered mental status. Conclusion: We found the mortality of an ALS EMS program led to a large mortality reduction
rate after prehospital, non-traumatic hypotension to be high for respiratory distress patients. In this study, we sought to
and reproducible. Prehospital hypotension should trigger determine which specific factors are associated with better
a clinical protocol to ensure adequate resuscitation and survival. Methods: The Ontario Prehospital Advanced Life
investigation of etiology. Support (OPALS) Study evaluates EMS programs for
critically ill and injured patients. The respiratory component
was a multicenter before-after controlled trial that enrolled
024 Prospective Application of a Decision Rule by adult patients with a primary complaint of shortness of
Paramedics and Emergency Physicians to Identify breath. During the before phase, care was provided at the
Pulmonary Embolism as Cause of Arrest in Outpatients BLS-D level and during the after phase, ALS providers
with Pulseless Electrical Activity D Mark Courtney, performed endotracheal intubation and administered IV
Thomas H Blackwell, Jeffrey A Kline; Northwestern Memorial drugs. We conducted stepwise logistic regression analyses
Hospital: Chicago, IL, Carolinas Medical Center: Charlotte, NC to identify independent predictors of survival. Results: The
7,478 patients enrolled during the two 6-month phases had
Background: A retrospectively-derived clinical decision
these characteristics: mean age 70.6 (16–107), female 53.3%,
rule (CDR) found that 57% of outpatients with witnessed
survival rate 86.7%. This table compares survivors and non-
arrest þ pulseless electrical activity (PEA) had PE as cause
survivors and gives the adjusted odds ratios for predictors
of cardiac arrest. Objectives: 1. Test the feasibility of
associated with survival:
implementing this CDR in a large, urban EMS and ED
system to prospectively measure its predictive accuracy. 2.
PREDICTOR SURV NON-S O.R.
Prospectively test if the clinical triad of respiratory distress,
altered mental status and HR/SBP [0.8 predicts presence Age in years 69 76 0.97
of PE. Methods: All EMS personnel (N ¼ 204) of an Male gender 46% 51% 0.77
integrated urban EMS system and ED physicians (N ¼ 143) Respiratory rate/min 28 31 0.97
at 7 hospitals were in-serviced on the CDR and data collec- Pulse rate/min 100 104 NS
Prehospital GCS \ 15 10% 28% 0.44
tion procedure. Inclusion criteria: age 18–70, non-trauma,
EMS life-threatening 13% 22% 0.77
witnessed arrest, PEA as the first and primary rhythm.
CHF 28% 26% 1.7
Exclusion: defibrillation before or [1 time after PEA. COPD 22% 11% 2.5
Criterion standard for PE: autopsy or predefined cardiopul- Pneumonia 12% 21% NS
monary imaging for PE. Results: Over 21 months, 44 Asthma 9% 0.1% 56.9
subjects were enrolled who met the CDR. 33 subjects had Bag ventilation 2% 5% 0.63
a criterion standard (N ¼ 20 autopsy, 13 other imaging). 18 Intubation 0.4% 1% NS
of 33 (54%; 95% CI 36–72%) had PE. Non-PE diagnoses Nebulized Salbutamol 36% 28% 1.2
included cardiac ischemia (N ¼ 5), aortic dissection (N ¼ 1), SL NTG 5% 4% 1.8
subarachnoid hemorrhage (N ¼ 2) and other (N ¼ 8). Of the IV Furosemide 7% 8% NS
IV Morphine 0.8% 0.9% NS
PE arrests, 88% were witnessed by EMS (N ¼ 8) or ED
physicians (N ¼ 8), compared to 47% in the non-PE group Hosmer-Lemeshow goodness-of-fit P ¼ .703
432
Conclusions: We believe this to be the largest dataset of out-
of-hospital respiratory distress patients. After adjustment
for demographic, clinical, and EMS factors, the only inter-
ventions associated with better survival were salbutamol
and NTG.
026 US Emergency Department Visits for Transient
Ischemic Attack, 1992–2000 Jonathan A Edlow,
Sunghye Kim, Jennifer A Emond, Carlos A Camargo Jr; Beth
Israel Deaconess Medical Center: Boston, MA, Massachusetts
General Hospital: Boston, MA
Objective: To describe the epidemiology of US emergency
department (ED) visits for transient ischemic attack (TIA),
including trends in imaging and hospitalization. Methods:
Data were obtained from the 1992–2000 National Hospital
Ambulatory Medical Care Survey. Cases had ICD9 code 435.
National estimates were obtained using assigned patient
visit weights. 95%CI were calculated using the relative
standard error of the estimate; analysis used chi2 and
logistic regression. Results: From 1992–2000, there were
2,623,000 ED visits for TIA (0.3% of all ED visits). The
overall rate per 1,000 US population was 1.1 (95%CI, 0.9–1.3)
and did not differ by year, sex, race, or US region. Rates
increased with age, from 0.1 for age \50 to 13.5 for age $ 90
(p ¼ 0.002). The TIA visit rate per 1,000 ED visits was 3.0 (2.5–
3.6), with results similar to those based on US population.
Compared to the other ED visits, TIA cases were more likely
to be female (52% vs 60%; p ¼ 0.002) and white (77% vs 90%; p
\ 0.001). The most common chief complaint was a speech
problem (31%); only 61% of cases presented with a sensori-
motor symptom. 77% of cases were considered urgent/
emergent at triage, but only 28% arrived by ambulance.
Antihypertensives were given to 19% (95%CI, 10–27%),
aspirin 17% (9–26%), and other antiplatelet agents 5%
(1–11%); 31% (21–41%) did not receive any medication. CT
was done in 56% (45–66%) with no differences by age, sex,
insurance type, or region; MRI was done in \5% of cases.
Although admission rates did not vary by year (p ¼ 0.12),
with 54% (42–67%) admitted, rates varied by region (e.g.,
Northeast 66%, South 40%). On multivariate testing, the only
predictor of admission was Northeast (OR 1.8; 1.1–2.9).
Conclusion: The frequency of ED visits for TIA was stable
between 1992–2000. Medical management appeared sub-
optimal, and imaging underutilized. TIA admission rates
varied by US region, a finding that may reflect the limited
evidence base for deciding ED disposition in this patient
group.
027 Blood Glucose Control after Acute Stroke: A
Retrospective Study Nina T Gentile, Michael
Seftcheck, Ramelle Martin; Temple University School of
Medicine: Philadelphia, PA
Objectives: Hyperglycemia after acute stroke worsens
postischemic brain injury. This study assessed the relation-
ship between blood glucose (BS) levels on presentation and
evaluated the impact of early BS management on mortality
and rate of discharge after acute stroke. Methods: A hospital
database of patients with discharge diagnosis of ischemic
stroke between 7/99 and 7/02 was used. Patients were
grouped in terms of initial BS levels and according to BS
2003 SAEM ANNUAL MEETING ABSTRACTS
control in the first 48 hrs of hospitalization. Patients with
initial, 24 h and 48 h BS \130 mg/dL were considered
euglycemic. Hyperglycemic patients were defined as having
uncontrolled (BS [180 mg/dL), moderate control (BS $ 30%
to 130 and 180 mg/dL) or strict control (BS reduced $ 30%
to \130 mg/dL) over the first 48 hours of hospitalization.
Demographic data and outcomes were compared between
groups. Results: 765 patients with ischemic stroke were
included. Patients with hyperglycemia on presentation (n ¼
295) were less likely to survive and be discharged home
than patients with initial BS \ 130 mg/dL (p # .01, Chi-
square). Most patients’ BS with hyperglycemia on pre-
sentation remained high; and, relatively few patients (14%)
had BS reduced to normal levels. BS control was associated
with a greater proportion of patients discharged home (*p ¼
.03) and fewer inhospital deaths (**p ¼ .07, Fisher’s Exact
Test).
Euglycemic Uncontrolled Moderate Strict
(n ¼ 204) (n ¼ 102) (n ¼ 39) (n ¼ 42)
D/C Home(%) 111 (54.4) 46 (45.1) 20 (51.3) 27 (64.3)*
Died(%) 4 (2.0) 13 (12.7) 2 (5.1) 1 (2.4)**
Conclusion: Hyperglycemia is detrimental after stroke.
Maintaining near normal BS levels over the first days after
stroke may improve outcome.
028 Short-term Prognosis after Emergency Department
Diagnosis and Evaluation of Transient Ischemic
Attack (TIA) Peter D Panagos, Arthur M Pancioli, Jane
Khoury, Kathleen Alwell, Rosie Miller, Brett Kissela, Daniel
Woo, Dawn Kleindorfer, Alex Schneider, Edward Jauch,
Charles Moomaw, Rakesh Shukla, Joseph Broderick; University
of Cincinnati College of Medicine: Cincinnati, OH
Objective: To determine the short-term risk of recurrent TIA,
stroke and death after emergency department (ED) evalua-
tion for TIA in a population-based study. Methods: TIA cases
were identified between 7/1/93–6/30/94 from the Greater
Cincinnati/Northern Kentucky population of 1.3 million
inhabitants by previously published surveillance methods.
Cases were ascertained by several techniques: ICD-9 dis-
charge codes for hospitalized cases, prospective screening of
ED admission logs, review of coroner’s cases, and a sampling
scheme to ascertain cases in the out-of-hospital setting. All
potential cases underwent a detailed chart abstraction by
study nurses, followed by physician review. The primary
outcomes measures were risk of stroke, recurrent TIA and
death during the 6-months after index TIA. Life-table
methods were used to estimate the rates. Results: A total
of 790 patients were identified with a TIA during the study
period, mean age was 71.5, 114 (14.4%) were African-
American, 365 (46.2%) were female and overall 463 (72%)
of all ED patients were admitted. The rate of stroke within 30-
days was 9.2%, 13.3% at 90-days and 16.7% at 6-months. The
rate of recurrent TIA, stroke, combined stroke/TIA and death
at 6-months was: 9.3%, 16.7%, 25.3% and 14.9%, respectively.
Admitted patients were more likely to have the follow-
ing symptoms: weakness face/arm/leg (p \ 0.0001), ab-
normal speech (p \ 0.002) and abnormal vision (p \ 0.06).
Conclusions: We report the first population-based data
regarding the short-term risk of stroke, recurrent TIA and
death after initial presentation to the ED for TIA. Based on
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
our data, TIA is a high-risk sentinel event and admission or
expedited outpatient evaluation should be considered.
029 Long Term Mortality in Stroke Patients Treated
with TPA: Emergency Physicians vs NINDS
Physicians Phillip A Scott, Robert Silbergleit, Shirley M
Frederiksen, Rodney W Smith; University of Michigan: Ann
Arbor, MI, St. Joseph Mercy Hospital: Ann Arbor, MI
Objectives: Debate exists on the effectiveness of tPA use in
stroke in the community setting where conditions may not
replicate those of the NINDS trial. Previous community-use
studies evaluated mortality data primarily from groups
using stroke teams. We report the first long-term mortality
results of patients treated by community physicians without
an acute thrombolytic team. We tested the null hypothesis
that no difference exists in the one-year death rate following
treatment by community physicians vs. the NINDS treatment
group. Methods: Prospective historical double-cohort study
of consecutive IV tPA-treated stroke patients from a single
geographic region without a thrombolytic stroke team, with
comparison made to the NINDS one-year data. Death within
one-year of treatment established by cross-referencing each
patient’s social security number with the Social Security
Death Master File through April 2002. Double-keystroke data
entry used. Analysis made with Chi-squared test; attribut-
able risk and 95% confidence intervals reported. Results:
Community physicians treated 124 stroke patients with IV
tPA between March 1996 and April 2001. All patients had
Social Security numbers and were well matched for age,
gender, NIHSS, cardiac disease, prior TIA/stroke and stroke
risk factors to their NINDS counterparts. At one-year, 27%
[95% CI: 0.19–0.34] of community treated patients were dead
compared to 24% [95% CI: 0.20–0.29] in the NINDS cohort (p
¼ 0.71). Attributable risk of death at one-year in community
treated patients was 2.2% [95% CI:
0.07 to 0.11]. Conclu-
sions: No significant difference in the long-term mortality of
tPA-treated stroke patients was identified between a system
without an acute thrombolytic team and patients treated in
the NINDS study. Limitations include the possibility of a type
II error due to limited sample size; however, we have
excluded large, clincally important, differences in mortality
between the two groups.
030 Is Hospitalization Required for All Children with
Post-traumatic Seizures? James F Holmes, Michael J
Palchak, Matthew J Conklin, Nathan Kuppermann; UC Davis
School of Medicine: Davis, CA
Objectives: Controversy exists whether all children with
post-traumatic seizures require hospitalization. We hypoth-
esize that children with post-traumatic seizures who do not
have evidence of traumatic brain injury (TBI) on cranial
computed tomography (CT), and who have regained normal
levels of consciousness may be discharged home from the
emergency department (ED). Methods: Prospective obser-
vational series of children \18 years of age who sustained
blunt head trauma and had a post-traumatic seizure.
Children were divided into two cohorts based on the
presence or absence of TBI on cranial CT scan. Hospitalized
patients were followed for clinical outcomes including
further seizure activity and neurosurgical procedures.
Patients discharged to home from the ED were contacted
433
by telephone to identify any complications related to
potential head injuries. Patients were considered to require
hospitalization if they had recurrent seizures or underwent
a neurosurgical procedure. Results: Sixty-three children with
a mean age of 8.3 6 5.8 years had a post-traumatic seizure
and all but one underwent cranial CT. Ten (16%, 95% CI 8,
27%) patients had TBI on CT scan, and all were hospitalized.
Three of these ten patients underwent craniotomy, and two
had repeat seizures during hospitalization. Fifty-two patients
had cranial CT scans interpreted as normal, and 20 were
hospitalized and followed clinically. Telephone follow-up
was obtained in 31 of the 32 patients discharged from the ED.
None of the 52 patients (0%, 95% CI 0, 5.6%) with normal
cranial CT scans had further seizure activity or required
neurosurgical intervention. The one child who did not
undergo cranial CT scanning was discharged from the ED
and was normal at telephone follow-up. Conclusion:
Children with post-traumatic seizures and cranial CT scans
without evidence of TBI are at low risk for further com-
plications and may be safely discharged home from the ED
once normal mental status is regained.
031 Antimicrobial Susceptibility Patterns of Pediatric
Uropathogens; Data from the Surveillance
Network Romolo J Gaspari, Eric W Dickson, James
Karlowski, Gary Doern; University of Massachusetts:
Worcester, MA, University of Iowa: Iowa City, IA, The
Surveillance Network Database: Herndon, VA
Background: The treatment of children with acute urinary
tract infections (UTIs) is largely based on empiric guidelines.
However, there is limited data on pediatric uropathogen
resistance trends. Objectives: We examined the antimicrobial
susceptibility patterns of the 5 most common uropathogens
(Escherichia coli, Enterobacter cloacae, Proteus mirabilis, Staphy-
lococcus saprophyticus, Klebsiella species, and Enterococcus
species) recovered from children as part of a national
surveillance network. Methods: Antimicrobial susceptibility
patterns to commonly prescribed antibiotics were performed
on urine of children presenting to participating hospitals
between 1999–2001. Using antimicrobial resistance rates
multiplied by pathogen incidence, weighted averages of
antibiotic resistance were determined. Results: There were
14,406 uropathogens from 264 infants (0–4 weeks), 2717
toddlers (5 weeks–24 months), 8295 pre-teens (2–12 years),
and 3130 teens (13–17 years). The antibiotic resistance to
five common antibiotics is contained in the table below. In
general, resistance to TMP-SMZ was higher in toddlers and
pre-teens while resistance to Nitrofurantoin increased as
patient age increased. For all other antibiotic tested, re-
sistance decreased as patient age increased.
TABLE. Weighted Average Resistance
of Uropathogens
0–4 1–24 2–12 13–18
wks months yrs yrs Total
Amox/clav 7.8 6.3 6.0 5.1 5.9
Ampicillin 48.4 48.2 45.6 38.8 44.7
Cefazolin 9.1 6.4 4.4 4.0 4.8
Ciprofloxacin 3.0 1.3 1.3 1.3 1.36
Nitrofurantoin 3.5 5.4 5.3 6.6 5.6
Trimeth/Sulfa 9.3 18.6 19.7 13.2 17.9
434
Conclusion: Uropathogen resistance to ampicillin in the
pediatric population is alarmingly high which should
preclude it’s use as empiric treatment for pediatric UTIs.
The overall resistance rates of uropathogens to cefazolin
make it an excellent choice for the empiric treatment of
pediatric UTIs.
032 Pain Assessment and Management of Pediatric
Emergency Department Patients: Impact of
a Multidisciplinary Intervention Catherine A Marco,
Cheryl Black, Nancy Buderer; St. Vincent Mercy Medical
Center: Toledo, OH
Objective: This study was undertaken to measure the
effects of a multidisciplinary intervention on the assessment
and management of pain in pediatric ED patients. Methods:
In this quasi-experimental study, with a multidisciplinary
intervention, 200 medical records were reviewed to identify
pain assessment and management, before and after the
intervention, which consisted of physician and nursing
inservice training sessions, and implementation of a new
nursing pediatric assessment tool, which includes a manda-
tory pain assessment. Results: Among 100 historical
controls and 100 post-intervention participants, there were
no differences in gender, ethnicity, or diagnoses. Following
the intervention, there was increased nursing utilization of
the 0–10 subjective pain scale (5% pre-intervention, 41%
post-intervention, p \ 0.001, Chi-square), increased utiliza-
tion of the Wong-Baker faces scale (0% pre-intervention,
14% post-intervention, p \ 0.001) and decreased utilization
of adjective descriptors (95% pre-intervention, 45% post-
intervention, p \ 0.001). There were no differences in
physician documentation using adjective or scale measure-
ments (90% and 10%, respectively, pre-intervention; 88%
and 12% respectively, post-intervention, p ¼ 0.6). Following
the intervention, 41% of patients received pain medication,
compared to 31% of patients prior to the intervention (p ¼
0.14). There were no differences in utilization of narcotic
agents compared to nonsteroidal antiinflammatory agents
(p ¼ 0.2). There was a shift toward using written pain
management discharge instructions, rather than verbal
discharge education (p \ 0.001) during the study period.
Conclusions: A multidisciplinary intervention was associ-
ated with effective improvements of pain scale measure-
ments, and written discharge instructions, among nursing
staff. Physician preferences of adjective measurements over
pain scale measurements, and pain medication prescribing
practices, were unaffected by the intervention.
033 The Effectiveness of Oral Dexamethasone in the
Treatment of Moderate to Severe Pharyngitis in
Children and Young Adults Robert P Olympia, Hnin Khine,
Jeffrey R Avner; Children’s Hospital at Montefiore, Albert
Einstein College of Medicine: Bronx, NY
Objective: The purpose of this study is to determine the
effectiveness of oral dexamethasone (DEX) in reducing pain
associated with moderate to severe pharyngitis in children.
Methods: A prospective, randomized, double-blinded pla-
cebo controlled study was conducted in an inner city
pediatric ED. Patients aged 5 to 18 years with moderate to
2003 SAEM ANNUAL MEETING ABSTRACTS
severe pharyngitis, defined as the presence of odynopha-
gia/dysphagia associated with a McGrath Pain Face Scale
of F or higher [happy(A)-sad(I)] and moderate to severe
pharyngeal erythema or edema, were eligible. Patients were
randomized to receive one dose of either oral DEX (0.6 mg/
kg with a maximum of 10 mg) or placebo. Patients were
contacted by phone daily until complete resolution of
pharyngeal symptoms. Results: 86/98 (88%) of patients
enrolled completed the study. 40 received DEX and 46
received placebo. Groups were similar in age (mean age 12.2
years in DEX vs. 11.0 years in placebo, p ¼ 0.2) and sex.
There was no significant difference between the groups on
initial presentation in the duration of fever and sore throat
or presence of associated symptoms. Pharyngeal exam
(presence of ulcers, vesicles or exudate) and the presence/
absence of group A strep were similar between the groups.
Patients who received DEX reported earlier onset of pain
relief (9.8 hours vs. 15.8 hours, p ¼ 0.02; difference of 6 hrs,
95%CI: 0.5–11.5) and had a greater improvement in McGrath
Pain Scale (initial pain score minus pain score at follow-up)
at 24 hours (4.8 vs. 3.7, p ¼ 0.03). 32/40 (80%) of patients
who received DEX reported complete resolution of pain at
48 hrs (McGrath Pain Scale of A or B) compared to 27/46
(59%) in the placebo group (p ¼ 0.03). There was no
significant difference in the use of analgesics, persistence of
associated symptoms, or the rate of hospitalization. There
were no reported side effects associated with DEX. Conclu-
sions: In children and young adults with moderate to severe
pharyngitis, oral dexamethasone relieves pain quicker
compared to placebo.
034 Emergency Department Prevalence of Subclinical
Methemoglobinemia among Dehydrated Infants
Robert J Freishtat, James M Chamberlain, Christina MS Johns,
Melissa M Murphy-Smith, Neelam Gor, Stephen J Teach;
Children’s National Medical Center: Washington, DC, The
George Washington University School of Medicine and Health
Sciences: Washington, DC
Objective: To determine the prevalence of sMHb among
dehydrated infants with diarrhea compared to well-
hydrated controls. Methods: We conducted a pilot cross-
sectional study of MHb levels of acyanotic dehydrated
infants #3 months-of-age with diarrhea, presenting to an
urban pediatric ED. Bivariable and multivariable analyses
were used to measure the association of historical and
clinical data with sMHb (MHb [1%). Results: We enrolled
a cohort of 27 subjects: 10 with dehydration and 17 controls.
The mean age of the entire cohort was 59 6 29 days; 70%
were male. The subgroups were similar with regard to age,
gender, breastfeeding and race. The prevalence [95%CI] of
sMHb was 30% [8.3,62] among dehydrated subjects and
11.8% [2,33.7] among controls (p ¼ 0.51). Of note, two out of
ten dehydrated patients, and none of the controls, had MHb
[5%. Among all patients, linear regression demonstrated
a significant association between levels of MHb and
hemoglobin levels (p ¼ 0.02), but not other predictors (i.e.
degree of dehydration, pH, glucose, chloride, and anion
gap). Bivariable analysis of the outcome variables demon-
strated a significantly higher rate of hospitalization among
sMHb cases (100% vs. 36%, p ¼ 0.04) and a trend toward
a longer median length-of-stay between the two groups (60
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
6 80.5 hours vs. 5 6 63 hours, p ¼ 0.11) In fact, for patients
with sMHb, the OR for risk of hospitalization ¼ 18.8 [1.1, ‘]
and for LOS [48 hours ¼ 19.8 [1.2, ‘]. Conclusions: We
identified a trend towards increased sMHb among an ED
group of dehydrated infants #3 months-of-age with di-
arrhea compared to controls. Among all patients, the
presence of sMHb was associated with increased odds of
hospital admission and an extended LOS. Further confir-
mation of sMHb as a cause of morbidity, would prompt
changes the diagnostic and therapeutic approach to these
commonly hospitalized infants.
035 The Effect of Limited English Proficiency on
Admission Rates from a Pediatric Emergency
Department: Stratification by Acuity Alexander J Rogers,
Carlos A Delgado, Harold K Simon; Emory University:
Atlanta, GA
Objective: Limited English Proficiency (LEP) has been
shown to increase resource utilization in the Pediatric ED.
This study will compare admission rates for LEP vs. English
speaking patients and evaluate the relationship to triage
acuity status. Methods: A retrospective chart review using
a fully computerized medical record. All visits to a tertiary
care PED from 7/02 to 11/02 were reviewed. Visits were
excluded if triage acuity, language, or disposition was
unavailable. Language spoken was considered to be English
in the case of English speaking or bilingual families. LEP
patients were those with limited English at registration.
Patients were triaged as low, moderate or high acuity per
departmental standards. Admission rates were compared for
English speaking and LEP patients. LEP Spanish speakers
were stratified by triage acuity and analyzed independently.
Results: 13,586 visits were identified of which 12,431 (91%) fit
study criteria. There were 12,188 English speaking visits and
243 LEP visits. LEP visits had a higher rate of admission than
English speakers, 21.8% vs. 13% (p \ 0.001, OR 1.87, 95% CI
1.35–2.56). Spanish speakers represented the largest group of
LEP patients (84%). For high acuity visits, 23 of 48 (48%) LEP
Spanish speakers were admitted vs. 961 of 1963 (49%) English
speakers (p ¼ 0.89). For moderate acuity visits, LEP Spanish
speakers were admitted at a significantly higher rate than
English speakers, 17 of 73 vs. 549 of 4431 (23.3% vs. 12.4%, p ¼
0.005, OR 2.15 with 95% CI: 1.16 to 3.78). Low acuity patients
showed no difference, with a 1.2% admission rate for both
groups (p ¼ 0.97). Conclusions: The data showed a higher
overall admission rate for LEP visits. In particular, a higher
admission rate was found for moderate acuity Spanish
speakers. Possible explanations for this include differences
in initial triage, underlying illness, or a more conservative
approach due to a perceived lack of follow-up. The data may
help to target limited resources for LEP patients.
036 The Utility of Anti-microbial Therapy for Dental
Pain without Overt Infection Michael S Runyon,
Michael T Brennan, Jayne J Batts, Theodore E Glaser, Philip C
Fox, James Norton, M Louise Kent, Timothy L Cox, Peter B
Lockhart; Carolinas Medical Center: Charlotte, NC
Background: Dental pain is a common ED complaint for
which many physicians routinely prescribe antibiotics. To
435
our knowledge, no prospective data exists on the efficacy of
this practice. Objective: To test our hypothesis that
antibiotics are not beneficial in the treatment of dental pain
without overt infection. Methods: This was a prospective,
randomized, double-blinded, placebo-controlled study con-
ducted at an urban teaching hospital with 110,000 ED visits
per year. A convenience sample of adult ED patients with
dental pain was enrolled from 2/00 to 10/01. Exclusion
criteria included fever [1008F, oral swelling, trismus,
pregnancy, immunocompromised state, valvular heart
disease, and a history of acute dental trauma. Subjects were
randomized to receive penicillin or placebo. Both groups
received standardized analgesia with ibuprofen and hydro-
codone/acetaminophen. A structured evaluation for signs
of infection (fever, oral swelling, trismus, or purulent
drainage) was performed at enrollment and at a 5–7 day
follow-up visit. Pain was recorded on a visual analog scale
(VAS) and pill counts were performed. The study was
powered to detect a 15% difference in the development of
overt infection at a sample size of 69 subjects per group.
Results: We enrolled 195 subjects. Ninety-eight (50%) were
randomized to the penicillin group. One hundred twenty-
five (64%) followed up. We identified 6 additional study
patients who returned to the dental clinic or ED due to
dental pain. Overall, 13/131 (9.9%) subjects had signs of
infection at follow-up, 6/63 (9.5%) from the antibiotic group
and 7/68 (10.3%) from the placebo group (p ¼ 0.88). There
was no significant difference between the antibiotic and
placebo groups in baseline characteristics, medication
compliance, or VAS pain scores at enrollment (mean 72.1
vs. 77.1, p ¼ 0.17) or follow-up (mean 42.0 vs. 43.5, p ¼ 0.89).
Conclusion: Our data do not support a role for routine anti-
microbial therapy in the treatment of dental pain without
overt infection.
037 Who Needs a Blood Culture? A Prospectively
Derived and Validated Clinical Prediction Rule
Nathan I Shapiro, Richard E Wolfe, Sharon Wright, Jeffrey
Spears, David W Bates; Beth Israel Deaconess Medical Center:
Boston, MA, Brigham and Women’s Hospital: Boston, MA
Objective: To derive and validate a clinical prediction
rule for obtaining blood cultures in the Emergency Depart-
ment (ED). Methods: Prospective, observational, cohort
study of ED patients from an urban university hospital
between 2/1/00–2/1/01. Consecutive patients, aged 18 or
older, who had a blood culture obtained, were included.
Patients were randomly assigned to a derivation set (2/3)
used to build a regression model and clinical decision rule,
or a validation set (1/3) used to test the rule. The outcome
was ‘‘true bacteremia’’ classified by blinded review to
exclude contaminants. ROC areas were calculated. Results:
Of 3926 eligible patient visits, 3730 (95%) were enrolled.
There were 205/2466 (8.3%) patients with true bacteremia
in the derivation set and 101/1264 (8.0%) in the validation
set. The independent predictors from the regression model
were divided into ‘‘major’’ or ‘‘minor’’ criteria. A blood
culture was indicated if at least one ‘‘major’’ or two
‘‘minor’’ criteria were present; otherwise patients were
classified as ‘‘low risk’’. ‘‘Major criteria’’: temperature
[103.08F, indwelling vascular catheter, or clinical suspicion
of endocarditis. ‘‘Minor criteria’’: temperature 101–102.98F,
436
age [65, chills, vomiting, hypotension (SBP \ 90),
neutrophil% [80, WBC [18k, bands [5%, platelets
\150k, suspicion of a urinary source, or creatinine [2.0.
The ROC area for derivation set ¼ .80 and validation set ¼
.75. In the derivation set, only 4/634 (0.8%) low risk
patients had a positive culture. In the validation set, 330/
1264 (26%) patients were low risk, of which only 4 (1.5%)
had a positive culture. The rule had a sensitivity of 98%
(95%CI ¼ 94–99%) in the derivation set and 96% (88–98%)
in the validation set with a culture reduction of 26% in each
group. Conclusions: We derived and validated a clinical
prediction rule for bacteremia in the ED that selected
patients with a low risk for bacteremia in whom blood
cultures may be restricted. Our rule needs external
validation before universal use.
038 Efficacy of a New High Dose, Short Course of
Levofloxacin vs Standard 10 Day Therapy for
Treatment of Community Acquired Pneumonia (CAP)
Caused by Atypical Pathogens Lala M Dunbar,
Mohammed M Khashab, Alan M Tennenberg, James B Khan;
LSUHSC: New Orleans, LA, OrthoMcNeil Pharmaceuticals:
Raritan, NJ
Introduction: Recognition that the atypical bacteria, Chla-
mydia, Mycoplasma and Legionella, are significant patho-
gens of CAP has led to the incorporation of antimicrobials
effective against these organisms in empiric treatment
regimens. Levofloxacin (Levo)at 500 mg/day 3 10 days
has been shown to be highly efficacious in such infections.
Kinetic data on Levo suggests that a higher daily dose for
a shorter time would be equally effective with less de-
velopment of resistance. Objective: The present study
analyzes outcome of atypical infections from a study
comparing Levo, 750 mg/day 3 5 days vs 500 mg/day
3 10 days in Pts with CAP. Methods: Design: IRB
approved, prospective, randomized, double blind, multi-
center trial at 70 sites in the US. Consent obtained.
Treatment groups were randomized by site and severity of
illness based on Fine Score. Subjects: Pts were 18þ y/o with
diagnosis of pneumonia confirmed by CXR. Sputum and
blood were cultured and serum collected for acute and
convalescent titers to atypicals. Case definition for ’atypical’
included a fourfold change in IGM or IGG titers for any,
a titer [1:256 by Wampole EIA assay or þ urine antigen for
Legionella or single IGM [1:16 or IGG [1:128 for
mycoplasma. Outcome was based on clinical response at
post therapy and post study visits. Equivalence between
treatments was determined by the two-sided 95% CI.
Results: 528 pts received medication, 256 in the 750 mg
group and 272 in the 500 mg dose group. In the 750 mg dose
group atypical pathogens identified were: (# and % clinical
success) 22 (90.9%) Chlamydia, 12 (100%) Legionella and 43
(95.3%) Mycoplasma. Corresponding values in the 500 mg
dose group were 16 (100%) for Chlamydia, 5 (100%)
Legionella and 36 (94.4%) Mycoplasma. CI showed no
significant difference. Conclusions: Levo, 750 mg once
daily for five days has excellent clinical efficacy in patients
with CAP caused by atypical pathogens and compares
favorably with the approved regimen of 500 mg once daily
for 10 days.
2003 SAEM ANNUAL MEETING ABSTRACTS
039 Inability to Predict Antimicrobial Resistance of
UTI Pathogens in Emergency Department Patients
Robert Norton, Craig Warden, Craig Newgard, Carrie
Breithaupt, Tatyana Shaw, Eun Jung Yi, David Vo; Oregon
Health & Science University: Portland, OR, University of
Portland: Portland, OR
Objective: To develop a clinical decision rule to predict
trimethoprim/sulfamethoxasole (TMP/SMX) resistance for
urinary tract infection (UTI) pathogens in patients presenting
to the emergency department (ED). Methods: Resistance
patterns were retrospectively reviewed for all adult female
patients discharged from a university hospital ED with UTI
during 26 months. 18 predictor variables were collected: age,
vital signs, nursing home residence, recent hospitalization,
previous UTI, recent and current antibiotic use, diabetes,
recent travel, indwelling catheter and pregnancy. Classifica-
tion and regression tree analysis (CART) was used to derive
a clinical decision rule for predicting TMP/SMX resistance
among patients with true UTIs (defined by colony counts and
organisms). Trends for resistance over time were assessed
by adjusted and unadjusted analyses. We used logistic
regression to assess factors associated with TMP/SMX
resistance. Results: Of 512 cultures, 104 (20%) were TMP/
SMX resistant and 10 (2.0%) were resistant to ciprofloxacin
(CIPRO). There was no combination of variables in the CART
analysis that reliably predicted resistance to TMP/SMX. Time
trend analysis demonstrated a stable resistance-rate. Logistic
regression analysis showed only pulse [100 to be signifi-
cantly associated with TMP/SMX resistance (OR 1.8, 95% CI
1.1–3.1). CIPRO was prescribed most often (57.8%). TMP/
SMX was prescribed for 12 (2%) and CIPRO for 3 (0.5%)
patients with resistant organisms before culture results were
known. Conclusion: TMP/SMX resistance is common
among adult females discharged from the ED with UTI. It
is difficult to accurately predict which patients will have
a resistant organism. Unless a reliable rule can be developed,
empiric treatment with CIPRO is appropriate in settings with
high TMP/SMX resistance.
040 Severe Urinary Obstruction as an Indicator of
Adverse Outcome in Renal Colic Patients Linda
Papa, Ian G Stiell, George A Wells, Ian Ball, Giuseppe Ricci,
John E Mahoney; University of Florida: Gainesville, FL,
University of Ottawa: Ottawa, Ontario, Canada
Objectives: No prospective studies have addressed the
clinical significance of severe urinary obstruction (SUO) on
outcome in renal colic patients (RCP’s). Our study: (1)
defined clinically significant SUO on IVP and (2) assessed
the association between SUO and adverse outcome (AO).
Methods: Using a cross sectional survey, questionnaires were
sent to all emergency physicians (EP’s), radiologists (RAD’s),
and urologists (URO’s) at 2 university teaching hospitals
asking them to define SUO. Results were presented to a 7
member expert panel composed of a RAD, an EP and 5
URO’s to finalize a definition. Subsequently, an 8-month
prospective cohort study of RCP’s having an IVP in the ED at
the same 2 hospitals was conducted. All IVP’s were reviewed
by a RAD and an URO using the derived definition. After 4
weeks patients were assessed for AO’s including urinary
infection, renal failure, and urological intervention. Statistical
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
associations used Fisher’s Exact test. Results: A total of 47 of
73 questionnaires (64%) were completed. It was agreed that i)
extravasation and/or ii) delayed visualization of contrast
beyond the obstruction over 2 hours were the most sig-
nificant findings of SUO on IVP that should prompt urgent
referral to an URO. Using this definition, 45 of 326 (14%)
RCP’s demonstrated SUO on IVP: 7 IVP’s with extravasation
alone; 34 IVP’s with delayed filling alone; and 4 IVP’s with
both. Of those with SUO, 38% were admitted from the ED
versus 11% without SUO (p \ 0.001). We followed 178
patients over 4 weeks and found that 18% of patients with
SUO had undergone a urological procedure versus 6% of
those without SUO (p ¼ 0.02). Additionally, 14% of SUO
patients developed renal failure or urinary infection versus
3% of those without SUO (p ¼ 0.01). Overall, the proportion
of AO’s was 48% in those with SUO and 19% in those without
SUO (p ¼ 0.004). Conclusion: There are significantly more
AO’s in RCP’s with SUO. Its early detection in the ED could
optimize patient outcomes.
041 A Prospective Randomized Controlled Trial of
Acupressure vs Sham for Pregnancy-related Nausea
and Vomiting in the Emergency Department Edwin Hsu,
Veronica Pei, Frances S Shofer, Stephanie B Abbuhl;
University of Pennsylvania Medical Center: Philadelphia, PA
Objectives: One of the reasons the treatment of nausea and
vomiting in pregnancy is difficult is the desire to limit drug
use, especially in the first trimester. Previous studies have
suggested that acupressure may improve these symptoms,
but no studies have been done in the ED. The purpose of our
study was to determine if an acupressure wristband would
decrease pregnancy-related nausea/vomiting during the
initial period of ED evaluation. Methods: An IRB-approved,
double-blinded, prospective randomized controlled trial of
acupressure vs. sham was conducted in an urban ED. A
convenience sample of women with nausea/vomiting
related to pregnancy was identified at triage and random-
ized to 1 of 2 groups while still in the waiting room, placing
the acupressure device over either the traditional ‘‘P6’’
acupressure site (ACU) or over the sham site (SHAM). A
black forearm cover was used to keep the intervention
blinded. The main outcome was nausea severity, which was
measured by a previously validated tool, the McGill Nausea
Questionnaire. The measurements consisted of 3 parts:
a nausea rating index, an overall nausea index and a visual
analog scale. The questionnaire was administered before
the device was placed (baseline), at 30, and 60 minutes.
Outcomes between the 2 groups were analyzed by ANOVA
in repeated measures. Results: To detect a 20% difference
between groups with 80% power and alpha ¼ .05, a sample
size of 40 per group was required. There were 38 patients in
ACU, 39 in SHAM, mean age 23.6, 94% black, mean
gestational age 9 weeks (range 3–18). No difference between
ACU and SHAM was detected at baseline, 30 or 60 minutes
for any of the indexes (p [ .2 for all). Additionally, there was
no difference between ACU and SHAM in subsequent
antiemetic administration (72% vs 75%, p ¼ 1.0) or length of
ED stay (6.3 hr vs 5.5 hr, p ¼ .3). Conclusions: In the initial
ED evaluation, there is no benefit in treating nausea/
vomiting of pregnancy with an acupressure wristband vs
a sham control group.
437
042 Predictors of a Clinically Significant Diagnostic
Nasogastric Aspirate Jeff Schneider, Jeff Evans,
Patricia M Mitchell, Clara Safi-Berty, Rehan Azeem, Thomas
Perera, Supriya D Mehta; Boston Medical Center, Boston
University School of Medicine: Boston, MA
Objectives: Nasogastric intubation (NGI) is commonly
performed in the ED to facilitate diagnosis of gastrointes-
tinal bleeding (GIB). The study goal was to determine
clinical predictors of positive diagnostic NG aspirate in
patients with suspected GIB, and compare anticipated
disposition to disposition after NGI. Methods: Subjects
were consecutive ED patients aged $21 years undergoing
diagnostic NGI. Physicians placing the NG tube recorded 16
history and exam findings routinely collected to evaluate
suspected GIB. NG aspirate outcomes were defined as
positive (coffee grounds, blood) and negative (clear/food/
nothing). Statistical analysis was chi-square, t-test, and
logistic regression for risks for positive NG aspirate, and
kappa statistic for agreement of disposition prior to and
after NGI. Results: 78 patients were enrolled 9/02–12/02.
Patients were mean age 52 years, 76% male, 26% Hispanic,
33% Black, 32% White. 26/73 (60%) patients had positive
NG aspirate. In univariate analyses, patients who were male
(p ¼ 0.088), orthostatic, vomited, had blood in vomit, had
a positive or unknown history of esophageal varices, or
pulse [80 (p \ 0.05 each) had increased risk of positive NG
aspirate. In multivariate logistic regression, risks for positive
aspirate were: history of esophageal varices (OR ¼ 2.98, p ¼
0.047), pulse [80 (OR ¼ 5.0, p ¼ 0.082), blood in vomit (OR
¼ 10.0, p ¼ 0.059). Overall percent agreement between
anticipated disposition and disposition after NGI was 84%
(47/56) and kappa ¼ 0.78. Of the 9 patients with altered
disposition after NGI, 1 (2%) patient with anticipated
disposition of discharge to home was admitted due to
NGI results, and 4 (7%) had a change in hospital level of
care. Conclusions: Positive or unknown history of esoph-
ageal varices, pulse [80, and blood in vomit are predictors
of a positive NG aspirate. In this preliminary analysis,
diagnostic NGI rarely upgraded the ED disposition of
patients with suspected GIB to a more advanced level of
care.
043 Clinically Significant Improvement in Nausea as
Measured on a Visual Analog Scale Neil F Donner,
Gregory W Hendey, Kimberly Fuller; University of California
San Francisco: Fresno, CA
Objective: Many studies have reported measurements of
nausea on a visual analog scale (VAS), but it is unclear what
degree of change in VAS is clinically significant. Our
objective was to determine the minimum clinically signif-
icant improvement in nausea as measured on a VAS.
Methods: Prospective study of adults presenting to the ED
with a complaint of nausea. After consent, patients were
asked to report the severity of their nausea on a 100 mm
VAS at several times during their ED stay. They were also
asked if their nausea was ‘‘a lot less,’’ ‘‘a little less,’’
‘‘unchanged,’’ ‘‘a little more,’’ or ‘‘a lot more’’ compared to
previous measurements. The minimum clinically significant
improvement in nausea was defined as the mean difference
438
in VAS in those patients reporting ‘‘a little less’’ nausea.
Results: 133 VAS measurements were collected from 50
patients who met all inclusion criteria. 58% were women
and the mean age was 41. The mean changes in VAS with
the corresponding qualitative changes were: ‘‘a lot less’’ ¼

42.2 mm; ‘‘a little less’’ ¼
15.4 mm; ‘‘no change’’ ¼
0.4
mm; ‘‘a little more’’ ¼ þ16 mm; ‘‘a lot more’’ ¼ þ23.7 mm.
The mean VAS of the group reporting ‘‘a little less’’ nausea
(
15.4 mm, 95% CI
19.8 to
11.0) was significantly
different (t ¼ 4.44, p \ 0.0001) from that of the ‘‘no change’’
group (
0.4 mm, 95% CI
5.3 to þ4.5). Conclusion: We
determined that the minimum clinically significant im-
provement in nausea is 15 mm on a VAS. This finding is
similar to previous studies of pain measurements on a VAS,
and helps in the interpretation of clinical studies reporting
nausea improvement on a VAS.
044 Neuroprotective Effect of Gamma-hydroxybutyrate
and Its Chemical Precursors, Gamma-butyrolactone
and 1,4-Butanediol, in the Rodent Model of Focal
Cerebral Ischemia by Permanent Middle Cerebral Artery
Occlusion Lawrence S Quang, Shankar Sadasivan,
Timothy J Maher, Michael W Shannon; Children’s Hospital
Boston: Boston, MA, Massachusetts College of Pharmacy and
Health Sciences: Boston, MA
Objective: Gamma-hydroxybutyrate (GHB) has neuropro-
tective properties; it decreases cerebral glucose utilization,
lowers O2 demand/consumption, acts as a free radical
scavenger, & decreases release of glutamate. This study
evaluated therapy with GHB & its precursors, gamma-
butyrolactone (GBL) & 1,4-butanediol (1,4-BD), in the rodent
model of focal cerebral ischemia by permanent middle
cerebral artery (MCA) occlusion. Methods: 42 male Spra-
gue-Dawley rats (300–350g) were anesthetized with 1.2%
isoflurane. Under stereoscopic microscopy, a small incision
was made in the left internal carotid artery & 4/0 mono-
filament passed 2 cm proximally until it lodged in the
anterior cerebral artery, thereby occluding the origin of the
MCA. The filament was sutured into place & the incision
closed. 6 rats were sham controls & 36 rats were divided
into groups treated with GHB, GBL, or 1,4-BD at 30 min.
before as well as 180 min. & 360 min. after infarction (dose
300 mg/kg i.p.; N ¼ 12 each group). 24 hrs. later, brains
were removed, cut into 1 mm coronal slices, stained with 2%
triphenyltetrazolium chloride (TTC), photographed with a 4
megapixel digital camera, & analyzed with image analysis
software. The infarct volumes (which failed to stain with
TTC) were calculated & averaged for each group, repre-
sented as the mean volume (cu.mm) 6 SEM & mean % of
total brain volume with ischemic injury 6 SEM, &
compared to those of sham controls by ANOVA with post-
hoc Neuman-Keuls Test (significance at P \ 0.05). Results:
The mean volume of infarction for controls was 323 6 29.5
cu.mm compared to 149.7 6 45.2 (P \ 0.05), 103.5 6 35.1
(P \ 0.05), & 229.4 6 40.5 cu.mm for rats receiving treatment
with 1,4-BD, GBL, & GHB, respectively. The mean % volume
of total brain infarcted for controls was 30.1 6 2.0%
compared to 13.1 6 4.0 (P \ 0.05), 8.2 6 3.0 (P \ 0.05), &
19.1 6 3.4% (P \ 0.05) for rats receiving treatment with 1,4-
BD, GBL, & GHB, respectively. Conclusion: GHB, GBL, &
1,4-BD offer neuroprotection in this rodent model of focal
cerebral ischemia.
2003 SAEM ANNUAL MEETING ABSTRACTS
045 The Role of Decoy Molecules in Neuronal Ischemic
Preconditioning Daniel P Davis, Satoki Inoue, Paul J
Kelly, Piyush M Patel; University of California, San Diego:
San Diego, CA
Objectives: Neuronal ischemic preconditioning (nIPC) is an
endogenous neuroprotective strategy by which sublethal
insults confer temporary tolerance to subsequent lethal
ischemia. Apoptosis is an important mediator of neuronal
death following ischemia and represents an attractive
candidate for nIPC regulation. The TNF-receptor family
members (TNF, FasR, TRAIL1, TRAIL2) all have intracellu-
lar ‘‘death domains’’ that activate caspase 8 and apoptosis;
this family also contains a group of decoy molecules (DcR1,
DcR2, DcR3, cFLIP) that competitively inhibit the parent
receptors in certain tumor lines. This study explores
a potential role for decoy molecules in mediating nIPC.
Methods: A rat model of sublethal ischemia (SLI) (BCAO þ
MAP 35 mmHg) was used as the nIPC stimulus. Immuno-
histochemistry was used to compare expression at 48 h post-
SLI to baseline for two decoy molecules (DcR1, cFLIP) and
two parent molecules (FasR, TRAIL1). Both untreated
animals and nIPC-inhibited animals (pre-administration of
NMDA antagonist MK801) were used (n ¼ 5 in each group).
An investigator blinded to group assignment used the
following semi-quantitative expression scale: 0 ¼ no
expression; 1 ¼ 1–25% cells stained; 2 ¼ 26–50%; 3 ¼ 51–
75%; 4 ¼ 76–100%. Non-parametric statistics were used.
Results: Upregulation of DcR1 (cortex ¼ 1.6 to 3.3, p \ 0.05;
hippocampus ¼ 1.9 to 2.8, p \ 0.05) and cFLIP (cortex ¼ 1.9
to 3.3, p \ 0.05; hippocampus ¼ 1.9 to 2.7, p \ 0.05), but not
FasR (cortex ¼ 2.3 to 2.0, p ¼ NS; hippocampus ¼ 2.2 to 2.0,
p ¼ NS) or TRAIL1 (cortex ¼ 2.25 to 2.50, p ¼ NS;
hippocampus ¼ 2.0 to 2.3, p ¼ NS), was observed following
SLI in untreated animals. The pre-administration of MK801
abolished this upregulation. Conclusions: The decoy mole-
cules DcR1 and cFLIP are upregulated following an nIPC
stimulus; this upregulation is abolished with administration
of an nIPC inhibitor. Decoy molecules and their parent
receptors appear to have independent regulatory strategies.
These data support a role for the decoy molecules in nIPC.
046 WITHDRAWN
047 Temperature Dependence of tPA Thrombolysis
in an In-vitro Clot Model George J Shaw, Ashima
Dhamija, Christy K Holland, Kenneth R Wagner; University
of Cincinnati: Cincinnati, OH
Objectives: Controlled hypothermia (30–338C) can be used
to limit the amount of neurologic damage in acute ischemic
stroke patients (COOL AID pilot, COOL AID 1). Such
thermal treatments may alter the efficacy of thrombolytic
therapy for acute stroke. However, little is known about the
efficacy of the thrombolytic action of tissue plasminogen
activator (tPA) at lower temperatures. It is hypothesized that
the action of tPA is reduced at these lower temperatures.
Methods: Whole blood porcine clots were prepared by
aliquoting 2 ml of whole blood into glass tubes (Vacutainer).
The clots were incubated at 378C for three hours and aged
[3 days prior to use to ensure maximal clot retraction. The
clots were placed in a sample holder and suspended in
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
porcine fresh frozen plasma (Animal Biotech Industries)
with tPA to achieve a concentration of [tPA] ¼ 0.0126 mg/
ml, which corresponds to the total dose of tPA in a 70 kg
human. The sample clot was placed in a water bath and
treated at a temperature in the range 30–408C. The mass of
the clot was measured before and after tPA exposure to
determine the percent mass loss (ML) as a result of the
treatment. Results: The ML increased linearly with temper-
ature (p \ 0.05) from 5.8% at 308C to 15.8% at 408C. The
slope of ML versus temperature was 1.07 (95% Confidence
Limits ¼ 0.75–1.39) percent mass loss per degree tempera-
ture. Conclusions: The efficacy of tPA is reduced in the
temperature range proposed for hypothermic treatment of
acute ischemic stroke in an in-vitro clot model.
048 Mathematical Modeling of the
Electroencephalogram David M Schreck,
Ian Leber; Capital Health System: Trenton, NJ
Background: The electroencephalogram (EEG) is a lead-
vector system that models the electrical activity of the brain.
Factor analysis (FA) is a computer-aided statistical tech-
nique that identifies a minimum number of factors
accounting for variance in observed data. The EEG is not
routinely performed in the emergency department (ED) due
to the complexity of its acquisition. The EEG may be
described by a minimum lead-vector factor space making
it convenient and cost effective to acquire in the ED.
Objective: To derive the EEG from a minimum number of
abstract lead-vectors identified by FA. Methods: Ten EEGs
of varying pathology were acquired and digitized resulting
in voltage-time data arrays suitable for mathematical
processing. The arrays consisted of 19–36 leads with 2000–
12000 time points in each lead. The voltage-time arrays were
factor analyzed to identify transformation coefficients and
a minimum number of lead-vectors spanning the EEG data
space. Results: All 10 EEGs were predicted correctly from
an abstract 3 lead-vector set. No significant morphologic or
diagnostic changes were noted in the derived EEGs. The
reduction of the measured EEG data set to 3 leads allowed
the display of a vector plot of the movement of the electrical
forces resulting in a 3-dimensioanl spatial EEG curve.
Conclusions: This work in progress demonstrated that a 3
lead-vector system may be the major contribution to brain
electrical activity. The EEG may be derived from only 3
measured leads. The comparison of the measured and
derived EEGs is clinically and morphologically similar. No
diagnostic information is lost in this set of 10 test cases. This
type of data processing may allow a continuous, convenient,
and cost-effective acquisition of the EEG from telemetry
equipment in the ED and in the prehospital setting. Further
studies are warranted for clinical validation of this
computer model.
049 Bispectral Analysis of Head Injured Patients as
a Predictor of Trauamtic Brain Injury Eric Haug,
James R Miner, Mark Dannehy, Michelle Biros; Hennepin
County Medical Center: Minneapolis, MN
Background: Bispectral analysis of single lead EEGs (BIS)
have proven valuable in assessing the level of awareness in
439
sedated patients. The relationship of this to head injury has
not been studied. Objective: To determine if bedside BIS
monitoring correlates with head CT findings suggestive of
traumatic brain injury (TBI) or abnormal neurological out-
comes of patients with head trauma. Methods: A conve-
nience sample of patients with known or suspected head
trauma presenting between June and August of both 2001
and 2002 were entered into the study by having a BIS
monitor placed upon entrance into the Emergency De-
partment. BIS scores were recorded continuously. Head CT
results and discharge dictations were then evaluated to
determine the presence of TBI. Results: 52 patients were
entered into the study, 13 were excluded due to receiving
sedatives prior to enrollment. Of the remaining 39 patients,
14 had intracranial hemorrhage on initial head CT. Of these
14, 2 had BIS scores over 95. Both of these were
neurologically intact at discharge. 11/12 of the remaining
patients died or left the hospital neurologically impaired. Of
the patients with no abnormalities on initial head CT, 19/25
had initial BIS scores [95 and all left the hospital
neurologically intact. Of the patients with normal initial
head CT and initial BIS score \95, 5/6 died or were
neurologically impaired at discharge. Logistic regression
was also utilized comparing initial BIS score to positive CT
findings, yielding a correlation coefficient of
0.04 (p ¼
0.012), and to neurological outcome, with a correlation
coefficient of
0.156 (p ¼ 0.002). Utilizing a cutoff of initial
BIS score of 85 gives a sensitivity of 88% and a specificity of
74% for a CT suggestive of TBI, and a sensitivity of 88.2%
and a specificity of 86.9% for an abnormal neurologic
outcome at discharge. Conclusion: BIS scores obtained prior
to sedative medicines in the face of trauma are predictive of
TBI and neurologic outcome at discharge.
050 Bispectral EEG Analysis of Acute Overdose
Patients Ryan Fringer, James Miner, Teague Dombeck,
Todd Seigel, Louis Ling, Michelle Biros; Hennepin County
Medical Center: Minneapolis, MN
Background: Bispectral EEG analysis (BIS) has been used to
assess the level of awareness in sedated patients. Many
patients present to the ED after ingestion or suspected
ingestion of sedative substances. Objective: To determine if
serial bedside BIS monitoring can be used to predict which
overdosed patients will require intubation or hospital
admission during observation in the ED. Methods: This
was a prospective, observational study of a convenience
sample of patients who presented to our ED between June
2002 and November 2002. Patients being observed for
ingestion were eligible. Upon presentation, a Bispectral
EEG probe was applied to the patient’s forehead, and a BIS
score was recorded at time 0, þ20, þ40, and þ60 min. Data
regarding disposition and hospital course, if admitted, was
obtained from computerized medical records. Results: 76
patients were enrolled. Mean initial BIS score was 83.9 (95%
CI 79.7–88.1, range of 29 to 99). Fifteen patients had an initial
score \70. Five of these patients were intubated immedi-
ately. The 10 who were not intubated had a mean increase in
BIS score of 23.3 (95% CI 11.7 to 33.9) in the first 20 minute
interval. Of the remaining 61 patients, six were intubated at
some point in their ED course. The mean change in BIS
scores during the observation period for the patients who
440
went on to be intubated was 34.6 (95% CI ¼ 20.5 to 48.7) and
was 5.9 (95% CI ¼ 1.8 to 10.0) for those who were not
intubated. 20/61 patients were admitted. The mean change
in BIS score for the admitted patients was 21.5 (95% CI ¼
11.1 to 31.9) and for those not admitted was 2.8 (95% CI ¼
0.1 to 5.7). Logistic regression showed a correlation between
BIS score and intubation (OR 1.03) and admission (OR 1.08).
Conclusion: A larger mean decrease in BIS scores was seen
in patients requiring intubation or admission after observa-
tion in the ED. BIS monitoring may prove useful for earlier
treatment and decision making regarding overdose patients
in the ED.
051 The Utililty of the Bispectral Index in Procedural
Sedation in the Emergency Department James R
Miner, Karen Kirven, Michelle Biros; Hennepin County
Medical Center: Minneapolis, MN
Background: The bispectral index (BIS) may be a useful
monitor to predict the level of consciousness in patients
undergoing procedural sedations (PS) in the Emergency
Department (ED). Objective: We hypothesize that using the
BIS index during ED PS will increase the recognition of
adequately sedated patients, thus reducing over-sedation
and the corresponding increased rate of respiratory de-
pression (RD). As a result, the occurrence of RD will be
reduced. Methods: This was a prospective randomized
study of ED PS with midazolam, methohexital, etomidate,
or propofol between 6/15/2002 and 12/31/2002. Sedations
were randomized to have the treating physician either
blinded (B) or unblinded (UB) to data from the BIS monitor.
Vital signs, pulse oximetry, end-tidal CO2 (ETCO2), sedative
used and dosages, and the BIS index were recorded. RD was
defined as a change in ETCO2 [ 10, an oxygen saturation of
\90% at any time, or an absent ETCO2 waveform. RD rates
were compared with chi-square tests. Results: 69 patients
were enrolled in the study, mean age 39.1 (95%CI 35.3 to
42.8), 59% male. 57 received propofol (83.8%), 6 methohex-
ital (8.8%), 3 etomidate (4.4%), and 2 midazolam (2.9%). No
adverse events were reported. RD was seen in 21/69 (30.4%)
patients. Overall, 8/35 of the UB group and 13/34 of the B
group had RD (p ¼ 0.16). For patients requiring only a single
dose of sedatives, 3/15 of the UB and 3/18 of the B group
had RD (p ¼ 0.80). For patients requiring multiple doses of
sedatives, 5/20 of the UB and 10/16 of the B group had RD
(p ¼ 0.02). Conclusion: There was a significant difference
in the rate of respiratory depression when physicians had
access to the BIS index during procedural sedations
requiring multiple doses of sedative agents. There was no
difference in the rate of RD when only one dose was given.
052 Clinical Predictors of Respiratory Syncytial Virus
(RSV) in Children Magdy W Attia, Marla J Friedman;
Alfred I. duPont Hospital for Children: Wilmington, DE
Background: RSV is a common cause of respiratory illness
with a significant morbidity to the pediatric population. It is
difficult to distinguish RSV from other respiratory illnesses
clinically. Several rapid diagnostic tests are available to aid
in the diagnosis; however, they have limited sensitivity and
specificity. A prediction model that identifies patients likely
2003 SAEM ANNUAL MEETING ABSTRACTS
to have RSV may enhance the predictive values of these
tests. Objective: To identify clinical features that are most
predictive of RSV infection in children. Methods: Patients
who presented to a pediatric emergency department with
a respiratory illness in January and February of 2002 and
who were tested for RSV infection based on a clinical
decision by the ED physician were enrolled. Each patient
received a nasal wash for rapid RSV testing. Samples with
negative rapid test were further processed for viral culture.
Demographic information and clinical features were col-
lected prospectively using a standardized form. Stepwise
logistic regression analysis of 20 clinical variables was
performed to determine clinical features independently
predictive of RSV. Results: 197 patients were enrolled.
Median age and range was 5 and 31 months respectively.
57% were males. There were 126 (64%) patients positive for
RSV by either rapid test or viral culture. There was no
significant difference between the RSV group and the
remainder of patients in age or gender. In the regression
analysis 33 cases (17%) were removed due to incomplete
data points. Cough (p \ 0.0001), wheezing (p ¼ 0.002), and
retractions (p ¼ 0.007) were independently associated with
RSV infection. Hosmer-Lemeshow goodness of fit test x 2
was 4.0; p ¼ 0.9. The model of these 3 clinical features has
a sensitivity of 80% (95% CI:71,87); a specificity of 69% (95%
CI:53,79), and likelihood ratio of 2.5 (95%CI:1.8,3.7). Con-
clusion: Clinical predictors of RSV in children are identified.
If validated, this model may enhance the predictive abilities
of available laboratory tests.
053 Clinical Predictors of Influenza in Children
Marla J Friedman, Magdy W Attia; Alfred I. duPont Hospital
for Children: Wilmington, DE
Background: The classic symptoms of influenza in older
children and adults are not easily identified in young
children. Rapid diagnostic tests used to diagnose influenza
are limited by their sensitivity and specificity. A prediction
model that identifies children likely to have influenza can
enhance the predictive values of these tests. Objective: To
identify clinical features predictive of influenza infection in
children. Methods: Patients who presented to a pediatric
emergency department with a febrile respiratory illness
from January to March 2002 were eligible. Children
suspected of having influenza infection based on a prede-
termined set of criteria were enrolled. Each patient received
a nasal wash for both rapid influenza testing and viral
culture. Data was collected prospectively using a standard-
ized form. Influenza patients were compared to those with
negative test results. Logistic regression analysis was
performed to determine clinical features significantly
associated with influenza. Results: Samples were collected
on 128 patients. Median age of patients was 4.8 years; 54%
were male. Viral isolates included:influenza A 45 (35%),
influenza B 13 (10%), other viruses 10 (8%), no virus 60 (47%).
Seventeen cases (14%) were removed from the regression
analysis due to incomplete data. Cough (p ¼ 0.004), head-
ache (p ¼ 0.011), and pharyngitis (p ¼ 0.018) were indepen-
dently associated with influenza infection. Notably, fever
and myalgias were not significant. Hosmer-Lemeshow
goodness of fit test was not significant (x2 7.7; p ¼ 0.45).
The model’s sensitivity is 78% (95%CI: 63,88); the specificity
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
is 79% (95%CI: 65,88), with a likelihood ratio of 3.6 (95%CI:
2,6). Conclusion: The clinical triad of cough, headache, and
pharyngitis could be a useful clinical predictor of influenza
infection in children. Utilizing a pediatric prediction model
that selects patients likely to have influenza may enhance
the diagnostic abilities of available laboratory tests.
054 The Frequency, Location and Age Distribution
of Acute Invasive Procedures Performed on
Severe Pediatric Trauma Patients in Ontario Angelo
Mikrogianakis, Maureen Brennan-Barnes, Martin H
Osmond; Children’s Hospital Of Eastern Ontario:
Ottawa, Ontario, Canada
Objectives: Management of severe pediatric trauma re-
quires proficiency in a variety of life saving procedures. The
objective of this study was to describe the frequency,
location and age distribution of acute invasive procedures
performed on pediatric trauma patients in order to guide
the future direction of emergency physician educational
programs. Methods: Retrospective review of all severely
traumatized pediatric patients age 0–19 years entered in the
Ontario Trauma Registry’s Comprehensive Data Set with an
ISS $ 11 and admitted to a Lead Trauma Hospital over a
4-year period (April 1/96 – March 31/00). The procedures
investigated were oral endotracheal intubation (ETI), chest
tube insertion, central line insertion, DPL and thoracotomy.
Results: There were 5622 cases of severe pediatric trauma in
the province over the 4-year study period. Most trauma,
87.9%, resulted from a blunt mechanism with motor vehicle
collisions accounting for 61.2% of the total. A total of
3028 (53.9%) patients received oral ETI. Of these, 3.4% were
performed pre-hospital arrival, 51.2% at the primary
hospital and 45.4% at the Trauma Center. A total of 1371
chest tubes were placed in 1057 (18.8%) patients. Of these,
46.8% were performed at the primary hospital and 53.2% at
the Trauma Center. Only 133 (2.4%) patients had central
lines placed with 82% occurring at the Trauma Center. Only
61 (1.1%) patients required DPL while thoracotomy was
performed on only 9 (0.16%) patients. Eighty-five percent of
pediatric trauma patients were $10 years old and accounted
for 95.2% of chest tubes, 86.7% of ETIs and 90% of DPLs.
Conclusions: ETI and chest tube placement are commonly
required in severe pediatric trauma and are often performed
at the primary hospital. Pediatric trauma educational
programs for emergency physicians in Ontario should focus
on achieving and maintaining competence in pediatric
intubation and chest tube insertion. Insertion of central
lines, performance of DPL and thoracotomy should be de-
emphasized.
055 Pain Assessment: A Comparison of Patient,
Physician and Parent Ratings and of Rating
Scales Debra L Weiner, Paul C Stark, Patricia L Hibberd;
Children’s Hospital Boston: Boston, MA, Harvard Medical
School: Boston, MA, Tufts-New England Medical Center:
Boston, MA, Tufts University School of Medicine: Boston, MA
Objective: Accurate pain assessment is challenging and
critical. In sickle cell disease (SCD) optimal pain assessment
is important not only to guide appropriate therapeutic
441
dosing, but also to evaluate exciting new treatment
strategies. Our goal was to compare pain assessment by
patients with SCD VOC with physician and parent, and to
evaluate association between numeric and categorical
assessments. Methods: Pain was assessed prospectively in
20 patients, with SCD, a. 10–21 yrs, during severe VOC.
Patients were consecutively enrolled in a double-blind,
randomized, placebo-controlled clinical trial to evaluate
inhaled nitric oxide for treatment of VOC. Pain was rated
independently by patient, physician investigator and parent
immediately prior to inhalation, and hourly for 4 hrs of and
2 hrs after inhalation, using a 10 cm visual analogue scale
(VAS) and 5 point categorical scale (CS; none, mild,
moderate, severe, very severe). Patient scores were com-
pared to physician and parent scores. Intra-rater VAS and
CS scores were compared. Comparisons were performed
using repeated measures regression. Results: Mean patient
VAS score was greatest prior to inhalation, 8.23 cm (SD 1.36
cm; 6.2–10.0 cm), and lowest at 4 hrs, 6.72 cm (SD 2.31
cm; 2.4–9.9 cm). Physician scores averaged 0.92 cm \ patient
(p \ 0.0001), parents averaged 0.60 cm \ child (p ¼ 0.004).
Physician and parents also rated pain lower than patients
using CS (p ¼ 0.0006 and p ¼ 0.05, respectively). VAS and
CS scores were highly correlated for patients (r ¼ 0.66, p \
0.0001), parents (r ¼ 0.66, p \ 0.0001) and physician (r ¼
0.90, p \ 0.0001). Vital signs, activity level and treatment
assignment were unrelated to pain scores. Conclusions:
Pain score assessments by patients, physician and parents
follow similar trends, but rating by physician and parents is
consistently lower than by patients. VAS and CS scores are
strongly correlated. The results emphasize the importance
of patient self-reporting, and demonstrate that VAS scores
reflect clinical status.
056 Measures of Emergency Department Use in
Suburban vs Urban Infants Enrolled in
Medicaid Evaline A Alessandrini, Warren B Bilker, Kathy
N Shaw; The Children’s Hospital of Philadelphia: Philadelphia,
PA, The University of Pennsylvania: Philadelphia, PA
Objective: To test the hypothesis that, after controlling for
individual factors, residing in a suburban versus urban
locale is associated with decreased ED use in infants.
Methods: Prospective cohort study of 1564 Medicaid
enrolled newborns at 1 suburban and 2 urban hospitals
followed for 6 months. Independent variables were obtained
via post-partum interview and medical record review.
Outcomes: a) proportion of subjects with a visits, b) number
of visits per visitor and c) high ED reliance (proportion of all
ambulatory visits occurring in ED) ¼ ED reliance [33%.
Results: 354 infants (23%) resided in the suburbs. 11% of
suburban patients (SP) had at least 1 ED visit compared to
48% of urban patients (UP). Only 2% of SP’s were highly ED
reliant compared with 22% of UP’s. Median number of visits
for ED visitors did not differ: 1 SP and 1 UP, p ¼ 0.13. SP’s
were more likely to have a 1-day nursery stay, foreign born
mother, access to car or phone, and to live in their own home
or with their father. Controlling for these variables, logistic
regression revealed adjusted odds ratios (AOR) for SP’s of
0.15 (95% CI: 0.10, 0.22) for having an ED visit, and AOR ¼
0.08 (0.03, 0.21) for high ED reliance. Poisson regression
showed no effect of suburban locale on number of ED visits
for visitors: incidence rate ratio (IRR) ¼ 0.84 (0.63, 1.12).
442
With regard to health care factors, 99% of SP’s compared to
16% of UP’s received private office primary care. Still,
comparing SP’s to private office UP’s revealed nearly
identical results. For SP’s, AOR ¼ 0.21 (0.12, 0.36) for
having an ED visit, and AOR ¼ 0.05 (0.02, 0.17) for high ED
reliance. There was no effect of suburban locale on number
of ED visits for visitors: IRR 0.72 (0.48, 1.09). Conclusions:
Suburban locale remains protective against ED use, even
while controlling for individual factors. Once a visit has
occurred, number of ED visits does not differ. These results
suggest that access to or quality of health care in urban areas
may be improved.
057 Wrestling with Reality: Are Pediatric Injuries
Related to Media Violence? Thuy T Bui, Harold K
Simon; Emory University: Atlanta, GA, Children’s Healthcare
of Atlanta: Atlanta, GA
Objective: To describe the scope and significance of
pediatric injuries secondary to imitating behavior seen in
the media, particularly TV, video games, and movies.
Methods: A convenience sample of patients and their
caregivers presenting to the emergency rooms at 2 urban
pediatric hospitals were interviewed between 3/02–11/02.
The investigator-conducted interview consisted of a detailed
survey regarding the child’s media habits/exposures and
history of injury, mainly any sustained while copying
behavior seen in the media. Families were also asked about
any contacts having sustained media-related injuries. Data
is reported using descriptive statistics. Results: 44 of 100
children participating reported having known $1 incident
in which a child had hurt himself copying a media behavior.
Of these 44, 25(57%) reported 1 incident, 13(30%) reported 2
incidents, 6(14%) reported $3 incidents. 11(25%) of the 44
reporting injuries were either the victim or perpetrator.
Overall, 64 separate injuries were described. 47(73%)
needed medical care outside of the home. Mean age of the
injured was 10yrs (range 2–17yrs), 69% male. Types of
media copied included 56(88%) TV, 5(8%) movies, 1(2%)
video games, and 2(3%) other. Of the 56 copying TV, 34(61%)
copied professional wrestling (stunner, rockbottom), 9(16%)
copied cartoons (Spiderman, Power Rangers), 9(16%) copied
sports, and 4(7%) copied other shows (Jackass). The 64
reported injuries included 21(33%) extremity fracture/
dislocations, 18(28%) head injuries, 11(17%) joint sprains,
5(8%) repaired lacerations, 5(8%) neck injuries (1 being
a ‘‘broken neck’’ needing a brace/collar). Other injuries
included a MVC vs. pedestrian, a third-degree facial burn
with disfiguration, and a testicular injury. Conclusion: The
degree and acuity of injuries secondary to children imitating
behavior seen in the media appear more dramatic than once
thought. Therefore, families with children should be
advised of the potential relationship between childhood
injuries and media exposure.
058 Medicaid-enrolled Infants Seeking Care for Viral
Upper Respiratory Infections: The Primary Care
Office or Emergency Department Amy L Puchalski,
David Rubin, Kristen L Robinson, Evaline A Alessandrini;
The Children’s Hospital of Philadelphia: Philadelphia, PA
Objective: We sought to identify factors that differentiate
Medicaid-enrolled infants \6 months old who make their
2003 SAEM ANNUAL MEETING ABSTRACTS
first visit for a viral URI to an ED from those who use a PCP.
Methods: Design-Nested case-control study within a pro-
spective cohort of Medicaid-enrolled newborns [34 wks
gestation, [2 kg at birth, born a 1 of 3 area hospitals, and
had a URI visit by age 6 mos. Main Outcome-First visit for
a URI was evaluated in the ED (cases) or at the PCP
(controls) based on medical record review. Independent
Variables-Maternal, infant and health care characteristics
obtained via post-partum interview and medical record
review. Analysis-Logistic regression using independent
variables with a p-value [0.2 in the model. Results: Of
1564 cohort patients enrolled, 553 (35%) made a URI visit by
6 mos., with 383 (69%) using the PCP and 170 (31%) visiting
the ED. Based on univariate analysis, the following factors
were included in the logistic regression; urban, first born,
Aftican American infant, preterm (\37 weeks), hospital-
based PCP, teen mom, single mom, nursery stay \2 days,
living with father or maternal grandmother, no phone at
home, cash assistance, male infant, foreign-born mother, age
\2 months at visit and weekend visit. While controlling for
increased weekend ED use, several factors remained
associated with an ED visit for URI—
Characterisitic Adjusted OR 95% CI
Weekend Visit 24.2 10.4–56.2
Live in Urban Setting 2.8 1.4–5.6
Infant of Single Mother 2.7 1.2–6.2
Age \ 2mo at Visit 1.7 1.0–2.7
Male Infant 1.6 1.0–2.4
Conclusions: We were able to identify characteristics of
infants more likely to seek care for a URI in the ED, even
after controlling for increased ED use on the weekends.
These factors may facilitate identification of patients who
would benefit from interventions to influence care-seeking
behavior.
059 Does Parental Report of Insurance Status Agree
with Hospital Administrative Data for Children
Presenting to the Emergency Department? Mark I
Neuman, Michael S Radeos, James A Gordon, Jennifer A
Emond, Carlos A Camargo Jr; Children’s Hospital: Boston,
MA, Lincoln Medical Center: Bronx, NY, Massachusetts
General Hospital: Boston, MA
Objective: To determine whether parent/guardian self-
report (PGSR) of insurance status agrees with hospital
administrative data (HAD), and to examine the relation of
patient characteristics with any observed discordance.
Methods: We performed structured interviews of consecu-
tive patients at 11 US emergency departments, as part of
a multicenter trial on Children’s Health Insurance Program
(CHIP) outreach. Children age \18 years, who were
accompanied by an adult, were screened by asking ‘‘Is your
child covered by any kind of health insurance, such as
private insurance, Medicaid, special state insurance, an
HMO, or any other program?’’ PGSR responses were
compared to HAD. Subgroup analysis was performed
stratifying by age, sex, and race/ethnicity. Data analysis
used chi2 and 95% CI. Results: Of the 9,295 parents/
guardians interviewed, 7,715 (83%) had both the PGSR and
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
HAD insurance status recorded. ‘‘Uninsured’’ status was
10% (95% CI, 10–11%) per PGSR vs 12% (11–13%) per HAD;
p \ 0.001. Insurance coverage (per HAD) was lower in older
children (age \2 [89%], 2–7 [89%], 8–12 [87%], 13–18 [83%];
p \ 0.001) and differed by race; blacks (88%; 87–89%) and
Hispanics (86%; 85–88%) had lower rates of insurance
coverage than whites (92%; 90–93%). Among patients
without insurance per HAD, PGSR of having insurance
was 17% (15–19%). Although discordance was not associ-
ated with sex (p ¼ 0.50), it was highest among children age
\2 (26%; 21–31%) and blacks (23%; 19–27%), and lowest
among children age 13–18 (6%; 2–10%) and Hispanics (9%;
5–12%). Conclusion: Overall, there is a relatively little
discordance between parent/guardian self-reporting of
insurance status and hospital administrative data. However,
parents of specific groups (young children, blacks) are more
likely to report having health insurance even though
hospital administrative data lists such patients as self-pay.
A better understanding of this discordance would advance
efforts to identify children in need of health insurance
coverage.
060 How Are Pediatric Patients Managed by EMS and
What Are Their Outcomes? Julie Richard, Ian G Stiell,
Martin Osmond, Lisa Nesbitt, Tammy Beaudoin, , for the OPALS
Study Group; ; University of Ottawa: Ottawa, Ontario, Canada,
Queens University: Kingston, Ontario, Canada, University of
Western Ontario: London, Ontario, Canada, Niagara Regional
Base Hospital: Niagara Falls, Ontario, Canada, Ontario
Ministry of Health: Toronto, Ontario, Canada, University of
Arizona: Tucson, AZ
Objectives: There has been little research describing the
effectiveness of prehospital care and the outcomes of
children managed by EMS. We evaluated the prehospital
interventions and outcomes of pediatric cases within the
Ontario Prehospital Advanced Life Support (OPALS) Study,
which is a large multicenter initiative to evaluate the impact
of EMS programs on 40,000 critically ill and injured patients.
Methods: We conducted a prospective cohort study in
a single city with a 2-tiered BLS-D/ALS EMS system.
Enrolled were all children \16 years managed by EMS over
a 6-month period. Data were collected from ambulance
reports, centralized dispatch data, ED records, and in-
hospital records. We performed descriptive statistics with
95% CIs. Results: The 1,368 study patients had these
characteristics: Mean Age 8.0 (range 0–15); Male 57.5%;
EMS Case Severity: life-threatening 2.4%, severe 14.3%,
moderate 39.5%, minor 34.6%; EMS Return Priority urgent
8.1%; Primary Problem: minor trauma 44.7%, seizure 11.0%,
respiratory distress 8.5%, overdose 4.4%, allergic 2.7%,
psychiatric 2.7%, major trauma 1.0%, cardiac arrest 0.1%;
Pick-Up Location: residence 52.0%, street 16.9%, public
place 15.6%, school 9.6%. 28.0% of patients were not
transported (parental transport 24%, monitoring at home
17%). BLS interventions were oxygen 19.6%, glucose
measurement 16.8%, immobilization 12.0%, salbutamol
3.4%, SC epinephrine 0.7%. ALS interventions were cardiac
monitor 21.0%, IV insertion 8.5% (mean volume 98.1 ml), IV
diazepam 0.9%, IV morphine, 0.8%, intubation 0.1%.
Disposition from ED was home 94.5%, ward 3.5%, ICU
0.9%, death 0.5%. Conclusions: This is the most compre-
hensive review of EMS pediatric management and reveals
443
that most children are not severely ill, most do not receive
ALS interventions, there is a high rate of non-transport, and
the vast majority are discharged home from the ED. Future
research should evaluate the effectiveness of ALS interven-
tions and the efficiency of EMS care for children.
061 Vomiting after Liquid Steroid in Children with
Asthma Michael K Kim, Kenneth Yen, Ryan L Redman,
Tom J Nelson, Janice Brandos, Halim M Hennes; Medical
College of Wisconsin: Milwaukee, WI, Children’s Hospital of
Wisconsin: Milwaukee, WI
Objectives: To compare the palatability and incidence of
vomiting after administration of generic preparation of
prednisolone compared to Orapred. Methods: A double
blind clinical trial was conducted at a tertiary care children’s
hospital emergency department. Children age 2 to 10 years
presenting with acute asthma exacerbation were eligible.
Patients with allergy to prednisolone, corticosteroid use
within 2 weeks, h/o vomiting in last 24 hours, required
vascular access, and preference for other forms of cortico-
steroid were excluded. Enrolled children were randomly
assigned either to the generic prednisolone group or the
Orapred group by receiving the study medication delivered
from the pharmacy only labeled with a study number. In
children 4 years of age or older, a taste score was obtained
after administration using a 5 point hedonic face scale (1 ¼
bad to 5 ¼ great). Patients were monitored for 30 minutes
for vomiting. Chi square test was used to analyze the
incidence of vomiting, and the Mann-Whitney U test was
used to analyze the taste score. Confidence intervals were
calculated when appropriate. Results: Of the 90 children
enrolled, 46 received generic prednisolone and 44 received
Orapred. The mean age and gender ratio were similar in the
2 study groups. Taste scores were obtained from 27 children
in the generic prednisolone group and 28 in the Orapred
group. The median taste score was 2 for the generic
prednisolone group and 4 for the Orapred group (p ¼
0.003). In the generic prednisolone group, 8/46(17.4%)
children vomited compared to 4/44(9.1%) children in the
Orapred group. fp ¼ 0.2(¼8.3%,95%CI: 5.6%,22.2%)g. Con-
clusion: Based on our preliminary data, Orapred has higher
taste score than generic prednisolone and there is no
statistical difference in the incidence of vomiting after
Orapred compared to generic prednisolone.
062 Clinical Significance of Extreme Leukocytosis in
the Emergency Department Evaluation of Young
Febrile Children Samir S Shah, Frances S Shofer, James S
Seidel, Jill Baren; The Children’s Hospital of Philadelphia:
Philadelphia, PA, Harbor-UCLA Medical Center: Torrance,
CA, University of Pennsylvania School of Medicine:
Philadelphia, PA
Background: In the emergency department (ED) evaluation
of young febrile children, a white blood cell (WBC) count
[15,000/mm3 has been associated with an increased likeli-
hood of serious bacterial illness (SBI). It is not known
whether the subset of children with a WBC count [25,000/
mm3 (extreme leukocytosis) are at even greater risk of SBI.
Objective: To determine the clinical significance of extreme
444
leukocytosis in young febrile children evaluated in a pedi-
atric ED. Methods: We prospectively identified children 2 to
24 months of age with extreme leukocytosis (cases) and
compared them to age- and gender-matched controls with
WBC between 15,000–24,999/mm3. Diagnoses included in
the definition of SBI included bacteremia, meningitis,
urinary tract infection (UTI), mastoiditis, osteomyelitis,
septic arthritis, and pneumonia. Results: There were 69
cases and 94 controls. Mean age was 9.9 months and 91
patients (55.8%) were male. The most common diagnoses
were similar in cases and controls; otitis media (46% vs.
47%), pneumonia (19% vs. 15%), UTI (16% vs. 14%), and
viral syndrome (10% vs. 15%). SBI occurred in 45% (95% CI:
26–64) of cases compared to 32% (95% CI: 14–50) of controls.
Urine, blood and cerebrospinal fluid cultures were positive
for pathogens in 26%, 2%, and 1% of children, respectively.
There was a single patient with each of the following SBI:
Osteomyelitis, septic arthritis, mastoiditis, and bacterial
meningitis. Each of these patients had extreme leukocytosis.
Eighteen children (7 cases, 11 controls) were well-appearing
and had a non-localizing physical exam. Ten of the 18
children had a UTI, 2 had aseptic meningitis, and 1 had
pneumonia. No patient in this study was diagnosed with
malignancy. Conclusions: Young febrile children whose ED
evaluation revealed extreme leukocytosis had similar di-
agnoses and rates of SBI compared to children with
leukocytosis. Degree of leukocytosis alone does not appear
to differentiate children at higher risk of SBI.
063 Etomidate vs Pentobarbital for Sedation of Children
for Head and Neck CT Imaging Andrew J Kienstra,
Mark A Ward, Fahimeh Sasan, Jill V Hunter, M Craig Morriss,
Charles G Macias; Baylor College of Medicine: Houston, TX
Objectives: We compare etomidate to pentobarbital for
sedation of children for head and neck CT imaging.
Methods: We performed a randomized, double-blinded
trial of patients aged 6 months to 6 years enrolled from the
emergency department or radiology department at a large
urban children’s hospital. The primary outcome measure
was sedation success rate. Results: A total of 61 patients
were enrolled in the study (27 etomidate group, 34
pentobarbital group) at 2 different dosing regimens for
etomidate. The final analysis group included 17 etomidate
patients and 33 pentobarbital patients. The success rate for
the etomidate group was 57% at total doses of up to 0.3 mg/
kg (n ¼ 7) and 76% at total doses of up to 0.4 mg/kg (n ¼
17); in contrast to a success rate of 97% for pentobarbital
at a total dose of up to 5 mg/kg (n ¼ 33). The success rate
for pentobarbital was significantly greater than the final
etomidate group (p ¼ 0.04; difference in proportions 20.5%,
95%CI 1.9–44.4%). Patients receiving etomidate had signif-
icantly shorter induction times (p ¼ 0.02; difference of
means 2.1, 95%CI 0.35–3.86), sedation times (p \ 0.001;
difference of means 31.3, 95%CI 24.0–38.5), and total
examination times (p \ 0.001; difference of means 53.1,
95%CI 40.8–65.3). Significantly more parents in the etomi-
date group perceived their child to be back to baseline
by discharge from the hospital (p \ 0.001; difference of
proportions 60.7, 95%CI 29.1–92.4) and expressed fewer
concerns about their child’s behavior after discharge (p ¼
0.024; difference of proportions 28.6, 95%CI 6.5–50.7).
2003 SAEM ANNUAL MEETING ABSTRACTS
Conclusions: At the dosing used in this study, pentobarbital
is superior to etomidate when comparing success rates for
sedation. However, among the successful sedations, the
duration of sedation was shorter in the etomidate group
than in the pentobarbital group. Pentobarbital is associated
with more frequent side effects and greater parental
dissatisfaction than etomidate.
064 The Practice of Pain Medication Administration
Following EMS Protocol Change Joe Chang,
Constance J Doyle, Robert M Domeier, Candice Sobanski,
Samuel A McLean, Ronald F Maio, Shirley M Frederiksen;
University of Michigan: Ann Arbor, MI, Saint Joseph Mercy
Hospital: Ann Arbor, MI
Objectives: Providing adequate pain control has been
recognized as an important issue in all areas of medicine,
including the pre-hospital setting. In October 2001 the
Southeastern Michigan EMS protocols were revised to
include standing orders for the administration of narcotic
analgesia to patients with painful isolated traumatic injuries
and suspected cardiac chest pain, after nitroglycerin
administration, without the necessity for on-line medical
direction. The purpose of the study is to determine how this
protocol change affected the number of patients who receive
narcotic pain medication. Methods: This was a retrospective
review of EMS run data. EMS data were reviewed for 6
months prior to and one year after the protocol implemen-
tation and includes runs from 4/2001 through 9/2002. Two
patient groups representing the patients most directly
affected by the protocol changes were examined. These
included chest pain patients who had received nitroglycerin
(CP-NTG) by the EMS providers and ALS trauma (ALS-T)
patients. EMS patient records were examined through a data
base search of transported patients. Chi-squared analysis
was used to compare the percentage of patients who
received narcotic pain medication for the study periods.
Results: 10,165 patient transports were examined. 492 CP-
NTG and 1026 ALS-T patients were included. CP-NTG
patients who received pain medication for the study periods
increased from 15.3% to 27.0% (p ¼ 0.0033). ALS-T patients
who received pain medication increased from 17.9% to
27.8% (p ¼ 0.00059). Conclusion: The implementation of
protocols for administration of pain medication without on-
line medical direction resulted in a significant increase in the
percentage of EMS patients receiving pain medication.
065 Out-of-hospital Cardiac Arrest Survival Rates in
an EMS System Utilizing the System Status
Management Dispatch Model Rollin J Fairbanks,
Manish N Shah, E Brooke Lerner, Kumar Ilangovan, Eric A
Davis, Sandra M Schneider; University of Rochester Medical
Center: Rochester, NY
Introduction: There are no large cardiac arrest studies in the
EMS literature that utilize the system status management
(SSM) dispatch model. This dispatch model theoretically
results in consistently short call-response intervals, which
should improve out-of-hospital cardiac arrest (OHCA)
survival rates. Objective: To calculate call-response inter-
vals and OHCA survival rates in a northeastern city where
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
the SSM dispatch model was utilized. Methods: EMS
medical records were reviewed for all OHCA patients with
a resuscitation attempt that occurred within the city limits
(pop. 220,000) during a four year study period (1998–2001).
Utstein criteria were used as a guide in data collection and
reporting. Adult OHCA of cardiac etiology with complete
survival data were included. The outcome measures were
return of spontaneous circulation (ROSC), 30 day and one
year survival. Survival was determined using hospital
medical records, medical examiner data, and the Social
Security Death Index. Results: 1213 consecutive OHCA
were identified. 546 met inclusion criteria, of which 456
(84%) had complete survival data. The median call-response
interval was 5 minutes (range 0–21), with 93% less than 9
minutes. The initial rhythm was shockable in 209 cases
(46%), not shockable in 155 cases (34%) and in the remaining
92 cases the initial rhythm was unknown (20%). 180 OHCA
(39%) were bystander witnessed and 64 (14%) received
bystander CPR. Overall, 86 patients experienced ROSC
(19%), 16 survived to 30 days (4%), and 8 to one year (2%).
Conclusion: Utilizing SSM resulted in good OHCA re-
sponse intervals. However, the survival rates appear to be
similar to national averages.
066 Improvement in Misplaced Endotracheal Tube
Recognition within a Regional Emergency Medical
Services System Salvatore Silvestri, George Ralls, Eric
Carter, Amy Senn, Steven G Rothrock, Philip A Giordano,
Patricia Brandt, Jay L Falk; Orlando Regional Medical Center:
Orlando, FL, University of Florida College of Medicine:
Gainesville, FL, The Institute of Emergency Medical Services
Education and Research, Inc.: Orlando, FL
Objective: To determine if a new airway management
protocol had an impact on the incidence of unrecognized,
misplaced endotracheal tubes in a regional emergency
medical services system. Methods: A prospective observa-
tional study was conducted on all patients arriving at
a regional level I trauma center emergency department (ED)
who underwent pre-hospital endotracheal (ET) intubation.
Prior to the study period, the EMS system where the trauma
center is located implemented a new airway management
protocol which required continuous CO2 monitoring (ET-
CO2) of all intubated patients. Over a 10-month period
emergency physicians (senior EM residents and attendings)
assessed the ET tube placement according to an airway
confirmation algorithm. All of the patients that arrived at
the ED with a pre-hospital placed ET tube were compared to
a preexisting study cohort presenting to the same ED. Chi
square analysis was used to compare unrecognized mis-
placed endotracheal tube rates. Results: Data from 152
consecutive pre-hospital endotracheal intubation patients
(study group) were compared to a control group consisting
of 108 consecutive cases presenting to the same ED during
an 8-month period prior to implementation of the new
protocol. Study group patients had a significantly lower
rate of unrecognized misplaced ET tubes compared to
control patients (9% vs. 25%, p \ 0.001). Moreover, the rate
of unrecognized misplaced ET tubes fell to 0 for the subset
of patients with 100% protocol compliance (i.e. continuous
ETCO2 monitoring). Conclusion: Implementation of a pre-
hospital airway management protocol requiring continuous
445
ETCO2 confirmation substantially decreased the number of
unrecognized, misplaced endotracheal tubes. This problem
was eliminated among patients in whom the protocol
requirements for continuous ETCO2 was adhered to.
067 Are Out-of-hospital Endotracheal Intubation Errors
Associated with Patient Mortality? Henry E Wang,
Douglas F Kupas, Paul M Paris, Joseph P Costantino, Donald M
Yealy; University of Pittsburgh: Pittsburgh, PA, Geisinger
Health System: Danville, PA
Objectives: We sought to determine whether out-of-hospital
endotracheal intubation (OOH-ETI) errors are associated
with field and ED mortality. Methods: We evaluated data
from a prospective, multi-center observational trial of adult
ETI performed by 45 EMS services in a mid-Atlantic State.
Rescuers used a standard form to report clinical and
physiologic details of each ETI effort. We identified the
occurrence of three major OOH-ETI errors; failed ETI,
multiple attempts (three or more laryngoscopic attempts),
and ET tube misplacement or dislodgement (MOD). The
primary outcomes were death (CPR or field pronounce-
ment) at the end of the field course and death in the ED.
Using generalized estimating equations (GEE) to account for
clustering by individual services, we evaluated the associ-
ation of OOH-ETI errors with the primary outcomes
adjusted for the covariates cardiac arrest, trauma, method
of ETI (oral, nasal, or drug-facilitated), age, sex, estimated
weight and GCS. Results: We evaluated a total of 742 OOH-
ETI with complete data. Mortalities at the end of the field
and initial ED courses were 394/791 (54.7%) and 338/604
(56.0%). There were 96 failed ETI, 94 cases of multiple
attempts and 23 tube MOD. Adjusted for the effects of the
covariates, multiple ETI attempts were associated with
increased odds of field death (OR 1.92; 95% CI 1.17–3.16) but
not ED death (1.23; 0.67–2.36). Failed ETI were associated
with decreased odds of field (0.39; 0.20–0.77) and ED (0.37;
0.20–0.93) death. Tube MOD were not associated with field
(4.52; 0.81–25.19) or ED (3.07; 0.68–19.00) death. Field and
ED death were more likely for cardiac arrest and male
patients. ED death was more likely for trauma patients.
Conclusions: Multiple ETI attempts are associated with
increased risk of field death. Tube MOD may be associated
with the risk of field or ED death. These findings support
protocols to limit OOH-ETI efforts.
068 Intubating Conditions Produced by Etomidate Alone
vs Rapid Sequence Intubation in the Prehospital
Aeromedical Setting William P Bozeman, Douglas M
Kleiner, Vicki Huggett; University of Florida: Jacksonville, FL
Objectives: Intubating conditions are a better measure than
eventually successful intubation rates when comparing
intubation medication regimens. We sought to evaluate the
intubation conditions produced by etomidate (Etom) seda-
tion alone compared to those produced by rapid sequence
intubation (RSI) with succinylcholine (Sux) and Etom.
Methods: A prospective crossover trial design used two
helicopters staffed by the same flight crews. Each aircraft
utilized an Etom intubation protocol of 20 mg adult dose
with a second dose of Etom or rescue Sux available if
446
needed for six months. RSI with the same dose of Etom plus
Sux (1 mg/kg) was used for the other six months. Intubating
conditions were graded at each attempt by three scales: 1)
global difficulty using a Likert scale of 1 (very easy) to 5
(very difficult), 2) the Percentage Of Glottic Opening
(POGO) score, and 3) formal Laryngoscopy Grading Scale
(LGS) resulting in a ‘‘good,’’ ‘‘acceptable’’ or ‘‘unacceptable’’
rating. Orotracheal intubation success was recorded at each
dose. Results: A total of 56 patients were intubated. Mean
age was 39 years, 79% were male, and 88% were intubated
for trauma. Conditions were assessed for all 69 laryngos-
copy attempts. Laryngoscopy was performed after Etom 20
mg (n ¼ 15), Etom 40 mg (n ¼ 9), RSI (n ¼ 31), and no meds
or other (n ¼ 14). Mean values after Etom or RSI were as
follows for subjective difficulty, POGO score (% visualized),
LGS resulting in either ‘‘good’’ or ‘‘acceptable’’ conditions,
and orotracheal intubation success rate:
Diff POGO LGS G/A Success
RSI 3.1 59% 74% 90%
Etom 40 4.4 17% 0% 44%
Etom 20 4.9 9% 13% 13%
Intubating conditions with RSI were significantly improved
by all measures (p \ .005) compared to each etomidate
group. Conclusions: In this setting RSI produces signifi-
cantly better intubating conditions than etomidate at either
low or high doses and results in higher orotracheal
intubation success rates.
069 The San Diego Paramedic Rapid Sequence
Intubation Trial: A Three-year Experience Daniel P
Davis, Mel Ochs, David B Hoyt, Lawrence K Marshall, Peter
Rosen; University of California, San Diego: San Diego, CA,
San Diego County EMS: San Diego, CA
Objectives: The San Diego Paramedic RSI Trial was
designed to determine the impact of paramedic RSI on
outcome in severely head-injured patients. This analysis
reports the prehospital experience over the first three trial
years. Methods: Patients were enrolled prospectively using
the following inclusion criteria: adult major trauma victim
with head injury by mechanism or exam, GCS 3–8, greater
than 10 min transport time, and unable to be intubated
without RSI medications. Midazolam and succinylcholine
were used for RSI; rocuronium was administered following
tube confirmation. Combitube insertion (CTI) was used as
a salvage technique if orotracheal intubation (OTI) was
unsuccessful. This analysis reports OTI success rates,
prehospital course, arrival ABG values, and complications.
Descriptive statistics (95% CI) and rank-sum testing were
used. Results: A total of 349 patients underwent RSI by
paramedics. OTI was successful in 84%, and CTI was
successful in 14%. Of the remaining 7 patients, medication
errors led to failure of paralysis in 4 patients, and airway
management was unsuccessful in 3 patients. Medication
errors with midazolam remained constant while paralytic
errors increased over the course of the trial. Median SaO2
improved from 95% to 99% (p \ 0.05); mean arrival pO2 was
310 mmHg (292–329). Desaturations (SaO2 \ 90%) occurred
in over half of patients in whom SaO2 was monitored during
RSI. Mean arrival pCO2 values were 30 mmHg or less in
2003 SAEM ANNUAL MEETING ABSTRACTS
35% of patients. Two-thirds of patients underwent RSI on
scene, which added 13 min to scene times. Conclusions:
Successful airway management with either OTI or CTI was
observed in 98% of patients. Overall oxygenation was im-
proved, but there was a high incidence of desaturations prior
to intubation, and inadvertent hyperventilation occurred
in many patients. Medication errors and prolonged scene
times may also have adversely affected outcomes.
070 Inadvertent Hyperventilation following Paramedic
Rapid Sequence Intubation of Severely
Head-injured Patients Daniel P Davis, James V Dunford,
Mel Ochs, David B Hoyt; University of California, San Diego:
San Diego, CA, San Diego County EMS: San Diego, CA
Objectives: Inadvertent hyperventilation has been docu-
mented during aeromedical transports but has not been
studied following paramedic RSI. The San Diego Paramedic
RSI Trial was designed to study the impact of paramedic RSI
on outcome in severely head-injured patients. This analysis
explores ventilation patterns in a cohort of trial patients
undergoing end-tidal CO2 (ETCO2) monitoring. Methods:
Adult severely head-injured patients (GCS 3–8) unable to be
intubated without RSI were prospectively enrolled in the
trial. Midazolam and succinylcholine were used for RSI;
rocuronium was administered following tube confirmation.
Standardized ventilation protocols were used by most
paramedics; however, one agency instituted ETCO2 moni-
toring during the 2nd trial year, with paramedics instructed
to target ETCO2 values of 30–35 mmHg. The incidence and
duration of inadvertent hyperventilation (ETCO2 \ 30
mmHg) and severe hyperventilation (ETCO2 \ 25 mmHg)
were determined for patients undergoing ETCO2 monitor-
ing. The initial, final, minimum, and maximum values for
ETCO2 and the maximum and minimum respiratory rate
values were also calculated using descriptive statistics (95%
CI). Results: A total of 76 trial patients had adequate ETCO2
data for this analysis. The mean initial, final, maximum, and
minimum ETCO2 values were 40.8 mmHg (37.5–44.2), 28.4
mmHg (25.4–31.4), 45.1 mmHg (41.4–48.8), and 23.5 mmHg
(21.4–25.5). The mean maximum and minimum respiratory
rate values were 36.0/min (33.5–38.5) and 12.8/min (11.9–
13.7). ETCO2 values less than 30 mmHg and 25 mmHg were
documented in 79% and 59% of patients, respectively, with
mean durations of 485 sec (378–592) and 390 sec (285–494).
Conclusions: Inadvertent hyperventilation is common
following paramedic RSI despite ETCO2 monitoring and
target parameters. This analysis did not explore the effect of
hyperventilation on outcome; however, the frequency and
duration are concerning due to the potential for compro-
mised cerebral perfusion.
071 The Effect of Paramedic Rapid Sequence
Intubation on Outcome in Severe Traumatic Brain
Injury Daniel P Davis, David B Hoyt, Mel Ochs, Troy
Holbrook, Dale Fortlage, Lawrence K Marshall, Peter Rosen;
University of California, San Diego: San Diego, CA,
San Diego County EMS: San Diego, CA
Objectives: Aggressive airway management is fundamental
in the management of traumatic brain injury, but many
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
patients cannot be intubated under current paramedic
protocols. This analysis explores the impact of paramedic
RSI on outcome in severely head-injured patients. Methods:
Adult trauma patients with severe head injury (GCS 3–8)
who could not be intubated without RSI were prospectively
enrolled in the trial. Midazolam and succinylcholine were
used for RSI; rocuronium was administered following tube
confirmation. Exclusion criteria for this analysis included:
absence of head injury (Head/Neck AIS \ 2), death in the
field or within 30 min of arrival, and failure to intubate.
Each remaining trial patient was hand matched to two non-
intubated controls from the county trauma registry based
on: age, gender, mechanism, AIS scores for each body
system, and ISS. The primary outcome measure was in-
hospital mortality. In addition, discordant groups with re-
gard to outcome were analyzed to explore the impact of
technical errors on outcome. Results: Of the 426 trial
patients, a total of 347 met inclusion criteria for this anal-
ysis and were hand-matched to 694 controls. Trial patients
and controls were identical with regard to all matching
parameters (age 37.1 vs. 37.7 yrs; sex 80.8% males for both;
H/N AIS 3.89 vs. 3.90; Face AIS 0.57 vs. 0.58; Chest AIS 1.23
vs. 1.26; Abdomen AIS 0.65 vs. 0.77; Extremities AIS 0.92 vs.
1.07; Skin AIS 0.88 vs. 1.02; ISS 26.6 vs. 27.3). Trial patients
had 31.4% mortality vs. 23.6% for controls (OR 1.48, 95% CI
1.13–2.00, p ¼ 0.005). Discordant groups were also identi-
cally matched; an increased mortality was observed with
hypoxic episodes during RSI and hyperventilation follow-
ing intubation. Conclusions: Paramedic RSI was associated
with an increase in mortality despite identically matched
controls. Hypoxia and hyperventilation may be contributing
factors. Limitations include the use of matched controls
rather than a randomized design.
072 The Pre-transport Index: A Prospective
Validation Sarah Joanne McPherson, Jeff Plant,
Kelsey Juzwishin, Chip Doig, Mike Betzner, John Kortbeek;
University of Calgary: Calgary, Alberta, Canada
Objectives: A prospective validation of the sensitivity and
specificity of the PTI (Pre-Transport Index) in identifying
rural trauma patients who require rapid transport to
a tertiary trauma center as determined by a cumulative
endpoint of mortality, time to emergent surgery \4 hours,
ICU length of stay [48 hours, and mechanical ventilation
[24 hours. Methods: Prospective cohort study. 2 cohorts
were identified by a PTI score calculated by a transport
physician through a dispatch center for Southern Alberta,
Canada prior to patient transport. Consecutive patients [16
years of age with traumatic injuries were enrolled from
September, 2001 – September, 2002. Patients with a PTI score
$4 were defined as major trauma patients and were
transported by the most rapid means as determined by
a regionally validated chart of call. Patients with a PTI score
\4 were transported by the next fastest means. The primary
outcomes and transport times were measured. Results: In
the first year of a planned two year study 187 patients were
enrolled. 145 met inclusion criteria, 41 were excluded and 1
was lost to follow up. Of the included patients 88 were
identified as major trauma patients and 57 were minor. Of
the major patients, 33 had none of the primary outcomes
and 55 had at least one outcome. In the minor cohort 46
447
patients had none of the primary outcomes and 11 had at
least one. The sensitivity of the PTI score for identifying
patients with at least 1 of the primary outcomes was 83%
with a specificity of 58%. The median transport time for the
major cohort was 140 minutes with an interquartile range of
117–201 minutes. The median transport time for the minor
cohort was 197 minutes with an interquartile range of 131–
234 minutes. Conclusions: The PTI may be a useful tool in
identifying trauma patients requiring rapid transport to
a Level I trauma center. Further investigation to complete
two years of patient enrollment will help clarify the utility of
this scoring system.
073 Comparison of Patient Needs Following Two
Hurricanes Kevin E Nufer; University of
New Mexico: Albuquerque, NM
Objectives: The New Mexico Disaster Medical Assistance
Team (NMDMAT) has responded to more hurricanes than
any other disaster. To asses if patient needs may be applied
to future hurricanes, the patient needs after Hurricanes
Andrew (HA) (FL, 8/92) and Iniki (HI) (HI, 9/92) were
compared. The study question: did patient needs differ after
these hurricanes? Methods: Design: Retrospective review.
Subjects: All patients seen by NMDMAT following HA and
HI. Observations: Age, past medical history (PMH), chief
complaint (CC), diagnosis, treatments, diagnostic tests,
triage level (green/yellow/red) and disposition. Age was
analyzed with Student’s t-test, other data with chi-square.
Results: 1056 patients seen, 712 after HA and 344 after HI.
Age did not differ. More patients had a PMH after HA
(43.1% v 30.2% p \ .001). There was no difference in the
most common CCs of wounds, musculoskeletal pain (MSK),
medication refill or rash. More patients had cold symptoms
(URI) in HI (18.9% v 9.0% p \ .001). The most common
diagnoses of wounds, MSK, and cellulitis did not differ.
URIs were diagnosed more often in HI (5.6% v 2.3%, p ¼
.003). There was no difference in tetanus toxoid, antibiotics
or analgesics given. Patients in HA had more diagnostic
tests (29.5% v 2.3%, p \ .0001). Patients had a higher acuity
in HA (p \ .0001). The proportion of patients sent to
a hospital did not differ. Conclusion: Patient needs were
similar after HA and HI and may be generalizable to future
hurricanes. Only the proportion of URIs differed, which is
insignificant when planning for disasters. Importantly,
DMATs should be well stocked with wound care supplies,
tetanus toxoid and analgesics when responding to hurri-
canes. The same proportion of patients required transport
to a hospital despite a higher acuity level in HA, likely due
to the increased availability and use of diagnostic tests.
These results should be tested prospectively in a future
hurricane.
074 Impact of an EMS Physician at Mass Casualty
Incidents Allen W Cherson, Michael G Guttenberg,
Abraham Glatzer; Fire Department City of New York: Brooklyn,
NY, New York Methodist Hospital: Brooklyn, NY
Objective: To determine the impact of an emergency
medical service (EMS) physician at the scene of mass
casualty incidents (MCIs) on ambulance utilization.
448
Methods: We performed a retrospective observational study
of MCIs (Defined as an incident producing 20 or more
patients, the potential to produce multiple patients, or any
unusual circumstances) in NYC from January, 2001 to July,
2002. Data from the Fire Department City of New York EMS
Command computer aided dispatch system and Office of
Medical Affairs were reviewed. Outcomes (treatment and
transport trends) were categorized by the presence of an
EMS physician. Data from the World Trade Center and the
crash of American Flight 547 were not included. Results:
66 incidents were reviewed. Types of incidents included
ground transport incidents/MVA (42.4%), construction/
structural collapse (16.6%), hazardous materials (10.6%),
multiple alarm fires (10.6%), aircraft incidents (3.0%), and
others (16.6%). A total of 1,070 patients were identified. An
EMS physician arrived at 56 (84.8%) incidents and 937
patients were identified. With an EMS physician present,
446 (47.6%) patients were transported to the hospital, 179
(19.1%) patients refused medical aid (RMA), and 312 (33.3%)
patients were triaged, evaluated, and released by the on
scene physician. Of the incidents without an EMS physician,
133 patients were identified. 121 (91%) patients were
transported to the hospital, 12 patients RMA, and 50
ambulances were utilized. Based upon the estimate of three
patients per ambulance, 167 ambulance responses were
saved. These ambulances were kept in service for other 911
responses. No negative outcomes were reported nor were
any patient complaints generated. Conclusions: Inclusion of
an EMS physician in the response matrix for mass casualty
incidents can result in a significant reduction in transporta-
tion requirements and improve ambulance availability.
075 Statistical Modeling of EMS Rescue Calls
Martin L Lesser, David Barlas; North Shore University
Hospital: Manhasset, NY
Objectives: The frequency of rescue calls, while random in
nature, can vary considerably. Calls may cluster together at
some times, and there may be long intervals between calls at
other times. The ‘‘Poisson process’’ (PP) is a well-known
statistical model for describing the occurrence of ‘‘random’’
and ‘‘rare’’ events, as opposed to ‘‘clustered’’ events that
may have an underlying association. The purpose of this
study was to determine if the PP explains the pattern of
rescue calls at an EMS agency with the goal of improving
resource allocation. Methods: We retrospectively analyzed
the timing of all rescue calls over a 1-year period at
a volunteer EMS rescue squad that serves a suburban
community of approximately 10,000. This call timing data
was compared with a PP distribution to determine if they
are similar. Results: 658 rescue calls were analyzed. There
was a mean of 1.8 calls/day or 0.075 calls/hr. The mean time
between calls was 13.3 hrs. A histogram shows that the
distribution of calls/day has the shape of a Poisson
probability distribution. This was confirmed by goodness-
of-fit testing. Further analysis shows that the sequence of
calls over time behaves like a PP. The PP has the
‘‘memoryless’’ property (constant hazard function) which
states that the length of time from the last rescue call to the
next does not depend on how long one has been waiting for
the next rescue call to occur. As for clustering of calls, the
model’s equation shows that the probability that 2 rescue
calls will occur within 1 hr of each other is 7.2%; within 1–2
2003 SAEM ANNUAL MEETING ABSTRACTS
hrs 6.7%; and [24 hrs apart 16.5%. Conclusions: Rescue call
patterns in this EMS system behave like a PP—consistent
with statistical theory. Based on the model derived for
a particular EMS system, calculations about the timing of
rescue calls (e.g. number of calls in a given interval of time)
can be made, and allocation of staff and equipment can be
improved. This type of modeling may be applied to other
EMS systems to aid in resource utilization.
076 Emergency Department Communication Systems
(CS) Performance and Disaster Plan Response
during the World Trade Center Attack (9/11/01) Rachel T
Moresky, Mark A Davis, Philip L Rice Jr, Jennifer Learning;
Institute for International Emergency Medicine and Health,
Brigham and Women’s Hospital, Harvard Medical School:
Boston, MA
Objective: This objective is to examine the functioning of
the Communication System (CS) and disaster plan systems
in the New York City (NYC) area Emergency Departments
(EDs) during the September 11, 2001 attack. Methods: The
study design is an observational retrospective telephone
survey of 59 NYC area hospitals from the 911 Ambulance
Designation Advisory Committee Membership List (10/25/
99). Two interviewers conducted the study from 2/23/02
until 12/23/02. The ED chairperson was contacted in 70%
(41/59) of cases and if unable to reached after 5 attempts
then another administrator was contacted. Results: All 59
designated hospitals (100%) were contacted. In 88% (52/59)
the ED chairperson/administrator learned of the attack
within the first 10 minutes. However, almost half of the
respondents recalled that they were notified/heard by
TV 44% (26/59), 3.4% (2/59) by a lay person, 9% (5/59)
multifrequency radio, none over 800mhz OEM radio, 3%
(2/59) high frequency radio, 2% (1/59) by cell phone, 17%
(10/59), over a land line and 9% (5/59) were paged about
the attack. The disaster committee was notified only 71%
(42/59) of the time. Over half, 54% (32/59) initiated the
disaster plan within 10 minutes and 49% (29/59) had ED set
up for the disaster plan within a half hour of the attack.
Respondents felt there was a discrepancy between CS
planned responses and actual responses during 9/11
(averages of 4 and 8 /10 Likert scale, respectively). Almost
two-thirds 73% (43/59) stated that there had been major
changes in disaster CS made since the attack. Recall bias
poses a significant limitation to the study. Conclusion: CS
breakdown in NYC hospital EDs influenced the hospital
disaster plan response during the WTC attack. Understand-
ing successful methods of communication during 9/11 may
have important implications for future disaster planning.
077 Emergency Physician Verified Prehospital
Intubation, Missed Rates by Ground
Paramedics James H Jones, Michael P Murphy, Robert L
Dickson, Geoffrey G Somerville; Indiana University School of
Medicine: Indianapolis, IN
Objectives: A recent prospective study of prehospital
intubations showed a 25% unrecognized miss rate of
endotracheal tubes. This result is in disagreement with
previous field verification studies reporting a 1–5% miss rate
by paramedics. The objective of this study was to pro-
spectively quantify the number of unrecognized missed
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
intubations in a large Midwestern urban setting using
emergency physician evaluation as the gold standard for
endotracheal tube placement. Methods: Design: Observa-
tional, prospective study of consecutive intubated patients
arriving by ground EMS during the six month study period.
Setting: Two academic emergency departments at level one
trauma centers with a combined annual census of greater
than 200,000 visits. Subjects: All paramedic performed oral
or nasal prehospital intubations. Air medical patients,
prisoners, patients transferred from outside hospitals,
surgical airways, and those treated with alternative airways
were excluded. Observations: Endotracheal tube placement
was verified using physician evaluation by upper level EM
residents or EM staff. Evaluation included a physical exam
and other verification methods at the discretion of the
examining physician, including direct visualization, color-
imetric ETCO2, and esophageal detector device. Capture of
a consecutive sample was ensured by cross checking
physician data sheets against all ED charts with prehospital
intubations. Results: During the 6 month enrollment period,
155 prehospital intubations were evaluated consisting of 120
medical (77.4%) and 35 trauma (22.6%) patients. 7.1% of
intubations were found to be incorrectly placed outside the
trachea (7.5% medical and 5.7% trauma). Conclusions:
These results are more consistent with previous field veri-
fication studies and are not consistent with a recent study
using physician verification of prehospital intubations.
078 Quality of Life Outcomes for Respiratory Distress
Patients Treated by EMS Graham Nichol, Ian G Stiell,
Josee Blackburn, Tina Luciano, Lisa Nesbitt, George A Wells, Ella
Huszti, , for the OPALS Study Group; ; University of Ottawa:
Ottawa, Ontario, Canada, Queens University: Kingston,
Ontario, Canada, University of Western Ontario: London,
Ontario, Canada, Niagara Regional Base Hospital: Niagara
Falls, Ontario, Canada, Ontario Ministry of Health: Toronto,
Ontario, Canada, University of Arizona: Tucson, AZ
Objectives: Little is known about the outcomes of re-
spiratory distress patients treated by EMS. We followed
a group of these patients to measure their health-related
quality of life (HQRL). Methods: The Ontario Prehospital
Advanced Life Support (OPALS) Study is a large multicen-
ter initiative to evaluate the impact and cost-effectiveness of
EMS programs on 40,000 critically ill and injured patients.
As part of the ongoing OPALS Study economic evaluation,
we conducted a prospective cohort study and included
consecutive adult respiratory distress patients treated in the
BLS-D/ALS EMS system of one OPALS Study city over a
5-month period. Patients were interviewed every 3 months
for up to one year after discharge by a study nurse using the
Health Utilities Index Mark 3 (HUI3) HQRL tool. HUI3
consists of 8 attributes (vision, hearing, speech, mobility,
dexterity, emotion, cognition, and pain), and is scored from
0 (equal to dead) to 1 (perfect health). Results were
evaluated by using descriptive and regression analyses.
Secondary analyses will compare these scores to those after
cardiac arrest and correlated HUI3 scores with process
measures. Results: Of 169 eligible patients, 152 were
interviewed at least once and had these characteristics:
mean age 67.7 (SD 18.3), female 54.4%, EMS status severe or
life threatening 42.6%, length of stay in days median 6.0
449
(IQR 2.5–10.5) and survival to discharge 85.7%. During the
follow up period, 70 patients died (41% of eligible). HUI3
scores at 3, 6, 9 and 12 months post discharge were median
(IQR): 0.47 (0.17–0.78); 0.51 (0.21–0.80); 0.41 (0.11–0.70); and
0.54 (0.26–0.81), P value for trend [0.05. Conclusions: This
is the first longitudinal study of HRQL of patients with
respiratory distress transported by EMS. HRQL is stable in
this population but the scores are much lower than those for
cardiac arrest patients (median 0.80). These data are critical
inputs to analyses of whether ALS EMS care for respiratory
distress patients is cost-effectiveness.
079 Ultrasound in Helicopter EMS William G Heegaard,
David Plummer, RJ Frascone, Greg Pippert, David Steele, David
Dries; Hennepin County Medical Center: Minneapolis, MN,
Regions Hospital: St. Paul, MN, Lifelink III: Minneapolis, MN,
St Cloud Hospital: St. Cloud, MN
Introduction: Recent advances in ultrasound (US) have now
made out of hospital US feasible. It has been shown that
paramedics and nurses can perform cardiac, abdominal and
pelvic US exams. Objectives: In this study, we evaluated the
ability of air medical clinicians (AMCs) to perform cardiac,
abdominal and pelvic US in the helicopter environment
with EP’s supervision for quality assurance. Our hypothesis
was that AMCs would be able to produce adequate US
images with a high degree of correlation between AMC and
EP interpretations. Methods: Hennepin County Medical
Center’s IRB approved this study. A SonoSite 180 was used
to perform the ultrasound examinations. All images were
captured and then downloaded into A PC format and
over read by one of the authors (WGH). All studies were
performed in a Bell 222 out of one base location. Conve-
nience sampling was employed from August 1, 2001 to July
31, 2002. Results: A total of 100 US examinations were
included, 39 medical, 52 trauma, 8 obstetrical, and 1 neonatal
patient. Regarding both medical and trauma cardiac US 93%
(85/91) were read as negative by the AMC and MD for
pericardial effusion, and 1% (1/91) as positive for pericardial
effusion by the AMC and MD. In 5.4% (5/91) of the cardiac
cases the AMC was unable to get an adequate US view. No
false positive or negative cardiac US were performed by the
AMC. In trauma cases, the hepatorenal view was read as
negative for fluid in 75% (39/52), 5.7% (3/52) were true
positives, 5.7% (3/52) false positives, and 3.8 (2/52) false
negatives. In 9.6% (5/52) of the hepatorenal cases the AMC
was unable to obtain an adequate view. Splenorenal and
pelvic views were performed in less than 50% of cases and
a true FAST exam was only performed in 23% of trauma
cases due difficultly accessing these views and time
constraints. Conclusions: AMCs can successfully perform
US in a helicopter environment. The FAST exam may not be
the appropriate goal for Helicopter EMS.
080 The Effect of Bunker Gear on Physician Performance
of Advanced Life Support Procedures C Crawford
Mechem, Jessica Hill, Frances S Shofer, Edward T Dickinson;
Hospital of the University of Pennsylvania: Philadelphia, PA
Background: Physicians (MDs) at times assist emergency
medical services (EMS) personnel with patient care in the
prehospital setting. Physical hazards may require them to
450
use the same bunker gear worn by firefighters and
paramedics. Most MDs have no experience working in this
gear, and little is known about its impact on their
performance of advanced life support (ALS) skills. Objec-
tive: To determine if wearing bunker gear affects the speed
with which MDs perform endotracheal intubation (EI)
and intravenous (IV) line placement. Methods: This was a
prospective crossover study of a group of 17 emergency
medicine residents and 4 attendings. 4 were female. Mean
ages of the residents and attendings were 29.0 and 38.5
respectively. ALS skills assessed were EI of a manikin head
and IV insertion on a training arm. To standardize the
process, EI was broken down into 4 steps and IV insertion
into 3. Participants were randomized to first perform the
skills in regular work clothes or in bunker gear, which
consisted of turnout coat, bunker pants, and fire helmet with
visor. All wore latex gloves. Each skill was performed three
times. Following a washout period averaging 8.2 days
hours, the subjects repeated the skills in the other outfit.
Skills were timed by the same individual and averages
calculated. Data were analyzed by analysis of variance in
repeated measures and presented as means 6 SE. Results:
12 participants started in bunker gear and 9 in work clothes.
The average times for EI in bunker gear and work clothes
were 69.9 6 6.2 sec and 68.0 6 7.1 sec respectively. The
average times for IV line placement in bunker gear and
work clothes were 45.4 6 3.1 sec and 46.4 6 3.6 sec
respectively. Participants were significantly slower during
the first ALS skills performed, regardless of the uniform
worn. Conclusions: The use of bunker gear did not ad-
versely affect the speed with which MDs performed ALS
skills. Its use should not impede MDs’ ability to provide
medical support to EMS systems.
081 Adverse Events Resulting from the Discontinuation
of Prehospital Droperidol Use Marc Martel, James
Miner, Kristin Sufka, Ryan Fringer, Joseph Clinton, Michelle
Biros; Hennepin County Medical Center: Minneapolis, MN
Background: Droperidol (Drop) use has declined since the
FDA warning of potential QT prolongation and torsade de
pointes. Alternative therapies for the treatment of agitation
have been employed in order to safely transport patients
to the ED. Objectives: To detect a change in the rates of
continuous ED pulse oximetry (POX) monitoring and in-
tubation in patients receiving prehospital Drop or mid-
azolam (MDZ) for agitation from all causes. Methods: An
iMedics electronic database search was performed from
January 1, 2001 through December 5, 2002 for patients
receiving either Drop or MDZ in the prehospital setting.
Patients were divided into 4 groups, those receiving Drop
or MDZ in 2001 and 2002. Records were reviewed for
paramedic assessment, ED POX monitoring, and intubation.
Data was analyzed using descriptive statistics and chi-
squared. Results: 72 patients received either Drop or MDZ
for agitation prior to arrival in the ED. Drop was removed
from the prehospital formulary; subsequently no patients
received Drop in 2002. Drop was used in 42 agitated
patients in 2001. MDZ was used in 3 agitated patients in
2001 and 27 in 2002. Continuous POX monitoring rates were
8/42 (19.0%) for Drop, 3/3 (100%) for MDZ in 2001, and 18/
27 (66.7%) for MDZ in 2002. The change in continuous POX
2003 SAEM ANNUAL MEETING ABSTRACTS
monitoring rates for agitated patients receiving Drop in 2001
and MDZ in 2002 was statistically significant (p \ 0.001).
Intubation rates for agitated patients were 4/42 (9.5%) for
Drop, 2/3 (66.7%) for MDZ in 2001 and 10/27 (37.3%) for
MDZ in 2002. The change in intubation rates for agitated
patients receiving Drop in 2001 and MDZ in 2002 was
statistically significant (p ¼ 0.006). Conclusions: The in-
creased use of MDZ in 2002 appeared to result in a sig-
nificantly increased rate of continuous POX monitoring and
intubations required for agitated prehospital patients, com-
pared to the use of Drop in the same patient group in 2001.
082 Effect of a Paramedic Pain Management Training
Program on Pre-hospital Analgesic Use David
Lovesky, Steven Bird, Marc Restuccia, Ginger Mangolds,
Eric W Dickson; UMASS Memorial Medical Center:
Worcester, MA
Objective: To determine the effect of a pain management
training program on the utilization of analgesics by
paramedics in a pre-hospital setting. Methods: A six month
retrospective chart review was completed from September
1, 2000 to February 28, 2001 on patients transported by
an urban EMS system with a chief complaint of isolated
extremity trauma. Data extracted included patient demo-
graphics, use of any pre-hospital analgesics and documen-
tation of a pain assessment. A departmental survey was
then conducted to determine paramedic rational for
withholding analgesics from this patient population. Data
from the six-month chart review and survey was then
incorporated into a departmental training session focusing
on the following topics: the establishment a standardized
pain scale (0–10 Numeric Rating Scale), the efficacy of
analgesics such as Morphine and Fentanyl and the eli-
mination of barriers to analgesia including the miscon-
ception that short transport times result in a more rapid
ED pain intervention. A second six-month chart review
beginning immediately after the training session was then
conducted. Results: A total of 25,655 EMS charts were
screened with 847 (446 pre-training session and 401 post-
training session) identified as involving isolated extremity
trauma. Prior to the departmental training session only 11%
of patients transported received any analgesics. This was in
sharp contrast to the 31% receiving pain medication in the
six months immediately following the training program
(p \ .05 by chi squared analysis*). As with analgesic use
a similar three fold increase in pain assessment documen-
tation was seen in the pre-post training program (14% vs
48%* respectively). Conclusions: A self reflective pre-
hospital pain management training program significantly
improved analgesic use and pain assessment documenta-
tion by paramedics. Further investigation to determine how
long the improvements last and the effect on patient
satisfaction are warranted.
083 Frequency of Use of Prehospital Blood Specimens
for Emergency Department Diagnostic
Testing Jason Allen Borton, Kevin Hoyt; Erie County
Medical Center: Buffalo, NY
Introduction: Local ALS protocols for the Western New
York region recommend that blood samples should be
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
drawn when an IV line is started. No known study has
investigated whether these prehospital blood specimens are
routinely used for diagnostic testing purposes for emer-
gency department patients. Objectives: To study how often
prehospital collected blood specimens are used for di-
agnostic testing in the emergency department. Our working
hypothesis is that most specimens collected in the pre-
hospital setting will not be used for diagnostic testing
purposes. Methods: A four month prospective observa-
tional study was conducted for patients that came in to
the study hospital with an IV line established. It was de-
termined whether bloods were collected by EMS personnel.
If the bloods were drawn, the number of tubes of blood
collected was recorded. If diagnostic tests were ordered,
then the number of prehospital drawn blood tubes that were
sent to the lab was recorded. Nurse drawn bloods were also
recorded. Results: 346 patients had IV lines established. 93
(26.9%) of these patients had no blood drawn by EMS
personnel while 253 (73.1%) had blood collected by EMS.
For cases where EMS blood was drawn, only EMS blood
was used in 128 (50.5%) cases, EMS and nurse drawn blood
was used in 52 (20.6%) cases, and only nursing blood was
used in 30 (11.9%) cases. No orders for blood tests were
received in 43 (17%) cases. For the 253 patients that had
blood drawn by EMS personnel, 1,170 tubes of blood were
drawn, an average of 4.6 tubes of blood per patient. Of these
1,170 tubes only 498 (42.6%) were used for diagnostic
purposes, while 672 (57.4%) were discarded. An average
of 2 tubes of prehospital obtained blood was used for
diagnostic testing purposes. Conclusions: EMS collected
blood tubes are often used for diagnostic purposes. EMS
personnel should decrease the number of tubes of blood
collected as more than half of collected tubes are not used
for diagnostic testing.
084 Glasgow Coma Scale and QTc Period: Can It Help
Us in the Prognosis of Patients with
Organophosphate Poisoning? Stefek Grmec, Petra Klemen,
Stefan Mally, Darko Cander; Center For Emergency
Medicine Maribor: Maribor, Slovenia
Objectives: In our area, organophosphate poisoning is
a frequent method of commiting suicide. The aim of this
study was to assess the value of the GCS and QTc period in
predicting outcome or complications during treatment.
Methods: This prospective study was undertaken from
February 1997 to May 2002 and included patients for whom
organophosphate poisoning was confirmed by means of
anamnesis and laboratory analysis (serum cholinesterase).
EtCO2, SaO2, QTc period and initial GCS values were
collected in prehospital setting. We compared group of
patients with respiratory failure and group without com-
plications. Sensitivity-Sn, specificity-Sp and correct pre-
diction of outcome-CPO were measured using the x2
method. The best cutoff point in GCS and QTc period was
determined using the Youden index. The difference in
Youden index was calculated using the Z score. For GCS
and QTc period, Receiver operating characteristic (ROC)
curve was obtained. The difference in ROC was calculated
using the Z score. P \ 0.05 was considered statistically
significant. Results: 65 patients (39 male and 26 female)
from 18–75 years with mean 56,9 6 17,5 were included, 31
had respiratory complications. EtCO2, SaO2 and initial GCS
451
values were significantly lower and QTc period longer (0,69
6 0,13s vs. 0,43 6 0,10s) in patients with complications.
Cutoff point for GCS was 6, Sn 70,2%, Sp 87,3%, CPO 82,1%,
ROC area 0,88; cutoff point for QTc was 0,65s, Sn 68,3%, Sp
84,5%, CPO 79,8%, ROC area 0,84. No significant difference
was found comparing CPO (P ¼ 0,81) and ROC area (P ¼
0,90) of GCS and QTc period. Conclusions: In the initial
nursing in prehospital setting of patients with organophos-
phate poisoning, monitoring of the QTc period and GCS is
essential, for it helps us in the prognosis of the patients and
suggests precaution due to the danger of complications
(respiratory failure). These parameters therefore facilitate
good ‘‘clinical communication’’ between prehospital work
and further hospital procedures and treatments.
085 Emergency Department Gridlock and Pre-hospital
Delays for Cardiac Patients Michael J Schull,
Laurie J Morrison, Marian Vermeulen, Donald A Redelmeier;
Sunnybrook and Women’s College Health Sciences Center:
Toronto, Ontario, Canada, University of Toronto:
Toronto, Ontario
Objective: To determine the effect of simultaneous ambu-
lance diversion at multiple emergency departments (grid-
lock) on transport delays for patients with chest pain.
Methods: Retrospective data on consecutive ambulance
patients with chest pain and the diversion status of EDs
in Toronto were obtained from January 1998 to December
1999. Gridlock was calculated separately for the four city
quadrants as the daily duration of episodes where all EDs
in the quadrant were simultaneously diverting ambulances.
The primary outcome was 90th percentile ambulance Trans-
port Interval (scene departure to hospital arrival). Results:
11,400 patients were included (mean age 67 years; female
51%; severity of illness moderate to life-threatening 89%).
Ambulance diversion resulting in gridlock was associated
with prehospital delays. Gridlock occurred an average 1.1
hour/day, and 3060 patients were transported on days when
it occurred. 90th percentile Transport Interval was 15.5min
(95%CI 15.3–15.9) for patients not exposed to gridlock vs.
17.4min (95%CI 16.8–17.8) for patients who were exposed to
gridlock. In multivariate analyses, gridlock was associated
with both Transport and Total Prehospital Interval delays
(0.2min/hour, 95%CI 0.1–0.4 and 0.2min/hour, 95%CI 0.04–
0.4 respectively), but the duration of ambulance diversion
was not associated with delays when gridlock was con-
trolled for. Delays were similar regardless of patient severity
of illness (p ¼ 0.5), and regardless of the duration. Age
(0.8min/10 years, 95%CI 0.5–1), female sex (1.9min, 95%CI
1.3–2.6), advanced care paramedics (5.3min, 95%CI 4.4–6.3),
and snowfall (0.8min/cm, 95%CI 0.2–1.5) were also in-
dependently associated with delays. Conclusions: Ambu-
lance diversion was associated with delays in prehospital
ambulance transport for chest pain patients, but only when it
resulted in gridlock. The magnitude of the prehospital delay
was the same regardless of the patient’s severity of illness.
086 Characteristics of Patients with Chest Pain
Arriving by Ambulance vs Private Transport
James M Christenson, Grant D Innes, Eric J Grafstein,
Barbara A Boychuk, Hubert Wong, Joel Singer, Karen P Wanger,
452
Ross G Berringer; Providence Health Care, University of British
Columbia: Vancouver, British Columbia, Canada, Vancouver
General Hospital: Vancouver, British Columbia, Canada,
British Colubmia Ambulance Service: Vancouver,
British Columbia, Canada
Objectives: Approximately 50% of patients with a final
diagnosis of AMI arrive to emergency departments by
ambulance. Regional policies for the care of ACS often focus
on patients transported by ambulance. We hypothesized
that patients with chest pain arriving by ambulance are
demographically distinct and more likely to have acute
coronary syndrome (ACS). Methods: We compared patients
enrolled in a prospective cohort study of 1819 patients
presenting with chest pain who arrived by ambulance
(AMB) or not (nonAMB). Subjects were consecutive con-
senting patients [25 years old, living in British Columbia
with complete follow-up at 30-days. Explicitly defined
diagnoses were applied for categories of ACS: AMI, definite
unstable angina (UA), possible UA, no ACS with an adverse
event (AE) and no ACS/AE. We compared presenting
demographics, risk factors, diagnostic outcomes and mor-
tality. Differences with 95% confidence intervals were
calculated. Results: 564 (31%) of patients arrived by
ambulance. The AMB and nonAMB groups were 64.6 vs
55.4 years old (95% CI of difference; 7.7,10.8), were 52% vs
61% male (95% CI of difference;
14,
4%), took a median
time of 100 min vs 135 min from symptom onset to ED
arrival (95% CI of difference;
42,
6), had an incidence of
54% vs 35% of past AMI or angina (95% CI of difference;
14,23), had a 19% (106/564) vs 11% (135/1255) final outcome
of AMI (95% CI of difference; 4,12) and a 8% (43/564) vs 9%
(114/1255) incidence of no unstable angina (95% CI of
difference;
4,1). Conclusions: Patients with chest pain who
arrive by ambulance are different from those not using
ambulance services. They are older, less likely to be male,
have shorter duration of symptoms, more likely to have
previous coronary disease and more likely to have ACS.
However, just as many patients with ACS arrive by private
means, highlighting the need for regional carepaths to
include strategies for patients who do not arrive by
ambulance.
087 Comparison of Endobronchial and Endotracheal
Epinephrine Delivery Methods Mark E Brauner,
Henry D Prange; Ohio University College of Osteopathic
Medicine: Athens, OH, Indiana University: Bloomington, IN
Objective: This study was designed to compare the efficacy
of endotracheal and endobronchial epinephrine (EPI)
administration using three different methods, during acute
hypotensive crisis in dogs. Methods: Prospective, random-
ized, experimental laboratory protocol. SUBJECTS: Six adult
female hounds weighing 28–32 kg. Interventions: Acute
hypotension (Mean Aortic Pressure (MAP) 20–25 mmHg.)
was induced using Esmolol (loading dose 5 mg/5 min
followed by an infusion of 700 mg/min for 5 minutes).
Epinephrine (20 mg/kg) or placebo (0.9% sodium chloride)
was administered into the proximal lumen of the endotra-
cheal tube (method 1), or endobronchially using a 5 French
catheter with the tip placed at the distal tip of the
endotracheal tube (method 2), or endobronchially using
2003 SAEM ANNUAL MEETING ABSTRACTS
a multi-lumen gas-driven aerosolizing catheter with the tip
placed at the distal tip of the endotracheal tube (method 3).
Forty-six inductions were performed including 12 control
inductions with placebo. Results: Before and after placebo
or EPI administration, samples were obtained from the
proximal aorta to measure plasma EPI concentration at
pharmacodynamically important intervals specific to EPI.
MAP was measure continuously at the proximal aorta.
Plasma EPI concentration and MAP data were analyzed
using ANOVA. Epinephrine administration via method 3
resulted in significant increases in plasma EPI concentration
and MAP (P ¼ .0001) over the other two methods with
decreasing relative efficacy of M3  M2 [ M1, respectively.
There was no significant difference between M2, M1 and
control. There was also less point-to-point standard de-
viation of the plasma concentration data with M3 over M2
and M1. Conclusion: During resuscitation from a chemically
mediated acute hypotensive crisis in hounds, EPI adminis-
tered endobronchially via an aerosolizing catheter is signi-
ficantly more effective and less variable than the other forms
of endobronchial or endotracheal administration tested
within this protocol.
088 The Effect of Race/Ethnicity on Survival to
Hospital Discharge after Out-of-hospital Cardiac
Arrest: A Survival Disadvantage for Whites
Jason S Haukoos, Roger J Lewis, James T Niemann;
Harbor-UCLA Medical Center: Torrance, CA
Objectives: Several recent studies report conflicting results
with respect to the effect of race/ethnicity on survival after
prehospital cardiac arrest, and with respect to the effects of
confounding factors. The purpose of this study was to re-
evaluate this effect in the setting of other prognostic factors,
including the site of arrest. Methods: This was a retrospec-
tive cohort study performed at an urban county teaching
hospital. The records for consecutive adult patients treated
for prehospital nontraumatic cardiac arrest and transported
to our institution between 1994 and 2002, were reviewed.
Study variables included age, sex, race/ethnicity (non-
Hispanic white or non-white), whether the arrest was wit-
nessed, whether bystander CPR was performed, the initial
arrest rhythm, site of the arrest, paramedic response time,
and whether the patient survived to hospital discharge
(SHD). An unadjusted OR for race/ethnicity and SHD was
calculated with a 95% CI. Adjusted analyses using logistic
regression were performed for all covariates in order to
assess the independent effect of each on the association
between race/ethnicity and SHD. Results: 848 cardiac arrest
patients were included in this study. Of these, 42 (5%) SHD.
The median age was 69 (IQR 57–79) years, and 483 (58%)
were non-white. The unadjusted OR for SHD in non-
Hispanic white patients was 0.4 (95% CI 0.2–0.9) with
respect to non-whites. Age, sex, whether the arrest was
witnessed, whether bystander CPR was performed, the
initial arrest rhythm, and paramedic response time did
not significantly affect the OR or 95% CI during adjusted
analyses. Adjustment for site of the arrest only slightly
modified the OR (OR 0.5, 95% CI 0.2–1.1). Conclusions: In
our population, non-Hispanic white patients had decreased
odds of SHD. None of the covariates studied accounted for
this effect. This result contradicts earlier work and demon-
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
strates that the direction of the effect of race/ethnicity on
SHD is dependent on setting and population.
089 Age Is Associated with Elevated Troponin T in
Out-of-hospital Cardiac Arrest Christopher S Lai,
David Hostler, Brian J D’Cruz, Clifton W Callaway;
University of Pittsburgh: Pittsburgh, PA
Objective: The incidence of myocardial ischemia preceding
out-of-hospital cardiac arrest (OOHCA) is unknown. Ele-
vated cardiac troponin levels are an early, persistent and
sensitive blood marker of myocardial ischemia. This study
determined the frequency of elevated cardiac troponin T
(TnTþ) levels in patients at the time of OOHCA, and the
association of clinical characteristics with TnTþ. Methods:
Citrated blood was collected during resuscitation from
subjects (age [18 years) with non-traumatic OOHCA.
Plasma was frozen at
708C until TnT was assayed by
elecrochemiluminescence using Roche Elecsys 2010. Values
in the normal range (0.0–0.03 ng/ml) were considered
normal (TnT
) and values [0.03 were positive (TnTþ).
Associations between clinical variables (age, sex, witnessed
arrest, bystander CPR, or initial rhythm), TnT, and outcome
(tranport, return of pulse) were assessed using multivariate
logistic regression and Fisher’s Exact test. Results: In 63
subjects with sufficient plasma for analysis, TnT levels
ranged from \0.010–1.040. (mean 0.09 6 0.21 ng/ml), with
TnTþ in 25 patients (39.7%). Detailed clinical data were
available for 59 subjects (22 TnTþ ¼ 37%). Proportions of
VF (26%), asystole (49%) and PEA (25%) as initial rhythm,
sex (55% male), witnessed arrests (58%) and bystander
CPR (35%) were similar between groups. Correcting for all
variables, increasing age was significantly associated with
positive troponin (odds ratio: 1.11, [95% CI:1.04, 1.17]).
Conversely, the TnTþ group was older than the TnT

group (57 6 15 vs. 72 6 12 years, t ¼ 3.94; p \ 0.001). Being
TnTþ vs. TnT
was not associated with return of pulses in
the field (24% vs. 49%, p ¼ 0.09), or in the ED (21% vs. 42%,
p ¼ 0.15), but was associated with a decreased likelihood of
transport to the hospital (40% vs. 69%, p ¼ 0.03). Con-
clusion: Increasing age is associated with TnTþ in OOHCA,
which may be associated with poorer short-term outcome.
Antecedent myocardial ischemia may be an important
contributor to OOHCA.
090 Protocol Adherence of Community Sites in the
Public Access Defibrillation Trial Robert E
O’Connor, Eleanor Schron, Andy Anton, Jennifer Holohan,
Mary A Peberdy, David Reed, Lois Van Ottingham, Alice
Birnbaum, , the PAD Investigators; ; PAD CTC: Seattle, WA
Objectives: The purpose of this study is to identify patterns
and characteristics associated with site adherence to the
Public Access Defibrillation (PAD) Trial protocol. Methods:
The PAD Trial recruited community sites to evaluate the
impact on survival from out-of-hospital cardiac arrest
(OOH-CA) when automated external defibrillators (AEDs)
are added to a volunteer-based lay OOH-CA response team.
Sites were grouped into either residential or public (hotel/
convention, shopping, community center, entertainment,
participant recreation, transit, office, industrial and other).
453
Volunteers at each site were trained to perform either CPR
or CPR þ AED skills according to site randomization
assignments. Four types of site non-adherence have been
defined: crossover (from assigned treatment arm), adminis-
trative drop (location closed or withdrew, unrelated to
randomization), withdrawal (site decided not to participate
in the trial), and never trained (unable to complete training).
Statistical analysis used chi-square test. Results: A total of
1304 entities participated, 211 did not adhere to the protocol,
with 29 (2%) crossovers 45 (3%) administrative drops, 50
(4%) withdrawals, and 87 (7%) never trained. Adherence
ranged from 73% (industrial, residential) to 97% (hotel/
convention). When compared with public, residential sites
had a higher percentage that dropped out (12% vs. 2%) or
were administratively dropped. (9% vs. 2%) (p # 0.001)
Public sites had a higher proportion of sites where volun-
teers were never trained. (7% vs. 3%) (p # 0.05) Both types
of sites had 2% crossover rates. (p ¼ NS) Twenty-four (83%)
of the crossovers crossed from the CPR to the CPR þ AED
arm. Conclusion: Adherence to the PAD protocol was good
overall (84%) but varied by type of site. Residential sites had
a significantly higher proportion of dropouts compared
with public, which had a higher proportion of sites never
trained. Crossovers were higher in sites randomized to the
CPR arm, but did not vary by type of site.
091 Retention of Advanced Cardiac Life Support
(ACLS) Skills Taught in a One-day Course Is Better
than That Found after a Two-day Course D Matthew
Sullivan, Mary Smith, David Hudson; Carolinas Medical
Center: Charlotte, NC, Central Piedmont Community
College: Charlotte, NC
Background: Recent revisions have made ACLS training
less cumbersome to teach and learn. Despite this, retention
of these skills over time is recognized to be poor. Objectives:
Our hypothesis is that physician providers will have similar
retention if material is presented in one day when compared
to the standard two-day course. Methods: Incoming first-
year housestaff were consented and then randomized (n ¼
18) to either an intensive one-day curriculum or the
standard two-day ACLS course. The two groups underwent
standard initial written and megacode testing, and then
were retested without warning using a standardized mega-
code scenario one month later. Performance was determined
using a pre-conceived score sheet for resuscitation skills.
Comparison of scores between the two groups was
performed using unpaired t-test of equal variance. Results:
Comparison of written test score and initial megacode
performance was not different between the two groups.
However, at one-month follow-up megacode testing, first-
year residents participating in the two-day course scored
significantly lower, with a mean score of 19 (610) compared
to one-day participants score of 31.1 (61.8) (p ¼ 0.003, 95%
CI 4.9–19.32) (Power with alpha of 0.05 ¼ 0.91). Conclusion:
Despite this small sample size, incoming housestaff taught
via a one-day curriculum not only had the same initial pass
rate, but better retention of resuscitation skills when com-
pared to those housestaff taught via the standard two-day
course. Development of an intensive curriculum for ad-
vanced providers might improve retention over time in
this given subset of students.
454
092 Ischemically Induced Ventricular Fibrillation (VF):
A Comparison of Fixed and Escalating Energy
Defibrillation James T Niemann, Robert G Walker, John P
Rosborough; Harbor-UCLA Medical Center: Torrance, CA,
Medtronic PhysioControl Corporation: Redmond, WA
Background: Electrically induced VF in animals with a low
transthoracic impedance (TTI) (30–50 ohms) is readily
terminated by lower energy (150J) shocks. We hypothesized
that a model of ischemically induced VF combined with
a TTI more typical of humans would require higher energy
shocks for defibrillation. Methods: 46 swine were random-
ized to fixed, low energy (150J) transthoracic shocks (Group
1) or escalating, higher energy (200-300-360J) shocks (Group
2). Thirty ohms were added in series to the measured TTI of
each pig. VF was induced by percutaneous balloon oc-
clusion of a coronary artery. After 1 min or 5 min of VF,
countershocks with a biphasic truncated exponential wave-
form were administered using adhesive electrodes. The
primary endpoint was successful defibrillation (termination
of VF for 5 sec) with #3 shocks. Differences between groups
were assessed using the Mann-Whitney Rank Sum Test and
Fishers exact test. Results: VF was induced with occlusion
or following reperfusion in 35 animals (Group 1, n ¼ 17;
Group 2, n ¼ 18). The median TTI (with interquartile range)
was not different between groups (Group 1, 82[77–89] ;
Group 2 84[81–86] ohms). First shock peak current was
greater (p # 0.001) in Group 2 (19.7[18–920.1]) than in Group
1 (16.0[15.5–16.9]). Only 5 group 1 animals (29%) could be
defibrillated with #3 shocks, each at 150J. Fifteen of 18
Group 2 animals (83%) were defibrillated with #3 shocks (p
# 0.002 vs Group 1). Nine of the 12 Group 1 animals (75%)
that could not be defibrillated with 150J shocks were
rescued with #3 shocks ranging from 200–360J. Conclu-
sions: In this ischemic VF animal model, 1. fixed, lower
energy shocks were less effective than higher energies
delivered in an escalating protocol, 2. the effective energy
dose for defibrillation was higher than that reported in
electrically induced VF, and 3. higher energy rescue shocks
were effective after failed low energy shocks.
093 The Fallacy of Energy as an Accurate Descriptor of
Relative Shock Intensity among Different
Clinically Used External Defibrillators Robert G Walker,
James T Niemann, John P Rosborough; Medtronic
Physio-Control: Redmond, WA, Harbor-UCLA Medical Center:
Torrance, CA
Objective: Concern exists over the possibility of myocardial
injury caused by defibrillation shocks. The potential for
shock-induced injury is known to be a function of shock
electric field intensity (voltage gradient–VG). However,
shocks are commonly described in terms of their energy
setting (ES) or delivered energy (ED), and there is sub-
stantial confusion over the significance of ES and ED as
descriptors of relative shock intensity, particularly among
different devices. To assess the correlation between shock
energy descriptors and VG, we measured intracardiac VGs
produced by clinically used shock doses from 4 common
external defibrillators. Methods: One monophasic (A) and 3
biphasic (B, C, D) devices were compared using trans-
thoracic sinus rhythm shocks at simulated human imped-
ance in 5 swine. For each shock, VG measurements via
2003 SAEM ANNUAL MEETING ABSTRACTS
multielectrode-tipped catheters were averaged across 3
intracardiac sites, and ED, impedance, and peak current
were recorded. Results: Impedance averaged 76 6 4 ohms
for all shocks. VGs (volts/cm) for shocks at 150 J, typical 1st
shock ES, and maximum ES from each device are shown.
150 J 1st (ES) maximum (ES)
A 11.4 6 3.3 13.5 6 3.8 (200 J) 18.4 6 5.3 (360 J)
B 7.3 6 1.6 8.5 6 1.8 (200 J) 11.5 6 2.4 (360 J)
C 8.5 6 1.8 7.7 6 1.5 (120 J) 11.8 6 2.5 (200 J)
D 9.6 6 2.4 9.6 6 2.4 (150 J) 11.5 6 3.3 (200 J)
In each animal, VG was strongly correlated to peak current
(mean R-squared ¼ 0.98 6 0.01, p \ 0.05 vs ES, ED) but not
ES (0.30 6 0.02) or ED (0.19 6 0.02). Conclusions: Among
different defibrillators, energy correlates very poorly to
actual shock intensity. At clinically used doses, monophasic
shocks expose the myocardium to substantially higher VGs
than biphasic shocks, even when ES is the same. Despite
divergent ES and ED, different biphasic defibrillators
produce comparable VGs at their maximum ES. If there is
a clinical risk of shock injury, it is equivalent among these
biphasic devices, and significantly greater for this mono-
phasic device.
094 The Impact of Emergency Medicine Student
Clerkships on Ambulatory Medical Education:
An Encounter-based Analysis John F Mahoney,
Elaine A Chong; University of Pittsburgh School
of Medicine: Pittsburgh, PA
Objective: A challenge posed by the increasing proportion
of medical student and resident education occurring in
outpatient settings is ensuring that they consistently have an
adequate breadth and depth of patient encounters. The
study objective was to determine the extent to which an
emergency medicine (EM) rotation can provide MS with
exposure to core ambulatory conditions. Methods: This
retrospective study analyzed 48,029 Learning Log entries
filed by 282 third year MS over 2 years, during a required 12-
week community/ambulatory medicine clerkship (CAMC).
CAMC consists of 3-week rotation in medicine (IM), family
medicine (FM), pediatrics, and a selective rotation in one of
these or EM. Log entries were from a list of 86 acute and
chronic ambulatory Symptoms, Diagnoses and Procedures.
Data analysis determined whether MS encountered each
diagnosis (DX) within each rotation of the clerkship, re-
flecting at least a minimum level of exposure to each DX.
Results: IM and FM results were compared with the subset
of 58 Adult EM MS. The average number of encounters
logged per MS was 42 in EM, 62 in IM, and 74 in FM. EM MS
encountered the full range of ambulatory Diagnoses, in-
cluding many that are considered primarily office condi-
tions. MS who did not participate in EM had exposure to
most of the same Diagnoses at some point during the overall
clerkship. However, for the subset of essential core Symptom
presentations, identified by published EM, IM and FM
curricula, MS were as or more likely to encounter these
patients during EM compared to IM or FM.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
% of MS who saw 1 or more patients with DX
Symptom EM IM
Abdominal Pain 86% 50%
Chest Pain 73 47
Syncope 53 22
Vomiting 69 17
Conclusion: EM rotations offer a time-economical solution
to satisfying a broad range of curricular goals. Rotations in
the unique ED environment may address curricular gaps not
readily filled by other medical school experiences.
095 The 2002 Emergency Medicine Program Directors’
Survey Michael S Beeson, John V Weigand, Sharhabeel
Jwayyed, Lowell W Gerson, Gloria Kuhn; Summa Health
System: Akron, OH, Northeastern Ohio Universities College of
Medicine: Rootstown, OH, Wayne State University: Detroit, MI
Objectives: To characterize emergency medicine (EM) pro-
gram directors (PDs). Methods: An online survey was
emailed to all ACGME approved EM PDs, and included
queries as to PD demographics, work hours, support staff,
potential problems, salary/expenses, and satisfaction. Re-
sults: 109/124 (87.9%) PDs (69.7% University, 27.5% Com-
munity, and 2.8% Military) completed the survey. 85.3% of
PDs are male. Mean age is 43.6 years (95% CI 42.6–44.7). The
mean time as PD is 5.7 years (95% CI 4.9–6.5), with 56% five
years or less. The mean time expected to remain PD is 6.0
years (95% CI 5.2–6.8). 65% had previously been associate PD.
63% would leave the position for promotion. Median
monthly hours are: clinical- 75, scholarly activity- 20, admin-
istrative- 80, and teaching/residency conferences- 20, for
a total of 195 hours per month. Median days expected to be
out of town for conferences is 20. Mean total FTEs of Asst. PD
is 0.77 (95% CI .65–6.8). 35% have a separate residency se-
cretary and coordinator. Of multiple potential problems
listed, lack of adequate time to do the job required, career
needs interfering with family needs, and lack of adequate
faculty help with residency matters were identified as most
problematic (mean of 3.5 (95% CI 3.2–3.7), 3.4 (95% CI 3.2–3.6),
and 3.1 (95% CI 2.9–3.3) respectively, on a scale of 1 to 5, 5
maximum). Median non-reimbursed expense amounts are:
Foundation giving- $250; conference attendance- $500; and
residency donation- $500. Median salary range is $176,000 to
$200,000. 61% receive additional CME/travel expenses com-
pared to other faculty. 75% believe there is a need for in-
creased clinical service dollars to support the residency. On
a scale of 1 to 10 (highest), the mean satisfaction with the posi-
tion of PD is 8.0 (95% CI 7.7–8.3). Conclusions: EM PDs are
predominantly male, work in a University setting, have been
PD less than 5 years, and have previously served as associate
PD. There is high satisfaction with the position of EM PD.
096 Impact of Medical Trainees on Clinician Efficiency
and Diagnostic Utilization Grant D Innes,
Julian J Marsden, James M Christenson, Eric J Grafstein,
Robert Stenstrom; Providence Health Care, St. Paul’s Hospital:
Vancouver, BC, Canada, University of British Columbia:
Vancouver, BC, Canada
Objectives: Trainees may enhance emergency physician
(EP) efficiency by reducing the time they spend with each
455
patient, but trainees may also increase diagnostic utilization.
Our hypothesis was that trainee care would reduce EP time
FM
with patients, increase hospital admission rates and prolong
63% ED length of stay (LOS) for discharged patients. Methods:
44 During a representative sample of ED shifts, research
16
assistants shadowed attending EPs and tracked patients
29
seen by trainees, patient characteristics and EP time spent
on patient care and teaching. Patient disposition, LOS and
test utilization were captured from hospital databases. The
number of shifts covered was based on project funding and
the size of the study groups was based on the number of
patients seen by trainees. Results: During 32 shifts, 22 EPs
treated 446 patients alone and 139 in conjunction with
trainees. Patients treated by EPs alone were more likely to
have comorbid conditions (34.8% vs. 28.8%), to arrive by
ambulance (30.1% vs. 25.7%), to require procedures (23.1%
vs. 19.4%) and to have GCS \15 (6.4% vs. 4.8%). For each
patient seen by a trainee, EPs provided more teaching and
less clinical care (table). Patients seen by trainees had higher
admission rates, longer LOS and more diagnostic tests.
Conclusion: Bedside teaching is ‘‘time-neutral’’ but trainees
may increase admission rates, ED LOS and test utilization.
Close supervision of trainee care is required.
Table EP only EP plusTrainee p
Clinical time/pt 19.4 min 12.4 min .0001
Teaching time/pt 0.3 min 5.0 min .0001
Total time/pt 19.7 min 17.4 min .10
Admission rate 13.9% 17.3% .39
Median LOS (disch pts) 1.8 hrs 2.3 hrs .01
Patients having lab tests 35.9% 41.7% .26
Pts having imaging study 34.3% 43.9% .05
097 The National Prevalence of Illegal and Inappropriate
Residency Interview Questions H Gene Herno Jr,
Monika do Valle, Eric R Snoey, Barry C Simon; Alameda County
Medical Center–Highland Hospital: Oakland, CA
Objectives: To document the prevalence of illegal and
inappropriate questions asked of residency applicants
during the 2001–2002 interview season. We hypothesized
that applicants were being asked illegal questions and that
women were more frequently asked questions regarding
family planning and marriage than men. Methods: We
conducted a cross sectional survey of all applicants applying
to residency programs through the Electronic Residency
Application Service (ERAS) of the AAMC. Applicants were
asked to recall if they experienced questions relating to
various topics including marital status, age, ethnicity, and
family planning. Surveys were sent after rank lists were
submitted, and analyzed using logistic regression. Results:
Of the 28957 applicants, 12560 returned a completed survey
(43.4%). Of respondents from US Medical Schools there was
a 50.3% response rate (9107 of 18113). 6755 (53.8%) were
male. During the course of their interviews: 67.9% were
asked at some point about their marital status, 42.1% if they
had children, 21.3% if they intend to have children, 23.0%
about their age, 30.5% about their ethnicity, 17.1% about
their religion, 1.2% about their sexual preference, and 18.4%
to give a verbal commitment to a program. Overall, 85.3% of
respondents reported some form of illegal or inappropriate
question during their interviews. Women were more likely
456
to be asked questions about their plans for having children
than men (25.8% vs. 17.4%, p \ 0.001 (OR 1.6)) and more
likely to be asked questions about couples matching (26.9%
vs. 19.3%, p \ 0.001 (OR 1.5)). They were equally likely to be
asked about their marital status or if they currently have
children. Applying to Emergency Medicine was protective
(p ¼ .004 (OR 0.75)) for being asked illegal questions as
compared with other specialties. Conclusions: Applicants to
residencies are frequently being asked illegal and inappro-
priate questions. Women face significantly more questions
about family planning than men.
098 What Aspects of a Residency Program’s Website Are
Important to Medical Student Applicants? Theodore
J Gaeta, David W Lamont, Neal Banga, Robert H Birkhahn,
Joseph J Bove; New York Methodist Hospital: Brooklyn, NY
Objective: Increasing pressures on available resources have
made the maintenance of residency web sites (RWS) more
difficult. The purpose of this study was to determine which
components of the RWP are important to potential student
applicants, and evaluate the impact a RWS has on the
application process. Methods: We performed a cross-sec-
tional observational study of residency applicants in Novem-
ber 2002. All applicants were invited to participate and were
provided with a nine-question survey. Applicants were asked
questions regarding the importance and impact of RWS on the
residency application process. They were also asked to rate
items regarding content and aesthetics on a four-point Likert
scale, ranging from 1(not important) to 4(essential), and then
rank each item in order of importance. Data were analyzed
using basic frequency displays and descriptive statistics are
reported. Results: 188(82%) of the applicants responded to
the survey. 78% of those surveyed reported that information
provided in a RWS influenced their decision to apply to
a particular program (41% decided not to apply to at least one
program based on the quality of its RWS). Applicants felt that
the residency curriculum (59%) and up-to-date informa-
tion (54%) were essential(mean ¼ 3.49 6 0.7, 3.41 6 0.8
respectively). Information about the hospital and its affiliates,
faculty and resident information (i.e. biography/interests),
and research activities followed in the rank order. Least
important to applicants were the aesthetic quality of the site,
faculty/resident photos, and educational resource materials
(2.00 6 0.7, 2.33 6 0.9, 2.84 6 0.9 respectively). Conclusion:
The content and not necessarily the aesthetic quality of
residency web sites appears to be important to student
applicants. This information has important implications for
training program directors and administrators. The student’s
perspective provides guidance for improving and optimizing
new or existing RWS for use by future applicants.
099 Determining Redundancy among Items Used to
Evaluate Practice-based Learning and
Improvement Earl J Reisdorff, Oliver W Hayes, Mat Reeves,
Brian Reynolds, Gregory Walker, Dale J Carlson; Ingham
Regional Medical Center: Lansing, MI, Michigan State
University, Emergency Medicine Residency–Lansing:
Lansing, MI, Michigan State University, College of Human
Medicine: East Lansing, MI
Objectives: The ACGME requires that emergency medicine
programs evaluate Practice-based Learning and Improve-
2003 SAEM ANNUAL MEETING ABSTRACTS
ment (PBLI)—a nontraditional paradigm for resident as-
sessment. We sought to detect any redundancy among 7
scoring items used to assess PBLI in a global assessment
device. Methods: This was an observational, multi-center,
cross sectional study approved by the IRB that first assessed
GC acquisition among emergency medicine residents.
Residents were scored with a global assessment device on
a 1 through 9 scale that contained 7 items for evaluating
PBLI acquisition. Data analyses included descriptive anal-
yses, ANOVA (for differences of PBLI acquisition at
different levels of training), and Pearson’s Correlation to
identify redundancy among highly correlating items. A
Pearson’s coefficient larger than þ.90 was considered overly
redundant. Results: Five EM programs participated for
a total of 150 residents. Mean scores with 95% confidence
intervals for PBLI were: EM1 4.60 (4.41–4.79); EM2 5.48
(5.32–5.64); and EM3 6.16 (5.99–6.33)(ANOVA p \ .001). The
range for Pearson’s Correlation between all paired items
was þ.34 to þ.82. There were no paired items with a
correlation coefficient [.90. Conclusions: Using Pearson’s
Correlation, we were unable to detect any items that were
overly redundant. All 7 items appear to be important and
distinct contributors to the evaluation of an EM resident’s
acquisition of PBLI. Therefore, no items had a high enough
correlation to consider elimination as a redundant scoring
item.
100 Do Emergency Medicine Residents’ Obsevations of
Their Residency Program Correlate with Emergency
Medicine Applicants’ Perceptions? Armando Hevia,
Cherri D Hobgood, Robert J Vissers; University of North
Carolina: Chapel Hill, NC
Objective: To determine if EM resident’s opinions are valid
indicators of factors perceived as important to EM residency
applicants by comparing (1) EM residency applicants’ per-
ceptions of strengths and weaknesses of a given program to
the actual observations of current residents’ at that program
and (2) essential strengths of an ideal EM residency program.
Methods: A written survey instrument was administered to
EM applicants and to current EM residents at a tertiary care
academic medical center. Survey asked participants to
choose the most important 5 of 32 criteria for (1) strengths
of the given program, (2) weaknesses of the given program
and (3) strengths of an ideal program. Results: The response
rate was 87% (69) applicants and 100% (22) residents. Appli-
cants and residents were highly correlated in 8 of the top
10 strengths of the program under consideration. The top
2 strengths listed by both applicants (AP) and residents (RE)
were Resident Happiness/unity (79%AP; 82%RE) and Loca-
tion (53%AP; 55%RE). EM residency weaknesses also corre-
lated in 7 of the top 10 criteria. The top 2 weaknesses listed by
both applicants and residents were Ultrasound Exposure
(57%AP; 55%RE) and Trauma Autonomy(26%AP; 46%RE).
Lastly, there was a high correlation between applicants and
residents when asked to choose the strengths of an ideal
program. Resident Happiness/Unity was again the most
common response among both (75%AP; 77%RE). Addition-
ally, Curriculum/Lectures/Didactics (39%, ranked #3 AP;
36%, ranked #4 RE) and Location (36%, ranked #4 AP; 46%,
ranked #2 RE) shared a high degree of correlation in regards
to an ideal EM residency program. Conclusions: Residents
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
and applicants possess a high degree of correlation in their
perceptions of a residency program’s strengths, weaknesses,
and ideal criteria. Thus, a database of resident observations
about their residency program may assist applicants in
focusing their choices for EM residencies and assist in the
identification of EM residency program’s weaknesses.
101 Determining Distinct Measures for the ACGME
General Competencies for Emergency Medicine
Training Earl J Reisdorff, Oliver W Hayes, Mat Reeves, Brian
Reynolds, Dale J Carlson, Greg Walker, Keith C Wilkinson,
David T Overton, Mary Jo Wagner, Terry Kowalenko, David
Portelli; Michigan State University Emergency Medicine
Residency–Lansing: Lansing, MI, Michigan State University,
College of Human Medicine: East Lansing, MI, William
Beaumont Hospital: Royal Oak, MI, Kalamazoo Center for
Medical Studies: Kalamazoo, MI, Saginaw Cooperative
Hospitals: Saginaw, MI, Wayne State University–Grace
Hospital: Detroit, MI, Henry Ford Hospital: Detroit, MI
Objectives: The ACGME has defined six areas called General
Competencies (GCs) that programs must evaluate. We sought
to determine the relative value of 86 scoring items from
a global assessment device with the intent of reducing the
number of items for determining a composite score for each
GC. Methods: This was an observational, multi-center, cross
sectional study approved by the Institutional Research Board
that first compared GC acquisition between EM1, EM2, and
EM3 residents. Five PGY1–PGY3 allopathic EM program
directors evaluated 150 residents using a global assessment
device on a 1 through 9 scale that contained 86 total items.
For each of the six GCs, Principal Component Analysis (PCA)
was used to determine the magnitude of variability explained
by up to three linear combinations or ‘‘principal compo-
nents’’. PCA is a complex form of regression analysis. The
eigenvectors of the first three principal components were then
examined to identify potentially redundant scoring items that
could be excluded from the assessment device. Results: Five
EM programs participated (150 residents). The first three
principal components explained the amount of variability in
each GC as follows: Patient Care 92%; Medical Knowledge
87%; Practice-based Learning and Improvement 90%; In-
terpersonal and Communication Skills 84%; Professionalism
74%, and Systems-based Practice 80%. After examination of
the individual eigenvectors of the first principal component
(as well as the first three principle components), no scoring
items could be clearly identified as redundant for any of the
GCs. Conclusions: In this preliminary analysis using PCA
techniques, we were unable to produce an abbreviated global
assessment device. All items appear to be important and
distinct contributors to the evaluation of EM resident
acquisition of the GCs.
102 Resident Error in Emergency Medicine: The REEM
Study Armando Hevia, Cherri D Hobgood, Bryan J
Weiner, Ralph J Riviello; University of North Carolina School of
Medicine and Public Health: Chapel Hill, NC, Thomas Jefferson
University: Philadelphia, PA
Objective: To detail the types, causes and severity of EM
resident errors as well as resident responses to these errors
457
including disclosure and behavioral learning modifications.
Methods: A 2-part written survey instrument was adminis-
tered to EM residents at 2 academic tertiary care institutions.
Section I asked residents to describe their most serious
medical error using the IOM definition of error. Section II
assessed (1)error epidemiological characteristics: type, cau-
sation, severity (2)residents’ responses to the error: psycho-
logical responses, disclosure practices, learning behaviors.
Results: The response rate was 78% (42 residents). Error
descriptions ranged from incorrect medication dosages to
faulty data analysis. The most common types of error were: in
treatment administration (49%), failure of communication
(46%) and delay in diagnosis 41%. The top three causes of
error were: lack of experience (54%), lack of knowledge (50%),
and competing demands (44%). After the error, 23% of
patients’ deteriorated clinically, 83% required extra monitor-
ing, 75% experienced physical discomfort, and 69% required
additional therapy. Residents’ report feeling completely or
primarily responsible for the error in 71% of cases. Residents’
felt remorse in 67% of cases and 62% felt emotional distress
including: 56% embarrassment, 51% guilt and 41% anger.
A majority of residents (77%) disclosed the error to the
responsible attending yet only 40% disclosed to patient/
family. Only 11% of cases were discussed at M&M conference.
Residents’ learning behavior was altered: 80% pay more
attention to details, 49% personally confirm data, 33% seek
senior staff help yet only 28% read more and 5% use more
evidence based medicine. Conclusions: Errors have a signif-
icant impact on emergency patients and the residents who
commit them. Further study will be required to confirm these
patterns and assist educators in the design of interventions to
limit error, insure disclosure and enhance positive learning.
103 ‘‘Healthy People 2010’’ Emergency Medicine
Module: A Survey of Emergency Medicine
Residency Programs and Validation Study Dominic A
Borgialli, Carlos A Camargo Jr; Michigan State University:
Lansing, MI, Massachusetts General Hospital: Boston, MA
Objective: The goal of this project is to educate EM
residents about ‘‘Healthy People 2010’’ (HP2010), the
nation’s public health agenda. Many of the HP2010
objectives are directly related to EM, making it a valuable
resource for academic activities and clinical practice. Our
hypothesis was that EM residents are not familiar with
HP2010 and that the ‘‘HP2010 EM Module’’ would improve
their understanding of HP2010. Methods: A 40-minute slide
presentation was developed and made available for
download off the SAEM website (http://www.saem.org).
A letter was sent to all EM residency program directors
encouraging use of the lecture slideset, along with distribu-
tion of a written post-test to the audience to assess study
objectives. In two residency programs, a before-after study
was conducted to assess resident learning; residents were
tested before the lecture, immediately after (as done with all
lectures), and two-weeks later. Data analysis used K-W
ANOVA. Results: 15 residencies participated. There were
289 individuals who attended these lectures, of whom 203
(70%) were EM residents. The mean age of residents was 29
(SD 6 3) and 74% were male. 94% of the EM residents
completed the post-test. Only 19% (95% CI, 14–25) reported
any knowledge of HP2010 before exposure to the Module.
Nevertheless, 182 (90%) scored 75% or higher on the 4 post-
458
lecture questions related to the informational content of the
Module. When asked about the ‘‘usefulness’’ of the Module
to their EM practice (on a scale of 1–5), 67% of residents
selected 4 or 5 (very useful). In the validation study, the 43
residents showed significant improvement on the pre-test
vs. early post-test (p \ 0.001) and pre-test vs. late post-test
(p \ 0.001); there was no difference between the early post-
test vs. late post-test two weeks later (p [ 0.05). Conclusion:
We found that EM residents’ baseline knowledge of HP2010
was poor, and that the EM Module appeared to improve
knowledge about this important public health document.
104 Does Attitude Affect Behavior?: Emergency
Physicians’ Attitudes and Beliefs toward Patients
with Alcohol-related Problems Maria C O’Rourke, Lynne
D Richardson, Ilene Wilets, Gail D’Onofrio; Madigan Army
Medical Center, University of Washington: Tacoma, WA,
Mount Sinai School of Medicine: New York, NY, Yale
University School of Medicine: New Haven, CT
Objective: We sought to determine whether emergency
medicine physicians’ attitudes (positive or negative) toward
patients with alcohol-related problems might affect their
support and practice of brief intervention (BI) in the ED.
Methods: Resident and attending physicians completed an
anonymous 45-item survey at the 2001 ACEP Scientific
Assembly which asked: size and type of practice, previous
education in alcohol problems, personal exposure to alcohol
problems in self, family and friends; overall general beliefs,
role responsibility toward patients with alcohol problems;
current practice of BI. We sought predictors that influence the
support and use of BI in the ED. Results: A total of 660 surveys
were completed: 2/3 by attendings, 1/3 by residents. Both
groups reported working with a high prevalence of patients
with alcohol-related problems in a typical shift (18%). Half of
the participants responded that it is important to use a form of
BI in the ED and 81% believed it was important to advise
a patient to change his behavior. There was a significant
difference (p ¼ 0.045) regarding the support of BI in the ED
between attending physicians (54%) and residents (46%),
despite the former group having 50% less training for the
most recent year. There was no statistical significance for
support for BI corresponding with ED census/site, gender,
race, age, number of lecture hours, or knowing someone with
alcohol problems. Variables most indicative to support for BI
were role responsibility (p \ .001) and positive attitude (p \
.001). A regression model derived to predict current practice
of brief intervention found positive attitude was most
predictive for current practice of BI. Conclusions: ED
physicians who felt that BI was an integral part of their job
tended to feel more positively about it and were more likely to
use BI in their daily practice. Increasing the use of BI will most
likely occur with institutional acceptance, and the subsequent
increase in role-models to teach the same.
105 What Characteristics of Emergency Medicine
Applicants Will Predict Future Performance as an
Emergency Medicine Resident? Stephen R Hayden;
UCSD Medical Center: San Diego, CA
Objective: To identify predictors of overall, academic, and
clinical success at end of residency from a set of variables
2003 SAEM ANNUAL MEETING ABSTRACTS
available at admission to the program. Methods: In this pilot
study, EM residents were confidentially assessed by EM
faculty on performance in residency at time of graduation.
For the outcomes of overall performance, academic perfor-
mance, and clinical performance, faculty compared a given
graduate to all residents they had previously worked with
using the scale: [90th percentile(%tile), 70–89th%tile, 50–
69th%tile, 30–49th%tile, or \ 30th%tile. Predictors from
residency applications included: demographics, ratings of
med school attended (MSA), med school record (MSR),
Dean’s letter rating (DLR), letter of recommendation (LOR),
interview rating (IVR), USMLE score, etc. Data analysis:
Univariate analysis(chi square test of association for
categorical data, ANOVA for continuous data)multiple
regression analysis, and ordinal logistic regression with
Friedman gradient boosting was used to model outcomes.
Results: Of 54 graduates; 9.3% were rated by faculty as
[90th%tile, 40.7% in 70–89th%tile, 35% in 50–69th%tile, 11%
in 30–49th%tile, and 3.7% \30th%tile. Univariate analysis
showed DLR, LOR, and MSA were predictors of overall
performance. Multiple regression demonstrated DLR and
MSA were predictors, and with gradient boosting the most
significant predictor was MSA with LOR, IVR, and EM
research weaker predictors. AOA, gender, age, prior para-
medic, and USMLE score were not predictors. Academic and
clinical success were strongly correlated with each other and
with overall success. Conclusions: Using regression model-
ing it may be possible to identify predictors of future resident
performance from variables available in standard residency
applications. Applicability is limited since data is from only
one EM residency. This study needs to be repeated with data
from multiple programs.
106 Does Fellowship Pay? Steven L Kristal, Karen A
Randall-Kristal; William Beaumont Hospital: Royal Oak, MI,
Henry Ford Hospital: Detroit, MI
Objective: Each of the last 5 SAEM Faculty Salary Surveys
has reported fellowship-trained (FT) faculty earn less than
non-fellowship-trained (NFT) faculty. This study examines
what types of jobs are being done by FT faculty, whether the
salary discrepancy holds true across all faculty job descrip-
tions, whether salary differences can be explained by
number of clinical hours worked, years of experience, or
regional differences, and what effect this apparent disin-
centive has upon the numbers of FT emergency physicians
taking academic positions. Methods: SAEM collects salary,
training, and work-hour data from RRC-approved residency
programs every 3 years. Data submitted by program chairs
are blinded by the SAEM office to the study investigators.
The database was evaluated with regard to study objectives.
Results: 244 of 1355 (18%) faculty in the 2001–02 SAEM
Faculty Salary Survey were FT, compared with 15% (146/
965) in 98–99 and 12% (120/1032) in 95–96. 18 of 124
(14.52%) first year faculty were FT. FT faculty earn 5.01%
less than NFT faculty. FT faculty have 6.10% less total years
of service and work 10.33% fewer clinical hours than NFT
faculty (note that for all faculty, total years of service varies
directly with salary, but that total clinical work hours does
not). 30% of FT faculty are female (females are 24% of total
faculty). Only 3 of the 17 job descriptions in the survey
reported more than 50% fellowship-trained faculty: Pediat-
rics Director (60%), Staff-Pediatrics-Only (72%), and Toxi-
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
cology Director (64%). Of those three, both directorship
positions showed FT faculty earning less than their NFT
colleagues. Conclusions: In other specialties fellowships are
primarily practice-focused and usually yield higher salaries
for advanced training. Emergency medicine fellowships are
primarily academic-focused and lead to lower salaries even
within academics. In spite of this apparent disincentive, the
number of fellowship trained faculty, as a percentage of total
faculty, continues to grow.
107 Evaluation of the Utility of an Off-service
Orthopedic Rotation for Emergency Medicine
Residents Barry Jay Hahn, Ethan Cowan, Brahim Ardolic,
Christopher Doty, Mark Silverberg, Stephan Rinnert, Richard
Sinert, Michael Lucchesi; SUNY-Downstate Medical Center
and Kings County Hospital Center: Brooklyn, NY
Objective: Emergency Medicine (EM) residents perform
a number of off-service rotations throughout their training.
The utility of these rotations in enhancing their knowledge
and performance in these areas has not been studied. We
have previously shown that the majority of off-service
rotations do not improve inservice scores. We will evaluate
whether an orthopedic off-service rotation (ORTH) will
improve resident skills in orthopedics. Methods: Published
criteria for skills and knowledge that should be obtained
during an ORTH were reviewed. Based upon these criteria,
we developed a novel tool to evaluate practical skills
learned during the ORTH. This included splint application
(SA), performance of a specialized orthopedic examination
(EX) and radiographic interpretation and general knowl-
edge (XR). A committee of EM trained physicians devised
scoring criteria. A 100-point scale was devised among the 3
areas: SA 27%, EX 25%, XR 48%. The same EM physicians
tested all subjects. Residents who had completed an ORTH
were compared to those who had not completed an ORTH.
Comparisons were made only between residents of the
same post-graduate year. Data was analyzed by Student’s
t-Tests. Alpha was set at 0.05. Results: 8 subjects were tested,
4 prior to their ORTH, and 4 after completing their ORTH.
Results were as follows:
With ORTH Without ORTH P-value
SA 61.3% 6 29.3% 68.5% 6 21.1%
EX 64.5% 6 14.3% 65.0% 6 15.1%
XR 67.5% 6 16.0% 61.8% 6 13.7%
Total 65.3% 6 16.7% 64.3% 6 6.7%
Conclusion: The ORTH did not appear to affect the subject’s
ability to perform on the examination. This data correlates
with results obtained from previous studies of performance
on inservice examinations. Reevaluation of off-service rota-
tions for EM residents is essential. Validation of these results
in multiple centers is necessary. Development of tools to
evaluate residents in other off-service rotation is warranted.
108 Female Chairs and Female Faculty David Cheng,
Judy Dattaro, Gail Ray, Kimberly Perkins; University of
Arkansas Medical Science: Little Rock, AR, Cornell University
Medical Center: New York, NY
459
Objectives: Faculty perceptions of the professional de-
velopment process differ between women and men. We
sought to determine if the presence of a female chair is
linked to a higher female faculty census. Our null hypo-
thesis is no difference exists in the faculty gender census
between male chairs and female chairs in academic emer-
gency medicine. Methods: Using the July 2002 SAEM
Residency Catalog, we determine the faculty gender census
in programs with a male chair versus programs with a
female chair. The Pearson Chi Square Test was used to
compare the two groups and a p value less than 0.05 was
considered significant to reject the null hypothesis. Results:
Out of the 125 academic emergency medicine programs, 116
programs had a male chair (93%) and nine programs had
a female chair (7%). In the male chair group, the gender
census was 717 female faculty (22%) and 2487 male faculty
(78%). In the female chair group, the gender census was 83
female faculty (33%) and 168 male faculty (67%). The p
value between the two groups was 0.0001. Conclusions: The
presence of a female chair is associated with a higher female
faculty gender census.
109 The Effect of Working Nights on Missed Diagnosis
among Patients with Acute Cardiac Ischemia in the
Emergency Department Denise C Rollinson, John L Griffith,
Robin Ruthazer, Joni R Beshansky, Harry P Selker; Tufts-New
England Medical Center: Boston, MA
Introduction: Federal guidelines have proposed work-hour
limitations of resident physicians in the emergency de-
partment (ED) to avoid medical errors from sleep depriva-
tion. We evaluated the effect of working nights on missed
diagnosis of acute cardiac ischemia (ACI) in the ED.
Methods: We performed a secondary analysis of the
database from the Acute Cardiac Ischemia Time-Insensitive
Predictive Instrument (ACI-TIPI) trial. In 1993, this multi-
center study enrolled 10,689 patients who were $30 years
old, with symptoms suggestive of cardiac ischemia. Patients
with ACI were defined as those with a final diagnosis of
acute myocardial infarction or unstable angina. We analyzed
demographic and clinical data on the 1855 patients with
ACI compared to the 8804 patients without ACI. Thirty
patients left AMA and were not included in the analysis. We
defined missed diagnosis as failure to admit patients with
ACI and defined nightshift as 7PM through 6:59AM.
0.70 Results: A greater percentage of patients had ACI during
0.96
the nightshift (20%) than the dayshift (16%), even though
0.61
more total patients with ACI were seen during the dayshift.
0.92
Among patients with ACI, those evaluated during the
nightshift, were more likely to be $ 65 years old, nonwhite,
had a chief complaint of shortness of breath, had rales on
exam, had a history of myocardial infarction and angina,
had congestive heart failure on chest xray, were taking beta-
blockers, ACE inhibitors, nitrates or nitroglycerin, and
arrived by ambulance. Fewer patients with ACI evaluated
during the nightshift (1.3%,9/709) compared to the day-
shift (2.8%,32/1140)were inappropriately discharged home.
Working the nightshift was not associated with an increased
odds of discharging patients with ACI, after adjusting for
age, gender, nonwhite race, and TIPI Score (Odds Ratio
0.5, 95%CI 0.2,1.0). Conclusion: Contrary to our hypothesis,
working the nightshift was not associated with an increased
odds of inappropriately discharging patients with ACI.
460
110 Is Fecal Leukocyte Esterase Testing Useful for the
Evaluation of Infectious Diarrhea? Edward A
Panacek, Randy W Stark, Peter E Sokolove; University of
California-Davis Medical Center: Sacramento, CA
Objectives: To determine the sensitivity and specificity of
the fecal leukocyte esterase test to diagnose infectious
diarrhea from bacterial causes. Methods: Approved by the
institutional IRB prior to study initiation. Design: Pro-
spective experimental study. Setting: Single university
medical center. Subjects: Convenience sample of stool
samples submitted to the clinical laboratory for enteric
pathogen culture testing. Interventions: Stool samples sub-
mitted for standard laboratory testing and culture were
further evaluated for the presence of leukocyte esterase.
This was performed prior to the culture results being
available and in a double-blinded fashion. Specifically, the
stool specimen was probed with a dacron swab until it was
saturated with fecal material. The swab was then placed in
2cc of normal saline in a small vial. The swab was
vigorously agitated until the fecal material entered solution,
or for at least 10 seconds. A urine multistix dipstick was
then dipped into the solution and the results read as
negative, 1þ, 2þ or 3þ, following the directions with the
dipstick. Results were then compared to the final culture
results, which was considered the gold standard for
bacterial enteric infection. Sensitivity and specificity were
calculated, along with 95% confidence intervals. Results:
100 stool specimens were studied, of which 8 were positive
by culture. The LE test detected all of these (no false
negatives), but also was also positive in 81 of the 92 culture
negative samples (false positives). Therefore the test had
a sensitivity of 100% (95% CI: 73–100%), but a specificity of
only 12% (95% CI: 8–20%). Conclusions: The fecal LE has
a high sensitivity, but a very low specificity for detecting
bacterial infectious diarrhea. The poor specificity likely
limits its clinical utility.
111 Influence of Age and Seasonality on Patterns of
Gastroenteritis in an Emergency Department
Biosurveillance System Vashun A Rodriguez, Michael E
Silverman, Dennis G Cochrane, John R Allegra, Barnet Eskin,
Jonathan Rothman; UMDNJ-Robert Wood Johnson Medical
School: Piscataway, NJ, Morristown Memorial Hospital:
Morristown, NJ
Objective: Syndromic surveillance of ED patient visits has
been advocated for the early detection of bioterrorism, and
depends on knowledge of expected baseline and seasonal
variations in patient visits for the syndrome. Previously, we
have shown a seasonal variation in ED visits for gastroen-
teritis (GE) over a 5-year period, but we did not know if this
pattern would persist over a longer period of time. Also, we
suspected that young children might have a disproportionate
impact on this pattern, due to the seasonal incidence of
rotavirus in that group. In this study, our objective was to
characterize the seasonality of GE over a longer period of
time and to determine the contribution of children age \60
months. Methods: Design: Retrospective, cohort study of ED
visits. Setting: 15 northern and central New Jersey EDs with
annual volumes of 20,000 to 65,000. Subjects: Consecutive
patients seen by ED physicians from 1988 through 2002.
Protocol: Two of the authors reviewed all ICD-9 codes used
2003 SAEM ANNUAL MEETING ABSTRACTS
during this period and chose by consensus those related to
GE. Patients were further separated into 2 age groups, \60
months and $60 months. Daily counts of visits meeting
the ICD-9 criteria were tallied and graphs of results were
inspected visually to determine seasonal peaks. Results: Our
database contained 5,182,019 visits, of which 88,504 were for
GE. Although the younger group accounted for only 8.7% of
all visits, it accounted for 25% of GE visits. The mean and
peak incidence of GE was higher within the younger age
group on a percentage basis (4.9% mean, 26.0 % peak) than in
the older group (1.4% mean, 3.6% peak). Visual inspection of
the time-series graphs showed a similar seasonal pattern for
each age group. Conclusion: There are consistent seasonal
GE peaks over the entire 15 year period. The younger age
group contributed disproportionately to the GE observed.
Factors of age and seasonality should be taken into account in
designing a system for surveillance of GE in the ED.
112 Is There a Relationship between the Size of a
Kidney Stone and the Degree of Hydronephrosis?
David C Lee, Jagruti Patel, Stacey Kesten; North Shore
University Hospital: Manhasset, NY
Objectives: There have been many studies reporting the
increase of medical complications related to the size of
a kidney stone. However there is scant literature describing
stone size and degree of hydronephrosis. We hypothesize
that the size of a kidney stone is directly related to the degree
of hydronephrosis. Methods: We performed a retrospective
pilot study reviewing charts on all patients in the Emergency
Department with a diagnosis of renal colic. Patients with
a radiographically documented kidney stone were eligible to
be enrolled. Radiology readings were recorded for presence
and size of stones and hydronephrosis. Data was collected
on a standard collection tool over a 6-month period from
January 1, 2002 to June 30, 2002. Data was analyzed by
ANOVA statistics. Results: 187 patients were identified. 7
patients had stones without hydronephrosis (mean 8.36 mm
CI 0.91–6.80). 128 patients had a stone with mild hydrone-
phrosis (mean 3.83 mm CI 3.42–4.24). 29 patients had a stone
with moderate hydronephrosis (mean 5.03 mm CI 4.26–5.80).
3 patients had a stone with severe hydronephrosis (mean
9.67 mm CI 2.07–21.4). P ¼ 0.001. Conclusions: In this
retrospective study, we found a statistically significant
correlation between kidney stone size and degree of
hydronephrosis. The greater the size of the stone the more
likelihood there was a greater degree of hydronephrosis.
113 Pharmacotherapeutic Approach to Nausea and
Vomiting in the Emergency Department Manish M
Patel, Jonathan J Ratcliff, Stephen R Pitts, Debra Houry, Michael
A Miller, David W Wright; Emory University: Atlanta, GA,
Darnall Army Community Hospital: Fort Hood, TX
Objective: To describe the demographics and the pharma-
cotherapeutic approach to the treatment of nausea &
vomiting (N&V) in ED patients. Methods: Secondary
analysis of the 1997–2000 National Hospital Ambulatory
Medical Survey, a probability sample of ED visits in the US.
All patients with a chief complaint of N&V were included.
Descriptive & univariate analysis using SAS (v 8.02).
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org 461

Multivariate modeling and clustered analysis are ongoing.
Results: There were an estimated 30.5 million ED visits for
N&V, over 4 years (7.5% of all ED visits). Mean age was 31.9
(95% CI ¼ 31.3, 32.5) and 70% were less than 44 years old.
62% were females; 77% were Caucasian, and 20% African-
American. Mean waiting times were similar for patients
with and without N&V (45.2 vs. 43.8 mins; p ¼ 0.11).
Diagnostic tests included CBC (47%), other blood tests
(41%), ECG (15%), cardiac monitoring (8%), chest x-ray
(17%), and CT scan (5%). Approximately 5.4 million (17.9%)
patients with N&V were admitted. 36.4% received IV fluids
and 81% received medications in the ED. Antiemetics were
used in 11.2 million patients with N&V (36.8%) and in-
cluded promethazine (55.0%), prochlorperazine (25.3%),
hydroxyzine (5.5%), metoclopramide (5.2%), trimethoben-
zamide (4.5%), droperidol (3.1%), and ondansetron (1.3%).
Patients \ 12 years were less likely to receive antiemetics
than those [12 (OR ¼ 0.31; 95% CI ¼ 0.27, 0.35).
Approximately 700,000 patients with N&V were pregnant
(2.3%). FDA pregnancy category ‘‘C’’ drugs, promethazine
(49.1 %), prochlorperazine (33.8%) and trimethobenzamide
(7.4%), were used more commonly than ‘‘B’’ category drugs,
ondansetron (3.0%) and metoclopramide (2.8%). Conclu-
sion: Despite the frequent side effects of promethazine and
prochlorperazine, they are the most often used drugs for
control of N&V in the ED. Further investigation of drug
efficacy, adverse effects, and health care costs in comparison
to well tolerated and efficacious medications such as
ondansetron is warranted.
higher in Medicare (23%), privately insured patients (19%),
and non-profit hospitals (21%) but infrequent in the South
(6%). Among patients triaged as severe, promethazine
(50%), trimethobenzamide (15%), and droperidol (10%)
were more commonly selected. Conclusions: N/V is a
common ED complaint with a wide variation in treatment
patterns across the US. Promethazine is the most common
drug used. Qualitative differences between treatment
approaches cannot be compared from these data but
deserve future study.
115 The Clinical Presentation of Acute Biliary
Pancreatitis Larissa Velez, Larkin Gregory, Kathleen A
Delaney; UT Southwestern Medical School: Dallas, TX
Objectives: To identify clinical factors that distinguish
biliary pancreatitis from non-biliary pancreatitis. Method:
A retrospective 2 year study of consecutive patients in an
urban ED with a first diagnosis of acute pancreatitis. Pa-
tients with a chronic pancreatitis were excluded. ‘‘Biliary
pancreatitis’’ was diagnosed in patients who had acute
pancreatitis associated with pathologically documented
stones. ‘‘Non-biliary’’ pancreatitis was diagnosed in patients
with a likely cause of pancreatitis and negative radiologic
assessment for stones. Statistics: 2 tail independent sample t
test for equality of means. Results: The sentinel episodes of
acute pancreatitis were identified in 306 patients, 88 non-
biliary, 203 biliary, 15 inderminant.

Demographics Nonbiliary (88) (%) Biliary (200) (%)

114 Nausea and Vomiting Management in US Emergency
Female 36 (41) 157 (77)
Departments Jonathon M LaValley, Cameron S Afr-Am 34 (39) 21 (10)
Crandall, Darren Braude; University of New Mexico: Mex-Am 28 (32) 148 (73)
Albuquerque, NM Cauc 24 (27) 26 (13)
Other 0 5 (2)
Objectives: To describe the incidence of and treatment
Pregnant \1 year 0 55 (27)
patterns for nausea and vomiting among US Emergency
Departments (ED) patients. Methods: Design: Cross-sec- Laboratory Nonbiliary Biliary
tional. Subjects: All patients with a reason for visit or diag- Amylase mean 357 1093 (p \ .05)
nosis code for nausea and vomiting (N/V) whose records Lipase mean 1250 3656 (p \ .05)
were sampled in the 1999 ED National Hospital Ambula- 48 hour lipase 304 150 (p \ .05)
tory Medical Care Survey (NHAMCS). Observations: de- AST or ALT [100 or bili
mographics, reason for visit, diagnosis, treatments provided, [1.5 31% 81% (p \ .05)
disposition, and hospital characteristics. Analysis accounted Sonographic common
for the multistage probability sampling design. Results: bile duct (% normal) 76/80 (95) 144/191 (75)
N/V accounted for 8.3 million ED visits (8.1% of all ED
visits). Common treatments for N/V included intrave- Conclusion: Acute biliary pancreatitis was associated with
nous fluids (40%), antiemetics/antihistamine medications female gender, recent pregnancy, and Mexican ethnicity.
(AE) (39%), and other gastrointestinal treatments (such as Elevations of hepatic markers were common in patients
antacids and motility agents) (13%). 15% received no with biliary pancreatitis and uncommon in non-biliary
treatment. 31% were admitted. 45% of pregnant women pancreatitis. Dramatic elevation of the lipase followed by
and 22% of pediatric patients (\15 years) received an AE. rapid normalization was also characteristic of biliary pan-
Among the AE agents used, promethazine was the most creatitis.
common (48%), followed by prochlorperazine (18%), tri-
methobenzamide (7%), and droperidol (5%). Newer agents
(e.g., ondansetron) were rarely used. Less than 3% received
116 Do Not Resuscitate Orders: Do They Extend
more than one AE. When an AE was used, the agent
beyond the Arrest Situation? David E Manthey,
selected differed by insurance status, age, hospital type,
Jason Stopyra; Wake Forest University Baptist Medical
triage urgency and region. Promethazine was most com-
Center: Winston-Salem, NC
monly used overall, but notably higher in self-pay (64%),
Medicaid (54%), pediatric (70%), proprietary hospitals (57%) Objectives: Our Do Not Resuscitate (DNR) order states ‘‘In
and southern US region (73%). Prochlorperazine use was the event of cardiac and/or pulmonary arrest of the patient,
462
efforts at cardiopulmonary resuscitation of the patient
SHOULD NOT be initiated. This order does not affect other
medically indicated and comfort care measures.’’ Do
physicians interpret the DNR order to include withholding
care in five emergent treatment areas in distress situations?
Methods: A confidential survey was distributed to all
physicians at a tertiary care Level 1 Trauma center. The
premise of the questionnaire stated: ‘‘If a non-communica-
tive patient has a valid DNR order with no family to ask,
which treatment options would be initiated?’’ The treatment
options included bag valve mask (BVM), intubation, CPR,
defibrillation, and cardioversion. The two responses for each
treatment option were 1) ‘‘Do not initiate ‘‘treatment option’’
under any circumstances.’’ and 2) ‘‘Do not initiate ‘‘treat-
ment option’’ in the event of an arrest. However, initiate
‘‘treatment option’’ in the event of distress based on the
anticipated reversibility of disease.’’ Results: 784 surveys
out of 1073 distributed (73.1%) were returned. Of these, 87
elected not to fill them out (11.1%). The table indicates the
percentage of physicians who would initiate the treatment.
The data is divided into responses from all physicians and
from those physicians who regularly interpret DNR orders
(Interpret).
Treatment All Interpret
BVM 75.6 78.6
Intubation 27.6 24.6
CPR 12.8 10.7
Defibrillate 14.3 12.5
Cardiovert 36.6 41.7
Conclusion: Although the DNR order is specific to the
arrest situation, the majority of physicians at this institution
would not institute certain treatment options in a distress
situation on patients with a valid DNR. The DNR order is
interpreted differently by individual physicians which may
lead to inappropriate withholding or initiation of emergent
treatments.
117 Families and Friends Are Inadequate Sources for
Advanced Directive Decisions Patrick Pettengill,
Frank McGeorge, Scott Compton; William Beaumont Hospital:
Royal Oak, MI, Wayne State University: Detroit, MI
Objective: Family and friends who accompany patients to
the ED (ED-proxies) are often consulted by EM physicians
to provide substitute judgment for the patient’s resuscita-
tion (resus) preferences if the patient is incapacitated. This
substitute judgment has not been studied for ED patients.
The objective is to evaluate the concordance of patient resus
preferences and ED-proxy substitute judgment. Methods: A
convenience sample of stable ED patients and accompany-
ing ED-proxies completed questionnaires on the patient’s
resus preferences. Patient/ED-proxy concordance of the pa-
tient’s resus preferences were assessed. Results: 100 pa-
tient/ED-proxy pairs consented to participate. Most (69%)
patients were over 50 y.o., white (88%), and male (53%). The
ED-proxy identified their relationship to the patient as
spouse (43%), parent (10%), child (26%), or other family/
friend (21%). Most patients indicated a preference for chest
2003 SAEM ANNUAL MEETING ABSTRACTS
compressions (88%), intubation (81%), ventilation (70%),
and defib. (83%). Concordance of patient/proxy resus
preferences were as follows [%agreement, Kappa, p-value]:
chest compressions [84.0%, K ¼ 0.184, p ¼ 0.065], intubation
[72.0%, K ¼ 0.126, p ¼ 0.208], ventilation [68.0%, K ¼ 0.252,
p ¼ .012], and defib. [79.8%, K ¼ 0.171, p ¼ 0.085]. Overall,
66% of the patients wanted all resus attempts, which 46
(69.7%) of their proxies correctly identified. Of proxies who
knew to limit resus in some form, only 5 (14.7%) of 34
proxies agreed to limit resus specifically as the patient did.
The other 29 patient/proxy pairs showed the following
agreement for each item: compressions (55.2%), intubation
(41.4%), ventilation (48.3%), defib. (44.8%). Conclusion: This
study demonstrates that ED-proxies are not a reliable source
for determining a patient’s resus preferences as the con-
cordance is poor. Given that most patients prefer all efforts,
and that proxies are significantly likely to be incorrect; the
general stance that full resus should be done in the absence
of a directive is supported.
118 Informed Consent for Emergency Department
Procedures Catherine A Marco; St. Vincent Mercy
Medical Center: Toledo, OH
Objective: This study was undertaken to determine current
practice regarding obtaining and documentation of informed
consent for emergency department (ED) procedures. Meth-
ods: In this national mailed survey of randomly selected
members of the American College of Emergency Physicians
(ACEP), respondents estimated the number of procedures
performed per month, percentage of cases in which informed
consent is obtained, documented, and/or considered ex-
empt, for 25 common ED procedures. Results: Among 309
respondents, 81% were male, 91% were Caucasian, and 62%
practiced in community settings. Participants identified the
most commonly performed procedures in their practices as
blood drawing, intravenous lines, laceration repair, fracture
splinting, and regional anesthesia. The five procedures for
which informed consent is most commonly obtained include
lumbar puncture (95%), conscious sedation (89%), arthro-
centesis (85%), joint reduction (73%), and transfusion (73%).
Procedures most likely to be performed without informed
consent include cardiac resuscitation (7%), thoracotomy
(9%), pericardiocentesis (17%), and endotracheal intubation
(31%). Physician factors associated with increased likelihood
of obtaining informed consent included greater number of
years in practice (Student’s t-test Z2 ¼ 3.45 with a Bonferroni
adjustment, p\0.01). There were no differences in likelihood
of obtaining informed consent when comparing physician
age, gender, ethnicity, or type of practice. Conclusions:
Practices regarding informed consent for emergency proce-
dures vary widely, and are associated with physician years in
practice. Physicians are most likely to obtain informed
consent for urgent procedures, such as lumbar puncture,
and least likely to obtain informed consent for emergency
procedures, such as resuscitation and thoracotomy.
119 Interactions between Emergency Medicine Programs
and the Pharmaceutical Industry Samuel M Keim,
Mary Z Mays, David Grant, David Andreski; University of
Arizona College of Medicine: Tucson, AZ
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Objectives: To examine the beliefs and practices of
emergency medicine programs regarding interactions with
the pharmaceutical industry. We also sought to study the
prevalence of program policies and the desire for organiza-
tional policies. Methods: The Board of the Council of
Emergency Medicine Residency Directors (CORD) re-
quested and approved a survey of member programs. An
IRB-approved web-based 30-item survey was sent to all
programs subscribed to the organization’s listserv in May
2002. Programs were surveyed as to both their beliefs and
practices regarding industry sponsorship of speakers, social
events, drug samples, travel to conferences and the
educational value of marketing representatives. Subjects
were queried about their awareness of existing guidelines
and whether they desired policy development by CORD.
Results: Surveys were returned from 106 programs (85%).
Four types of programs were represented: university (56%),
community (30%), county (11%), and other (3%). The
majority of programs (72%) ‘‘never’’ or ‘‘very rarely’’ allow
unrestricted interactions between pharmaceutical represen-
tatives and residents at work. However, only 52% of
programs said that they ‘‘never’’ or ‘‘very rarely’’ allow
pharmaceutical representatives to give residents free drug
samples at work. Only 46% said that they ‘‘never’’ or ‘‘very
rarely’’ allow pharmaceutical representatives to teach
residents. Practices were unrelated to program type or
participant’s level of experience in academic medicine. Two
out of every three programs wanted CORD to provide
guidelines. Programs seeking guidelines were less likely to
allow pharmaceutical representatives to teach residents (p ¼
0.001). They were also less likely to allow pharmaceutical
representatives unrestricted interactions with residents (p ¼
0.05). Conclusions: A wide range of practices exists among
emergency medicine residency programs and most desire
organizational guidelines regarding interactions with the
pharmaceutical industry.
120 Activation of Myocardial Caspase in Experimental
Septic Shock in Rats John A Watts, Lisa R Thornton,
Sukhdev S Brar, Jeffrey A Kline; Carolinas Medical Center:
Charlotte, NC
Objective: To determine if myocardial caspase activation,
a major component of apoptosis, occurs during experimen-
tal septic shock and to determine if activation occurs via
release of cytochrome c from mitochondria. Methods: Male
Sprague-Dawley rats were anesthetized and received either
a laparotomy (sham) or a laparotomy with cecal ligation and
puncture (CLP) to induce septic shock. Hearts were isolated
12–14 hours later. Caspase activity (DEVDase) was de-
termined by fluorometric assay of myocardial extracts (n ¼ 6
hearts/group). Release of cytochrome c from mitochondria
was assessed by measuring cytochrome c in cytosolic and
mitochodrial fractions using western blot (n ¼ 3 hearts/
group). Bax and Bcl-2 proteins, which often regulate
cytochrome c release from mitochondria, were assessed in
mitochondrial fractions using western blot (n ¼ 6 hearts/
group). Values are mean 6 S.E. Significance was determined
with t-test, p \ 0.05. Results: CLP induced septic shock
(mean arterial pressure was 62 6 5 CLP vs 105 6 3 sham, p
\ 0.05). Caspase activity was significantly increased 2.4-fold
in hearts from CLP animals (5.37 6 0.73) compared with
463
sham animals (2.23 6 0.61). Cytochrome c levels were not
significantly increased in the cytosol fraction, or decreased
in the mitochondrial fraction in CLP hearts, compared with
sham. Bax and Bcl2 proteins were unchanged in mitochon-
dria from CLP hearts, compared with sham. Conclusions:
Experimental septic shock results in activation of caspase
(DEVDase). The data do not support activation of caspase
by release of cytochrome c from mitochondria. Ongoing
work is evaluating receptor pathways of caspase activation.
121 Comparison of the Effects of DADLE and
Norepinephrine Treatments on Hemodynamics
and Survival in Hemorrhagic Shock Richard L Summers,
Zizhuang Li, Drew Hildebrandt; University of Mississippi
Medical Center: Jackson, MS
Objective: Selective d receptor agonists such as DADLE
(D-Ala2-Leu5-enkephalin) have been shown to reduce meta-
bolic rates and provide protection against ischemic insults.
We also demonstrated an improvement in survival and
hemodynamic stability when DADLE was used as a treat-
ment in hemorrhagic shock. In this study we compared the
effects of DADLE to norepinephrine treatment on lactate
production in an animal model of severe hemorrhagic
shock. Methods: Conscious Sprague Dawley rats (300–350
grams) with indwelling catheters were hemorrhaged at
a rate of 3.25 ml/100grams over 20 minutes. Following
control measurements of heart rate (HR), arterial pressure
(AP) and plasma lactate as a marker of tissue ischemia, the
rats were randomized to receive intravenous DADLE (1mg/
kg), normal saline, or norepinephrine (7mg/kg; NOR) in
a 200 ml bolus and monitored for life signs for up to 3 hours.
Results: While none of the saline rats (n ¼ 3) survived for
the monitored period, 4 of 5 of the NOR rats and 6 of 7
DADLE rats survived the full 3 hours post-hemorrhage. The
surviving groups experienced similar hemodynamic shock
(Mean AP before hemorrhage (124 6 4 mmHg NOR; 121 6 3
DADLE) and following hemorrhage (94 6 4 mmHg NOR;
94 6 5 DADLE) ; HR before (277 6 9 bpm NOR; 261 6 4
DADLE) and after (260 6 19bpm NOR; 247 6 10 DADLE).
However, the plasma lactate, increased in NOR rats (1.1 6
0.3 to 4.5 6 2.7 mmol/L) but not in the DADLE group (0.8 6
0.2 to 1.0 6 0.3). Conclusions: While vasoactive agents such
as norepinephrine can stabilize blood pressure during shock
they do little to alleviate metabolic demands and protect
against ischemia. In an animal model of severe hemorrhagic
shock there was similar improvement in hemodynamic
stability and survival with both DADLE and NOR treat-
ments. However, lactate levels were significantly increased
only in the rats receiving NOR. Physiologic manipulation
during shock with a selective d receptor agonist appears to
attenuate ischemia and may be preferred to pressor agents.
122 Hypertonic Saline Invokes Divergent Inflammatory
Effects on Human Vascular Smooth Muscle Maria E
Moreira, Todd D Morrell, Anirban Banerjee, Charles B Cairns;
Denver Health Medical Center: Denver, CO, University of
Colorado Health Sciences Center: Denver, CO
Introduction: Hypertonic saline (HTS) has been used as
a intravascular volume expander in resuscitation from
clinical hemorrhagic shock. Recently, the anti-inflammatory
464
effects of HTS have been recognized as potentially more
important in shock resuscitation. Yet, the optimal dosing
and timing of these clinical effects remain unknown. The
sustained pro-inflammatory cascade in humans includes the
activation of various mitogen activated protein kinases
(MAPK). Hypothesis: HTS results in uniform anti-inflam-
matory effects on the MAPK cascade in human vascular
smooth muscle cells. Methods: Human vascular smooth
muscle cells (HVSMC) were incubated for 0 to 30 min with
100ng tumor necrosis factor (TNF)-alpha with or without
HTS (180 mM) and assessed for p38 MAPK and p42/44,
ERK-1, -2 phosphorylated activation using SDS-PAGE gels
and confirmed by digital immunofluoresence imaging
(ANOVA with post-hoc Scheffe testing). Results: HTS
inhibits p42/44 ERK-1 and -2 activation of HVSMC by
TNF-alpha, despite elevation of baseline levels by HTS (0.60
vs. control 0.35, p \ .01). In contrast, p38 MAPK activation
was moderately enhanced at baseline (0.34 vs. 0.05 control,
p \ .01) and HTS did not block p38 MAPK activation by
TNF-alpha. Indeed, p38 MAPK activation appeared to be
elevated by HTS after 30 min TNF exposure (0.79 vs 0.04
control, p \ .01). Conclusions: While HTS adequately
blocked ERK-1 activation, it augmented and sustained the
p38 MAPK activation in human vascular smooth muscle.
This suggests that while hypertonic saline may inhibit cer-
tain inflammatory pathways, other stress-induced inflam-
matory pathways may be exacerbated.
123 Preliminary Study of Nicotinamide (Vitamin B3) as
a Neuroprotective Agent Following Experimental
Spinal Cord Injury Kori L Brewer, Todd Nolan; Brody School
of Medicine at East Carolina University: Greenville, NC
Background: A transient increase in exictatory amino acids
(EAA) is viewed as contributing to a ‘‘central cascade’’ of
secondary pathological changes that occur following spinal
cord injury (SCI). This EAA induced neurotoxicity occurs, in
part, through the generation of nitric oxide (NO). In turn,
NO-induced injury is mediated by ADP-ribosylation. The
vitamin, nicotinamide (NAm), has been shown to be an
inhibitor of poly-ATP ribose polymerase (PARP) and is
effective in reducing neuronal loss and behavioral deficits
in models of stroke and traumatic brain injury. Objective:
Determine the usefulness of a single systemic dose of NAm
for protection against neuronal death following an experi-
mental spinal cord injury in rats. Methods: Male, Long-
Evans rats were given intraspinal injections of 125 mM
quisqualic acid (QUIS) which simulates the increase in
extracellular glutamate that is known to occur following SCI.
The treatment group (n ¼ 5) was given a single i.p. injection
of NAm (500 mg/kg), 30 minutes post-injury. Control
animals (n ¼ 5)recieved an equal volume of normal saline
i.p. Animals were allowed to survive for 7 days at which
time the spinal cords were removed, fixed in formalin, cut
into 75-micron serial sections and stained with cresyl violet.
Microscopic analysis was performed to assess the lesion
volumes in each group of animals. Results: Lesion analysis
revealed that the administration of NAm reduced the lesion
volume by 20.2% over the 1.5mm length of cord examined.
While there was no difference in the size of the lesion at the
epicenter of damage, the rostrocaudal extent of damage was
reduced in the NAm group. Conclusions: NAm appears to
2003 SAEM ANNUAL MEETING ABSTRACTS
be effective in reducing lesion size in this model of SCI.
Because it can be used clinically in large doses with few side
effects, further research into the use of NAm as a neuropro-
tective agent in SCI is warranted. In addition, studies are
needed to detemine the optimal dosage(s) and therapeutic
window for its use.
124 Regional Blood Flow and Organ Perfusion in a Swine
Model of Hemorrhagic Shock Lance D Wilson, Jack
Mitstifer, James Aiello; MetroHealth Medical Center: Cleveland,
OH, Akron General Medical Center: Akron, OH
Objectives: Current treatment for hemorrhagic shock is
fluid resuscitation to restore blood pressure, however
during active bleeding, resuscitation may worsen hemor-
rhage and shock. We developed a model based on clinical
parameters reflecting the management of controlled or
uncontrolled hemorrhage. We hypothesized that fluid
resuscitation would improve organ perfusion in controlled
hemorrhage (CON) but be deleterious in uncontrolled
hemorrhage (UNCON). Methods: Design: experimental
study in which 17 pigs were randomized to: 1) CON with
no resuscitation (NR) 2) CON þ resuscitation (R) 3)
UNCON NR 4) UNCONþR. Interventions: Main outcome
measures were peripheral and splanchnic blood flow and
perfusion. Hemorrhage was initiated through an arterial
catheter (CON) or pulling an aortotomy wire (UNCON) and
pigs were randomized to resuscitation or 30 minutes of
permissive hypotension. Next, the aortotomy was repaired
and resuscitation performed in all groups to maintain mean
arterial pressure (MAP) for 1 hour. Statistical significance
was determined by ANOVA. Results: After hemorrhage,
MAP decreased in all groups by 37% (p \ .03). Pigs with
UNCON received more fluid (1740 vs. 562 cc, p \ .02) to
maintain target MAP. In the UNCONþR group, baseline
MAP could not be restored. Decreases in superior mesen-
teric artery blood flow occurred after hemorrhage in all
groups and persisted (p ¼ NS). Femoral artery blood flow
decreased 52% for all groups after hemorrhage (p \ .001)
and returned towards baseline except in the CON NR group
(p \ .03). After resuscitation, arterial, portal and femoral
vein lactate remained elevated only in the CON NR and the
UNCONþR groups. Portal vein lactate increased 190% and
97% in these groups, respectively (p \ .02). Conclusions:
Permissive hypotension was deleterious to organ blood flow
and perfusion, particularly in controlled hemorrhage. Re-
suscitation was beneficial in controlled hemorrhage, but in
uncontrolled hemorrhage, resulted in hypotension and
decreased organ perfusion.
125 CNI-1493 Enhances Reepithelialization of Second
Degree Burns in Swine Adam J Singer, Steve A
McClain, Galina Botchkina, Arzu Buyuk, Thomas Zimmerman,
Paul Cameau, Marcia Simon; State University of New York:
Stony Brook, NY, Montefiore Hospital: Bronx, NY
Objective: Tumor necrosis factor alpha (TNF) is a pro-
inflammatory cytokine that is locally produced in burns,
which may contribute to extension of tissue necrosis after
thermal injury, delaying reepithelialization. We hypothe-
sized that administration of a novel macrophage inhibitor,
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
CNI-1493, would blunt the local production of TNF in
second-degree burns leading to reduced depth of injury and
faster reepithelialization. Methods: Design–prospective,
blinded, controlled, experimental study. Participants–Nine
isoflurane anesthetized swine. Interventions–Ten standard-
ized second-degree burns were created in each of 9 animals
(total ¼ 90 burns) by applying an aluminum bar preheated
to 80 degrees centigrade to the pigs’ backs for 20 seconds.
The experimental animals (n ¼ 6) received 1 (at 30 min) or 2
(at 30 min and 24 hr) intravenous boluses of CNI-1493 1
mg/kg. The control pigs (n ¼ 3) received an IV bolus of NS
and all burns were treated with topical silver sulfadiazine
daily for 14 days. Outcomes–full thickness biopsies of the
burns were taken after 1, 3, 7, 10, 14, and 90 days for blinded
determination of depth of collagen damage and cellular
necrosis, % reepithelialization, and depth of scarring.
Results:
CNI-1493 CNI-1493
Control once twice P value
Depth of
follicular Necrosis,
day 3, mm (SD) 1.14 (0.58) 0.79 (0.47) 0.93 (0.39)
Depth of
thrombosis,
day 3, mm (SD) 1.29 (0.27) 1.08 (0.34) 1.12 (0.27)
% Reepitheli-
alization,
day 10 (SD) 31.8 (36.4) 59.7 (44.8) 61.7 (45.9)
% Reepitheli-
alization,
day 14 (SD) 74.5 (43.4) 80.5 (37.5) 100.0 (0)
Depth of scar,
day 90 1.63 (0.99) 1.45 (1.04) 1.56 (0.85)
Conclusions: CNI-1493 reduces the depth of follicular
necrosis and thrombosis after second degree burns in swine
resulting in more rapid reepithelialization than controls.
126 Prospective Countywide Trial to Decrease
Ambulance Diversion Hours Gary M Vilke, Roneet
Lev, Edward M Castillo, Patricia A Murrin, Theodore C Chan;
Univerisity of California, San Diego Medical Center: San Diego,
CA, Scripps Mercy Hospital: San Diego, CA, San Diego County
Emergency Medical Services: San Diego, CA
Objectives: ED ambulance diversion is a major issue in
many communities. When patients do not get to requested
facilities, challenges in care are compounded by lack of
available medical records and delays in transferring
admitted patients back to the originally requested facility.
Analysis in our county demonstrated significant increases in
ambulance diversion hours as well as patients not getting to
requested facilities. Hypothesis: If all hospitals would
attempt to limit bypass hours following standardized
‘‘rules’’ and accept patient requests, diversion hours could
be decreased and a greater number of patient requests could
be honored. Methods: Design: Prospective, observational.
Setting: County of 2.8 million (urban, suburban, rural);
150,000 9-1-1 transports annually; 21 emergency depart-
ments. Intervention: A countywide committee was formed
including representative from all hospitals, county EMS,
465
pre-hospital providers and paramedic base stations. ‘‘Rules’’
for diversion were established and agreed upon: Diver-
sion only to last one hour. Once coming off and taking an
additional ambulance patient, diversion for one hour could
be re-established. During diversion, a hospital will still take
own requests—unless there is a significant patient safety
issue. Data for 12 months prior was compared with the three
month trial period. Statistics: Student t-test. Results:
Monthly average Baseline data Trial period P-Value
Ambulance runs 9623 9809 NS
Diversion hours 4007 1079 p \ 0.05
Pts not getting
to requested ED 1320 322 p \ 0.05
Conclusion: A voluntary community-wide approach to
attempt to get ambulance patients to requested facilities
and to decrease ambulance diversion can be effective in
attaining these goals.
127 Aspiration of Gastric Contents: Association with
0.037 Prehospital Intubation Jacob W Ufberg, Joseph S
Bushra, David J Karras, Wayne A Satz, Friedrich Kueppers;
Temple University Hospital: Philadelphia, PA
0.025
Objective: To compare the incidence of pulmonary aspira-
tion of gastric contents among patients endotracheally
0.012 intubated in the prehospital setting and those intubated in
the emergency department using a qualitative pepsin assay.
Methods: This was a prospective, observational study of
0.010 a consecutive sample of patients presenting to the ED of
a busy, urban, level I trauma center over an eight month
0.92
period. All patients who were endotracheally intubated
either before or during their ED visit, and from whom
a tracheal aspirate could be collected, were included in the
study. Sputum samples were obtained using a standard
sputum suction trap as soon as possible after intubation and
verification of endotracheal tube position. An investigator
blinded to the site of intubation tested the tracheal aspirates
for the presence of pepsin (as a marker of gastric contents)
using a previously validated fibrinogen digestion technique.
Results: One hundred sixty-eight patients were enrolled,
with 20 intubated in the prehospital setting and 148 intub-
ated in the ED. The pepsin assay was positive in 10 of
20 (50%) patients intubated in the prehospital setting, as
opposed to 33 of 148 (22%) of those intubated in the ED
(chi-square p ¼ .008, odds ratio 3.5, 95% CI 1.34 to 9.08).
Conclusions: Patients endotracheally intubated in the pre-
hospital setting are more likely to aspirate gastric contents
than patients intubated in the emergency department. Fur-
ther study may delineate whether this increased likelihood
of aspiration is due to severity of illness or operator de-
pendent variables.
128 Intranasal Naloxone Is a Safe First-line Treatment for
Patients with Respiratory Compromise Due to
Suspected Opiate Overdose Anne-Maree Kelly, Debra Kerr,
Ian Patrick, Tony Walker; Joseph Epstein Centre for Emergency
Medicine Research: Melbourne, Australia, Metropolitan
Ambulance Service: Melbourne, Australia, Rural Ambulance
Victoria: Melbourne, Australia
466 2003 SAEM ANNUAL MEETING ABSTRACTS

Objectives: To compare the effectiveness of intranasal (IN)

LOCATION %
Naloxone to intramuscular (IM) Naloxone for treatment
of respiratory depression due to opiate overdose in the Single-residential 56.1%
prehospital setting. Methods: Study Design: Randomised Multi-residential 22.7%
unblinded trial. Setting: Metropolitan and Rural Ambulance Nursing home 5.9%
Single store/Strip mall 3.0%
Services Victoria [Australia] for the period 15 January-15
Street/Highway/Road 2.7%
August 2002. Patients: Patients requiring prehospital treat- Recreation facility 2.1%
ment for suspected opiate overdose with GCS \ 12 and Office building 1.2%
respiratory rate (RR) \11/min. Intervention: Patients re- Indoor shopping mall 1.0%
ceived either IM Naloxone 2 mg or IN Naloxone 2 mg via Hotel 0.8%
a mucosal atomizer. All patients received respiratory Factory/Industrial site 0.7%
support and supportive care according to standing proto- Restaurant/Bar 0.6%
cols. Rescue IM naloxone was administered after 8 minutes Hospital (non-acute) 0.5%
as required. Outcome measures: Primary outcome measures Medical office/Clinic 0.5%
were the proportion of patients with RR [10/min and GCS School/College/University 0.5%
Missing 0.4%
[11 at 8 minutes. Secondary outcomes were the proportion
Casino 0.4%
of patients requiring rescue Naloxone and the rate of adverse Sports field/Park 0.2%
events. Analysis: Chi-square analysis /Fisher’s Exact test. Other 0.2%
Results: 91 patients were enrolled: IM 44 and IN 47. There Golf course 0.1%
was no statistically significant difference between the IM and
All other locations were less than 0.1%.
IN routes for the proportion of patients with RR [10 (IM:
79%; IN: 62%, p ¼ 0.1342), GCS [11 (IM: 67%; IN: 53%, p ¼
0.2944) or the requirement for rescue Naloxone (IM: 20%; IN:
33%, p ¼ 0.2585). There were no major adverse events and Conclusion: This is the largest review of cardiac arrest
the rate of minor events was similar (IM:23%, IN:15%). location ever conducted. Most cardiac arrests occur in
Conclusions: In most patients treated with IN Naloxone, it private locations (84.7%) compared to public places
was sufficient to reverse acute opiate toxicity. This avoided (15.3%). Communities should review locations of their
the risk of needlestick injury and transfer of blood borne cardiac arrest when designing CPR training and public
infection to paramedics. If there is a system to provide access defibrillation programs.
appropriate respiratory support and to administer addi-
tional therapy if required, IN Naloxone appears to have
acceptable effectiveness to warrant its use as first-line
therapy for acute opiate toxicity in the prehospital setting. 130 Comparing the Ability of Colorimetric and Digital
The IN route could also potentially increase access to this Waveform End Tidal Capnography to Verify
life-saving therapy, for example via outreach workers. Endotracheal Tube Placement in the Prehospital
Setting Amar Singh, Ross E Megargel, Michael R Schnyder,
Robert E O’Connor; Christiana Care Health System: Newark,
DE, Office of EMS: Dover, DE
129 Determination of Accurate Out-of-hospital Cardiac
Objectives: We performed this prospective study to
Arrest Location in 20 Communities Christian
evaluate the efficacy of colorimetric and digital waveform
Vaillancourt, Valerie J De Maio, Ian G Stiell, George A
end tidal capnography (ETCO2) to verify endotracheal tube
Wells, Lisa Nesbitt, Michael T Martin, Donna Cousineau, , for
placement in the prehospital setting. Methods: Patients
the OPALS Study Group; ; University of Ottawa: Ottawa,
undergoing endotracheal intubation by EMS during 2002
Ontario, Canada
were eligible. Following intubation, a digital waveform
Objectives: Many communities are implementing CPR ETCO2 reading was obtained to confirm placement. Place-
training and public access defibrillation programs with little ment was verified by additional clinical means. Subjects
information on cardiac arrest location. We sought to de- were grouped according to initial ETCO2 measurement to
termine accurate out-of-hospital cardiac arrest location in correlate with categories of colorimetric measurement:
20 communities. Methods: Prospective cohort. The OPALS \0.5% (group A), 0.5% to 2.0% (group B) and [2.0% (group
study is the largest population-based cohort of adult out-of- C). Group A was considered negative, Group B was
hospital cardiac arrest cases in 20 communities with BLS-D considered indeterminate, and Group C was considered
and ALS paramedics. We merged the OPALS and provincial confirmatory of endotracheal placement. Esophageal or
dispatch databases using a unique identifier to obtain tracheal placement was recorded. The presence or absence
addresses where cardiac arrest occurred. Addresses were of a perfusing rhythm was noted. Data were analyzed using
then retrieved from the municipal property assessment the McNemer and Mann-Whitney U tests. Results: A total
corporation database to obtain accurate description of of 88 patients were enrolled, 9 in Group A, 29 in group B
cardiac arrest location. Cardiac arrest location was classified and 50 in Group C. A total of 73 were in cardiac arrest. Of
within 26 predetermined categories. Missing information the 15 (17%) with perfusing rhythms, all were in group C. Of
was submitted to base hospitals for review. Data was the 9 with undetectable ETCO2, 2 (22%) had esophageal
analysed using descriptive statistics. Results: From 1995 to intubations. Both of these cases had ETCO2 readings of 0,
2000, there were 7,707 consecutive cardiac arrest cases. Mean with flat waveforms. Only two tracheal intubations had had
age 68.9, 67% male, 37% VF/VT, 49% witnessed, 16% ETCO2 readings of 0, with flat waveforms. Digital capno-
bystander CPR, and 4.0% survival to discharge. graphy was 97% sensitive and 100% specific, whereas
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
colorimetric (using Group C) was 89% sensitive and 100%
specific, or (using Groups B and C) 57% sensitive and 100%
specific. These differences are significant. (p \ 0.001) The
mean ETCO2 was 17 in arrest, and 37 in patients with
perfusing rhythms (p \ 0.001). Conclusions: Due to an
ability to detect low levels of exhaled CO2, digital
capnography is superior to colorimetric methods in con-
firming correct endotracheal tube placement, especially in
cardiac arrest. Given its low specificity, EMS personnel may
be misled by colorimetric Group C readings in patients with
correctly placed endotracheal tubes.
131 Out-of-hospital Cardiac Arrest Locations in
a Predominantly Rural Community: Where Should
We Place AEDs? Marc E Portner, Marc L Pollack,
Steven K Schirk, Melissa K Schlenker; York Hospital: York, PA,
Penn State University, College of Medicine: Hershey, PA
Objectives: Poor survival of out-of-hospital cardiac arrest
(OHCA) in rural communities is partially due to prolonged
time to defibrillation and might be improved by optimal
placement of Automated External Defibrillators (AED). The
objective of this study was to determine locations of OHCA
to identify high-risk locations that might benefit from AED
placement. Methods: Retrospective case review of OHCA
in a rural community of 350,000 residents over 5.5 years
involving 5 ALS units. All non-traumatic OHCA in patients
older than 8 years without advanced directives where EMS
initiated resuscitative efforts were included. Non-residential
OHCA were categorized based on location. Results: 941
OHCA occurred over the study period. 676(71.8%) were
residential and 265(28.2%) were non-residential. Of the non-
residential, 127(47.9%) were in healthcare related locations,
including 104(39.2%) in extended care facilities (ECF). There
were 5 non-healthcare related locations that had 2 OHCA
but no location had more than two. Most non-residential,
non-healthcare related OHCA occurred as isolated events in
146 different locations. Conclusion: In this predominantly
rural community, the vast majority of OHCA (86.7%) occur
in private residences or as isolated events in a variety of
public settings and survival would not likely be impacted
by strategic placement of AED. However, almost half
(47.2%) of the non-residential OHCA occurred in a health-
care related facility suggesting that these locations may
benefit from AED placement. First responders, such as
police officers, with AED might have the greatest impact in
these non-healthcare related locations.
132 Use of the Intubating Laryngeal Mask Airway in
Prehospital Patients with Failed Rapid Sequence
Intubation Michael Gibbs, Eric Swanson, Vivek Tayal, Bruce
Horwood, Deepi Goyal, Steve Carlton, Mark Lowell; Maine
Medical Center: Portland, ME, University of Utah: Salt Lake
City, UT, Carolinas Medical Center: Charlotte, NC, Maricopa
Medical Center: Phoenix, AZ, Mayo Clinic: Rochester, MN,
University of Cincinnati: Cincinnati, OH, University of
Michigan: Ann Arbor, MI
Objectives: As neuromuscular blockade becomes more
widely used in the prehospital setting rational approaches
467
to airway rescue must be adopted. The purpose of this study
was to evaluate the use of the Intubating Laryngeal Mask
Airway (ILMA) in patients with failed rapid-sequence-
intubation (RSI). Methods: We conducted a prospective,
observational study at six tertiary-care, hospital-based, air
medical transport programs where RSI is utilized. Air
medical personnel completed standardized LMA manikin-
based training. The study protocol utilized the ILMA as
a rescue device in consecutive ‘‘failed RSI’’ cases ([3
intubation attempts and/or inability to ventilate). Demo-
graphic information, reasons for failed RSI, success of ILMA
insertion, and complications were recorded on a standard-
ized data form. Results: Thirty-four patients were enrolled
from 11/99 to 10/02. No patients meeting the failed RSI
definition were excluded during the study period. The mean
subject age was 36 years (range 14–79), 50% were male.
Ninety-four percent of patients were injured. Reasons for
failed RSI included inadequate visualization (76%), bleed-
ing/secretions (68%), altered airway anatomy (44%) and
esophageal intubation (38%). Successful LMA ventilation
was achieved in 100% of patients (94% 1st attempt, 6% 2nd
attempt). Insertion of the ILMA endotracheal component
was successful in 28 (82%) patients (70% 1st attempt, 12%
2nd attempt). Rescue cricothyrotomy was required in 2
patients. Complications were observed during airway
management in 40% of patients although none appeared
attributable to ILMA use. Conclusions: Following standard-
ized training, air medical providers were able to effectively
utilize the ILMA as a rescue device. Successful LMA
ventilation was achieved in all failed RSI patients while
successful passage of the ILMA endotracheal component
proved more difficult with an 82% rate of success.
133 Emergency Medicine Residents’ Skill Development
in Airway Management: Analysis of 8367 Intubation
Attempts Mark J Sagarin, Erik Barton, Yi-Mei Chng, Peter
Pang, Ron M Walls; Mount Auburn Hospital: Cambridge, MA,
University of Utah Health Sciences Center: Salt Lake City, UT,
Brigham & Women’s Hospital: Boston, MA, Harvard Affiliated
Emergency Medicine Residency: Boston, MA
Objective: The pace of skill development in airway
management among EM residents(EMRs)has not been
evaluated in a large multicenter study. We hypothesized
that EMR airway skills progress to a high level in the first
several years of training. Methods: Phase 2 of the National
Emergency Airway Registry was a prospectively gathered,
observational study of ED intubations (EDIs) in 31 Univer-
sity-affiliated EDs in 3 nations over a 28 month period. At
the time of EDI, physicians completed a data form which
included the specialty and level of training of physicians,
the number of attempts, methods used, success or failure,
and adverse events. Outcomes included success on first
attempt (SFA%) and success overall (SO%), meaning the
patient was successfully intubated by the initial intubator.
‘‘Rescue’’ intubations (REDIs) were defined as intubations
performed after another physician had failed to intubate.
Results: Of 8586 EDIs in the database, 8484 had complete
information. Of these, 7433 (88%) of initial intubation at-
tempts were performed by EPs, including 6072 (72%) by
EMRs. For initial attempts by EMRs, SFA was 82% and SO
was 89%. Of 1176 EDIs that required rescue, 934 (79%) were
468 2003 SAEM ANNUAL MEETING ABSTRACTS

performed by EPs including 428 (36%) by EMRs. For REDIs general anesthesia during anesthesiologist monitored EDPS
by EMRs, SFA was 79% and SO was 88%. with propofol. Hypoxia, the only major complication noted,
occurred significantly more often in patients reaching
general anesthesia than in less sedated patients.
Initial intubation Rescue intubation
attempts attempts

N SFA SO N SFA SO
135 Assessing Mallampati Scores, Thyromental
pgy1 701 72% 80% 10 50% 60% Distance, and Neck Mobility in Emergency
pgy2 2591 81% 89% 67 82% 88% Department Intubated Patients Richard M Levitan, Edward
pgy3 2317 87% 93% 279 79% 89%
T Dickinson, Janet McMaster, Worth Everett; Hospital of the
pgy4 460 82% 90% 72 79% 89%
University of Pennsylvania: Philadelphia, PA
attending 1132 88% 97% 487 72% 86%
unknown lvl 229 85% 92% 19 90% 95%
Physiognomic assessment of difficult laryngoscopy prior
to RSI has been advocated for all ED intubations. Such
TOTAL 7433 83% 91% 934 76% 87% screening tests are typically done in pre-op settings with
cooperative patients, sitting upright, and leaning forward
Re initial attempts, there were improvements in both SFA with the neck flexed and the atlanto-occipital joint extended.
and SO from pgy1 to pgy2 and from pgy2 to pgy3 (p \ Objective: The objective of this study was to determine the
0.001). Rescue attempts improved similarly (p \ .05) from feasibility and potential utility of assessing Mallampati
pgy1 to pgy2 only. Conclusion: In both initial attempts at scores, thyromental distance, and neck mobility in our ED
EDI and rescue EDIs, EMRs demonstrate a high level of intubated patients and to specifically examine our RSI
success which increases in the first few years of training. associated failures. Methods: Setting: Inner city, level 1
trauma center, ED census 50,000. We retrospectively
reviewed 3 years of intubations using chart review and
trauma registry data. Mallampati scoring was deemed
134 General Anesthesia during Emergency Department unobtainable in persons who could not follow simple
Procedural Sedation with Propofol William E commands (GCS motor \6) on presentation. Neck mobility
Hauter, William H Cordell, Christopher S Weaver, Edward J and thyromental measurement were deemed unobtainable
Brizendine; Indiana University School of Medicine: with C-spine precautions. Results: Total intubations ¼ 945,
Indianapolis, IN, Methodist Hospital of Indiana: trauma ¼ 658, non-trauma ¼ 287. After excluding cardiac
Indianapolis, IN arrest, 857 total; 599 and 257 in each group. Overall, 452
Objectives: Control of sedation depth and avoidance of (53%, 95% CI 49–56%) were not following commands; 370
general anesthesia (GA) are major objectives of the Amer- (43%, 40–47%) were C-spine immobilized. Not following
ican Society of Anesthesiologists (ASA) practice guidelines commands þ C-spine immobilized: 210 (25%, 22–28%).
for procedural sedation. Propofol can unintentionally in- Following commands and non-immobilzed: 271 (32%, 29–
duce GA during emergency department procedural seda- 35%). There were 3 failed RSI cases (3/841 RSI, 0.36%, 0–1%;
tion (EDPS). We conducted a prospective study to evaluate 1 trauma, 2 non-trauma); all could be ventilated by mask or
how often and how long GA is induced during EDPS with LMA. None of the 3 RSI failures were following commands,
propofol as well as the complication rate. Methods: Pro- 1 was C-spine immobilized. Conclusions: Mallampati
spective, observational study of patients [17 years of age scoring plus testing of neck mobility and thyromental dis-
consenting to EDPS with propofol in the EDs of two urban tance potentially could have been done in only about one
academic Level I trauma centers. All patients underwent third of the patients we intubated, and would not have
EDPS with standard monitoring by emergency physicians been feasible in our RSI failures. This limited applicability
using propofol in their usual fashion. In addition, one coupled with the low overall incidence of failed RSI (leading
anesthesiologist separately monitored all patients for depth to poor positive predictive values) causes such screening
of sedation and complications using ASA guidelines, ETCO2 tests to have limited utility in ED intubations.
and Bispectral Index monitoring. ‘‘Major complications’’
were defined as hypoxia (SpO2 \ 90% for 10 seconds),
aspiration, bag-valve-mask ventilation, intubation, blood
136 Comparison of Topical Anesthetics and Lubricants
pressure or heart rate interventions, hospital admission and
Prior to Urethral Catheterization in Male Patients:
death. Results: During the six-month study period, 76
A Randomized Controlled Trial John Siderias, Flavio G
patients were enrolled. The median age was 39 (range 18–81)
Gaudio, Adam J Singer; State University of New York:
and 47% were male. Patients underwent EDPS most often
Stony Brook, NY
for I & D (47%), joint reduction (29%) and fracture care
(12%). Nineteen (25%) patients undergoing EDPS with Objective: Urethral catheterization (UC) is one of the most
propofol achieved a depth of sedation consistent with GA painful ED procedures. We compared the pain of UC after
while 57 (75%) were moderately or deeply sedated. The pretreatment with a topical anesthetic versus a lubricant
average length of a GA state was 1.2 minutes (SD 0.6). only. Methods: Design—A prospective, randomized, con-
Hypoxia was the only noted major complication. For GA trolled, double blind trial. Setting—University based ED,
patients, 26% (5/19) were hypoxic compared to 7% (4/57) of annual census of 75,000. Subjects—convenience sample of
less deeply sedated patients (p ¼ 0.038). The combined adult male ED patients requiring UC. Interventions—Pre-
average hypoxia time was 1.2 minutes (SD 0.4). Conclu- treatment of the urethra was performed using 2% lidocaine
sions: Emergency physicians often induced a brief period of jelly or sterile lubricant with an 18-gauge plastic catheter.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Physicians and patients were masked to study assignment.
Outcomes—Patients rated overall pain/discomfort from UC
on a previously validated 100-mm visual analogue pain
scale. Other outcomes were pain of anesthetic/lubricant
injection, ease of insertion, number of attempts, and post UC
bleeding. Data analysis—Pain scores were compared using
a 2-tailed t-test. This study had an 80% power to detect a 20-
mm between-group difference in the pain scale (alpha ¼
0.05). Results: We evaluated 36 patients evenly distributed
between study groups. Mean age was 62 (range, 22–85).
Urinary retention was the most common indication. Com-
pared with controls, patients pretreated with Lidocaine
experienced significantly less pain of catheterization (38 6 28
mm vs. 58 6 30 mm; mean difference 20 mm, 95% CI 0.4 to
32; P ¼ 0.04), less pain of injection (23 6 17 mm vs. 40 6 25
mm; mean difference 17 mm, 95% CI 3 to 32 mm p ¼ 0.02);
and UC was easier (60% vs. 41%), although this difference
was not significant (P ¼ 0.32). There were no differences in
the number of attempts and incidence of adverse events
between the groups. Conclusion: Use of topical lidocaine
reduces the pain associated with urethral catheterization in
comparison with topical lubricants only. Their use should be
encouraged prior to urethral catheterization.
137 Analgesia for Musculoskeletal Injuries in Children:
A Randomized, Blinded, Controlled Trial
Comparing Acetaminophen, Ibuprofen and Codeine
Eric A Clark, Amy Plint, Rhonda Correl, Isabelle Gaboury,
Brett Passi; Children’s Hospital of Eastern Ontario: Ottawa,
Ontario, Canada
Background: Many children present to the ED with acute
musculoskeletal injuries and require analgesia. To date no
study has compared the analgesic efficacy of the 3 common
PO analgesics for children; acetaminophen, ibuprofen and
codeine. Objectives: To compare the analgesic efficacy of
acetaminophen, ibuprofen and codeine for acute musculo-
skeletal injuries in children. The primary endpoint was
a reduction in the visual analog pain scores at 1 hour.
Secondary endpoint was the number of patients who
achieved adequate analgesia; defined as a VAS score less
than 30 mm. Methods: All patients 7–18 years old, present-
ing presenting with acute, painful musculoskelatal injuries
were randomized to receive one of the 3 study medications
in a blind manner. The patient’s VAS was recorded at
presentation and again at 30, 60, 90, 120, 180 and 240
minutes. The study was designed to detect a clinically
significant difference on the VAS of 15 mm. Observational
VAS were also recorded by the parents and research
assistants. Results: To date 298 subjects are enrolled. The
study groups were similar with regards to age, gender,
baseline VAS and discharge diagnosis. At 1 hour, pain
scores were lowered by 24.9mm in the ibuprofen group
versus 6.9mm for codeine and 10.1mm for acetaminophen.
At 1 hour, 56.5% of the ibuprofen group versus 38.6% and
40.5% of the acetaminophen and codeine groups had
achieved adequate analgesia. By 4 hours 72.5% versus
60.4% versus 52.9% of the codeine, ibuprofen and acetamin-
ophen groups had achieved adequate analgesia. Conclu-
sions: This is the first pediatric study of these 3 common PO
analgesics. Of the 3 drugs, ibuprofen was the only drug to
achieve clinically significant analgesia by 1 hour. By 4 hours,
469
both ibuprofen and codeine were equally effective and had
performed better than acetaminophen. In the pediatric ED,
ibuprofen is the initial drug of choice for acute analgesia for
musculoskeletal injuries.
138 A Randomized Controlled Trial Comparing Femoral
Nerve Block to Intravenous Morphine in Isolated
Femur Fractures James Levine, Wayne R Triner, Shin Yi Lai;
Albany Medical Center: Albany, NY
Objective: To compare the analgesic efficacy between IV
morphine and femoral nerve block (FNB) in isolated femur
fractures. Methods: Adult patients with isolated midshaft
femur fractures were randomized to receive either mor-
phine 0.1 milligram per kilogram intravenously, or FNB of
the affected leg (bupivacaine 0.5% 20 milliliters). Visual
analog pain scales (VAS) were administered prior to
administration of the study intervention and again one hour
later. The requirement for rescue analgesia was recorded,
as were adversities attributed to the study intervention.
All providers underwent training and certification in FNB
administration. The hospital’s institutional review board
approved the study. Results: Data was collected on sixteen
patients (10 FNB, 6 morphine). Age distribution was not
significantly different between groups. There were more
females in the morphine group (4 of 6) than in the FNB group
(1 of 9)(p ¼ 0.04). The change in VAS at one hour was
significantly different between groups, with the FNB group
receiving greater relief (Wilcoxon Rank Sum p ¼ 0.004).
median VAS pre-treat median VAS change
FNB 77 56
morphine 86 11
The need for rescue medication was significantly greater in
the morphine group (RR 8.3 95%CI 1.2, 55.3). The presence of
a clinically significant change in VAS (defined as greater than
13 mm VAS difference before and one hour following
intervention) was significantly greater in the FNB group
(Fisher’s Exact p ¼ 0.036). There were no reported adverse
effects in either group. Conclusions: FNB results in sig-
nificantly greater pain relief than does a standard dose
of morphine and subsequent opiate analgesia for isolated
femur fractures. Patients receiving a FNB for isolated femur
fractures require less additional analgesia and are more
likely to experience greater clinically significant pain re-
duction.
139 A Prospective, Randomized, Double-blind
Comparison of Buffered vs Plain Tetracaine in
Reducing the Pain of Topical Ophthalmic
Anesthesia Christopher S Weaver, Daniel E Rusyniak,
Edward J Brizendine, Steve Abel, Geoffrey G Somerville, John D
Howard, Timothy Root; Indiana University School of Medicine:
Indianapolis, IN, Purdue University: Indianapolis, IN
Objective: Two to three percent of patients presenting to
emergency departments have primary complaints related to
470
the eye. Patients with eye complaints often require topical
ophthalmic anesthesia to aid in their physical examination
and diagnosis. Tetracaine hydrochloride ophthalmic solu-
tion is a commonly used ocular anesthetic agent but patients
receiving ocular tetracaine commonly complain of pain
upon instillation. This study was conducted to determine if
buffering ocular tetracaine hydrochloride from its normal
pH of 4.54 to a pH of 7.4 reduces the pain of instillation.
Methods: Prospective, randomized, double-blind, 2-treat-
ment, 2-period cross-over, single center study of healthy
volunteers 18 years of age or older. Participants were ran-
domized to receive either two drops of buffered or plain
tetracaine in a randomly assigned eye. After a mean wash
out period of 24 days (range 7–54) participants returned to
have two drops of the other medication instilled in the same
eye. The participants recorded the pain of instillation on
a 100-mm visual analog scale (VAS) immediately and five
minutes after instillation. Adverse events were also re-
corded at these intervals. The primary outcome measure
was the intensity of pain as measured on a VAS immediately
after instillation. Results: Sixty persons were enrolled in the
study with 100% follow up. Immediately after instillation,
the adjusted mean VAS for buffered tetracaine was 29.1 mm
while the adjusted mean VAS for plain tetracaine was 16.0
mm. The estimated difference was 13.1 mm (95% CI: 6.9
mm, 19.3 mm). There were no adverse events following the
instillation of either solution. Conclusion: Buffering of
tetracaine hydrochloride significantly increases the pain of
its instillation in healthy volunteers suggesting that factors
other than pH change may be responsible for the pain
reduction reported in other studies of ophthalmic anes-
thetics.
140 Low Dose Naloxone Does Not Improve Nausea
and Pruritus Associated with Bolus IV Morphine
Administration Jennifer Provataris, Peter Wagoner
Greenwald, John Coffey, Polly Bijur, E John Gallagher; Albert
Einstein College of Medicine: Bronx, NY, Columbia College of
Physicians and Surgeons: New York, NY
Objective: Very small doses of naloxone have been found to
reduce nausea and pruritus associated with continuous IV
infusion and epidural morphine administration by as much
as 50% in postoperative patients without impairing analge-
sia. We wished to test the effect of low dose naloxone when
co-administered with bolus IV morphine in the Emergency
Department. Methods: Randomized, double-blind, placebo
controlled trial. All adult patients at two urban university
EDs receiving IV morphine bolus [0.10 mg/kg for acute
pain met entry criteria. Patients were excluded if they were
unable to complete a visual analog pain scale (VAS) or if
they they were allergic to morphine or naloxone. Subjects
were asked to rate their pain, nausea, and pruritus prior to
morphine administration on a 100 mm VAS. They were then
randomized to receive either 0.25 mcg/kg naloxone or an
equal volume of normal saline with their morphine bolus.
After 20 minutes, patients were again asked to rate their
pain, nausea and pruritus on the VAS. The incidence of
vomiting and use of rescue antiemetics during this interval
were noted. Results: Of the 135 patients enrolled, 123(91%)
had sufficient data available for analysis, 24(18%) received
less than 10mg/kg morphine and were excluded. There
2003 SAEM ANNUAL MEETING ABSTRACTS
were no differences between groups at randomization, nor
between the groups with respect to pain, nausea, pruritus,
vomiting, or the use of rescue antiemetics 20 minutes post
drug administration. Nausea decreased in both the nalox-
one and saline groups when measured at 20 minutes.
Pain (95%CI) Nausea (95%CI) Pruritus (95%CI)
Saline
37mm (
45mm
14mm (
21mm 1mm (
2mm
to
28mm) to
6mm) to 3mm)
Naloxone
42mm (
50mm
13mm (
20mm 1mm (
1mm
to
33mm) to
6mm) to 3mm)
Conclusion: The addition of low dose naloxone (0.25mcg/
kg) to morphine administered as an IV bolus for acute pain
in ED patients appears to have little effect on nausea,
pruritus, or analgesia.
141 A Comparison of the Use of Iontophoresis and Oral
Non-steroidal Anti-inflammatory Medication in the
Pain Management of Acute Soft Tissue Injuries in the
Emergency Department Setting Dean Christopher Bailey,
Alison Patrice Southern, Tara Lynn Shamy, Kristopher
Brickman; Medical College of Ohio: Toledo, OH
Objective: Iontophoresis is the induction of ionized medica-
tions topically via low level electric current, commonly used
in Physical Medicine and Rehabilitation settings. This study
evaluated the effectiveness of iontophoresis for the pain
management of acute soft tissue injuries in the emergency
department. Methods: This was a prospective randomized
study performed at a university hospital emergency de-
partment. Eligible patients were divided into control and
intervention groups based on the day of the week. In-
tervention patients were administered ionized lidocaine via
iontophoresis at the site of maximal pain. Control patients
were administered oral non-steroidal anti-inflammatory
medication (NSAID) based on age and weight. Pain levels
were recorded initially and at ten-minute intervals up to
thirty minutes in both patient populations utilizing a visual
analog pain scale of 0–10. Results: The data suggests
a statistically significant difference in the effectiveness of
the iontophoresis treatment compared to the NSAID control
group. There were a total of 42 patients enrolled in the
study, 20 in the iontophoresis group and 22 in the control
group. The iontophoresis group at 10, 20, and 30 minutes
demonstrated a pain decrease of 1.73, 2.48, and 3.13 points
respectively on the visual analog pain scale with p values
#0.01. The control group at 10, 20, and 30 minutes
demonstrated a pain decrease of 0.43, 0.80, and 1.30
respectively with p values #0.01. Evaluating the two
groups, the iontophoresis showed improvement in the pain
response of 302%, 210%, and 141% respectively at the 10–30
minute intervals when compared to the NSAID group.
Conclusion: Iontophoresis is an effective and efficient
adjunct to the traditional treatment in the emergency
department. The results from this study have demonstrated
iontophoresis to show clinically significant improvement in
the pain management of acute soft tissue injuries compared
to commonly used treatment in the emergency department
setting.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
142 Identifying Patients at Risk for Hospital-acquired
Venous Thromboembolism in the Emergency
Department Susan B Sheehy, Nathan I Shapiro, Jeffrey Spear,
Mary E Duffy; Beth Israel Deaconess Medical Center: Boston,
MA, Boston College William Connell School of Nursing:
Chestnut Hill, MA
Objective: To identify risk factors in Emergency Depart-
ment (ED) patients who are at increased risk of developing
venous thromboemboli (VTE) while hospitalized. Methods:
Design: Retrospective, observational, case control. Setting:
Urban, academic, Level I medical center. Subjects: Cases
were patients admitted to the hospital from the ED with
a diagnosis of other than a VTE who developed a VTE
during hospitalization. Controls were patients admitted to
the hospital who did not develop a VTE during hospital-
ization, matched on age and sex in a 1:3 ratio. Study period:
9/1/99–8/31/01. Diagnosis was confirmed by chart review.
Major data elements - age, sex, length of stay, in-hospital
VTE, prophylaxis, admitting diagnosis, history, co-morbid
conditions, hospital activity level. Univariate analysis was
performed to identify factors associated with in-hospital
VTE, followed by multiple logistic regression to identify
independent predictors. Results: 116 cases were initially
identified, 8 excluded due to symptomatology suggestive
of VTE or VTE diagnosed within one day of hospital
admission. There were 108 cases and 324 matched controls
in the study. Ages ranged from 17–97. The following factors
were identified as independent predictors of hospital-
acquired VTE: Cancer (OR ¼ 2.1, 95%CI ¼ 1.1–3.1), head
trauma (17.8, 1.9–163.6), central IV line (3.3, 1.0–10.3),
multiple trauma (7.3, 2.0–25.8), pneumonia (2.6, 1.0–6.6),
seizures (1.6, 0.65–4.0), history of VTE (2.9, 1.2–7.3), hospital
activity–bed rest (2.0, 2.4–6.8). Conclusions: We have iden-
tified risk factors for developing hospital-acquired VTEs.
These patients should be considered to be at greater risk for
VTE than others and, therefore, should be considered for
VTE prophylaxis that could begin in the ED. Lack of diag-
nostic studies obtained to detect asymptomatic VTEs present
on hospital admission limit the results of this study.
143 An Independent Validation of the Liatest D-dimer
Assay for Pulmonary Embolism Frank Anthony
Klanduch, Tae Kim, Steve Green; Loma Linda University:
Loma Linda, CA
Objective: Expensive ELISA D-dimer assays are highly
sensitive compared to inexpensive agglutination assays.
Our hospital laboratory selected an intermediate cost but
unproven turbidimetric assay (Liatest). We wished to
validate this assay for the Emergency Department exclusion
of pulmonary embolism (PE). Methods: We prospectively
evaluated 233 adults who presented to our tertiary Emer-
gency Department with a clinical suspicion of pulmonary
embolism. Liatest D-dimers were obtained concurrent with
either a V/Q scan or helical CT. We followed patients over 3
months and assigned a final diagnosis of PE using the criteria
of Kline (Ann Emerg Med 2002; 39:144). We then calculated
the sensitivity and specificity of this assay (normal #0.4 mg/
ml) and constructed a receiver operating characteristic (ROC)
curve. Results: At the time of abstract submission we have
enrolled 233 of the planned 400 subjects. There were 21 PEs
diagnosed (prevalence 9.0%). The Liatest D-dimer assay was
471
normal in 55 (24%) of all patients. An abnormal test was 86%
sensitive (18/21, 95% CI 64–97%), and 25% specific (52/212,
95% CI 19–31%). Three patients with PEs had normal
D-dimers; however, all three were high-clinical probability
patients in whom the D-dimer exclusion of imaging is not
currently recommended. The area under the ROC curve was
0.77. Conclusion: In this validation analysis the intermediate
cost Liatest D-dimer assay thus far has exhibited similar
sensitivity and specificity for PE to that observed in prior
studies for high-cost ELISA assays.
144 The Frequency of Pulmonary Embolism Depends on
the Suspected Diagnosis Christopher Kabrhel,
Andrew T McAfee, Samuel Z Goldhaber; Brigham and
Women’s Hospital and Massachusetts General Hospital
Harvard Affiliated Emergency Medicine Residency:
Boston, MA,
Introduction: Pre-test probability is crucial to interpreting
the results of radiological studies for pulmonary embolism
(PE). Knowing which disease entities are commonly sus-
pected prior to the correct diagnosis of PE being made may
help characterize patients with PE and aid in the clinical
assessment of pre-test probability. We sought to prospec-
tively determine which diagnoses were suspected prior to
the diagnosis of PE, and compare these to the final diagnosis.
Methods: Emergency physicians in an urban academic
emergency department (ED) were prospectively surveyed
as to the diagnosis they considered most likely prior to
initiating a work-up for PE. Surveys were administered prior
to the results of any diagnostic studies for PE (d-dimer, CT
scan, V/Q scan), but not necessarily prior to the results of
radiographs or EKG. PE was defined by positive PA-gram,
CT scan or V/Q scan. Rate of PE was calculated for the
following suspected diagnoses: PE, angina, pneumothorax,
pneumonia, COPD/asthma, pleural effusion, musculoskel-
etal pain, CHF, viral syndrome, anxiety, or other. Results: Of
625 patients, 161 (25.8%) were thought to have PE, and 33
(20.5%) of these had PE: sensitivity 0.53 (95%CI: 0.40 - 0.66),
specificity 0.77 (95%CI: 0.74–0.81), LRpos 2.34 (95%CI: 1.77–
3.09), LRneg 1.65 (95%CI: 1.26–2.16). When other diagnoses
were considered more likely prior to testing, PE was
diagnosed in the following percentage of cases: pneumonia
(32.1%), pleural effusion (18.75%), pneumothorax (16.7%),
CHF (15.8%), angina (7.5%), musculoskeletal pain (2.2%),
anxiety (1.7%), viral syndrome (0.0%), COPD/asthma
(0.0%), other (6.3%). Conclusions: When clinicians sus-
pected PE, the final diagnosis was PE about one-fifth of the
time. However, PE was diagnosed even more frequently
when clinicians suspected pneumonia. When COPD/
asthma, musculoskeletal pain, or viral syndrome were
suspected, PE was very rarely diagnosed.
145 Use of Spiral CT Angiogram to Replace Ventilation-
Perfusion Scan or Pulmonary Angiogram in
Strategies for the Diagnosis of Pulmonary Embolism: A
Cost-Effectiveness Analysis Rodney W Smith, Hyungjin
Myra Kim; St. Joseph Mercy Hospital: Ann Arbor, MI,
University of Michigan: Ann Arbor, MI
Background: Prior cost-effectiveness analyses (CEA) using
spiral CT angiogram (CTA) for the diagnosis of pulmonary
472
embolism (PE) have used high sensitivities of CTA and
have not used clinical probability of PE in the analysis.
Objective: To determine if CTA can replace ventilation-
perfusion scan (VQ) or pulmonary angiogram (PA) for the
diagnosis of PE. Methods: A decision-analysis model was
constructed to compare various validated strategies for PE
diagnosis with similar strategies that replace PA with CTA,
and with strategies using only d-dimer (DD), venous
ultrasound (USN) and CTA. Mortality and cost at 3 months
were estimated. Clinical probability was varied among low
(3.2%; range 1%–10%), moderate (14.3%; range 10%–38%)
and high (49%; range 38%–78%) prevalence of PE.
Sensitivity of CTA was set at 70% (range 60%–99%) based
on a prospective management study of ED patients
evaluated for PE. Turbidimetric DD was used (sensitivity
0.98, specificity 0.43). One- and two-way sensitivity anal-
ysis was performed on uncertain variables in the model.
Strategies were considered equally effective if mortality
difference was \¼0.5%. Results: Strategies using DD, USN
and CTA without VQ were not cost effective at any clin-
ical probability. At low clinical probability, no strategy
with CTA is cost-effective compared with DD-VQ-USN.
At moderate clinical probability, 2 strategies using CTA
are cost-effective compared to a reference strategy of
DD-VQ-USN-PA: DD-VQ-USN-CTA has equal efficacy
and costs $601 less per patient, and VQ-USN-DD-CTA is
equally effective and costs $466 less per patient. At high
clinical probability, substituting CTA for PA in VQ-USN-PA
is equally effective at $737 less per patient. Conclusion:
This CEA suggests that CTA cannot replace VQ scan in
diagnostic strategies for PE. At low clinical probability,
CTA strategies are not cost-effective, but at higher prob-
ability, CTA can replace PA in the diagnosis of PE. These
strategies should be prospectively validated in clinical
trials.
146 A Comparison of Faculty Contact Time with
Emergency Medicine Residents in Different
Teaching Venues Carey D Chisholm, Laura F Whenmouth,
Elizabeth A Daly, Edward J Brizendine, William H Cordell;
Indiana University School of Medicine: Indianapolis, IN
Objective: Emergency Medicine (EM) residencies must
implement the 6 ACGME core competencies by 2006. EM
educators recommend direct observation (DO) as the
optimal evaluation tool for 4 of the 6 core competencies
(Patient Care, Systems-Based Practice, Interpersonal and
Communication Skills, and Professionalism). The 24/7
faculty presence in the Emergency Department (ED) is
believed to facilitate DO as an assessment technique.
Methods: Observational study of faculty contact in 2 EDs,
2 trauma services, inpatient medicine, adult & pediatric
ICUs, and a pediatric outpatient clinic (UVC). Faculty con-
tact was categorized as DO of patient care, indirect pa-
tient care, or non-patient care activities using a priori
definitions. EM residents were shadowed for 2-hour
intervals. Subjects were blinded to the nature of the study
and data gathering was encrypted. Results: 270 observation
periods of 2 hours each were conducted, sampling 32 EM
R1, 33 EM R2-3, 41 EM and 38 non-EM faculty. Total faculty
contact time ranged from a maximum of 30% (95% CI ¼ 20,
41) in the pediatric ICU to a minimum of 10% (3, 16) on
2003 SAEM ANNUAL MEETING ABSTRACTS
internal medicine wards. Overall ED faculty contact was
20% (18, 22). DO by faculty ranged from a high of 5% (3, 8)
in the pediatric UVC to a low of 1% (0, 2) on internal
medicine wards. Overall ED DO was 3.6% (2.6, 4.7). ED DO
did not vary across EMR level or by site. DO varied by
treatment area within the ED with the critical area being
substantially higher (6%) when compared with the non-
critical care areas (1%). Conclusions: Direct observation of
EM residents was low in all training venues studied. Overall
DO was the highest in ED critical care areas and lowest on
medicine ward rotations. EM faculty who are already
involved in routine teaching, supervision, and patient care
rarely performed DO in spite of their immediate physical
presence 24/7. This suggests that alternative strategies may
be required to assess core competencies through direct
observation in the Emergency Department.
147 Assessing Global Performance in Emergency
Medicine Using a High-fidelity Patient Simulator:
A Pilot Study James A Gordon, David Tancredi, William
Binder, William Wilkerson, David W Shaffer, Jeffrey Cooper;
Center for Medical Simulation: Boston, MA, Harvard Medical
School: Boston, MA, Massachusetts General Hospital: Boston,
MA, University of Michigan: Ann Arbor, MI, University of
Wisconsin: Madison, WI, Massachusetts Institute of
Technology: Cambridge, MA
Objective: Realistic patient simulation promises to enhance
performance assessment in medicine, yet validation of
simulator-based assessment tools remains a challenge. We
sought to evaluate a previously-validated oral board exam-
ination tool for use in a simulator-based testing environ-
ment. Methods: Twenty-three subjects were evaluated
during 5 standardized encounters using a high-fidelity pa-
tient simulator (6 emergency medicine students, 7 house
officers, 10 chief resident-fellows). Performance in each 15-
minute session was compared with performance on an
identical number of oral exam sessions used as controls. The
order of the sessions was randomized; each was scored by
a faculty rater familiar to the subjects, using the American
Board of Emergency Medicine (ABEM) oral board scoring
system (8 skills rated 1–8; passing ¼ 5.75). A blinded
reviewer re-scored one-quarter of the simulator sessions (n
¼ 6) by videotape. Results: On both simulator exams and
oral controls (mean scores), chief-fellows earned a ‘‘passing’’
score (sim ¼ 6.4 [95%CI: 6.0–6.8], oral ¼ 6.4 [95%CI: 6.1–
6.7]); house officers earned a ‘‘borderline’’ score (sim ¼
5.6[5.2–5.9], oral ¼ 5.5[5.0–5.9]); and students earned
a ‘‘failing’’ score (sim ¼ 4.2[3.8–4.7], oral ¼ 4.5[3.8–5.1]).
There were significant differences among the mean scores of
the 3 cohorts, for both oral (t-test, p \ .05) and simulator (p
\ .05) test arms. No difference was seen between simulator
exam scores and oral controls (p ¼ .77). In the blinded
videotape analysis (2 students, 2 house officers, 2 chiefs),
both students earned failing scores, while both chiefs earned
passing scores (kappa ¼ .67 for pass-fail vs. non-blinded
ratings, with a single outlier). Conclusions: In this pilot
study, the ABEM assessment tool appeared to discriminate
extremes of expertise on a simulator-based examination.
While this argues for the validity of the scoring tool in this
setting, further study is required to evaluate the use of
simulators in routine certification testing.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org 473

148 Comparison of Learning Rates and Skill Retention
for Two Procedure Training Methods Richard L
Lammers; Kalamazoo Center for Medical Studies: Kalamazoo, MI
Objective: Procedural skills are often learned by demonstra-
tion followed by application (DA). A more effective method
of training may be a cycle of demonstration, practice, and
feedback for each step of a procedure(DPF). The objective of
this study was to compare the learning rate and skill retention
of resident physicians trained in posterior epistaxis manage-
ment using these two methods. Methods: A prospective,
repeated-measures assessment of procedural competence
was conducted in 28 residents randomly assigned to one
of two training methods. The nasal packing procedure
was divided into 70 steps to create a performance scoring
protocol. Both groups watched a video of the procedure. Each
subject in the DPF training group immediately repeated the
procedure once on a training model while observing,
performing, and then receiving corrective feedback at each
step. After five hours, both groups repeated the procedure on
the model until completing the procedure correctly within 30
minutes during one uninterrupted performance (compe-
tency testing). Performance scores and speed were measured
one week and one hour before training, and one week and
three months after training. Mann-Whitney test, independent
samples t test, and two-way repeated measures were used
to analyze the data. Results: Groups were matched for
pretraining skills, confidence, motivation, and level of fat-
igue. Scores improved significantly in both groups from
pretraining levels (p \ 0.001). Subjects in the DPF group (n ¼
13) had higher scores and shorter times on the first attempt
during competency testing (p ¼ 0.002). There were no
differences in the one-week and three-month scores or times
between groups. Three-month scores and times deteriorated
in both groups (p \ 0.001). Conclusions: DPF training
brought residents to an acceptable level of competence in
posterior epistaxis management faster than DA training, but
there were no long-term differences between the two
methods. Competence declines within three months.
149 Does the Demand for Clinical Productivity
Compromise Teaching in Academic Emergency
Departments? Todd J Berger, Doug S Ander, Metrecia L
Terrell, Weimin Lu; Emory University: Atlanta, GA
Background: Many emergency medicine (EM) attendings
believe the demands of clinical productivity limit their
ability to effectively teach medical students in the emer-
gency department (ED). In an informal survey of 50 of our
faculty members, 96% felt the time demand for clinical
productivity was the most limiting factor on effectively
teaching students. Objective: Determine if there is an
inverse relationship between clinical productivity and
effective teaching. Methods: We conducted a prospective,
observational, double-blinded study. Visiting and local
medical students enrolled in our EM rotation were asked
to evaluate each EM attending who precepted them at
3 academic EDs. After each shift, students anonymously
evaluated 10 aspects of clinical teaching by their supervising
EM attending physician. Each attending’s clinical produc-
tivity was measured by calculating their ED-specific
Relative Value Units (RVUs) per scheduled clinical hour
during the study interval. Medians of the ordinal data
gathered from the teaching evaluations were compared to
total RVUs/hr using a Spearman Rank-Correlation test.
Results: 64 out of 84 students returned surveys, evaluating
530 shifts taught by 54 board-certified or prepared EM
attendings over an 8 month period. Each attending received
an average of 10 evaluations (median score 5 out of 6) and
generated a mean of 5.40 RVUs/hr during the study period.
The correlation between evaluation median scores and
RVUs/hr was
0.13 (p ¼ NS). Conclusions: We found no
significant statistical relationship between clinical produc-
tivity and effective teaching. While many EM attendings
perceive patient care responsibilities to be too time
consuming to allow them to be good teachers, we found
that several of our more productive attendings also teach
well. Given the time constraints imposed by EM practice,
faculty development workshops should concentrate on
teaching efficient time management techniques that target
efficient patient care as well as efficient bedside teaching.
150 Inter-rater Variation in the Emergency Department
Abdominal Exam in Patients Presenting with
Abdominal Pain Jesse M Pines, Annara Hall, John Hunter,
Rajagopalan Srinivasan, Marat Ivanov, Chris A Ghaemmaghami;
University of Virginia: Charlottesville, VA
Objectives: The physical examination (PE) of the abdomen
is crucial to the management of patients presenting to the
emergency department (ED) with the chief complaint of
abdominal pain (AP). The subjectivity of the PE, however,
has not been clearly quantified. We hypothesized that there
would be a significant range of inter-rater variation between
EM attendings (EMAs) and residents (EMRs) in the de-
tection of various abdominal exam findings in ED pts with
AP. Methods: A prospective, observational study was
conducted in which research enrollers surveyed EMAs
and EMRs immediately after they assessed pts with the
chief complaint of AP. For each pt, a survey of 1 EMA and 1
EMR was performed inquiring on the presence or absence of
common physical exam findings (PEFs). The strength of
agreement in survey results between EMAs and EMRs was
calculated using the kappa statistic. Results: A convenience
sample of 122 surveys was completed over a 2-month
period. Inter-rater variation for PEFs was as follows:
Kappa 95% CI
Masses 0.82 0.59–1.06
Guarding 0.49 0.31–0.68
Tenderness 0.42 0.23–0.61
Distention 0.42 0.16–0.68
Normal bowel sounds 0.36 0.10–0.61
In the 88 pts in which at least one evaluator noted
tenderness, inter-rater variation for the location of tender-
ness was as follows:
Kappa 95% CI
Epigast 0.69 0.54–0.84
RUQ 0.57 0.40–0.75
Supraumbil 0.56 0.34–0.78
Suprapubic 0.44 0.23–0.64
LLQ 0.43 0.24–0.64
RLQ 0.40 0.20–0.59
LUQ 0.39 0.16–0.62
474
Conclusions: Only fair to moderate inter-rater agreement
was demonstrated between EMAs and EMRs for the
majority of PEFs in pts with AP. There was substantial
agreement on the detection of masses and epigastric
tenderness, but much less agreement for the detection of
RLQ tenderness and normal bowel sounds. The recognition
that selected PEFs are more variable than others should
encourage careful confirmation of EMR assessments by
EMAs in teaching settings.
151 Randomized Trial of Three Methods of Improved
Pain Assessment: Graphing Pain as a Vital Sign
Results in Improved Awareness of Analgesic Needs Lisa
M Andruszkiewicz, Stephen H Thomas; Massachusetts General
Hospital: Boston, MA, Harvard Medical School: Boston, MA
Objectives: This study’s goals were to determine if 2 new
techniques of pain assessment and display, as compared to
a control intervention of documenting an initial and followup
pain assessment, improved: 1) MD awareness of pain levels,
2) likelihood of timely analgesia (defined as within 30
minutes of presentation), or 3) MD perceptions of adequacy
of pain assessment/treatment. Methods: This prospective
trial, conducted 6/02–8/02 in an urban academic ED (census
80,000) with EM staffing, randomized 300 adults into 3
groups: Group 1/Control—pain assessed using a 10 cm
visual analog scale (VAS) at ED presentation (T0) and at
2-hours (T120); Group 2/Tabulation—T0 VAS assessment
plus q12-minute assessments for 2 hours, with data tabulated
in the ED chart; Group 3/Graph—same as Tabulation but with
graphic display of VAS at head of ED stretcher. Other data
collected were assessments of MD, RN, and patient percep-
tion of VAS utility and quality of pain assessment and care.
Analysis was univariate (chi-square, Kruskal-Wallis for VAS)
and multivariate logistic regression with odds ratio (OR) and
95% confidence intervals (CIs). Results: Baseline character-
istics of the 3 groups were similar. Proportions of MDs aware
of Graph patients’ pain levels at T0 (77%) and T120 (73%) were
higher (p \ .001) than found for patients in the Tabulation
(42% T0, 43% T120) or Control (36% T0, 21% T120) groups.
Adjusting for pain severity, diagnosis, age, gender, and race,
the likelihood of timely analgesia administration improved
with increasing group number (OR and 95% CI: 3.4 {1.3–8.6}).
For the group of patients indicating that pain relief was the
primary reason for ED presentation, increasing group
number was associated with likelier MD perception that the
VAS technique ‘‘gave useful information’’ (p ¼ .02) or
‘‘improved quality of care’’ (p ¼ .04). Conclusions: Use of
improved pain tracking techniques was associated with
marked improvements in assessment and therapy of pain as
analyzed by a number of endpoints.
152 The Anesthetic Effectiveness of
Lidocaine-Adrenaline-Tetracaine Gel on Finger
Lacerations Nicholas White, Michael Kim, David Brousseau,
Jo Bergholte, Halim Hennes; Medical College Of Wisconsin:
Milwaukee, WI
Background: The efficacy and safety of Lidocaine-Adrena-
line-Tetracaine (LAT) topical anesthetic is well documented
for facial lacerations. Its use for finger lacerations has not
2003 SAEM ANNUAL MEETING ABSTRACTS
been reported. Objective: 1. To determine the efficacy of
LAT in providing adequate anesthesia for the repair of
finger lacerations. 2. To monitor the risk of digital ischemia
related to the application of LAT gel on finger lacerations.
Methods: Children aged 5–18 years with a simple finger
laceration requiring repair were eligible for enrollment. The
primary outcome measure was LAT success/failure. Failure
was defined as any sharp sensation reported by the patient
either before or during suturing. Enrolled patients had LAT
gel applied to their laceration for 45 minutes, followed by
digit exam for signs of ischemia and suture repair. Needle
anesthesia (local infiltration/digital block) was provided for
all LAT failures. The digit was again examined 30 minutes
after LAT removal to assess for signs of ischemia. CIA
program was used to calculate 95% CI. Results: 63 patients
were enrolled in the study. The mean age was 12.1 years.
68.3% of all patients were male and 73.0% were white.
Location of the lacerations were equally distributed on the
dorsal and ventral surfaces. The overall LAT success rate
was 57.1% (95% CI, 44.0%–69.5%). The success rate for
dorsal surface lacerations was 69.7% (95% CI, 51.3%–84.4%)
vs. ventral surface lacerations 43.3% (95% CI, 25.5%–62.6%).
The difference in success rates was significant between
dorsal and ventral surface lacerations (D 26.4% [95% CI,
2.7%–50.0%]). There were no differences in success rates for
age or sex. No signs of digital ischemia were found in the 63
cases (0% [95% CI, 0.0%–5.7%]). Conclusions: LAT gel
appears to be a safe and effective alternative to painfully
administered needle anesthesia for the repair of simple
finger lacerations in most children. It appears particularly
effective on the dorsal surface of the finger.
153 Feasibility of Pain Measurement in the Prehospital
Setting Samuel A McLean, Robert M Domeier, Heather
K DeVore, Ronald F Maio, Shirley M Frederiksen; University
of Michigan/St. Joseph Mercy Hospital: Ann Arbor, MI
Background: There is widespread evidence that pain is
inadequately assessed and treated in emergency care
settings. The feasibility of pain assessment in the prehospital
setting is unknown. Objective: To determine the feasibility
of pain measurement in the prehospital setting. Methods:
Retrospective cross-sectional study of runsheets from an
EMS system after adoption of a universal pain assessment
protocol for all prehospital patients. A sequential (1:4)
sample of runsheets from the first three months after
adoption of the protocol was coded to obtain demographic,
location and call information. Qualitative (none, mild,
moderate, severe, unable), quantitative, and narrative assess-
ments were coded. Runsheets without pain assessment
underwent structured review and classification according to
predefined protocol. Nature of call and patient characteristics
were also obtained. Descriptive statistics and 0.95 CIs were
calculated. Multivariate logistic regression was used to
determine predictors for failure of obtaining pain measure-
ments; statistical significance was set at p\0.05. Results: 1298
runsheets were reviewed, 623 (48%) were male, mean age was
52 (S.D. 24) and 960 (74%) were non-trauma transports. Pain
was assessed in 1115 (85.9%[83.9–87.7%]) of patients. Of those
183 patients with no pain assessment information, 76 (41.5%)
were patients with altered mental status, 20 (10.9%) un-
conscious, 9 (4.9%) preverbal (age \3 years-old), 24 (13.1%)
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
nonverbal (ventilator-dependent, severe mental retardation,
chronic aphasia), 1 (0.5%) had a language barrier, 8 (4.4%) had
psychiatric complaints, and 8 (4.4%) had other known
reasons. On multivariate analysis, altered level of conscious-
ness and preverbal age group were characteristics signifi-
cantly associated with inability to measure pain. Conclusion:
Pain assessment is feasible in the prehospital setting.
154 Role of Single Worst Injury vs Multiple Injuries in
Predicting Pediatric Trauma Mortality Thomas
Sullivan, Stephen M DiRusso, Peter Nealon, Donald Risucci,
Michel Slim; New York Medical College/Westchester Medical
Center: Valhalla, NY
Background: Recently in the adult trauma population it had
been suggested that the worst injury predicts mortality best
(Kilgo et al: J Trauma 2002,53:196). Objective: To compare
worst injury and combined injury scores in prediction of
death using a large national pediatric trauma registry.
Methods: The patient population is the National Pediatric
Trauma Registry Phase IV data comprising admissions from
April of 1994 through Jan 2002. The dataset was randomly
divided into a development set (for ICISS and ICISS1) and
a test set. ICISS and ICISS1 were established using the de-
velopment set. ISS, NISS, MaxAIS, ICISS, and ICISS1 were
than calculated on each member of the test dataset. Max-AIS
is worse anatomic injury in the six body parts. ICISS is ICD-9
injury severity score; ICISS1 is based on single worst
probability of survival from patients ICD-9 diagnosis codes.
Discrimination was assessed by the area under the Receiver
Operator Characteristic Curve (ROC A(z)) (with 95% CI) and
calibration assessed for ICISS and ICISS1 using the Leme-
show-Hosmer C-Statistic (L/H C-stat). Results: There were
50199 patients in the cohort. Average age was 8.1 years.
There were 1449 deaths (2.9%). NISS and ISS were identical
in prediction of mortality. ICISS and ICISS1 had better
prediction of mortality. The single worst injury scores (Max-
AIS and ICISS1) were not better predictors of mortality then
their combined injury counterparts. The table below shows
the discrimination and calibration results.
ROC Az 95% CI LH-C
ISS 0.888 0.869–0.907
NISS 0.890 0.870–0.908
Max-AIS 0.882 0.863–0.901
ICISS 0.956 0.948–0.965 3374
ICISS1 0.954 0.945–0.963 4217
Conclusions: In this pediatric population single worst injury
was not superior to scores which use the patient’s multiple
injuries in prediction of mortality.
155 Ethanol Use and Drug Ingestion Do Not Affect the
Diagnostic Performance of Base Deficit Use in
Trauma Patients Shahriar Zehtabchi, Bonny J Baron,
Richard Sinert, Tom-Meka Archinard-Thibodeaux, Jamil
Ibrahim, Michael Lucchesi; SUNY Downstate Medical
Center/Kings County Hospital: Brooklyn, NY
Objectives: Base deficit (BD) and lactate (LAC) are valuable
triage tools for injured patients (pts). They reflect degree of
475
oxygen debt and have been shown to predict outcome.
Ethanol and illicit drug ingestion may further derange acid-
base status. We evaluated the effect of ethanol (BAC) and
drugs on admission BD and LAC in trauma pts. Methods:
Prospective, observational study of trauma pts in an urban
emergency department. Inclusion criteria: Penetrating and
blunt trauma. Exclusion criteria: None. Predictor variables:
BD and LAC. Outcome variables: Pts were stratified into
Major (MJ) or Minor (MN) trauma groups. MJ was defined
by an Injury Severity Score [15, blood transfusions, or a fall
in hematocrit of $10%). Trauma groups were further
subdivided into Intoxicated (þT) and Non-Intoxicated (
T),
based upon the presence of a BAC [100 mg/dl and/or
positive urine toxicology (benzodiazepines, cannabinoids,
cocaine, methadone, methaqualone, opiates, phencyclidine
or propoxyphene). Statistical analysis: Data were reported
as mean 6 standard deviation. Interval data were analyzed
by ANOVA with post-hoc testing by Bonferroni (a ¼ 0.05, 2
tails). Receiver Operating Curves (ROC) compared the
diagnostic performance of BD to differentiate MJ from MN
between þT and
T pts. Results: 154 patients (90% male)
with a mean age of 29 6 10 years were studied.
n BD(mEq/l) LAC(mMol/l)
MJ þ T 39
5.7 6 4.2 4.9 6 3.1
MJ
T 15
7.1 6 6.5 6.9 6 5.5
p 1.00 0.32
MN þ T 66
1.5 6 4.0 2.8 6 3.0
MN
T 34
0.1 6 2.4 2.7 6 2.3
P 0.61 1.00
BD and LAC were significantly higher in the MJ than MN in
both the þT and
T groups. No significant (p ¼ 1.00)
difference was noted between the areas under the ROC for
BD in the þT (0.82) and
T (0.88) groups. Conclusions: The
presence of ethanol and/or other toxins did not affect the
ability of BD or LAC to differentiate between major and
minor trauma.
156 Validation of a Decision Instrument to Limit Pelvic
Radiography in Blunt Trauma Brandie Anne Niedens,
Eric Alan Gross; Maricopa Medical Center: Phoenix, AZ
Objective: Standard practice involves routine pelvic radiog-
raphy for blunt trauma patients. Previous studies suggest
that many of these patients could safely forego these films,
resulting in signigicant cost savings. We sought to validate
a set of criteria that predicts, with a high degree of sensitivity,
which patients may safely forego pelvic radiography in their
initial trauma evaluation. Methods: This is a prospective
observational study. Patients presenting to Maricopa Med-
ical Center ED, an urban city hospital, from July 1, 2002
to May 1, 2003, as a Level I trauma patient with blunt
mechanism of injury undergoing pelvic radiography were
eliglble for the study. Inclusion criteria were: blunt mecha-
nism trauma, pelvic flim obtained and greater than 17 years
old. Exclusion criteria were: penetrating trauma, pregnancy
and previous evaluated at other facility for same injury.
Physicians completed a data sheet, which outlined five
criteria, prior to viewing pelvic radiographs. Final radio-
graphic results were concatenated to the data sheets.
476
Results: As of December 31, 2002, 476 patietns were enrolled
in the study; 32 patients had pelvic fractures (6.7%). The
decision instrument predicted no fracture in 31 of those 32
patients, (sensitivity 96.9%, 95% CI 91.8–100%). 444 patients
did not have a pelvic fracture. 213 of those met no criteria for
obtaining a pelvic radiograph, (negative predictive value
99.5%, 95% CI 98.8–100%); 231 had at least one positive
criteria, (specificity of 48%, 95% CI 44.1–100%). The negative
likelihood ratio was 0.07, (95% CI 0.01–0.33). Conclusions:
The decision instrument predicts, with a high degree of
sensitivity, those who may safely forego pelvic radiography
after blunt trauma. Approximately 44% of our patients could
have done without a pelvic x-ray, resulting in significant
saving of health care dollars. This study is limited by its
small sample size; however, we continue to enroll patients.
Lastly, the criteria were not prospectively derived.
157 Rapid Bedside Ultrasonic Evaluation of Depressed
Skull Fractures Kishani Heendeniya, Chu William,
Selmon Chana, Shiblee Towhid, Stanley Dirk, Carl K Hsu; The
Brooklyn Hospital Center: Brooklyn, NY
Background: Radiologic confirmation of a depressed skull
fracture (DSF) may be difficult for the unstable multiple
trauma patient. Objective: To evaluate the use of ultrasound
in the rapid diagnosis of DSF. Methods: Porcine heads were
harvested from an IACUC approved lab. Using a flap
incision, skin was reflected from the skull. A one cm
diameter hole was drilled into the ‘‘fracture’’ area and the
fragment depressed to a depth of 1 cm. Gel filled the cavity
formed by the depressed fragment. For ‘‘control’’ areas, no
holes were drilled. The skin flaps in both fractures and
controls were sutured into place. A blinded sonographer
evaluated labeled fracture and control areas with ultra-
sound. Randomized ‘‘unknown’’ fracture and control areas
were presented to the sonographer in a darkened room.
Circles drawn on the skin represented areas of injury. An
un-blinded assistant placed the 10 MHz linear ultrasound
probe onto the area of injury. The sonographer could twist
or tilt the probe. No lateral movement of the probe on the
head was permitted such as to avoid detection of any
irregularity of the skull by feel. Results: Each assessment
lasted less than thirty seconds. Thirty of 32 fractures were
correctly identified. Thirty-six of 36 intact sites were
correctly identified. N ¼ 68 Sensitivity ¼ 0.9375. Specificity
¼ 1.0000. PV ¼ 1.0000. NPV ¼ 0.9473. Uncorrected: Chi
Square 60.39 (P-values 0.0000000). Mantel-Haenszel: Chi
Square 59.51(P-values 0.0000000. Yates corrected: Chi Square
56.65 (P-values 0.0000000). Conclusion: Ultrasound may be
used to rapidly evaluate and diagnose depressed skull
fractures in this non-living animal model. The effect of fresh
or clotted blood in the DSF cavity may alter the sonographic
image.
158 Multicenter Comparison of GCS and RTS Scores at
the Scene vs at the Trauma Hospital Majid
Al-Salamah, Ian McDowell, Ian G Stiell, George A Wells, Lisa
Nesbitt; University of Ottawa: Ottawa, Ontario, Canada
Objective: Prehospital triage of trauma patients is a difficult
task. This study evaluated the predictive validity and
2003 SAEM ANNUAL MEETING ABSTRACTS
reliability of the Revised Trauma Score (RTS) and Glasgow
Coma Scale (GCS) by comparing scores at the scene
by paramedics to those made at the ED by physicians.
Methods: This multicenter prospective cohort study was
conducted in 20 communities as part of the Ontario
Prehospital Advanced Life Support (OPALS) Study, which
evaluates the impact of ALS programs. EMS care was
provided at both the BLS-D and ALS level. Included were
adult trauma patients with ISS [12 and who were treated at
12 regional Level 1 trauma hospitals. We linked ambulance
call report data to that from the Ontario Trauma Registry to
compare scene and ED evaluations. Analysis included
Cronbach’s Alpha; Interclass Correlation Coefficients
(ICC); area under the Receiver Operating Characteristic
(ROC) curves and Kendal’s Tau C Correlation Coefficient
(KcCC) for predicting survival. Mann-Whitney U-test was
performed to test association with ICU admission for
survivors. Results: For the 922 patients, scene and ED RTS
scores had similar internal consistency with similar patterns
of inter-item correlation (Alpha ¼ 0.82, 0.85). Scene and ED
GCS scores also had similar patterns of inter-item correla-
tion (Alpha ¼ 0.93, 0.93).
ROC KcCC ICU Adm. P-value
RTS Scene 0.79 0.34 0.67
RTS ED 0.81 0.29 0.13
GCS Scene 0.78 0.36 0.94
GCS ED 0.81 0.34 0.03
Interobserver agreement between scene and ED scores was
very good both for cases requiring 20-minute transfers (ICC
for RTS 0.92, ICC for GCS 0.85) and for those with 15-minute
transfers (ICC for RTS 0.96, ICC for GCS 0.88). Conclusions:
Paramedic scoring at scene showed good internal consis-
tency and interobserver reliability and are as valid as ED
physician scores in predicting survival. Although they
showed poor association with ICU admission, timing of
the score seemed to be the main factor, rather than the
performance of paramedics.
159 Multicenter Comparison of the Predictive Value of
the Revised Trauma Score and the Glasgow Coma
Scale Majid Al-Salamah, Ian McDowell, Ian G Stiell, George
A Wells, Lisa Nesbitt; University of Ottawa: Ottawa, Ontario,
Canada
Objective: Identifying risk of mortality is an important
aspect of ED care of multiple trauma patients. This study
evaluated the predictive accuracy of the Revised Trauma
Score (RTS) and Glasgow Coma Scale (GCS) and their
components. Methods: This multicenter prospective cohort
study was conducted in 20 communities as part of the
Ontario Prehospital Advanced Life Support (OPALS) Study.
Included were adult trauma patients with ISS [12 and
who were treated at 12 regional Level 1 trauma hospitals.
Physician trauma team leaders assessed each patient for the
RTS and GCS. The outcome measures collected and their
associations with RTS and GCS were analyzed by: 1)
Receiver Operating Characteristic (ROC) curve areas and
Kendal’s tau c correlation coefficient (KcCC) for survival to
hospital discharge, 2) Mann-Whitney U-test for ICU
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
admission, 3) Spearman’s Correlation Coefficient for the
disability measures, Glasgow Outcome Scale (GOS) and
Functional Independence Measure (FIM). Results: We
enrolled 912 patients with these characteristics: median
age 39, male 71.3%, blunt trauma 90.1%, mortality 20.3%.
The table shows ROC curve area and KcCC for survival,
Spearman’s for GOS and FIM, and P-value for ICU
admission:
ROC KcCC FIM GOS
RTS TOTAL .80 .29 .01 .21
– RR .69 .19
.16 .16
– SBP .62 .16
.25 .10
GCS TOTAL .81 .34 .11 .21
– Eye .76 .32 .28 .22
– Verbal .81 .34 .13 .17
– Motor .80 .37 .15 .24
Conclusions: The GCS score and its Motor and Verbal
components showed consistent accuracy in predicting
survival and ICU admission. The Motor and Eye compo-
nents predicted disability better than either GCS or RTS. The
RTS failed to show an advantage over the GCS in our study
population which was mostly blunt trauma patients. These
findings validate the use of GCS for triage of trauma
patients, and the use of the Motor component where the
GCS may be unobtainable, as for intubated patients.
160 Multicenter Prospective Validation of the New
Orleans Criteria for CT in Minor Head Injury Ian G
Stiell, Catherine Clement, Brian H Rowe, Robert Brison, Michael
Schull, George A Wells, Gary Greenberg, Daniel Cass, Brian
Holroyd, James R Worthington, Mark Reardon, Mary Eisen-
hauer , for the CCC Study Group; ; University of Ottawa:
Ottawa, Ontario, Canada, Queens University: Kingston, Ontario,
Canada, University of Toronto: Toronto, Ontario, Canada,
University of Western Ontario: London, Ontario, Canada,
University of British Columbia: Vancouver, British Columbia,
Canada, University of Alberta: Edmonton, Alberta, Canada
Objectives: The New Orleans Criteria (NOC) for CT in
minor head injury were previously derived and validated in
a single site cohort of 1,429 patients. This study prospectively
and explicitly evaluated the accuracy, reliability, and
acceptability of the NOC in multiple sites. Methods: This
prospective cohort study was conducted in 9 tertiary care
EDs and enrolled adult minor head injury patients with
witnessed loss of consciousness, amnesia, or confusion and
a GCS score of 15. More than 350 physicians completed data
forms and interpreted the NOC status for patients prior to
diagnostic imaging. In some cases 2nd physicians performed
interobserver assessments. The outcome standards were
‘need for neurological intervention’ and ‘clinically important
brain injury’. Analyses included kappa coefficient, sensitiv-
ity, and specificity with 95% CIs. Results: The 1,733 patients
enrolled over 30 months had these characteristics: mean age
37.7 (range 16–99), male 68.2%, ambulance arrival 72.1%,
clinically important brain injury on CT 5.0%, unimportant
injury 2.7%, neurological intervention 0.5%, death 0%. The
NOC classified patients for neurological intervention (N ¼ 8)
with sensitivity 100% (95% CI 63–100), specificity 12.3% (11–
477
14), and would have required CT for 87.8%. The NOC also
classified patients for 87 important brain injuries with
sensitivity 100% (95% CI 96–100) and for 48 unimportant
brain injuries with sensitivity 95.8% (95% CI 85–98). The
kappa value for MD interpretation of the NOC was 0.47
(
0.13–1.0). MDs underestimated the risk in 5.4% and were
uncomfortable applying the rule in 11.5%. Conclusions: The
NOC have proven to be very sensitive for identifying im-
portant brain injury. Interobserver agreement is fair but
specificity is very low. The NOC may be appropriate for
ICU minor head injury patients in the U.S. where current CT rates
.13 are high but widespread implementation elsewhere would
.11 dramatically increase use of CT outside of the U.S.
.79
.03
.36
161 Multiple Episodes of Mild Traumatic Brain Injury
.03
.06 Impair Cognitive Performance in Mice Catherine E
Creeley, Philip V Bayly, David F Wozniak, Lawrence M Lewis;
Washington University: St. Louis, MO
Objective: Results from recent studies on mouse models of
concussion suggest that multiple, rather than single, epi-
sodes of mild traumatic brain injury (TBI) result in cognitive
impairments. In the present study, multiple impacts were
administered to the heads of mice while directly measuring
impact forces to determine how this parameter is related
to transient loss of consciousness and cognitive deficits,
characterisitic of mild TBI in humans. Directly measuring
impact force during TBI provides enhanced methodological
precision and important information related to the conse-
quences of TBI. Methods: Experimental design. Male C57/
BL6 mice (7 weeks old) were randomly assigned to a TBI
procedure (N ¼ 10) where they received 3 impacts to the
head, each impact being separated by 24 hours, or to a sham
control procedure (N ¼ 10). Impacts were delivered using
a weight-drop apparatus that delivered and measured the
force (Newtons; N) of an impact to the top of the head.
Righting reflex time following impact was measured
(seconds) to quantify loss of consciousness. Activity and
sensorimotor tests were conducted at 48 hours post-trauma
to evaluate impairmants that could affect cognitive perfor-
mance. Spatial learning/memory were assessed using the
Morris Water Maze (MWM) at five days post-trauma.
Results: A 21 g weight dropped from a height of 35 cm
delivered a mean force of 19.8 6 3.5 N (range ¼ 14.5–26.7 N).
An ANOVA showed that. overall, impacted animals had
significantly longer RRTs (185 6 61 s) vs. sham controls (41 6
5.2 s; p \ 0.001), and RRTs significantly increased after the
first impact (p \ 0.002). Groups performed similarly on
activity and sensorimotor tests and on cued trials in the
MWM. However, ANOVAs showed that the TBI mice were
impaired during place trials in the MWM, exhibiting sig-
nificantly longer path lengths and latencies to escape (p
\ 0.05). Conclusion: Repeated mild TBI delivered with
specifiable forces results in transient loss of consciousness
and cognitive deficits in mice.
162 How Does Octogenarian Status Affect Morbidity,
Mortality, and Functional Outcomes of Elderly
Drivers in Motor Vehicle Crashes in Pennsylvania, 1988 to
2001? Philip N Salen, Kelly Kellmell, William Baumgratz,
Mary Eberhardt, James Reed; St. Luke’s Hospital: Bethlehem, PA
478
Objective: The fastest growing segment of the geriatric
trauma population is octogenarians. We compared medical
outcomes of octogenarian driver victims, aged $ 80 years
(OD), of motor vehicle crashes (MVC) with the younger
geriatric cohort of driver victims, aged 65–79 years (YD).
Methods: The study population consisted of trauma patients
admitted to Pennsylvania Trauma Centers (PTC) from 1988
to 2001. The Pennsylvania Trauma System Foundation pro-
vided data for crash characteristics, hospital complications,
and outcomes. Statistical methods included Pearson’s
Chi-Square, Fisher’s Exact Test, and Analysis of Variance;
significance was set at P # 0.01. Results: There were 5522 YD
and 1815 OD admitted to PTC because of MVC over 14 years.
OD were as likely to wear seatbelts as YD (52.1% and 52.2%,
P ¼ 0.93). The injury severity score of OD and YD did not
differ significantly (15 vs 14.3, P ¼ 0.06), nor did the ad-
mission GCS differ between OD and YD (13.7 vs 13.8, P ¼
0.25). OD were more likely than YD to have preexisting
medical conditions and to suffer in-hospital pulmonary (P ¼
0.001), cardiovascular (P ¼ 0.03), hematologic (P ¼ 0.0001),
renal (P ¼ 0.001), and infectious (P ¼ 0.02) complications. OD
and YD did not differ in hospital length of stay (11 days),
intensive care unit stay (4 days), or ventilator usage (3 days).
OD were less likely to be discharged home and more likely
to be transferred to rehabilitation facilities (P ¼ 0.001).
Furthermore, the functional status at discharge was signif-
icantly worse in OD than YD in terms of feeding (P ¼ 0.001),
locomotion (P ¼ 0.001), and expression (P ¼ 0.001). Mortality
was higher in OD than YD (17% vs 10.5%, P ¼ 0.001).
Conclusion: OD are as likely to wear seatbelts and are as
severely injured from MVC as YD, but OD have more in-
hospital complications, higher mortality rates, and worse
functional status at discharge.
163 Utility of Performing Lumbar Puncture in the
Afebrile Elderly Patient with Altered Mental
Status Kaushal H Shah, Kathleen M Richard, Jonathan A
Edlow; Beth Israel Deaconess Medical Center: Boston, MA
Objectives: Anecdotally, lumbar punctures (LP) performed
on elderly patients solely for altered mental status (AMS)
are not diagnostically useful. We conducted a study to
determine the diagnostic utility and the incidence of
abnormal LP on elderly patients who are afebrile with
AMS. Methods: A retrospective study was conducted at an
urban, university tertiary care referral center with 50,000
annual ED visits. The study population included all elderly
patients (age 65 years and older) who had cerebrospinal
fluid (CSF) samples sent to the lab between 8/16/00–8/15/
01. A chart review obtained: temperature, mental status
(altered or normal), CSF analysis, discharge diagnosis, and
recent neurosurgical procedure or presence of a ventricular
shunt. Exclusion criteria were temperature $101, normal
mental status, recent neurosurgical procedure or presence of
a ventricular shunt, and missing medical records. Data from
repeat lumbar punctures performed in the same admission
were also not included. Abnormal LP was defined as $5
white blood cells (WBCs) in CSF tube #4. Results: 185 CSF
samples from elderly patients were recorded over 1 year. 24
samples were excluded for recent neurosurgical procedure
(2), ventricular shunt (11), repeat LP on the same admission
(7), and missing medical records (4). Of the remaining 161
patients, 44 were excluded due to a temperature $ 101 and
2003 SAEM ANNUAL MEETING ABSTRACTS
32 additional patients were excluded for normal mental
status. Of the remaining 85 patients (mean age 77), 19 (22.3%
[95%CI: 13.5 – 31.2]) had an abnormal LP and a mean age of
77 [95%CI: 75.3–78.7]). The number of WBCs in CSF tube
#4 ranged from 5–120. Diagnoses of the 19 patients with
abnormal LPs: 6 (31.6%) viral meningitis, 2 (10.5%) bacterial
meningitis, 1 (5.3%) intracranial bleed, 2 (10.5%) oncologic
etiology, and 8 (42.1%) patients were not given a clear
diagnosis. Conclusion: Approximately 22% of LPs per-
formed on afebrile elderly patients with AMS are abnormal
and the LP was diagnostically useful in 58% of cases.
164 Intracranial Pathology in the Elderly with Minor
Head Injury Niels Rathlev, Ron Medzon, Doug Lowery,
Charles Pollack, Mark Bracken, Jerome Hoffman, William
Mower; Boston Medical Center, Boston University School of
Medicine: Boston, MA, Emory University School of Medicine:
Atlanta, GA, Maricopa Medical Center: Phoenix, AZ, UCLA
School of Medicine: Los Angeles, CA
Objectives: To determine if blunt trauma victims age 65 or
greater are at increased risk of significant intracranial injury
(SII). The analysis is based on data from the NEXUS II
derivation study, which developed a decision rule for
indications for head CT in patients (pts) with blunt trauma.
Methods: This is a prospective, observational study from 18
institutions of all pts who had head CT for blunt traumatic
head injury. SII were defined as injuries likely to require
alteration in management and were diagnosed by pre-
determined radiographic criteria. The prevalence of SII in
pts age 65 or greater was compared to pts age \65 using Chi-
square analysis. The subgroup of pts with minor head injury
(MHI) defined by GCS ¼ 15 was similarly analyzed. Results:
13,326 pts were enrolled of which 1,934 were age 65 or greater
and 1,142 had SII. 10,476 pts had minor head injury (MHI). In
the age 65 or older group, 242 (12.5%; CI-95% 11.1–14.1) had
SII vs. 900 (7.9%; CI-95% 7.4–8.4) in the age \65 group (C-
square ¼ 44.9; p \ 0.001). Elderly with MHI had a dispro-
portionately high risk of SII independently of the following
high-risk criteria: 1) evidence of significant skull fracture, 2)
neurological deficit and 3) altered level of consciousness
(x-square ¼ 20.0; p \ 0.001). Compared with pts age \65,
elderly were less likely to sustain complex (1.7% vs. 4.8%),
depressed (1.7% vs. 6.9%) and linear (0.4% vs. 15.2%) skull
fractures and were less likely to reveal evidence of skull
fracture on exam (9.1% vs. 21.9%). Elderly were more likely to
sustain an acute on chronic subdural hematoma (3.7% vs.
0.2%). Conclusions: Age 65 or greater is a significant risk
factor for SII in blunt trauma and for otherwise occult injury
following MHI. It serves as a useful criterion for selective
imaging. The low incidence of significant skull fractures
presumably reflects the low energy mechanisms (e.g. ground
level falls) that are common in the elderly. The results require
confirmation in a prospective validation study.
165 Alcohol and Nicotine Dependence in Elderly
Emergency Department Patients: Rates, Health and
Medical Care Utilization Daren D Girard, Robert A
Partridge, Bruce M Becker, Beth Bock; Rhode Island Hospital:
Providence, RI
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Objectives: Determine rates of alcohol and tobacco use
among independent elder emergency department (ED)
patients and assess their health and health care utilization.
Methods: Convenience sample of independent elders (age
$65 years) in an urban academic ED. Patients were
excluded if medically unstable. The Fagerstrom Test for
Nicotine Dependence and the Alcohol Use Disorders
Identification Test (AUDIT) scale were used to measure
tobacco and alcohol use. Subjects completed questionnaires
about their health and utilization of the healthcare system.
Data was analyzed using t-tests to compare independent
variables. Results: 565 subjects completed the study. 296
(52.4%) were male and 269 (47.6%) were female, mean
age 77.1 years. Fifty four (9.5%), were smokers, and 22
(3.9%) were nicotine dependent by the Fagerstrom test
(Fagerstromþ). Alcohol use was reported once/month by
176 (31.2%) and twice/month by 76 (13.5%) of patients;
12 (2.1%) were alcohol dependent by the AUDIT scale
(AUDITþ). Two (0.35%) were both Fagerstromþ and
AUDITþ. Fagerstromþ subjects saw a primary care or other
physician less often than Fagerstrom- subjects (3.9 vs. 4.6
annual visits, p \ .001). AUDITþ subjects visited a primary
care physician less (3.3 vs. 4.2 annual visits, p \ .01) or
‘‘any’’ physician less (3.9 vs. 4.6 annual visits, p \ .05) than
AUDIT- subjects. AUDITþ and Fagerstromþ subjects did
not differ from AUDIT- and Fagerstrom- subjects in number
of annual ED visits, self reported general health, physical
symptoms (except nervousness, p \ .004), co-morbid
illnesses, hospital admissions and injuries. Conclusions:
Elder ED patients have low rates of nicotine and alcohol
dependence. Nicotine or alcohol dependent elders utilize
outpatient providers less often than non-dependent elders
but use ED’s at the same rate, and report similar health
patterns. Additional studies of elder ED patients who use
tobacco and alcohol may help improve health care utiliza-
tion and identify appropriate health care interventions.
166 Procedural Competence of New PGY1 Emergency
Medicine Residents Richard L Lammers, Mary Jo
Wagner, Dale Ray, K J Temple; Michigan State University/
Kalamazoo Center for Medical Studies: Kalamazoo, MI, Saginaw
Cooperative Hospitals: Saginaw, MI, Spectrum Health Care,
Grand Rapids: Grand Rapids, MI
Objective: Medical students are taught some procedural
skills during medical school, but there is no uniform set of
procedures that are mastered by all students before
residency. Supervising attending physicians may not know
which procedural skills new resident physicians possess.
The objective of this study was to determine the level of
competence in the performance of a lumbar puncture (LP) by
new PGY1 Emergency Medicine residents. Methods: An
observational study was conducted at 3 EM residencies
using 24 PGY1 residents who graduated from 18 various
medical schools. The LP procedure was divided into 28
major and 52 minor steps to create a scoring protocol.
Subjects performed the procedure without interruption or
feedback on a lumbar puncture training model using
a standard LP kit. A step was scored as correct if 2 of the 3
faculty evaluators concurred. Interrater reliability was tested
using the kappa statistic. Pre- and post-study questionnaires
assessed subjects’ prior instruction and clinical experience
with LP, self-confidence, sense of relevance, motivation, and
479
fatigue. Results: Subjects completed an average of 17 (61%)
of the major steps (range: 9–27) and 21 (36%) of the minor
steps (range: 10–30) in 15.7 minutes (range: 9.2–21.8). 62%
failed to obtain CSF fluid from the model. Subjects’ levels
of confidence changed slightly on a 5-point scale from 2.7
(‘‘little-to-some’’) before the test to 2.0 (‘‘little’’) after the test.
87% of subjects previously performed LPs on patients during
medical school (average attempts ¼ 1.7; range: 0–5), but only
38% of those who did so were supervised by an attending
during their first attempts. Conclusions: New PGY1 EM
residents have not attained competence in lumbar punctures
from training in medical school. Attendings must closely
supervise all PGY1 residents performing LPs until compe-
tent performance is demonstrated.
167 Predictors of Residency Program Scholarly
Productivity Sonia M Chacko, Gerald A Banet,
Kaavya Narsahimhalu, Christine Hyun, Douglas M Char;
Washington University: St Louis, MO
Objectives: Scholarly productivity is a key determinant of
a training program’s stature. Peer-reviewed manuscripts are
the gold standard of scholarly activity. We surveyed four
major Emergency Medicine (EM) peer-reviewed journals for
original articles and correlated this with residency program
demographic information to determine which factors
contribute to success in scholarly productivity. Methods:
In this descriptive study we tabulated all original articles
published in Academic Emergency Medicine, Annals of
Emergency Medicine, Journal of Emergency Medicine, and
American Journal of Emergency Medicine between January
2000 & June 2002. Each participating institution was given
credit for multi-institutional studies. Program specific in-
formation was obtained from the SAEM residency catalog.
A productivity rank list was compiled based on the number
of articles published. Regression analysis was applied to
determine which factors were significant. Results: Of 742
original articles queried, 598 (80.6%)were by residency
affiliated authors. Each program (n ¼ 124) produced on
average 4.8 articles (range 0–23). The top quartile (n ¼ 31)
produced 62% of the articles, while the bottom produced
only 2%. Twenty programs (16%) published none while
sixteen produced more than 10 (mean 14.4). Neither pro-
gram size nor longevity significantly correlated with pro-
ductivity. Surprisingly, a research requirement (91/124)
or rotation (29/124) appeared to have negative correlation
with scholarly activity (requirement 4.6 vs. none 5.3 and
rotation 3.5 vs. none 5.2). Positive predictors of productivity
(r ¼ .16) included having greater than 20 full-time faculty
(6.2 vs. 3.4), presence of a fellowship (6.1 vs. 3.0) and
training format (PGY 1–4, 8.7; PGY 2–4, 4.2; PGY 1–3, 4.3).
Conclusions: A majority of articles are contributed by a few
programs, resulting in a skewed distribution. The presence
of a large faculty, 4-year training format and fellowship
program correlated positively with scholarly productivity.
168 Exposure and Comfort of Emergency Medicine
Residents with Thrombolytic Therapy for Acute
Myocardial Infarction Jonathan Fisher, Charles L Maddow,
Barbara Sorondo, David FM Brown; Albert Einstein Medical
Center: Philadelphia, PA, University of Rochester: Rochester,
NY, Massachusetts General Hospital: Boston, MA
480
Objectives: The primary training sites for many EM
residencies utilize primary angioplasty as the preferred
method of reperfusion for acute myocardial infarction.
Nationwide, however, thrombolytic therapy (TT) is much
more frequently the reperfusion strategy utilized. Some have
voiced concern that EM residents are graduating without
sufficient training and experience in the delivery of TT. The
objective of this pilot study was to assess senior EM resident
experience and level of comfort with TT. Methods: A
confidential survey was distributed to senior EM residents
in three training programs in June 2002. Senior residents (SR)
were defined as PGY 3 or 4. Repeat surveys were distributed
to non-responders to improve the response rate. Descriptive
statistics, confidence intervals and regression analysis were
performed. The study received IRB approval. Results: Three
EM residency programs (two PGY1–4 format, one PGY1–3
format) with 56 SR were surveyed; 31 SR were graduating
residents (GR). The SR response rate was 87.5%; GR response
rate was 87.1%. The mean number of patients given TT by
each SR was 3.57 (95%CI 2.34–4.79) and GR was 3.86 (95%CI
1.95–5.76). 10 GR (34.5%) had never given TT. 71.4% of
patients treated with TT were seen at secondary training
sites. There was no significant difference in TT exposure
related to program format. Residents who were moonlight-
ing used TT 6 times. The mean hours of didactic instruction
received by GR in TT was 1.38 (95%CI 1.051–1.707). SR
reported a mean level of comfort (LOC) of 3.29 (95%CI 2.965–
3.607) on a 5 point scale (5 ¼ very comfortable). GR reported
a LOC score of 3.41 (95%CI 3.10–3.73). Regression analysis
showed no association between the LOC and the number
of times TT had been given, the amount of time spent
moonlighting, or at secondary training sites. Conclusions:
This pilot study suggests that residents have limited
training, experience, and comfort with TT. This training
flaw, if shown to be widespread, must be addressed.
169 Inaccuracies on Applications for Emergency
Medicine Residency Training Martha Susan Roellig,
Eric Daniel Katz, Kaavya Narashimalu; Washington University:
St. Louis, MO
Objectives: Studies have shown erroneous claims of author-
ship by applicants for residencies. We hypothesized that
investigation of advanced degrees, AOA status and peer-
reviewed publications would all show similar rates of
inaccuracy. Methods: After Human Studies Committee
approval, a retrospective review of all applicants offered an
interview for our EM residency program (entering class of
2002) was conducted. Foreign medical graduates (FMG) and
current members of our residency were excluded. Peer-
reviewed publications were verified by Medline search and
journal review, then tabulated by type of error (reference not
found, not delineated as an abstract, erroneous author list
or clerical error. AOA status was verified by the AOA
organization. Advanced degrees were verified by the
awarding institution. Results: 194 applications were
screened (58.3% of applications). 9 (4.6%) FMG’s and 12
(6.2%) current residents were excluded leaving n ¼ 173
applicants. 23/173 (13.3%, 95%CI 8.8–19.5%) of applicants
had at least one misrepresentation and 7/173 (4.0%, 1.8–
8.5%) had [1. 47/173 (27.2%) claimed authorship of at least
one peer-reviewed article. 10/47 (21.3%, 11.2–36.1%) had one
inaccuracy and 6/47 (12.8%, 5.3–26.4%) had multiple errors.
2003 SAEM ANNUAL MEETING ABSTRACTS
Of these 16, 11 (68.8%) referenced articles which were not
found, 5 (31.2%) published an abstract but referenced it as an
article, 2 (12.5%) promoted their position in the author list
and 2 (12.5%) made clerical errors. AOA membership was
claimed by 14 (8.1%), but 5 (35.7%, 14.0–64.4%). 2 (14.3%)
were not members and 3 (21.4%) were enrolled in D.O.
programs and ineligible for AOA. Advanced degrees were
claimed by 15 (8.7%). 4 (26.7%, 8.9–55.2%) were in error. 3
of these had listed projected graduation dates that were
not met. Conclusions: 13.3% of all applications contained
inaccuracies. 34.0% of applicants who claimed peer-re-
viewed publications, 35.7% of those claiming AOA member-
ship and 26.7% of advanced degrees were erroneous.
170 Cardiac Arrest and Hypothermia Increase GDNF in
Brain Katherine M Schmidt, Brian J D’Cruz, Donald B
DeFranco, Clifton W Callaway; University of Pittsburgh:
Pittsburgh, PA
Objective: Hypothermia improves brain recovery when
induced after cardiac arrest and also increases levels of
some neurotrophic factors in the brain. Glial-cell-line
derived neurotrophic (GDNF) is one such factor that can
improve recovery after ischemia. We hypothesized that mild
hypothermia after resuscitation will increase expression
of GNDF in the hippocampus and cerebellum. Methods:
Design: laboratory experiment. Subjects: Thirty-two Spra-
gue-Dawley rats. Interventions: After surgical preparation 5
minutes of cardiac arrest was induced by asphyxia (8
minute) and animals were resuscitated using chest com-
pression and mechanical ventilation. Rats were maintained
at 378C for 0–60 minutes after resuscitation and then
assigned to NORM (maintained at 378C) or HYPO (cooled
to 338C) groups until sacrifice at 3, 6, 12 and 24 hours.
Control animals were treated with surgery and NORM or
HYPO treatment, but no cardiac arrest. Total cellular protein
was extracted from the hippocampus and cerebellum in SDS
buffer. Measurements and Outcomes: GDNF levels were
measured by immunoblots that were imaged, digitized and
quantified. All blots were stripped and re-probed for actin
to control for loading and transfer. Levels were compared
between NORM and HYPO at individual times by t-test.
Results: GDNF levels increased overall and also in HYPO
compared to NORM groups for 12 hours after resuscitation
in hippocampus, and for 24 hours in cerebellum. HYPO
increased GNDF levels relative to NORM in hippocampus
at 6 hours after cardiac arrest (p ¼ 0.01). In HYPO, rats,
GNDF levels were slightly increased in cerebellum at 6
hours (p ¼ 0.07) and 24 hours (p ¼ 0.07). Other time-points
did not differ between groups. Conclusions: Hypothermia
accelerated the post-ischemia increase of GDNF in hippo-
campus. These results suggest a correlation between
a hypothermia regimen that improves recovery and the
overall expression of GDNF.
171 Adenoviral Transfer of the Heme Oxygenase-1 Gene
Protects Astrocytes from Heme-mediated Oxidative
Injury Zhi Ping Teng, Han Ming Wang, Lee-Young Chau,
Raymond F Regan; Thomas Jefferson University: Philadelphia,
PA, Institute of Biomedical Sciences, Academica Sinica: Taipei,
Taiwan
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Objectives: Heme oxygenase (HO)-1 is induced in the CNS
after hemorrhage, and may have an effect on injury to
surrounding tissue. In a prior study, we observed that HO
inhibitors increased the vulnerability of cortical astrocytes to
oxidized heme (hemin), which is present in hematomas. In
order to investigate the effect of HO more specifically, we
used an adenoviral vector to transfer the HO-1 gene. We
tested the hypothesis that this treatment was protective
after hemin exposure. Methods: Adenovirus containing the
entire coding sequence of human HO-1 was propagated in
HEK 293 cells; a control virus lacking the HO-1 gene was
separately produced. Viral titer was determined by cyto-
pathic effect assay. Cortical astrocyte cultures, prepared from
B6/129 mice, were exposed to indicated multiplicities of
infection (MOI) of control or HO-1 virus for 24 hours. HO-1
expression in cell lysates was evaluated by western blot
analysis. Other infected cultures were exposed to hemin 10–
60 mM after 24 hr virus incubation. Cell injury was quantified
by LDH release. Data were analyzed with ANOVA and the
Bonferroni multiple comparisons test. Results: Incubation
with HO-1 virus resulted in increased HO-1 expression at
100–1000 MOI; incubation with an equivalent dose of control
virus had no effect. Exposure to 10 mM hemin after treatment
with 100 or 1000 MOI of control virus resulted in death
of 63.75 6 5.32% and 65.5 6 4.33% of cells at 32 hrs,
respectively. In contrast, cultures treated with 100 or 1000
MOI of HO-1 virus sustained death of 26.35 6 5.94% and
6.63 6 5.32% (P # 0.001 for each comparison). Protection
persisted when the hemin concentration was increased to its
solubility limit of 60 mM (93.2 6 4.3% death for 1000 MOI
control virus v. 45.1 6 2.9% for HO-1 virus, P # 0.001).
Conclusions: Increasing HO-1 expression by adenoviral
gene transfer protects astrocytes from heme-mediated
oxidative injury. The efficacy of this treatment on injury to
other CNS cell types is currently under investigation.
172 A Novel Approach to Oligonucleotide Microarray
Analysis to Identify Candidate Genes for Neuronal
Ischemic Preconditioning Daniel P Davis, Satoki Inoue,
Paul J Kelly, Piyush M Patel; University of California, San
Diego: San Diego, CA
Objectives: Neuronal ischemic preconditioning (nIPC) is an
endogenous neuroprotective strategy by which sublethal
insults confer temporary tolerance to subsequent lethal
ischemia; nIPC requires expression of genes that have yet
to be identified. Microarray analysis allows simultaneous,
semi-quantitative expression measurement for thousands
of genes. Here we employ a novel strategy for microarray
analysis to identify candidate genes that mediate nIPC.
Methods: A rat model of sublethal ischemia (SLI) (3 min
BCAO þ MAP 35 mmHg) was used as the nIPC stimulus.
Rather than using sham-operated controls, we administered
an inhibitor of nIPC (NMDA antagonist MK801) to controls
undergoing SLI. Seven time endpoints were used: 0h, 1h, 2h,
4h, 8h, 16h, 24h. Hierarchical cluster analysis and ratio
analysis using a 3-fold expression increase/decrease as
a threshold were used to generate a candidate gene pool.
Several genes were selected based on expression pattern and
potential relevance to nIPC for further analysis using RT-
PCR, in situ hybridization (ISH), and immunohistochemistry
(IHC). Results: A candidate pool of 183 genes was generated;
481
virtually all had one of the following functions: synaptic/
receptor, apoptosis regulation, transcription/development
regulation, intracellular signaling, growth factors/hor-
mones, immunologic, and oxidative stress/mitochondrial.
RT-PCR confirmed expression patterns for the following
genes: retinoblastoma protein, HSP70, HSP70/90 binding
protein, and inhibitor of apoptosis. ISH documented HSP70
mRNA transcription and IHC was used to confirm retino-
blastoma protein translation in the CA1/CA3 regions of the
hippocampus. Conclusions: Microarray analysis is a useful
technique for screening candidate genes involved in com-
plex cellular processes involving gene expression. Use of
pathway-selective inhibitors in the control group helps
separate relevant genes from epiphenomena. RT-PCR, ISH,
and IHC should be used to confirm microarray data.
173 Inhibiting ERK Activation during Hypothermia
after Cardiac Arrest Brian J D’Cruz, Eric S Logue,
Donald B DeFranco, Clifton W Callaway; University of
Pittsburgh: Pittsburgh, PA
Objectives: Mild hypothermia improves survival and
neurological outcome after cardiac arrest, as well as in-
creasing activation of the extracellular-signal regulated
kinase (ERK) signaling pathway in hippocampus. ERK
signaling is involved in neuronal growth and survival. We
tested the hypothesis that the beneficial effects of hypother-
mia are mediated by ERK activation by inhibiting ERK
during induction of hypothermia. Methods: In 24 Sprague-
Dawley rats, a dose-response and time-course for the
selective inhibitor of ERK, U0126, were developed. ERK
activation was measured by immunoblotting with phos-
phorylation-specific antibodies. Separate rats (n ¼ 3 per
group) underwent 8 minutes of asphyxia with cardiac arrest,
and were resuscitated with chest compressions, ventilation,
epinephrine and bicarbonate. At 30 minutes after resuscita-
tion, vehicle (50% DMSO) or U0126 (100 mcg), was infused
intracranially. Cranial temperature was kept at either 338C
(Hypo) or 378C (Norm) between 1 and 24 hours. Neurolog-
ical function was assessed daily using a neurodeficit score
(NDS) for 14 days. NDS was compared between groups
using Mann-Whitney U. Results: Immunoblotting demon-
strated a dose-dependent decrease in active ERK, with
a complete inhibition of active ERK in hippocampus after
100 mcg U0126 for up to 24 hours. Despite this inhibition,
survival and NDS did not significantly differ between U0126
and vehicle in Hypo rats at any time point after cardiac
arrest. All Hypo rats survived to 14 days with normal NDS
by day 3. Norm rats exhibited abnormal NDS on all days
(p \ 0.05 compared to Hypo), and none survived more than
10 days. Conclusions: Inhibition of ERK signaling in hippo-
campus does not alter the beneficial effects of hypothermia
induced after resuscitation in rats. These results suggest that
hypothermia-induced improvement in outcomes involves
other mechanisms in addition to ERK activation.
174 Unrecognized Misplaced Endotracheal Tubes in
a Mixed Urban to Rural EMS Setting Michael E
Jemmett, Kevin M Kendall, Mark W Fourre, John H Burton;
Maine Medical Center: Portland, ME, Central Maine Medical
Center: Lewiston, ME
482
Objective: To determine the rate of unrecognized endotra-
cheal tube misplacement when performed by EMS person-
nel in a mixed urban and rural setting. Methods: We
conducted a prospective, observational analysis of pre-
hospital endotracheal intubations (EI) performed by EMS
personnel serving a mixed urban, suburban, and rural
population. From 7/1/98 to 8/30/99 emergency physicians
assessed and recorded the position of pre-hospital intuba-
tions using auscultation, direct laryngoscopy, infrared CO2
detectors, esophageal detector devices, and chest X-ray. The
state EMS database was also reviewed to determine the
number of EI encounters involving patients transported to
our medical center and paramedic assessment of success for
these encounters. Results: A total of 167 pre-hospital EI
encounters were recorded of which 136 (81.4%) were
deemed successful by EMS personnel. Observational forms
were completed for 109 of the 136 patients who arrived
intubated at our ED. Of the studied patients, 12.6% (13/109)
were found to have misplaced endotracheal tubes. For the
patients with unrecognized improperly placed tubes, 9.2%
(10/109) were in the esophagus, 1.8% (2/109) were in the
right mainstem, and 0.9% (1/109) were above the cords.
Paramedics serving urban and suburban areas did not
perform significantly better (P \ 0.05) than intermediate
level providers serving more rural areas. Conclusion: The
incidence of unrecognized misplacement of endotracheal
tubes by EMS personnel may be higher than most previous
studies making regular EMS evaluation and the pre-hospital
use of devices to confirm placement imperative. We were
unable to show a difference in misplacement rates based on
provider experience or level of training.
175 The Minimum Acceptable Reduction in Pain on
a Visual Analog Scale Barbara G Lock, Emily R
Carrier, Peter W Greenwald; New York-Presbyterian Hospital,
Columbia University: New York, NY
Background: The VAS has been validated as a measure for
acute pain. The minimum clinically significant change on
a VAS of 13 mm may be thought of as a measure of sensory
threshold, but does not address the clinically important
question: how much change on a VAS is associated with
pain relief? Objective: To identify the mean absolute and
percent change in pain on a VAS associated with patient-
reported pain relief. Methods: For this prospective obser-
vational study, 419 patients with pain recorded as part of
their triage chief complaint were recruited between Jan
30 2002 and Jul 20 2002 in our inner-city ED. Pain was
measured on a standard 100 mm VAS with word anchors at
time 0, 45 min, and 90 min. Patients chose from three verbal
descriptors at each time point: ‘‘I have pain and it bothers
me,’’ (dysalgesia) ‘‘I have pain but it doesn’t bother me,’’
(oligoalgesia) and ‘‘I have no pain.’’ (analgesia). Pain
changes (D) were calculated and correlated with the verbal
descriptors to determine clinical worth. Pain relief was
defined as pain improvement to oligoalgesia. Results: Of
419 patients recruited, 84 were excluded due to premature
admission or discharge. Of 335 remaining patients, 52
patients representing 84 Ds reported a change in pain from
dysalgesia to oligoalgesia. 1 patient (2 Ds) was then
excluded due to irreconcilable data irregularities. The mean
absolute reduction in VAS corresponding to pain relief was
2003 SAEM ANNUAL MEETING ABSTRACTS
32.0 mm (95% CI ¼ 26.33 mm to 37.69 mm) (S.E. ¼ 2.86). The
mean percent reduction in VAS corresponding to pain relief
was 58.1% (95%CI ¼ 50.5 to 65.6%) (S.E. ¼ 3.80). Conclu-
sions: The minimum acceptable reduction (MAR) in pain of
32.0 mm, or 58.1% on a VAS, appears to approximate pain
improvement acceptable to patients. The use of the MAR
may assist pain treatment researchers in their study of
clinically important outcomes.
176 NPO Status and Adverse Events in Children
Undergoing Procedural Sedation and Analgesia in
the Emergency Department Dewesh Agrawal, Shannon F
Manzi, Raina Gupta, Baruch Krauss; Children’s Hospital
Boston: Boston, MA, Saint Louis University School of Medicine:
St. Louis, MO
Background: Assessment of pre-procedural fasting state
(NPO status) is considered essential in minimizing the risk of
aspiration during procedural sedation and analgesia (PSA) in
the emergency department (ED). NPO guidelines for elective
procedures have been disseminated by the American
Academy of Pediatrics (for solids 4 hrs if age \6 months, 6
hrs if 6–36 months, 8 hrs if [36 months; for clear liquids 2 hrs
for all ages). However, these guidelines are consensus-based,
rather than evidence-based, and are difficult to follow for
non-elective procedures in the ED. Objectives: To character-
ize NPO status of children receiving PSA in the ED and to
assess the relationship between NPO status and observed
adverse events. Methods: This prospective cohort study was
conducted in a children’s hospital ED over an eleven month
period. All consecutive patients requiring PSA for non-
elective procedures or diagnostic imaging were included.
NPO status and adverse events (defined a priori) were
recorded. The percentage of patients undergoing PSA who
did not meet established NPO guidelines was determined.
Adverse events were then analyzed in relation to NPO status.
Results: 1,014 patients underwent PSA during the study
period, and data on NPO status was available on 905 (89%).
Of these 905 patients, 509 (56%; 95%CI 53–60%) did not meet
published NPO guidelines. Adverse events occurred in 70
(6.9%) of the 1,014 patients: in 32 of 396 (8.1%) patients who
met and 37 of 509 (7.3%) patients who did not meet NPO
guidelines (p ¼ 0.65). There were no episodes of aspiration
(one-sided 97.5%CI 0–0.4%). Emesis occurred in 15 (1.5%)
patients. Average NPO length in patients with emesis was 6.8
hrs 6 2.7 hrs for solids and 5.9 6 2.7 for liquids vs. 7.7 6 4.2
(p ¼ 0.42) for solids and 6.5 6 3.7 (p ¼ 0.52) for liquids
in patients without emesis. Conclusions: 56% of children
undergoing PSA in the ED were not fasted in accordance
with published guidelines. There was no association ob-
served between NPO status and adverse events.
177 Ketamine with and without Atropine: What’s the
Risk of Excessive Salivation? Lance Brown, Steven M
Green, Thomas S Sherwin, Barcega Besh, T Kent Denmark, James
A Moynihan, Aqeel Khan; Loma Linda University Medical
Center and Children’s Hospital: Loma Linda, CA
Objective: Historically, atropine has been given concur-
rently with ketamine during pediatric procedural sedation
to avoid excessive salivation (ES). Our objective was to
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
compare the incidence and magnitude of ES when ketamine
is given with or without atropine. Methods: We conducted
a prospective, non-randomized observational study on
a convenience sample of children undergoing procedural
sedation in our tertiary care pediatric emergency depart-
ment. Treating physicians did or did not administer atropine
according to their standard practice. The non-blinded
treating physicians were asked to assess ES using a 100
mm, unmarked visual analog ‘‘ES scale’’ with ‘‘None’’ on
the left end and ‘‘Worst Possible’’ on the right end. Age and
gender were recorded. Subjects were enrolled from 3/21/
2002 through 12/18/2002. Our Institutional Review Board
approved this study. Results: At the time of abstract
submission we have 297 subjects enrolled out of 600
planned for the study. We report the following preliminary
analysis. Study subjects ranged in age from 0.7 to 17.7 years
(median 6.0 years) and 36% were female. Atropine was
administered concurrently with ketamine in 70 (24%)
subjects. The atropine group had a median age of 4.1 years
and the no atropine group had a median age of 6.5 years. In
the atropine group ES was recorded as zero in 65 of 70 (93%)
cases and the 5 nonzero ES scores were 1, 1, 2, 4, and 10. In
the no atropine group ES was recorded as zero in 219 of 227
(96%) cases and the 8 nonzero ES scores were 1, 2, 4, 23, 34,
58, 61, and 76. Upon study completion we will perform
a multivariate analysis to assess the impact of atropine
while controlling for age and other potential confounders.
Conclusions: Our preliminary results suggest that ES is
uncommon in children receiving ketamine with or without
concurrent atropine administration. For children who
experienced ES, the magnitude appeared to be greater in
the group that did not receive atropine.
178 Comparison of Needle Cricothyrotomy with Manual
Jet Ventilation vs Surgical Cricothyrotomy in a Can
Not Intubate/Can Not Ventilate Sheep Model Seth
Manoach, Chalene Corinaldi, Robert Schulze, Jean Charchaflieh,
Lorenzo Paladino, Jesse Lewin, Anthony Forestine, Michelle
Mowad, Robert Glatter, Bruce Scharf, Richard Sinert;
SUNY-Downstate Medical Center and Kings County
Medical Center: Brooklyn, NY
Objectives: We developed a novel large animal model of the
‘‘Can Not Intubate/Can Not Ventilate’’ (CNI/V) scenario
to compare the efficacy of Manual Jet Ventilation (MJV)
through a percutaneous airway catheter with Surgical
Cricothyrotomy (SC). Methods: Twelve 40–80 kg sheep
were assigned either to MJV or SC groups. The animals were
sedated, intubated, and monitored. Central venous and
arterial lines were placed. CNI/V was then simulated by
removing the endotracheal tube and inducing paralysis
with Vecuronium. Once the SaO2 fell to 80% (t ¼ 0), MJV
catheter placement or SC was initiated. Ventilation with
100% oxygen at a rate of 20/minute began upon successful
airway placement. MJV was administered at 50 psi. HR, BP,
SaO2, pH, PCO2, and PO2 were recorded at t ¼ 0, 30, 60, 90,
120, 180 seconds, and t ¼ 5, 10 and 20 minutes. Data were
reported as mean 6 standard error of the mean over the
whole observation period. Group comparisons were ana-
lyzed by ANOVA with repeated values. All statistical tests
were two-tailed and alpha was set at 0.05. Results: Body
weights were not significantly (p ¼ 0.08) different between
the MJV (65 6 6 Kg) and SC (52 6 3 Kg) groups. Median
483
procedure time for MJV (20s) and SC (24s) was not
significantly (p ¼ 0.69) different.
Jet Ventilation Cricothyrotomy p
O2 Sat. (%) 93.5 6 15.5 94.0 6 5.1 0.88
MAP (mmHg) 99.9 6 8.2 87.9 6 7.0 0.95
HR 138 6 12 121 6 8 0.15
pH 7.51 6 0.05 7.49 6 0.05 0.64
pCO2 (mmHg) 29.9 6 4.1 33.95 6 5.0 0.35
pO2 (mmHg) 265 6 79 276 6 77 0.87
Conclusion: Using a realistic model of CNI/V we found no
difference in respiratory or hemodynamic parameters
between MJV and SC. Adequate ventilation and perfusion
was maintained solely by MJV for up to 20 minutes.
179 Patient Refusal of Pain Medication in the
Emergency Department David E Fosnocht, Kenneth A
Bean, Eric R Swanson; University of Utah: Salt Lake City, UT
Objectives: Patient refusal of pain medication has not been
characterized in the ED setting. The purpose of this study is
to evaluate the frequency and reasons for pain medication
refusal by patients in the ED. Methods: We conducted
a prospective observational study at an academic ED. A
convenience sample of patients was enrolled from 9/01 to
4/02. Inclusion criteria were patients presenting to the ED
with pain. Those excluded were under age 18 or too ill to
participate. We recorded when patients were offered and
refused pain medication with reasons for refusal and
demographic data. Pain at presentation was measured with
a 100 mm visual analog scale (VAS). Outcome variables were
acceptance or refusal of medication and reasons for refusal.
Results: 1400 patients were enrolled. 806 patients were
offered pain medication. 675 patients accepted and 131
(16%) rejected pain medication. 93 of 131 patients offered
a reason for medication refusal. The most common reasons
for medication refusal were: do not like medications 21/93
(23%), desire to be alert 16/93 (17%), worried about side
effects of the medication 9/93 (10%), and not in significant
pain 30/93 (32%). Only 2/93 (2%) voiced concern for
addiction. Mean age; 36 (95% CI 35 to 37) vs 36 (95% CI 32 to
40), gender; 310/675 (46%) male vs 62/131 (47%) male (chi
square [ 0.05), and frequency of common chief complaints
(chi square [ 0.05) were not significantly different for those
accepting or refusing pain medication. Pain intensity at
presentation with VAS was lower 57 mm (95% CI 53 to 61)
for those refusing than those accepting medication 73 mm
(95% CI 71 to 75). Conclusions: 16% of patients refuse pain
medication when offered in the ED. The most common
reasons for refusal were concerns related to effects of medi-
cation and the lack of significant pain. Those refusing pain
medication tend to have lower initial pain intensity at pre-
sentation.
180 Effect of Patient Volume and Acuity on Pain
Management in the Emergency
Department Matthew B Hollifield, David E Fosnocht, Eric R
Swanson; University of Utah: Salt Lake City, UT
484
Objectives: Volume and acuity are often cited as reasons for
the lack of adequate pain management seen in the ED. The
purpose of this study is to examine the relationship between
measures of ED patient workload and ability to meet patient
needs for pain relief. Methods: We performed a prospective,
observational study in a university ED. Inclusion criteria
were patients presenting to the ED with pain. Those
excluded were under age 18 or too ill to participate. A
convenience sample of patients was enrolled from 9/01 to
4/02. We recorded number of patients receiving pain
medication in the ED and multiple measures of ED
workload: Acuity Ratio (AR) ¼ Emergent patients (pts) 3
4 þ urgent pts 3 3 þ nonurgent pts 3 2 þ fast-track pts 3
1/Total pts, Bed ratio (BR) ¼ Total pts/# treatment spaces,
Physician provider ratio (PPR) ¼ total pts/total MDs, Nurse
provider ratio (NPR) ¼ total pts/total RNs, Physician
Demand Volume (PDV) ¼ PPR 3 AR, Nurse Demand
Volume (NDV) ¼ NPR 3 AR at patient arrival. Primary
outcome measure was prediction of patient response to the
question, ‘‘Have your needs for pain relief been met?’’ based
upon ED workload measures. Results: 923 patients were
enrolled. 527 (57%) patients were offered pain medication in
the ED and 581 (63%) reported that their needs for pain
relief had been met. Using univariate logistic regression,
prediction of meeting patient needs for pain relief was:
Acuity ratio (likelihood ratio (LR) 1.69, 95% CI 0.99–2.88,
p ¼ 0.053), Bed ratio (LR 1.02, 95% CI 0.54–1.93 p ¼ 0.94),
Physician provider ratio (LR 1.01, 95% CI 0.96–1.07, p ¼
0.75), Nurse provider ratio (LR 0.88, 95% CI 0.75–1.02, p ¼
0.094), Physician demand volume (LR 1.01, 95% CI 0.99–
1.04, p ¼ 0.34), and Nurse demand volume (LR 0.96, 95% CI
0.90–1.03, p ¼ 0.29). Conclusions: ED workload does not
predict meeting patient needs for pain relief. Other reasons
for lack of adequate analgesia in the ED need to be evaluated.
181 Measuring Pain Intensity in the Emergency
Department: Correlation of a Numeric Rating Scale
with a Visual Analog Scale David E Fosnocht, James M
Dahle, Eric R Swanson; University of Utah: Salt Lake City, UT
Objectives: The visual analog scale (VAS) has been validated
and is commonly used in the ED for pain research. The 11-
point (0 to 10) verbal numeric rating scale (NRS) is often used
clinically to measure pain intensity. However, there is little
data regarding validity of the NRS in the ED setting. The
purpose of this study is to evaluate the correlation between
pain intensity measured using the VAS and the NRS in the ED
setting. Methods: We conducted a prospective, observational
study at a university ED. We enrolled a convenience sample
of patients from 1/02 to 4/02. Inclusion criteria were patients
presenting to the ED with pain. Those excluded were under
age 18 or too ill to participate. The VAS was a 100 mm
horizontal line with the words ‘‘least possible pain’’ on the
left border and ‘‘worst possible pain’’ on the right. The NRS
was an 11-point scale with 0 described as no pain and 10 as
worst possible pain. We measured pain with VAS and NRS at
presentation, following medication and at discharge. Order
of measurement was reversed at the halfway point of the
study. Outcome variables were pain intensity measured by
VAS and NRS compared using Pearson’s rho. Results: 404
patients were enrolled with a total of 800 comparisons of pain
intensity. 404 comparisons were made at presentation, 129
after pain medication, and 267 at discharge. Overall, cor-
2003 SAEM ANNUAL MEETING ABSTRACTS
relation of VAS and NRS was r ¼ 0.904 (p \ 0.001). Rho at
presentation measuring VAS first was 0.921 (n ¼ 204) and
0.896 (n ¼ 200) measuring NRS first. Rho after medication
measuring VAS first was 0.894 (n ¼ 76) and 0.903 (n ¼ 53)
measuring NRS first. Rho at discharge measuring VAS first
was 0.915 (n ¼ 141) and 0.895 (n ¼ 126) measuring NRS first.
Conclusions: Pain intensity measured with the NRS strongly
correlates with pain intensity measured with the VAS. This
correlation is consistent at three clinically important times in
the ED and is independent of the order of measurement.
182 WITHDRAWN
183 Tracheal Tube Stylet Shape and Its Effect on Target
Visualization and Tip Maneuverability Richard M
Levitan, Bruce Rubin, Crawford C Mechem, Worth Everett,
Andrew E Ochroch; Hospital of the University of Pennsylvania:
Philadelphia, PA
Background: Malleable stylets are recommended for emer-
gency laryngoscopy and intubation. Objective: The objective
of this study was to investigate how stylet shape affects target
visualization and tip manipulation. Methods: We compared
a hockey stick stylet shape (straight to the proximal cuff, then
bent 30–40 degrees) to a gently curved stylet, pre-packaged
by the manufacturer and matching the natural curvature of
the tube. The primary comparison involved subjective
operator perception by 45 experienced intubators (ED staff
and anesthesiologists) using a non-embalmed cadaver and
two different manikins. All cases used an 8.0 ETT and a Mac 4
blade. A laryngoscopic suspension apparatus was used to
maintain the same laryngeal exposure between stylet
comparisons. The laryngoscope handle was modified to use
AC power and create consistent illumination. Results: 9/9
(100%; 95% CI 66–100%) persons who compared the two
different stylets on the cadaver felt that the hockey stick
shape had better target visualization and maneuverability. In
the first manikin group 13/16 persons (81%; 54–96%) felt that
the hockey stick provided better visualization and maneu-
verability, 1 chose the gentle curve, and 2 persons had no
preference. In the second manikin group, 16/20 (80%;
56–94%) felt that the hockey stick was superior, 2 chose the
gentle curve, and 2 had no preference. Overall, 38/45 (84%;
71–94%) preferred the hockey stick shape. Conclusions: With
laryngeal exposure and lighting constant, experienced
intubators prefer a hockey stick stylet shape over a gently
curved stylet. Subsequent videographic and radiographic
analysis on the cadaver showed that a gently curved stylet
blocks the line of sight to the target. A hockey stick shape
permits better tip visualization because the section of the
tube immediately before the bend point is directed out of
the operator’s view. A narrower long axis dimension with
this shape also permits better maneuverability within the
hypopharynx.
184 Alternating Day Emergency Medicine and
Anesthesia Resident Responsibility for Management
of the Trauma Airway: A Study of Laryngoscopy
Performance and Intubation Success Richard M Levitan,
Boaz Rosenblatt, Evan M Meiner, Janet McMaster, Patrick M
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Reilly; Hospital of the University of Pennsylvania: Philadelphia,
PA, North Shore University Hospital: Manhasset, NY
Objective: To compare laryngoscopy performance and
overall intubation success in trauma airways where primary
airway management alternated between EM and anesthesia
residents on an every other day basis. Methods: Data on all
trauma intubations over approximately three years was
prospectively collected. For cases with pre-notification by
EMS primary airway management was assigned to ED
residents on even days and anesthesia residents on odd
days. EM residents intubated patients who arrived without
pre-notification who needed immediate intubation. Setting:
Inner city, Level 1 trauma center with approximately 50,000
ED patients and 1,800 major trauma cases per year. Main
outcomes: success or failure at laryngoscopy and the number
of laryngoscopy attempts needed for intubation. Results: 658
trauma patients were intubated during the study period.
Laryngoscopy was successful in 654 out of 656 cases. Two
patients (0.3%) underwent cricothyrotomy following failed
laryngoscopy, and two patients (0.3%) had awake nasal
intubation without laryngoscopy. The specific number of
laryngoscopy attempts was unknown in 6 cases (three from
each service) resulting in 650 cases for laryngoscopy
performance analysis. Overall, 87% of patients were intu-
bated on first attempt and three or more attempts occurred in
2.9%. Laryngoscopy performance by service (broken down
by 1, 2, and 3 or more attempts) was as follows: EM 86.4%,
11%, and 2.6% vs. Anesthesia 89.7%, 6.7%, and 3.6%. Chi-
square analysis by service: p ¼ 0.18. Conclusions: There
were no differences in laryngoscopy performance and
intubation success in trauma airways managed on an every
other day basis by EM vs. anesthesia residents.
185 Evaluation of a Blind, Rotational Technique for
Selective Mainstem Intubation Melissa J Doherty,
Aaron E Bair, Richard W Harper, Timothy E Albertson; UC
Davis Medical Center: Sacramento, CA
Objective: Massive hemoptysis and major bronchial dis-
ruptions, while rare, are associated with high mortality.
Survival is often dependent on selective ventilation of the
uninvolved lung. Specialized devices used for single lung
ventilation are often not readily available in the ED. We
evaluated a blind, rotational technique for selective main-
stem intubation using either a standard endotracheal tube
(ET) or a directional-tip endotracheal tube (DTET). Meth-
ods: This was a prospective, randomized trial on 25 human
cadavers. The desired side of mainstem intubation was
determined by randomization. Each cadaver was utilized
for 4 ET, 4 DTET, and 4 control intubations. In the ET group,
the trachea was intubated. The tube was then rotated 90
degrees in the direction of desired placement and advanced
until resistance was met. When using the DTET, the tech-
nique was identical, except the trigger was activated to
flex the tip during advancement. In the control group an
ET was advanced in neutral alignment until resistance was
met. A bronchoscopist blinded to the desired placement
determined tube position. Comparison testing was per-
formed using Pearson’s chi square test. Results: When
attempting to intubate the left mainstem, use of the ET with
the rotational technique was successful 72.3% of the time
(95% CI, 57–84). Intubation of the left mainstem using the
485
DTET was successful 68.5% of the time (95% CI, 54–81), p ¼
0.67. Attempts to selectively intubate the right mainstem
utilizing the rotational technique were highly successful in
both groups (96% ET (95% CI, 90–99) vs. 97.8% DTET (95%
CI, 89–100)). Among controls, the right mainstem was
intubated 93% of the time (95% CI, 86–97). Conclusions: In
a cadaveric model, the left mainstem bronchus can be
selectively intubated with moderate reliability using this
rotational technique. Use of a directional-tip endotracheal
tube confers no significant advantage. The ability to
generalize these findings to living subjects is unknown.
186 Comparison of the Percentage of Glottic Opening
(POGO) Scale to Laryngoscopy Grading Scale (LGS)
and Global Difficulty of Intubation William P Bozeman,
Douglas M Kleiner, Vicki Huggett; University of Florida:
Jacksonville, FL
Background: The Percentage of Glottic Opening (POGO)
scale is an estimate of the portion of the vocal cords
visualized during direct laryngoscopy and has been used to
evaluate intubating conditions. The anesthesiology litera-
ture recommends a standard laryngoscopy grading scale
(LGS) for assessment and comparison of intubating condi-
tions. The LGS includes 2 measures of the ease of lar-
yngoscopy, 2 of the vocal cords, and 2 of patient reactions
to intubation; it results in ‘‘good,’’ ‘‘acceptable’’ or ‘‘un-
acceptable’’ intubation conditions. Objective: We sought to
validate the POGO scale by comparison to the LGS and to
overall intubation difficulty. Methods: In a prospective
study of intubation conditions over a one year period,
helicopter flight crew members graded each oral intubation
attempt by POGO scale and the LGS. Global difficulty of
intubation was assessed by a five point Likert scale of 1
(very easy) to 5 (very difficult). For analysis, POGO scores
were grouped into \25%, 25%, 50%, 75%, and 100% cord
visualization. Results: Laryngoscopy was performed in
a total of 56 patients, under 69 conditions including no
medication (n ¼ 14), sedation alone (n ¼ 24), and
succinylcholine (n ¼ 31). The POGO scale correlated with
the LGS (Spearman r ¼ .60, p \ .001 different from chance).
The LGS ranged from unacceptable conditions in 84% of
patients with POGO \25% to 0% of patients with POGO
100%. POGO scores also correlated well with global
difficulty of intubation assessments (Spearman r ¼ .83,
p \ .001). Mean intubation difficulty scores ranged from 4.8
(difficult to very difficult) at POGO \25%, to 1.5 (easy to
very easy) at POGO 100%. Conclusions: The POGO scale is
a valid measure of intubating conditions during direct
laryngoscopy and correlates well with formal LGS and
subjective global difficulty of intubation assessments.
187 The Insecure Airway: A Comparison of Knots and
Commercial Devices for Securing Endotracheal
Tubes Paris B Lovett, Alexander Flaxman, Kai Stürmann;
Beth Israel Medical Center: New York, NY, University of
Medicine and Dentistry of New Jersey–New Jersey Medical
School: Newark, NJ
Background: ETTs are commonly secured using adhesive
tape, cloth tape, or commercial devices. Adhesive and cloth
486
tape have been reported equally effective, but there has been
no experimental comparison of cloth tape tied with different
knots. Movement of an ETT by 3cm may be life-threatening.
Objectives: To compare rates of failure of the following
methods: cloth tape tied with 3 different hitches (Lark’s
Head (LH), Clove (CH), and Magnus (MH)); nasal cannula
tubing tied with CH (NC); and 6 commercial devices (Comfit
(Ackrad), Stabiltube (B & B Medical), Tube Restraint
(ErgoMed), ETAD (Hollister), Thomas ST (STI Medical)
and Dale ETT Holder). Methods: A 17cm diameter PVC tube
with 14mm ‘‘mouth’’ hole in the side served as a mannequin.
Cloth tape was 1.25cm synthetic twill. ETTs were secured
with cloth tape, NC or devices and subjected to repeated
jerks of 2.5, 5 or 10 lbs. 3–10 tests were performed for each
knot/device. All knots/devices were wet with saline. Failure
was movement $3cm. Results: 3 types of failure were
identified: slip, stretch and breakage. Cloth tape never broke:
all failures were stretch or slip. Stretch failure was similar for
all knots, averaging 2.8cm at 5lb 3 6 jerks. Comparing
hitches, MH (2.8cm) and CH (2.44cm) produced less
slippage than the commonly recommended LH (6.21cm).
NC produced almost no slip (1cm) but unacceptable stretch
occurred (3.25cm at 5lb 3 6 jerks). Among devices, all
devices failed consistently either at 2.5lb 3 12 jerks or 5lb 3
6 jerks—with the sole exception of the Dale, which
consistently passed both tests (p \ 0.01). All devices, in-
cluding the Dale, failed at loads $10lb. Conclusions: CH
and MH hitches are superior to the LH for securing ETTs. NC
stretches too much to be recommended. Cloth tape breaks
less easily than all commercial devices tested. Development
of a synthetic cloth tape with improved grip and reduced
stretch would markedly reduce failure. Among devices, for
dynamic loads #5lb, the Dale was clearly superior.
188 Sonographic Assessment of the Epiglottis Robert A
Jones, Sandra L Werner, Charles L Emerman; MetroHealth
Medical Center: Cleveland, OH
Objectives: The ideal diagnostic test for the diagnosis of
epiglottitis would be noninvasive, performed at the bedside
and lacking in ionizing radiation. This study evaluates the
ability of bedside ultrasound (US) to accurately assess
the epiglottis. Methods: This was a prospective study of
a convenience sample of 100 subjects between the ages of
18 and 50 years who had no acute or chronic laryngeal
diseases or surgeries. Subjects were scanned in both the long
and short-axis of the epiglottis with a 5–10 MHz linear
transducer. Sonographically the epiglottis appeared as
a curvilinear, hypoechoic structure with an echogenic pre-
epiglottis space. The sonographic appearance of the epi-
glottis and the pre-epiglottic space were documented and
anteroposterior (AP) measurements of the epiglottis just
distal to the hyoid bone were made. Comparisons between
men and women were performed with Student’s T test.
Pearsons’ correlation analysis was performed to evaluate
the relationship between height and epiglottic size. Results:
The epiglottis was visualized in all 100 patients including 62
women and 38 men. The average age was 35.2 6 8.1 years.
The epiglottic thickness was 2.39 6 0.15 mm. This was
greater in men (2.49 6 0.13 mm) than in women (2.34 6 0.13
mm; p \ .001). There was a moderate correlation between
height and epiglottic thickness R ¼ 0.48, however when this
2003 SAEM ANNUAL MEETING ABSTRACTS
was analyzed separately for men and women there was no
significant correlation between epiglottic thickness and
patient height. Incidental findings during the sonographic
exam included the ability to assess the patency of the
vestibular opening and movement of the true vocal cords in
97/100 patients (95% C.I. 92–99%). Conclusions: Bedside US
of the epiglottis is easy to perform and can accurately
evaluate the epiglottis. Further analysis should include
patients with known epiglottic disease to assess the ability
of this technique to identify pathlogic enlargement.
189 Deep Vein Thrombosis in the Emergency
Department (DVT-ED) Tenny Thomas, Tina G
Rosenbaum, Keith Boniface, Jeffrey Smith; George
Washington University: Washington, DC
Objectives: To determine if emergency physicians (EPs) can
diagnose proximal deep venous thrombosis (DVT) by
performing bedside compression ultrasound studies with
and without duplex examination of affected limbs as
compared to the standard ultrasound studies while com-
paring completion times for each study. Methods: All
patients above the age of 18 presenting to the emergency
department (ED) of a university center with symptoms
suggestive of DVT in the lower extremity with no history of
DVT in the past six months on whom the EP has decided to
obtain an ultrasound study were enrolled. After consent, the
EP performed a bedside compression ultrasound study to
ascertain the presence of clot and recorded time for
completion of the study. A second EP, blinded to the results
of the compression and confirmatory studies, timed duplex
and compression examinations of the extremity. Confirma-
tory studies were obtained through the radiology and
vascular departments. The study is powered to detect 5%
difference in detection rates between EP and standard
studies. Results: To date, 63 patients have been enrolled and
interim data shows sensitivity of 90% (95%CI 0.68–0.99) for
the compression study and 94% for the Doppler studies
(95%CI 0.69–0.99). The specificity for both compression and
Doppler studies was 98% (95%CI 0.88–0.99). Positive and
negative predictive values were 94–98% and 96–98% re-
spectively (95%CI 0.69–0.99) for both study types. The
difference in time spent performing the compression and
Doppler studies (7.9 vs. 16.4 minutes) was statistically
significant (p \ 0.0001). Concordance between ED and
confirmatory studies was high with positive likelihood
ratios of 40 (Doppler) and 21 (compression). The negative
likelihood ratio for both study types was 0.06. Conclusions:
EPs are able to accurately detect proximal lower extremity
DVT with minimal training and within an average of 7.9
minutes. Duplex examinations took significantly longer
without contributing to the accuracy of the EP results.
190 The Influence of Operator Confidence on the
Accuracy of Emergency Department
Ultrasound Daniel P Davis, Colleen Campbell, Julia Wang,
Jennifer Poste; University of California, San Diego:
San Diego, CA
Objectives: Ultrasound (US) accuracy is highly dependent
upon the technical abilities of the operator and conditions
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
unique to each patient; however, previous studies evaluat-
ing the accuracy of ED US have not included estimates of
operator confidence. This prospective observational study
explores the influence of operator confidence on the
accuracy of ED US. Methods: Patients were enrolled
prospectively for the 1st year following a departmental US
training module if they underwent one of the six approved
ED US exams: 1) FAST exam for intraperitoneal fluid, 2)
RUQ exam for gallstones, 3) renal exam for hydronephrosis,
4) obstetric exam for intrauterine pregnancy, 5) abdominal
exam for aorta diameter [3 cm, and 6) cardiac exam for
pericardial fluid. In addition, formal US, CT scan, or an
invasive procedure were required as a ‘‘gold standard’’ for
each patient. Operators recorded their interpretation of the
ED US and their confidence with the exam (1–10) prior to
the formal study. The sensitivity, specificity, PPV, NPV, LRþ,
and LR- were calculated for each exam type and for all
exams together. The influence of operator confidence was
explored using logistic regression and by stratifying patients
by confidence value and calculating parameters as above.
Results: A total of 276 ED US exams were included. There
were no significant differences between ED attendings and
residents with regard to accuracy.
N Sens Spec PPV NPV LRþ LR

All exams 276 92% 86% 92% 87% 6.8 0.09
Confidence 7–10 208 96% 89% 94% 91% 8.4 0.05
Confidence 9 or 10 113 99% 90% 97% 96% 9.6 0.01
Logistic regression revealed a significant effect of confidence
of ED US accuracy (p ¼ 0.001). Conclusions: Operator
confidence has a significant influence on ED US accuracy.
High confidence is associated with clinically useful values
for sensitivity, specificity, PPV, and NPV.
191 Short and Long Term Effects of Emergency Medicine
Ultrasound on Formal U/S Utilization: A Decade of
Experience Jeanne L Jacoby, Scott Melanson, Mary Eberhardt,
David Kasarda, James Reed, Michael B Heller; St. Luke’s
Hospital: Bethlehem, PA
Objectives: It has been reported that utilization of formal
ultrasound (U/S) studies by departments of radiology
initially increases after inception of an EM U/S training
program but there are no data on whether this trend
continues as the training program matures. The purpose of
this study was to evaluate the effect of an ongoing EM U/S
program on formal U/S utilization after more than a decade
of experience. Methods: This retrospective, computer-
assisted review compared ED abdominal U/S studies
ordered in the 3 years prior to inception of an EM U/S
program (1992–1994) to those ordered in the 8 years after its
inception (1995–2002). In order to adjust for changes in both
clinical practice and volume, all abdominal sonograms
ordered by ED physicians were compared to equivalent
outpatient ultrasounds ordered from the radiology depart-
ment by all other physicians in the hospital. The study site is
a community teaching hospital with a current ED census of
487
50,000. All comparisons were made using one-way ANOVA
with two-tailed alpha set at .05. Results: In the initial 4 years
(1995–1998) the number of formal studies increased signif-
icantly in both absolute numbers (annual mean 95 vs. 162, p
\ .002) and as a percentage of all outpatient sonograms
ordered at the institution (5.1% v 8.5%, p \ .0001). However,
in the following 4 years (1999–2002) the absolute number
of formal studies remained constant but decreased when
adjusted for an increased ED census. ED-ordered formal
studies also decreased as a percentage of all sonograms
ordered (5.1% v 4.1%, p ¼ .002), a 25% relative reduction,
temporally related to introduction of an EM U/S credential-
ling program. Conclusion: Introduction of an EM U/S
training program increases utilization of formal U/S services
in the first years after implementation. After this period,
relative ED U/S utilization declines to levels even below
those seen prior to initiation of EM ultrasound.
192 Success Rate of Peripheral IV Catheter Insertion by
Emergency Physicians Using Ultrasound
Guidance Thomas G Costantino, John P Fojtik; Drexel
University College of Medicine: Philadelphia, PA
Objectives: To assess the success rate of emergency
physicians in placing peripheral intravenous(iv) catheters
using ultrasound guidance in patients who were unsuc-
cessfully cannulated by emergency nurses. Methods: Pro-
spective convenience sample of patients who presented to
an urban ED between July 2002 and Dec 2002. The inclusion
criterion was the inability of any available emergency nurse
or paramedic to establish a peripheral iv. Patients who were
determined by the EM physician to be unstable or require
central iv access were excluded. Ultrasound guidance was
performed with a 7.5–10 MHz linear probe. Successful
cannulation was measured by blush on color power
Doppler with infusion of 5cc normal saline or blood return.
Results: 51 patients enrolled. 46/51 successfully cannulated
(92%). 43 were successful on the first attempt (84%). 4
patients had ivs placed in the brachial vein (8%). The rest
were placed in basilic, cephalic, antecubital or forearm
veins. There was one reported complication, a brachial
artery puncture (2%). The average time to successful
cannulation was 2.5 minutes. The other 5 patients received
central lines. Conclusion: In the setting where ED nurses
are unable to obtain peripheral iv access, the use of
ultrasound guidance allowed EM physicians to successfully
cannulate a peripheral iv 92% of the time. The majority of
peripheral lines successfully placed avoided the brachial
veins (82%).
193 Emergency Ultrasound Optic Nerve Sheath
Measurement to Detect Increased Intracranial
Pressure in Head Injury Patients: Preliminary Study of
Interobserver Variability in Normal Human
Subjects Troy Foster, Vivek S Tayal, Timothy Saunders,
James Norton; Carolinas Medical Center: Charlotte, NC
Objectives: Ultrasound has been proposed to rapidly detect
intracranial hypertension in head trauma patients. Previous
work has shown that patients with increased intracranial
pressure have increased ONSD (Optic Nerve Sheath Di-
488 2003 SAEM ANNUAL MEETING ABSTRACTS

ameter) in human subjects. Prior study data agree that the

MS3 PGY-2 PGY-3
normal ONSD is between 4.5 and 5.0 mm. We hypothesized
[seconds [seconds [seconds
that interobserver variability would not be significant Critical Events (SD)] (SD)] (SD)] p-value
between investigators in a series of normal patients.
Methods: Prospective case control study of transorbital Recognize
Unresponsiveness 17 (4) 14 (4) 14 (4) NS
ultrasound of the optic nerve in normal volunteers
1st Defibrillation 309 (186) 148 (29) 119 (29) .01*
performed by 4 experienced ultrasound investigators. The
Successful ETT 470 (245) 145 (77) 193 (81) .09
four investigators independently measured the ONSD in Placement n¼3 n¼4 n¼3
five volunteers and were blinded to the measurements of 1st IV Drug 377 (68) 270 (36) 258 (34) .05*
the previous investigators. ONSD was measured in both Successful
eyes by tenths of millimeters using a linear 7.5 MHz Resuscitation 60% 100% 100%
transducer. Descriptive statistics, including means, standard Return of 399 (88) 309 (30) 312 (55) NS
deviations, ranges, were calculated. The difference between Circulation n¼3
the observer’s measurement and the mean of the four Secondary Measures: Harmful Actions
observers was calculated for each eye. Additionally, the data Airway
was evaluated using the most experienced sonologist (ES). Managed
Results: Four observers measured five patients (n ¼ 5). The Incorrectly 20% 0% 20%
absolute difference from the mean of all observers was 0.30 CPR Performed
mm (p ¼ 0.18) with a standard deviation of 0.19 mm. The Incorrectly 40% 60% 60%
absolute difference from ES was 0.55 mm (p ¼ 0.21) with Inappropriate
a standard deviation of 0.31 mm. The range of the absolute Drug 20% 20% 0%
difference from the mean was 0.62 mm and the range for the
absolute difference from ES was 1.0 mm. The range of
values obtained was 2.8 mm to 3.9 mm. Conclusion: Four
emergency physicians were able to obtain ONSD using
ultrasonography in normal patients with no significant 195 The Validation of Simulation to Evaluate Flight
difference measured between observers using the mean as Crew Members’ Airway Management Skills Steven
the actual value. Furthermore, the range of values obtained A Godwin, David A Caro, Robert L Wears, Douglas M Kleiner;
was within the normal range established by independent University of Florida: Jacksonville, FL
studies. Future studies will need to establish this precision Background: It has been suggested that human patient
in patients with intracranial hypertension and an enlarged simulation (HPS) may be an effective method of teaching
ONSD. and evaluating skills. Objectives: The purpose of this study
was to evaluate HPS as a teaching and evaluation tool
for airway management skills. Methods: 23 experienced
members of a helicopter flight crew (14 paramedics and 9
194 High-fidelity Medical Simulation and
paramedic/nurses) had their performance in advanced
Its Role in Evaluating Advanced Cardiac Life
airway management assessed during two different rapid
Support (ACLS) Skills Marc J Shapiro, Leo Kobayashi,
sequence intubation (RSI) scenarios. Each subject was asked
Raveendra Morchi; Brown University School of Medicine:
to self-rate their comfort level and confidence in performing
Providence, RI
RSI before and after the simulation training. A 100 mm visual
Objectives: 1) To use high fidelity medical simulation analog scale was used, with 0 being ‘‘not comfortable/
(HFMS) to assess ACLS-certified medical trainees’ perfor- confident’’ and 100 being ‘‘very comfortable/confident’’.
mance in a standardized scenario. 2) To determine if Additionally, 6 teams (comprised of 14 of the 23 subjects) had
HFMS can differentiate performance across levels of their performance from the two HPS scenarios graded by
medical training. Methods: This observational study was a physician instructor, and the subjects self-analyzed their
performed using SimMan (MPL/Laerdal) to simulate performance from the same 20-point checklist of critical
a standardized ventricular fibrillation scenario. Third-year actions. Results: The pre-simulation self-rating of perceived
medical students (MS3) in teams of two were assessed for comfort and confidence was 76.2 (624.2), and the post-
ACLS skills within 6 months of certification. Individual simulation rating was 85.6 (619.9), indicating a significant
PGY-2 and PGY-3 EM residents underwent the same improvement of 9.4% (p ¼ 0.0053). There was also a
scenario. An ED nurse assisted in each scenario but was significant difference (p ¼ 0.0057) between the students’
instructed not to guide resuscitation. Audiovisual records self-evaluation of completed critical actions vs. the instruc-
and timed logs were used to score basic life support, tor’s evaluation of the team, with mean scores of 18.0 (62.3) &
defibrillation, airway management, drug administration, 15.9 (62.4), respectively (90% completion of critical skills vs.
and time to each critical event. Kruskal-Wallis one-way 79.5%). Conclusions: These data indicate the members of the
ANOVA was performed. Results: 5 groups of MS3 were flight crew rated their initial comfort level and confidence in
compared with 5 PGY-2 and PGY-3. There were statisti- performing RSI very high. However, their perception of their
cally significant differences between MS3 and residents’ performance was significantly better than that of an in-
time to first defibrillation and time to first intravenous structor observing their performance. Despite high initial
drug. Conclusion: HFMS can be used to objectively assess self-ratings in comfort and confidence, these subjects
application of ACLS skills. HFMS can detect differences in perceived a significant improvement in their skills as a result
performance of ACLS skills by trainees at different levels of simulation training. HPS appears to be an effective tool for
of medical education. assessing airway management skills.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
196 Retention of Emergency (EM) Residents’
Cricothyrotomy Skills at 14 Months after a
Procedure Lab Using a Deer Neck Model to Practice this
Procedure Robert Schwaner, James G Ryan, David Miranda,
Zhanna Roit, Joseph LaMantia, Mary F Ward, Andrew E Sama;
North Shore University Hospital: Manhasset, NY
Objective: To determine, using a deer neck model, if EM
residents could retain skills needed to perform open
cricothyrotomy fourteen months after being exposed to this
model. Methods: This study was performed at an academic
Emergency Department with a 3 year EM residency and 24
residents. Junior EM residents who had completed ATLS and
didn’t have other experience or training with open cricothyr-
otomy were eligible. The procedure lab consisted of a 1/2
hour lecture describing the technique, followed by a 1.5 hour
session during which the residents were able to practice this
procedure on deer necks obtained from hunting refuse. Prior
to the procedure lab each subject was asked to perform
a cricothyrotomy on a deer neck. The time from the initial
skin incision to placement of the tube in the trachea was
measured. Correct placement of the tube was confirmed by
cut-down on the trachea by an attending physician. This test
was replicated 14 months later for each of the residents.
Results: Seven residents participated in this study. The
median time for the residents to perform a cricothyrotomy
was significantly shorter on the 14 month follow-up test as
compared to the test prior to the deer neck lab (25 vs 61 s; p ¼
0.0156). On the pre-test, 2 residents had incorrect placement
of the tracheostomy tube. All were placed correctly on the 14
month follow-up test. The lifetest procedure found the time
to successful completion significantly shorter (p ¼ 0.028) on
the 14 month follow-up test when compared to the pre-test.
Conclusion: EM Residents retain the skills necessary to
perform successful open cricothyrotomy on a deer neck
model fourteen months after first exposure.
197 Full-scale High Fidelity Human Patient Simulation
vs Problem Based Learning: Comparing Two
Interactive Educational Modalities Wendy C Coates,
Randolph H Steadman, Yue-Ming Huang, Rima Matevosian,
Lynne B McCullough, Baxter Larmon, Danit Ariel; David
Geffen School of Medicine at UCLA: Los Angeles, CA,
Harbor-UCLA Medical Center: Torrance, CA, Olive
View-UCLA Medical Center: Sylmar, CA
Background: Simulators provide enjoyable, real time edu-
cation. There is a paucity of objective evidence to demon-
strate significant benefits compared to other educational
techniques. Objective: To determine if full-scale simulation
is superior to interactive problem based learning (PBL) in
teaching medical students acute patient management skills.
Methods: Prospective, randomized education methodology
study. IRB approval and informed consent were obtained.
Fourth year medical students in an acute care course were
eligible for inclusion and were randomized to simulator
(SIM) or PBL group. All participated in a simulator ori-
entation session on critical care management (CCM) on
day 1. A blinded investigator assessed each student’s
patient management skills with a standardized checklist
that was verified by a second investigator. Each student in
the group had a unique scenario and went in the same order
489
each day. On day 3, PBL group learned about dyspnea
(DYS) in a standard PBL format. SIM group learned DYS
using the simulator. To equalize simulator education time,
PBL group learned about acute abdominal pain on the
simulator, while SIM group used PBL format. On day 5,
each student was tested on new scenarios of shortness of
breath. Checklists were completed by the same investigators
who were blinded to randomization of students. Median
CCM and DYS scores between SIM and PBL groups were
compared with Wilcoxon Rank-Sum test. Means were
compared using t-test. Statistical significance: P \ 0.05.
Results: 31 students. SIM and PBL groups had similar
baseline mean and median CCM (day 1) scores, PBL: 0.440
mean, 0.431 median; SIM: 0.467, 0.467; p ¼ 0.6433, 0.4176,
and were deemed equivalent. SIM performed better than
PBL group on the final assessment DYS scenarios: Median:
SIM ¼ 0.714, PBL ¼ 0.535; p \ 0.0001; Mean: SIM ¼ 0.716,
PBL ¼ 0.526; p ¼ 0.0002. Conclusion: Students who were
taught about dyspnea on the simulator demonstrated better
patient management skills than those who were taught in
a standard PBL format.
198 Focused Computer Tutorials in the Pediatric
Emergency Department: A Randomized Controlled
Trial Martin V Pusic, Wendy A MacDonald, George Pachev;
University of British Columbia: Vancouver, BC, Canada, McGill
University: Montreal, Quebec, Canada
Objective: To demonstrate that exposure of medical
students to brief computer tutorials in the PED can result
in increased knowledge gain. Methods: Subjects: Medical
students on a 2-week rotation in the PED. Setting: Pediatric
Emergency Dept. Intervention: We created six computer
tutorials using Toolbook Instructor (Click2Learn Corp.,
Bellevue, WA) and installed them in a computer in the
central nursing station of the PED. Tutorial topics (Fever
without source, Febrile seizures, Gastroenteritis, Growth
Plate Fractures, Tissue Adhesives and C-spine Radiography)
were chosen to reflect common situations. The tutorials
varied in length from 36–88 screens. Preceptors were in-
structed to refer students to the tutorials. Study Design:
Randomized within-subject controlled trial. Students were
randomly assigned three of the six available tutorials.
Outcome Measure: We created one short-answer question
for each of the six tutorial topics and administered the
questions to all students on days 1 (pre-) and 12 (post-) of
their rotation. For each student, we compared scores on the
three questions for which they had been assigned a tutorial
with the scores for the three questions where they did not
receive a tutorial. Results: Between July 1, 2000 and Sept 15,
2001, eighty students completed the study procedure. On
average, students completed 1.9 of the three assigned
tutorials. For questions where the student had a tutorial
available to them, scores (out of 10 marks maximum)
increased by 2.5 (SD: 1.4) while, when they did not have
a tutorial available, the increase was 1.6 (SD: 1.7). The
within-subjects mean difference, tutorial available vs. not
available, was 0.9/10 (95% CI: 0.3, 1.4). Five of six questions
showed statistically significant benefit for tutorial availabil-
ity. Conclusions: Brief computer tutorials placed in a busy
PED can be effective aids for medical student learning.
490
199 Learning Style Analysis in Emergency Medicine
Residency Training David Barlas, Sanjey Gupta,
Martin L Lesser; North Shore University Hospital:
Manhasset, NY
Objective: EM training and practice requires the assimilation
of a great deal of knowledge and experience. Learners often
have a preference for the way they receive and process new
data—their preferred learning style (LS). Knowledge of the
LS of faculty and residents in an EM training program can be
helpful to 1) guide residents to learning modalities based on
their individual LS, 2) match them with faculty having com-
plementary LS, and 3) guide program directors in designing
a curriculum based on the residents’ preferred LS. LS analysis
has been performed in many fields, but not EM. We sought to
determine the LS of EM residents and compare it with that of
the faculty and with residents in other fields. Methods: In this
prospective, observational study, residents and faculty of an
established 3-yr university-affiliated EM residency program
completed the validated Kolb LS inventory. Comparisons
between the main groups and between subgroups based on
demographic and prior educational experience were made
using Fisher’s Exact test with a significance level of p \ 0.05.
Results: 22 residents and 24 faculty completed surveys. Half
of the residents were ‘‘assimilators,’’ 29% were ‘‘accommo-
dators,’’ 17% were ‘‘divergers,’’ and 4% were ‘‘convergers.’’
Of the faculty half were ‘‘convergers,’’ 18% ‘‘divergers,’’ 18%
‘‘assimilators,’’ and 14% ‘‘accommodators.’’ This difference
was highly significant (p \ 0.002). There was no difference in
the residents’ LS distribution by PGY or sex. There was no
difference in faculty’s LS distribution by years in practice, but
there was a difference by sex: 5/7 female faculty (71%) were
‘‘accommodators,’’ whereas 11/17 male faculty (65%) were
‘‘assimilators’’ (p ¼ 0.02). The resident LS resembles that of
pediatricians and family physicians. The faculty LS is more
like that of surgeons. Conclusions: The LS of EM residents in
our program differs from that of the faculty. Improved
understanding of individual and group LS can be used to
enhance postgraduate education in EM.
200 Risk Factors for a Traumatic Lumbar
Puncture Kaushal H Shah, Daniel McGillicuddy,
Jeffery Spear, Larry Nathanson, Jonathan A Edlow; Beth Israel
Deaconess Medical Center: Boston, MA
Objective: To identify risk factors for a traumatic lumbar
puncture (LP). Methods: A prospective study is being
conducted at an urban, university tertiary care referral center
with 50,000 annual emergency department (ED) visits. The
study population includes all patients who have a LP
performed in the ED. Prior to performing the LP, the following
potential risk factors were obtained: age; estimated height
and weight to calculate body mass index (BMI); history of
osteoarthritis, rheumatoid arthritis, back surgery or scoliosis;
whether the patient is agitated/uncooperative; ability to
visualize and palpate the spine; the anticipated level of
difficulty as assessed by the resident and the attending on
a scale of 1–5; position LP performed (lying/sitting); post-
graduate level; the number of previous LPs performed. After
performing the LP, the number of attempts by each clinician
and the CSF analysis were obtained. A ‘‘traumatic tap’’ was
defined as a red blood cell count greater than 400 cells/hpf
(high-powered field) in cerebrospinal fluid (CSF) Tube #1.
2003 SAEM ANNUAL MEETING ABSTRACTS
There are no exclusion criteria. Comparisons between groups
were made using Chi-square, Fisher’s exact, and Student’s
t-test as appropriate. Results: 58 LPs were enrolled over the
first 2 months. Of those, 6 (10.3%) were found to be traumatic
taps. Comparing the traumatic tap group with the non-trau-
matic tap group, respectively, the average BMI 30.9 vs. 26.5
(p ¼ 0.37), osteoarthritis 50%) vs. 3.9% (p ¼ 0.006), inability to
visualize spine 83% vs. 37% (p ¼ 0.072), and inability to easily
palpate spine 50% vs. 21% (p ¼ 0.14). More than one clinician
was needed to successfully obtain CSF in 50% of the patients
in the traumatic tap group compared with 27% of the non-
traumatic tap group. No difference has yet been noted for the
other potential risk factors. Conclusion: There may be cer-
tain risk factors, such as BMI, osteoarthritis, and inability to
visualize or palpate the spine, that can predict a traumatic LP.
201 Intravenous Atropine vs Intravenous Lorazepam for
the Treatment of Peripheral Vertigo Timothy Scott
Talbot, Marc E Levsky, Gregory Paul Garcia, Ian S Wedmore;
Madigan Army Medical Center-University of Washington
Emergency Medicine Residency: Fort Lewis, WA
Objective: The current standard of care for vertigo in the
emergency medicine literature is treatment with a benzodi-
azepine, an antihistaminic or antimuscarinic. This therapy is
not without risks; benzodiazepines and antihistaminics can
cause significant sedation putting those with postural in-
stability at additional risk of falls and subsequent injury.
There have been no studies directly comparing benzodiaze-
pines with antimuscarinics in the treatment of acute
peripheral vertigo. Methods: This study is a blinded, ran-
domized controlled trial of lorazepam versus atropine for
abatement of vertiginous symptoms as measured by ability to
ambulate, with the secondary outcome of sedation level.
Patients at an academic medical center who had a history and
physical examination consistent with a diagnosis of periph-
eral vertigo were enrolled. Sedation was assessed pre- and
post-treatment using the neurobehavioral assessment scale
(NAS). Each patient was randomized to receive either 1 mg
atropine or 1 mg lorazepam intravenously. Thirty minutes
after treatment the patient was assessed by the treating
physician on ability to ambulate on a 4 point ordinal scale, and
ability to be discharged to home. Results: Preliminary results
were obtained with 19 subjects enrolled in the study group. 12
were randomized to treatment with atropine and 7 were
randomized to treatment with lorazepam. The pre-treatment
mean NAS score was higher in the atropine group and the
post-treatment mean NAS score was higher in the lorazepam
group with a trend towards more sedation but was not
statistically significant (p\0.16). 29% of the lorazepam group
recieved rescue medications versus 0% in the atropine group.
There was no significant difference in the ability to ambulate
and discharge rates to home. Conclusion: On preliminary
analysis, atropine appears to be as efficacious as lorazepam,
and may be less sedating; atropine may therefore provide an
attractive alterative for Emergency Department treatment of
peripheral vertigo.
202 Assessing Urban Community Knowledge of
Acute Stroke: Results with a Culturally
Sensitive Instrument Davida E Manor, Lynne D
Richardson, Joanna Shen, Jennifer Holohan,
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Kevin Baumlin, Steven R Levine; Mt. Sinai School
of Medicine: New York, NY
Objective: Despite the recent development of time sensitive
thrombolytic therapy for acute stroke, most patients do not
seek medical care within the therapeutic window. Using
a culturally appropriate instrument, we conducted inter-
views to assess our urban community’s baseline knowledge
of acute stroke, prior to developing a community-based
educational intervention. Methods: Trained interviewers
administered a structured interview consisting of 15 open-
ended questions regarding the causes of acute stroke, the
identification of acute stroke symptoms, the urgency of
calling 911, and preferred methods of stroke education.
Interviews were conducted at NYC apartment buildings
known to have a high stroke-risk population (i.e. over age
50). The consent and interview process required an average
of 15 minutes to complete for each subject. Data were
entered and analyzed using SPSS. Results: 60 participants at
6 separate buildings completed interviews. Respondents
were 72% female; 63% African-American; mean age 69
(SD ¼ 616.2). 82% were unable to define stroke as occurring
in the brain. Only 58% were able to name any warning sign
of stroke; most frequently mentioned was numbness/weak-
ness (43%) followed by slurred speech (18%). 42% failed to
state ‘‘call 911’’ as the first thing they would do; 88% did not
know the treatments available for stroke. 87% were in-
terested in receiving stroke education; of these 38% pre-
ferred attending a lecture/workshop in their building, while
36% preferred reading a pamphlet. Level of education,
gender, and age had no significant correlation with knowl-
edge of stroke. Conclusions: In our urban community,
knowledge regarding acute stroke and the importance of
calling 911 is poor using a culturally sensitive instrument.
The community appears to be highly motivated to improve
its knowledge of stroke. Urban community-based education
may improve stroke outcomes by earlier presentations of
potential stroke patients to emergency departments.
203 Gender and Traumatic Brain Injury: Do the Sexes
Fare Differently? Jonathan J Ratcliff, Arlene
Greenspan, Felicia C Goldstein, David W Wright, Anthony
Y Stringer, Kathleen Bell, Tamara Bushnik, Jeffrey Englander,
Flora Hammond, Thomas Novack, John Whyte; Emory
University: Atlanta, GA, Santa Clara Valley Medical
Center: San Jose, CA, University of Washington:
Seattle, WA, Moss Rehabilitation Research Institute:
Philadelphia, PA, University of Alabama at Birmingham:
Birmingham, AL, Charlotte Institute of Rehabilitation:
Charlotte, NC
Objective: To examine the relationship between gender and
cognitive recovery 1 year following traumatic brain injury
(TBI). Methods: Patients with blunt TBI were identified from
the TBI Model Systems National Database, a longitudinal,
multicenter cohort study. The included patients (n ¼ 325)
were 16–45yrs at injury, admitted to an acute care facility
within 24 hours, received inpatient rehabilitation, had
documented admission Glasgow Coma Scale (GCS) scores,
completed neuropsychological follow-up 1 year post-injury,
and did not have a premorbid history of learning problems.
Multivariate analyses of variance examined the unadjusted
association between gender, and 6 cognitive domains
491
examining attention/working memory, verbal memory,
language, visual analytic skills, problem solving, and motor
functioning. Analyses of covariance models were constructed
to determine if confounding factors biased the observed
associations. Results: Females represented 31% of the cohort.
Sixty-three percent of patients sustained severe TBI (GCS 3–
8), 17% moderate TBI (GCS 9–12), and 20% mild TBI (GCS 13–
15). Females performed significantly better (p \ 0.05) than
males on tests of attention/working memory (Trailmaking B,
Symbol Digit Modalities written and oral versions), verbal
memory (Rey Auditory Verbal Learning), and language
(Controlled Oral Word Association). Gender remained
significantly associated with performance, except Trailmak-
ing B, when controlling for age, race, education, and severity
of injury. Conclusions: These results suggest a better cogni-
tive recovery of females than males following TBI. The
findings do not appear attributable to preinjury differences,
since males did not perform better in areas in which they
typically outperform females (i.e. visual analytic skills).
However, future studies need to include non-TBI patients to
control for possible preinjury gender-related differences, as
well as to conduct extended follow-ups to determine whether
the observed differences persist.
204 Common Misconceptions in the Evaluation of
Emergency Department Dizzy Patients Parallel
Those Found in Emergency Medicine Texts David Edward
Newman-Toker; The Johns Hopkins Hospital: Baltimore, MD
Objectives: We asked if misconceptions about bedside
evaluation of dizzy patients in the ED were common, and,
if so, whether Emergency Medicine [EM] textbooks were
sources of misinformation. Methods: We quizzed 28 physi-
cians attending a dizziness lecture at two university hospitals
(including 14 ED and 14 primary care physicians [PCPs])
using 10 true–false questions about evaluating dizzy patients.
In an unmasked, retrospective, anonymous survey study, we
calculated the percent correct responses for individuals and
for each question across individuals, which we then
compared to 50% (for guessing alone) using a binomial exact
statistic. Qualitative comparisons were made to textbook
findings. Results: Among 14 ED physicians, the mean
individual score was 31% (range 0–60%). The same results
were found among the 14 PCPs (mean score 29%, range 0–
70%). Across both groups, 6 of 10 questions were answered
correctly at rates below that expected by guessing (8–26%, p ¼
0.00002–0.02), implying misconceptions, rather than lack of
knowledge. We identified three misconceptions thought to
distinguish a benign (e.g. labyrinthitis) from serious (e.g.
stroke) cause of dizziness: (1) dizziness worsened by head
movement is benign, (2) direction-changing nystagmus (right
in right gaze and left in left gaze) is benign, and (3) vertigo
lasting 5–10 minutes is benign positional vertigo. Similar
misconceptions were identified in EM texts. Conclusions:
Our results indicate that misconceptions in the bedside
approach to dizzy patients may be commonplace, and
perhaps derive from published misinformation in EM texts.
Such misconceptions could increase the risk of misdiagnosis
and reduce patient safety. Limitations include the small and
potentially-biased sample, retrospective design, and lack of
instrument validation. Despite these limitations, the strength
of the associations, consistency across disparate groups, and
492
concordance between survey responses and textbook find-
ings provide strong support for our conclusions.
205 Perception of Stroke Acuity in US Emergency
Departments David W Wright, Stephen R Pitts,
Jonathan J Ratcliff, Manish M Patel; Emory University:
Atlanta, GA
Introduction: Stroke is the third leading cause of death in the
United States. Rapid assessment and treatment are known to
decrease mortality and morbidity. Several investigators have
identified areas where delays occur in an attempt to shorten
the interval between the time of onset and treatment (public
recognition of stroke, prehospital transport, time to physician,
time to CT, and time to neurological consultation). Objective:
To compare the perception of urgency for stroke-like sym-
ptoms (CVA sx) with symptoms suggesting an acute coronary
syndrome (ACS sx). Methods: We performed a secondary
analysis of the 1997–2000 National Hospital Ambulatory
Medical Care Survey, a probability sample of US emergency
department (ED) visits. Subjects under the age of 15 years,
were excluded. Adjusted analyses accounted for age, sex,
race, ethnicity, payment type, and time of day. Results: The
sensitivity of the complaint categories for a final ED diagnosis
of ACS or CVA was 84% and 49%, respectively. These com-
plaint categories were confirmed by a final ED diagnosis of
ACS or CVA 8.8% and 3.7% of the time, respectively. Twenty-
nine percent of patients with ACS sx and 18% of patients with
CVA sx arrived by ambulance (p \ 0.0001), adjusted odds
ratio 1.1 (95% CI 1.0 to 1.2). Forty-one percent of patients with
ACS sx and 19% of patients with CVA sx were assigned the
highest triage category (p \ 0.001), adjusted odds ratio 2.7
(95% CI 2.4 to 3.2). Conclusion: Patients arriving at the ED
with ACS sx are triaged as more urgent than those with CVA
sx. The perception that stroke is not as urgent as ACS may
contribute to delays in care of acute stroke patients.
206 Oral vs Intravenous Phenytoin Loading David E
Manthey, Chris Barnes; Wake Forest University Baptist Medical
Center: Winston-Salem, NC
Objectives: ED seizure management includes ‘‘loading’’
patients with phenytoin to quickly achieve therapeutic levels
with proponents of both the intravenous (IV) and oral (PO)
routes. The objective was to determine the number of
recurrent seizures, side effects and duration of stay associated
with each loading technique. Methods: A prospective,
randomized, double-blind, placebo controlled interventional
trial was carried out in a university tertiary care ED with
57,500 visits annually. Patients requiring a phenytoin load for
new onset seizures or a known seizure disorder with a level
less than 6 mcg/ml were enrolled consecutively over one
year. Exclusion criteria included status epilepticus, alcohol
withdrawal seizures, use of other seizure medications,
admission, age under 18, phenytoin allergy, pregnancy, and
post-ictal period beyond 90 minutes. All subjects received 18
mg/kg of phenytoin. IV phenytoin was administered at 40
mg/min. PO loading was dosed at 400 mg every three hours.
All patients received a PO or IV placebo. The primary
outcome was seizure recurrence within 72 hours. Secondary
outcomes included hypotension, sedation, dysrhythmias,
2003 SAEM ANNUAL MEETING ABSTRACTS
nystagmus, pain at IV site and ataxia. Data was collected by
direct observation and phone follow-up. IRB approval and
informed consent were obtained. Results: A total of 31
patients were enrolled (IV: 15, PO: 16). Four patients (IV: 3, PO:
1) were lost to follow-up. One IVarm patient (8%) and two PO
arm patients (13%) had recurrent seizures (p ¼ .43). There
were no significant differences in individual side effects of
hypotension, dysrhythmia, sedation, nystagmus, and ataxia.
The difference in IV site pain was significant with 33% IV vs
0% PO (p ¼ .03). Patients taking PO loading doses could have
been discharged an average of 2 hours earlier (p \ .0001).
Conclusion: Although small, this study suggests no differ-
ence in efficacy or side effects between the two therapies.
Further study with a larger patient group is warranted.
207 Interrater Reliability of Emergency Department
Glasgow Coma Scale Scores David G Reiley, Michelle
Gill, Steven M Green; Loma Linda University School of
Medicine: Loma Linda, CA
Objectives: Although the Glasgow Coma Scale (GCS) is
often used in the emergency department (ED) to quantify
neurological impairment, the precision of this scoring system
in the ED setting remains unknown and untested. The goal
of this study was to determine the interrater reliability
between attending physicians of GCS score assessments in
adults with altered levels of consciousness (ALOC). Meth-
ods: In this prospective observational study at a university
Level 1 trauma center, we enrolled a convenience sample of
ED patients over age 17 years with ALOC. Each patient had
two observers independently assess and record GCS scores
(including components) within a 5 minute time period. All
assessments were performed by board-certified or board-
prepared emergency physicians and/or board-certified
trauma surgeons. Data were analyzed using scatterplots
and Spearman correlations for each total GCS score as well as
each GCS component (Eye, Verbal, and Motor). Results:
Sixty-four patients were enrolled (23 female and 41 male)
having a mean age of 50 years. We found a strong correlation
for both the total GCS (Spearman rho 0.890, p \ 0.0001) and
for its components (eye rho ¼ 0.775; verbal rho ¼ 0.641;
motor rho ¼ 0.836, all p \ 0.0001). 39% of paired GCS
measures were identical, 73% were #1 point of each other,
86% were #2 points of each other, and 94% were #3 points of
each other. Conclusion: We found very good interrater
reliability for GCS assessments of ED patients with ALOC,
supporting its role as an appropriate ED tool. Motor as-
sessment is the most precise part of the GCS score.
208 A Randomized, Prospective, Cross-over Study to
Determine if There Is a Difference in Opening
Pressure in Cerebrospinal Fluid in Patients Placed in
a Flexed Lateral Recumbent vs Upright Sitting Position
during Lumbar Puncture M Andrew Levitt, Gurjeet S
Mahal, Claudine Dutaret; Alameda County Medical Center:
Oakland, CA
Objective: It is recommended that lumbar punctures (LP’s)
be obtained in the lateral recumbent position(LRP) to obtain
accurate opening pressures. This is based on a hypothetical
concern that the flexed sitting position (FSP) will give a falsely
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
elevated pressure. Many health care providers have found
the FSP to be easier to obtain a successful LP. This present
study determines if there is a difference in opening pressures
between the two positions. If a difference is found then
determine if it is of clinical significance and calculate an
adjustment equation so that the sitting pressure could be
converted to the recumbent pressure, if desired. Methods:
Design: Prospective, randomized (as to which pressure is
obtained first), crossover study. Setting: County hospital ED
and neurology clinic. Participants: Twenty-three patients
receiving a lumbar puncture with each patient receiving
pressures in both positions. Results: Mean age 43.2 6 20
years. Gender distribution was 50% male. Three patients
were not included in analysis for protocol violations—with
two, the randomized starting position was LRP and a
successful LP could only be obtained in the FSP. Reasons
for LP included suspected meningitis 9, SAH 1, other 8, and
known pseudotumor cerebri 2. FSP opening pressures
ranged from 16–53, mean 32.6 6 11 cm. H2O. LRP opening
pressures ranged from 11–44, mean 23.0 6 9.9 cm H2O. Mean
difference between FSP and LRP was 9.6, 95% CI 19.8–0.6 cm
H2O. A linear regression analysis determined a conversion
formula between the two positions to be LRP cm H2O ¼ 0.7
FSP cm H2O-0.8. Based on apriori criteria no clinically
significant difference was found between pressures in any of
the patients. Conclusion: Higher opening pressures are seen
in the FSP compared to the LRP. However,the difference was
not found to be of clinical significance and a conversion
formula is developed to allow the FSP to be used and the
pressure obtained to be converted to LRP.
209 Inappropriate Medication Use in Older Emergency
Department Patients: Results of a National
Probability Sample Scott T Wilber, Michelle Blanda;
Summa Health Systems/NEOUCOM: Akron, OH
Background: Explicit criteria for potentially inappropriate
medication use in older patients have been defined. Use of
these medications may result in adverse outcomes and
worse health related quality of life. Objective: To describe
national estimates and risk factors for emergency depart-
ment (ED) prescription of inappropriate medications in
patients $65 years. Methods: We analyzed National
Hospital Ambulatory Medical Care Survey ED data for
2000. Inappropriate medications were defined using the 1997
Beers’ criteria. Dose dependent medications, promethazine,
and barbiturates were not included, as the database did not
include dose or route of administration. Stata software was
used to produce national estimates, using sampling weight
and primary sampling unit variables. Odds ratios for risk
factors were derived from logistic regression. Odds ratios
whose 95% confidence interval (CI) did not include 1 were
significant. Results: Patients $65 years made an estimated
16,232,235 ED visits in 2000 (95% CI 11–22 million, 15% of all
visits). Inappropriate medications were prescribed in 10.3%
(1.7 million) visits. The majority (88%) involved a single
medication, 11% involved 2 and 0.8% 3 medications. The
most common category of inappropriate medications was
analgesics (6.4% of visits), followed by antihistamines
(2.7%). Benzodiazepines (0.7%), muscle relaxants (0.5%),
and GI antispasmodics (0.5%) were uncommonly pre-
scribed. The most common inappropriate medications were
493
meperidine (3.8% of visits), propoxyphene (2.6%), diphen-
hydramine (1.2%), and hydroxyzine (1.5%). Risk factors for
inappropriate medications were pain (OR 2.3, 95% CI 1.5–
3.6) and discharge from the ED (OR 1.9, 95% CI 1.2–3.0).
Presence of injury, age, sex, race, and ethnicity were not
significantly associated with inappropriate medication pre-
scription, nor was being seen by a resident or physician
extender. Conclusion: Despite explicit criteria, older patients
continue to be prescribed potentially inappropriate medica-
tions in the ED.
210 Emergency Department Physician Initiated Elder
Screen (PIES) for Health and Social Services: A Pilot
Study Michelle Blanda, Lowell W Gerson, David J Peter;
Summa Health System: Akron, OH, Northeastern Ohio
Universities College of Medicine: Rootstown, OH, Akron
General Medical Center: Akron, OH
Introduction: Emergency visits may be a sentinel event for
elders at risk for functional decline. Emergency physicians
(EPs) obtain biopsychosocial facts important to identify
elders but may not transfer them to an appropriate agency.
Objective: To describe the feasibility of completing a Physi-
cian Initiated Elder Screen (PIES) and the rate of referral to
agencies. Methods: Design: Prospective observational study
conducted for 4 weeks in 9/02. Setting: Community teaching
hospital ED (census 65,000/yr) Subjects: All 53 emergency
resident and attending EPs. Intervention: EPs completed
a 10-item PIES form on patients $65 yrs of age, discharged to
home. Items included questions shown to predict institutio-
nalization, repeat ED visits and hospitalization. EPs con-
tacted the social worker (SW) about screens with at least one
risk. The patient was contacted by phone for follow-up and
assessment. Statistics: We present percentages and 95%CIs.
Results: EPs screened 224/676 (33.1%, 95%CI, 29.6–36.8)
patients. 18 were admitted and 21 discharged to a nursing
home leaving 185/637 (29.4%, 95%CI, 25.5–32.7) screens
correctly completed. High risk factors for SW included 20/
184 (11%) needing more help, frequent ED visits 19/179
(11%), falls 15/184 (8%) and cognitive impairment 12/184
(7%). There were also 78/184 (42%) patients with 5 or more
medications and 23/183 (13%) with underlying disease. The
SW received 32 positive screens from MDs. Of these 14/32
(43.7%) were unable to be contacted, 6/32 (18%) already had
services, 5/32 (16%) felt no services were needed, 3/32 (9%)
had family support and 2/32 (6%) were readmitted to the
hospital prior to the day of contact. 2/32 (6.3%, 95%CI 9.7–
20.8) were given new services. EPs contacted the SW about 12
other eligible patients for whom no form was completed. Of
these, 2 had services, 6 were unable to be contacted and 4 felt
they had no need. Conclusion: Physician screening can be
done but does not result in large numbers of patients
referred for services.
211 Administration of Inappropriate Medications to
Elderly Emergency Department Patients: Results of
a National Survey Jeffrey M Caterino; Allegheny General
Hospital: Pittsburgh, PA
Objectives: To determine the frequency of administration of
inappropriate medications to elderly ED patients using
494
a database comprising a national probability sample survey
of ED visits and to identify the inappropriate medications
most commonly prescribed. Methods: A retrospective
observational cohort study was conducted using informa-
tion from the 2000 National Hospital Ambulatory Medical
Care Survey. The study population included all ED entries
with age greater than 64. Potentially inappropriate medica-
tions for the elderly were identified using the criteria
proposed by Beers in 1997. Data was analyzed using
descriptive statistics. Results: The cohort of elderly patients
represented 16,232,235 visits out of 108,016,777 ED visits for
the year 2000. A total of 1,211,611 or 7.5% of elderly patients
received an inappropriate medication in the ED (95%CI 7.49,
7.51). Patients receiving an inappropriate medication did
not differ from other elderly in race, sex, or rate of ad-
mission. Inappropriately medicated elderly patients re-
ceived an average of 3.4 drugs (95%CI 3.2, 3.6) versus 2.0
(95%CI 1.9, 2.0) in the entire elderly cohort. Inappropriate
medications most commonly prescribed were meperidine (n
¼ 609,054 administrations), diphenhydramine (n ¼ 185,275),
diazepam (n ¼ 110,602), and cyclobenzaprine (n ¼ 66,169).
Other inappropriate medications included amitriptyline,
methyldopa, propranolol, indomethacin, propoxyphene,
dipyridamole, methacarbamol, doxepin, oxybutynin, zolpi-
dem, and temazepam. Conclusions: Elderly ED patients
receive inappropriate medications at a high rate (7.5%).
Efforts at identifying reasons for inappropriate medication
use and means of correction should be undertaken. De-
creasing use of a select number of inappropriate drugs could
significantly decrease the exposure of the elderly to po-
tentially harmful medications.
212 The Effect of a Short Depression Screen on the
Care of Older Emergency Department Patients
Fredric M Hustey, Stephen W Meldon, Robert M Palmer; The
Cleveland Clinic Foundation: Cleveland, OH, MetroHealth
Medical Center: Cleveland, OH
Objectives: 1) Determine the effect of a short depression
screen on the care of older emergency department (ED)
patients. 2) Determine the prevalence of depression in older
ED patients. 3) Assess recognition of depression by ED
physicians (EPs). Methods: Design: Prospective, interven-
tional study. Participants: Convenience sampling of 269
patients 70 years or older presenting to an urban teaching
hospital ED over a 16-month period. Exclusions: refusal;
communication difficulty; critical illness. Patient screening:
Eligible patients were screened for depression using the
short form geriatric depression scale (SFGDS). The stan-
dardized cutoff score for the detection of depression was
used. Patients were also screened for alcoholism using the
standardized CAGE questionnaire. Emergency physicians
(EPs) were interviewed to assess recognition of depression,
patient disposition, and referrals while blinded to survey
results. Results of surveys were then given to EPs, and they
were re-interviewed regarding any change in care. Propor-
tions and 95% confidence intervals (CI) are reported.
Results: 269/327 eligible patients were enrolled. 44 (16%;
95%CI, 12–21%) scored positive for depression. Of these 44,
8 (18%; 95%CI, 8–33%) had a past history of depression, 7
(16%; 95%CI, 7–30%) had a history of dementia, and 4 (9%;
95%CI, 3–22%) screened positive for alcohol abuse. 15/44
2003 SAEM ANNUAL MEETING ABSTRACTS
(34%; 95%CI, 21–50%) were recognized as having depres-
sion by the treating EP. EPs altered management in 0/269
(0%; 95%CI, 0–1.4%) patients after presentation of SFGDS
results. No patient was given referrals or discharge in-
structions specifically to address depression. Conclusions:
Depression is highly prevalent and poorly recognized in
older ED patients. Use of the SFGDS did not alter the care of
older patients with depression. Further education of EPs
may be needed to improve care in this area.
213 The Pharmacokinetics of a Hemoglobin-based
Oxygen Carrier, HBOC 201, Does Not Change during
Second Trimester Pregnancy L Bruce Pearce, Virginia T
Rentko, Paula F Moon-Massat, Maria S Gawryl; Biopure
Corporation: Cambridge, MA
Objectives: Hemoglobin based oxygen carriers (HBOC),
like HBOC-201, have a high potential for use in the
management of hypovolemia and anemia associated with
both preterm and term blood loss during pregnancy.
Current observations indicate that the pharmacokinetics of
HBOC-201 (Biopure, Cambridge, MA) in the dog may
predict its behavior in man (Pearce et al, SAEM 2003
abstract). Accordingly, this study investigated the effect of
pregnancy on pharmacokinetics of HBOC-201. Methods:
Twelve pregnant beagle dogs (8.6 to 10.8 kg), divided into
two equal groups, received a 6 mL/kg/h toploading
infusion of 6 g/kg HBOC-201 (0.13 6 0.01 g/mL hemoglo-
bin (Hb)) on gestational day 25 or 33 (term ¼ 61 days). Blood
samples were collected immediately post-dosing and at 1, 4,
16, 24, 36, 48, 60, 72, 84, 96, 144, and 192 hours following the
infusion. Noncompartmental pharmacokinetic analysis was
performed (WinNonlin8 Version 3.1) on these data and these
results were compared to data from nonpregnant dogs that
received either 5.5 g/kg or 6.0 g/kg HBOC-201 in previous
studies. Results: The pharmacokinetics of total plasma Hb
was consistent with a first order mechanism and was
equivalent for both gestational ages. Furthermore, half-life
(t1/2), volume of distribution (Vss) and clearance (Cl) were
similar to earlier non-pregnant studies (Table).
HBOC Pregnant t1/2 Vss Cl
(g/kg) (Y/N) (hr) (mL/kg) (mL/kg/hr)
6.0 Y, Day 25 53.3 6 9.81 85.5 6 10.5 1.26 6 0.33
6.0 Y, Day 33 53.9 6 5.7 82.8 6 4.9 1.51 6 0.11
5.5 N 43.1 6 11.1 87.5 6 11.0 1.46 6 0.22
6.0 N 52.2 6 8.3 118.2 6 19.0 1.58 6 0.30
Conclusions: Infusion of 6 g/kg HBOC-201 to pregnant
dogs during embyrogenesis did not show evidence of
a significant effect of pregnancy on the plasma elimination
kinetics of HBOC-201. These data suggest that adjustments
in dosing of HBOC-201 may not be required during
pregnancy.
214 The Shock Index in Early Acute
Hypovolemia Robert H Birkhahn, Theodore J Gaeta,
John Tloczkowski, Douglas Terry, Joseph J Bove; New York
Methodist Hospital: Brooklyn, NY
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Background: The shock index (SI) is a simple calculation
composed of the heart rate (HR) divided by the systolic
blood pressure (SBP). Although the SI is elevated in
hemorrhage secondary to GI bleeding and trauma, the
utility of the SI in early hemorrhage is not known.
Objective: To determine the hemodynamic response and
calculated SI in early acute blood loss. Methods: A
prospective observational study that enrolled healthy blood
donors. Patients were excluded for weight \110lbs, fever,
hematocrit \12g/dL, age \17 years, or active medical
problems precluding blood donation. Baseline vital signs
were obtained pre-donation, 450 mL of blood was removed
over 20 minutes, and the vital signs were repeated
immediately post-donation lying, after 1 minute and 5
minutes of standing. The SI was calculated for each interval,
and means reported with 95% confidence intervals for each
measurement. Difference was tested using a paired t test
with p \ 0.01 set for significance (Bonferroni). Results: A
total of 46 patients were enrolled, means for each time
interval are shown below with 95% confidence intervals.
Conclusions: A significant elevation in mean SI was
observed in healthy volunteers after standing for 1 and 5
minutes after controlled blood loss of only 450 mL.
Although significant changes in HR and SBP were observed,
these indices were still within ‘‘normal’’ limits (\100bpm
for HR or [100mmHg for SBP), whereas the SI mean was
outside the previously established normal range of 0.5 to
0.7. The SI may be more useful in early acute hypovolemia
than either the HR or SBP alone.
HR (bpm) SBP (mmHg) DBP (mmHg)
Before
Donation
(0.58,0.64) 74 (71,77) 123 (118,127) 77 (75,80)
After (lying)
(0.61,0.70)* 74 (71,78) 117 (112,122)* 76 (73,78)
After (Standing
1 min)
(0.71,0.82)* 85 (80,90)* 114 (109,118)* 77 (74,80)
After (Standing
5 min)
(0.70,0.80)* 83 (79,88)* 114 (108,119)* 76 (73,79)
*represents p \ 0.01
215 Needle Thoracostomy in Trauma Patients: What
Catheter Length Is Adequate? Jonathon L Marinaro,
Charles V Kenny, S Rhett Smith, Scott D Valadez, Cameron S
Crandall, Carol R Schermer; University of New Mexico:
Albuquerque, NM
Objectives: Needle thoracostomy is performed in unstable
trauma patients to decompress a suspected tension pneu-
mothorax. The current ATLS manual recommends use of a 2
inch (5 cm) long catheter to perform this procedure. Our
hypothesis is that a 5 cm catheter may not decompress
a tension pneumothorax in many trauma patients. We report
the frequency of patients encountered at our institution that
we suspect would not receive adequate pleural decompres-
sion with the use of the recommended catheter length.
Methods: We retrospectively evaluated chest wall thickness
in a random sample of 30 adult male trauma patients who
had a chest CT scan as part of their initial trauma evaluation
495
at our Level 1 Trauma Center from January 2000 to April
2002. The chest depth was measured in centimeters at the
second intercostal space in the midclavicular line from the
skin to internal pleural border, perpendicular to the
horizontal axis in each patient. After training in measure-
ment technique, three radiologists, blinded to each others’
observations, independently measured the chest wall
thickness. A multi-rater kappa statistic measured agree-
ment. Results: The mean chest wall thickness was 4.6 6 0.2
cm. Ten of thirty (33%, 95% confidence interval (CI): 17.9%–
52.9%) patients had a chest wall thickness exceeding 5
centimeters. Three of 30 (10%, 95% CI: 2.6%–27.7%) had
a chest wall thickness that exceeding 6 cm. Kappa statistic
for the three raters was 0.34 (95% CI: 0.13, 0.55). Conclu-
sions: This small study demonstrates that one-third of
trauma patients admitted to our facility have a chest wall
thickness greater than 5 centimeters. The standard catheter
may not provide effective pleural decompression in these
patients. If the recommended catheter length were increased
to 6 cm 90% would have successful chest wall penetration. If
clinical improvement does not occur following initial
attempt at pleural decompression with a standard catheter,
a longer catheter should be considered.
216 Mortality and Functional Outcome in Pediatric
Trauma Patients with and without Head
Injuries Christine Pavlovitch, Stephen M DiRusso, Donald
Risucci, Thomas Sullivan, Peter Nealon, Michel Slim; New York
Medical College/Westchester Medical Center: Valhalla, NY
SI Objective: To determine the impact of traumatic head injury
(THI) on pediatric patients in the U.S. using a national
trauma database by assessing mortality rates and functional
0.61 outcome at hospital discharge. Methods: Data consisted of
the National Pediatric Trauma Registry Phase III. Patients
0.65 were categorized into those with or without head injuries
based on ICD9 diagnosis codes. Death, functional outcome,
extended care and ICU days were compared. Injury severity
0.76
was assessed using the New Injury Severity Score (NISS),
Relative Head Injury Severity Scale (RHISS) and GCS. Data
0.75
were analyzed by the chi-square test, Mann-Whitney U Test
and the T-Test. A p \ 0.05 was considered significant.
Results: There were 15,005 patients with head injuries and
20,380 patients without head injury. There were 1047 deaths
with an overall mortality rate of 6.0% in the head injury
group compared to 0.7% in the non-head injury group (risk
ratio 9.1, 95% CI 7.6–10.8). 86% of the deaths had a head
injury. THI was listed as the primary cause of death in 74%
of the non-survivors. The average NISS was also signifi-
cantly increased in the head injury group (6.54 vs 15.33). The
presence of head injury did not increase the chance a child
might require ICU. However, those in the ICU with a head
injury had a significantly longer stay there (1.85 days vs 0.47
days). Functional outcome at discharge was assessed in
three fields; speech, feeding and walking. Speech and
feeding difficulties were associated with increasingly severe
head injury whereas walking was not. The number of
patients discharged to extended care was also significantly
increased in the head injury group (7.8% vs 1.8%).
Conclusion: Head injury in a pediatric trauma patient
significantly increases mortality, is associated with worse
functional outcome at discharge and increased need for
496
extended care. It is unlikely for a child to die of trauma
without a THI. Therefore, prevention of head injury is of
paramount importance in this age group.
217 Early Damage to the Articular Cartilage Matrix
Occurs Following Traumatic Knee Injuries without
Fracture Gregory D Jay, Khaled A Elsaid, Clinton
O Chichester; Brown University School of Medicine:
Providence, RI, University of Rhode Island: Kingston, RI
Background: Osteoarthritis (OA) is characterized by the loss
of articular cartilage (AC). Previous studies have shown that
matrix metalloproteinases and possibly joint trauma play
a significant role in this degradation. Objective: Do ED
patients undergoing diagnostic knee joint arthrocentesis
following joint trauma evidence degradation of AC?
Methods: Retrospective laboratory analysis of synovial
aspirates from ED patients complaining of joint trauma. No
patients were diagnosed with fracture and injury ranged from
1 to 14 days in age. Synovial fluid from patients with OA
formed a comparison group. Normal synovial fluid (NSF)
was obtained intra-operatively from patients donating AC for
transplantation. Synovial fluid was assayed by sandwich
ELISA using two novel monoclonal antibodies (mAb’s):
18:6:D6 and 14:7:D8 against collagen type II (CII) peptide.
Sulfated glycoaminoglycans were assayed by the DMMB
binding assay and inhibition ELISA using mAb 5-D-4. Total
protein levels were quantified by BCA assay. Results: CII
peptides from ED patients (N ¼ 57) with synovial effusions
showed a wide range of concentrations between 0.068–3.37
mg/ml, 95%CI (0.860–1.204 mg/ml). The OA aspirates (N ¼
122) had a 95%CI (0.119–0.149 mg/ml) which were signifi-
cantly lower (t ¼ 7.66, P \ 0.001). CII peptide concentrations
normalized to total protein levels continued to demonstrate
these differences. CII peptide levels were undetectable in
NSF. The reverse was true for 5-D-4 epitope levels which were
significantly higher in SF from OA patients, indicating the
enzymatic degradation of proteoglycans is more pronounced
in OA. Conclusion: Collagen type II, the major collagen of the
extra-cellular network in AC, is released following traumatic
knee injuries. The release of CII peptides following such
injuries may constitute the predisposing factor in develop-
ment of post-traumatic OA. The selected epitopes confirm
that the articular damage is confined to the superficial layer,
as opposed to the deeper zones, as in OA.
218 Emergency Department Opioid Analgesia in Trauma
Patients Is Less Common in the More Severely
Injured Martha L Neighbor, Samantha Honner, Michael A
Kohn; San Francisco General Hospital: San Francisco, CA,
University of California, San Francisco: San Francisco, CA
Background: Many ED physicians hesitate to use opioids in
trauma patients for fear of lowering blood pressure, altering
sensorium, and masking the physical exam. Objective: To
identify factors associated with ED opioid administration to
trauma patients. Methods: Design–retrospective, cohort
study (record review). Setting–Urban, Level 1 trauma center.
Subjects–trauma patients (1/1–12/31/99) whose prehospital
findings prompted a high-level trauma team activation and
2003 SAEM ANNUAL MEETING ABSTRACTS
who were ultimately hospitalized. Predictors–Age, sex, race,
mechanism of injury, vital signs, oxygen saturation, Glas-
gow Coma Score (GCS), revised trauma score (RTS), and
procedures. Outcome–opioid administration within 3 hours
of ED arrival. Patients who only received opioids within 10
min. of procedures were excluded. Analysis – Univariate
and multivariate analysis with opioid administration as the
dichotomous outcome. Results: Abstracted data on 540
trauma patients were included in the analysis. 258 (48%)
received IV opioids. On univariate analysis, patients were
significantly more likely to receive opioids if they had
a fracture manipulation, a higher GCS, were not intubated,
had a higher RTS, were burned, or were in a motorcycle
crash. Selected multivariate odds ratios for opioid analgesia
are shown below:
Factor Odds Ratio 95% CI
Fx/Manipulation 16.37 4.40 60.93
Intubated 0.40 0.28 0.78
RTS (incorporates GCS) 1.55 1.22 1.97
Burn 3.26 0.88 12.03
Motorcycle crash 4.16 0.71 24.56
Assault/Brawl 0.48 0.13 1.79
Conclusion: Too few injured patients receive opioid
analgesia. Patients with obvious injuries such as burns or
fractures are more likely to receive opioids. More seriously
injured patients, particularly intubated patients or those
with altered mentation, are less likely to receive opioid
analgesia.
219 Are Mortality Rates for Teens with Severe
Penetrating Trauma Lower at Adult Trauma
Centers? Wayne A Satz, Jacob W Ufberg, Lewis J Kaplan;
Temple University Hospital: Philadelphia, PA, Yale University
Hospital: New Haven, CT
Objectives: Adult trauma centers care for a greater number
of patients with penetrating trauma than pediatric trauma
centers. Patients 13 to 18 years of age are physiologically
similar to young adults. We hypothesized that 13 to 18 year-
olds with severe penetrating trauma would have lower
mortality rates when they present to adult level I trauma
centers (LI) or adult level I trauma centers with advanced
pediatric qualifications (LIAQ) than those presenting to
pediatric level I trauma centers (PEDI). Methods: A re-
trospective review of a Pennsylvania state-wide trauma
foundation database consisting of 26 collected variables was
performed for the years 1988–1998. All patients aged 13 to
18 years old with penetrating trauma and an injury severity
score (ISS) greater than 24 were included. Mortality rates
were compared for combined LI and LIAQ versus PEDI.
Logistic regression for death was performed using age and
the log of the ISS (LISS) as covariates. Results: Over 10
years, 501 patients with penetrating trauma and ISS [ 24
presented to LI/LIAQ and 32 to PEDI. Mortality was
significantly higher (52% vs 20%, p \ 0.01) among patients
presenting to LI and LIAQ as compared to PEDI. Patients
presenting to PEDI were significantly younger (mean age 14
vs 16, p \ 0.001) and had similar ISS (32 vs 36, p ¼ 0.31)
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
when compared to those presenting to LI/LIAQ. After
controlling for age and LISS, mortality rates remained
significantly higher among patients presenting to LI/LIAQ
(Odds Ratio 4.8, 95% CI 1.9 to 12.5). Conclusions: In a single
state study, children aged 13 to 18 years with severe
penetrating trauma had approximately five-times greater
odds of mortality when they presented to adult level I
trauma centers and adult level I trauma centers with
advanced pediatric qualifications as compared to pediatric
level I trauma centers. Further investigation is necessary to
determine the reasons for this difference.
220 The Incidence of False Negative Initial Cervical
Spine Radiographs for Patients Admitted to a
Level-I Trauma Center Amar Singh, Robert E O’Connor,
Susan Mascioli, Glen H Tinkoff; Christiana Care Health
System: Newark, DE
Introduction: To determine the incidence of falsely negative
initial cervical spine (C-spine) radiographs for patients
admitted to a Level-I trauma center. Methods: This study
was conducted from January 1997 to June 2001 at a hospital
with approximately 2000 (85% blunt) annual trauma service
admissions. Patients with a discharge diagnosis of C-spine
fracture or dislocation were eligible for enrollment. All
patients had plain films and CT scans. Data was collected
on the radiologist’s initial plain radiograph and CT scan
interpretations, and whether operative intervention was
performed. Patients were excluded from the study if final
radiological or discharge dictation were not documented.
Plain films were considered positive if fracture, facet
dislocation, soft tissue swelling or other abnormality was
noted that would have triggered the physician to order a
C-spine CT. Films were considered negative in interpreted
as normal. Statistical analysis was performed using the
McNemar test and by determining 95% confidence inter-
vals. Results: A total of 373 C-spine fractures or dislocations
were identified from the trauma registry. Thirty-seven were
excluded due to inadequate charting, death, or transfer from
another hospital. Of the remaining 336 patients, 51
(15.2%) (CI 14.9%, 15.5%) had negative plain films and
required cervical CT scan for diagnosis. No patients with
abnormal CT had normal plain films. The remaining 285
patients had abnormalities on both plain film and CT. The
difference in diagnostic performance of the two tests is
significant. (p # 0.001) Of the 51 with abnormal CT, but
normal plain film, 11 (22%) required operative intervention
for spinal stabilization. Conclusion: Plain radiography fails
to reveal C-spine fracture or dislocation in approximately
15% of patients with proven injury. C-spine injury cannot be
excluded by plain film in a substantial number of patients.
Physicians should consider ordering C-spine CTs on
patients unable to be cleared by other means.
221 Performance of the Pediatric Glasgow Coma Scale in
Pediatric Head Trauma Michael J Palchak, James F
Holmes, Thomas I MacFarlane, Nathan Kuppermann;
UC Davis School of Medicine: Davis, CA
Objective: To compare the pediatric Glasgow Coma Scale
(GCS) score applied to preverbal children with blunt head
497
trauma with the standard GCS applied to older children as
a predictor of traumatic brain injury (TBI) on cranial CT and
TBI in need of acute therapy. Methods: We prospectively
enrolled children with blunt head trauma. Patients were
divided into two cohorts (children #2 and [2 years). A
pediatric GCS score was applied to the younger cohort and
the standard GCS to the older cohort. Outcomes included: 1)
TBI on CT scan or 2) TBI in need of acute therapy (defined
as a neurosurgical procedure, hospitalization $2 nights,
anticonvulsant treatment for [7 days, or persistent neuro-
logical deficit). Receiver operating characteristic (ROC)
curves with 95% confidence intervals (CI) were used to
evaluate and compare the association between the GCS
scores and the outcomes of interest between the two cohorts.
Results: 2043 children with blunt head trauma were en-
rolled and 327 were #2 years. Among children #2 years,
15 (4.6%) had TBI on CT and 9 (2.8%) had TBI in need of
acute therapy. In children [2 years, 83 (4.8%) had TBI on CT
and 96 (5.6%) had TBI in need of acute therapy. For the
pediatric GCS in children #2 years, the area under the ROC
curve was 0.72 (95% CI 0.56, 0.87) for predicting TBI on CT
scan and 0.97 (95% CI 0.94, 0.99) for predicting TBI in need
of acute therapy. For the standard GCS in older children, the
area under the ROC curve was 0.82 (95% CI 0.76, 0.87) for
predicting TBI on CT scan and 0.87 (95% CI 0.83, 0.92) for
predicting TBI in need of acute therapy. Conclusion: The
pediatric Glasgow Coma Scale for children #2 years
compared favorably to the standard Glasgow Coma Scale
used for older children in the evaluation of blunt head
trauma. The pediatric GCS is a reliable tool for predicting
need for acute therapy in preverbal children with blunt
head trauma and performed significantly better than the
standard GCS applied to older children.
222 Serum Glutathione in Trauma Patients Imo P Aisiku,
I Marc Moss, George Cotsonis; Virgina Commonwealth
University/Medical College of Virginia (VCU/MCV):
Richmond, VA, Emory University: Atlanta, GA
Introduction: Glutathione has been implicated in the
pathogenesis of various disease states including sickle cell
anemia, acute lung injury, and chronic alcoholism. Trauma
patients are usually young and otherwise healthy. Severely
injured trauma patients are at an increased risk of sepsis and
acute lung injury. Acute alterations in serum glutathione in
trauma patients have not previously been reported. Objec-
tive: Serum glutathione concentrations are decreased
acutely in severely injured trauma patients. Methods: The
study design is a nested case control. Patients were selected
from Grady Memorial Hospital, which is a level I trauma
center. All cases were critically ill trauma patients with
an injury severity score (ISS) $16 and were mechanically
ventilated. The cases were patients who met the cohort’s
inclusion criteria and in whom consent for blood could be
obtained within 12 hours. Patients with a history of alcohol
abuse were excluded. Historical controls were utilized. All
controls were healthy individuals below the age of 50 with
no prior history of alcohol abuse. The outcome of interest
was serum glutathione. Data was analyzed using a Kruskal-
Wallis test. Results: 25 patients were selected. 4 were
excluded due to a history of alcohol abuse. Mean time from
injury to sample collection was less than 8 hours. Mean
498
serum glutathione in controls was 3.71 and 1.41 in cases
with a p value of \ .0001. Conclusion: Critically injured
trauma patients have a significantly decreased level of
serum glutathione within the first eight hours post trauma.
Future studies are needed to associate glutathione metab-
olism to various complications of trauma patients.
223 Clinical Scaphoid Fracture—Overtreatment of
a Common Injury? Robert J Stenstrom; St Paul’s
Hospital: Vancouver, British Columbia, Canada
Background: Clinical scaphoid fracture [CSF] (tender
scaphoid and negative x-rays [XR]) is commonly managed
with thumb spica cast and repeat imaging. This may be
unnecessary. Objectives: 1. Estimate the proportion of CSFs
that are true fractures 2. Identify risk factors for ‘‘poor
outcome’’ of scaphoid fracture (AVN, non-union, malu-
nion). 3. Identify side-effects of treatment of CSF. Methods:
A separate study was conducted for each objective. 1.
Cohort study. 186 consecutive patients, diagnosed with CSF
in the ED over 2 years were followed to establish the
proportion of true fractures. 2. Case-control study. 27 cases
of ‘‘poor outcome’’ of scaphoid fracture were identified from
operative records from 3 hospitals. 2 matched controls per
case were chosen randomly from 285 consecutive patients
diagnosed with clinical and true scaphoid fracture. Blind
assessment of records for the following variables was
conducted: age, gender, initial treatment, initial x-rays þ
or
, location of fracture, and imaging modality 3. A
telephone survey of 50 randomly selected patients with CSF
assessed satisfaction with and side effects of treatment, and
disability. Results: 1. 176/186 (94.6%) of patients initially
diagnosed with CSF had repeat imaging (XR, bone scan,
MRI or CT) 10–42 days after initial injury. 7/176 patients
(3.9%) had a true scaphoid fracture (95% CI 2.1–5.7%). Over
3 years of follow-up, no patient with CSF had a ‘‘poor
outcome’’ (95% CI 0–1.7%). 2. Conditional logistic regression
identified these risk factors for poor outcome: initial XR
positive (odds ratio [OR] infinite), age [60 years (OR 4.1,
95% CI 1.5–12.9), and initial treatment (non-operative) (OR
3.6, 95% CI 1.7–8.8). 3. 41/50 of CSF patients telephoned
were casted. 3/50 had returned to the ED for a tight cast. 1/
50 patients had true fracture. 465 days of work were missed
in casted patients. Conclusion: This common injury is over-
treated and there is significant morbidity associated with
treatment.
224 Wound Bursting Strength and Surface
Characteristics of New Tissue Adhesives Adam J
Singer, Tom Zimmerman, Jean Rooney, Catherine Silberstein,
Paul Cameau; State University of New York: Stony Brook, NY
Objective: The FDA has recently approved a butyl-cyano-
acrylate (Indermil) and a high viscosity (HV) octyl-cyano-
acrylate (HV Dermabond) for wound closure. We compared
the wound bursting strength (WBS), mode of adhesive
failure, and surface characteristics of these tissue adhesives.
Methods: Design—randomized, controlled, blinded exper-
iment. Setting—University based ED animal lab. Sub-
jects—15 Long Evans female rats weighing 250–350 grams.
Interventions—Standardized 2 cm full-thickness incisions
were made in duplicate on both sides of rats with #15
2003 SAEM ANNUAL MEETING ABSTRACTS
surgical blade and closed with tissue adhesives follow-
ing manufacturer instructions. One side was closed with
Indermil while the other side was closed with HV
Dermabond. The order of closure was randomized. Measur-
ements—WBS was measured after adhesive polymerization
in-vivo with a validated vacuum-controlled wound cham-
ber device (BT-2000) that measures the pressure required to
disrupt the closed wound. The method of adhesive failure
was classified as adhesive (splitting of the adhesive) or
cohesive (peeling of adhesive off skin). Wound specimens
were observed under light (Oil red O stain) and scanning
electron microscopy for adhesive surface characteristics.
Data analysis—comparisons were performed with paired
t- and chi-square tests. This study had 80% power to detect
a 75-mmHg between-group difference in WBS (two-tailed
alpha ¼ 0.05). Results: We evaluated 30 incisions in 15 rats.
The mean bursting strength of HV Dermabond (330 6 93
mmHg) was significantly higher than that of Indermil (218
6 93 mmHg); mean difference, 113 mmHg (95% CI 36–189,
P ¼ 0.007). The mode of failure for Indermil was primarily
adhesive (86%) while that of HV Dermabond was primarily
cohesive (86%, P \ 0.01). The surface of HV Dermabond
was thicker and more uniform than that of Indermil.
Conclusions: High viscosity Dermabond is stronger, thicker
and smoother than Indermil.
225 Burn Outcomes: Patient Priorities and Agreement
with Practitioner Assessments Adam J Singer,
Maria Nable, Rebecca Bonner, Harry S Soroff; State University
of New York: Stony Brook, NY
Objective: To compare patient and practitioner assessments
of burn appearance and determine relative importance of
burn outcomes to patients. Methods: Design—descriptive
study. Setting—tertiary burn clinic. Measurements—burns
were independently assessed by two burn specialists using
a previously validated ordinal scale (OS) as well as a 100-
mm visual analogue (VAS) scale marked ‘best appearance’
at the high end. Elements of the OS included the presence (0
points) or absence (1 point) of abnormal pigmentation, scar
elevation, visual and tactile lack of uniformity, contractures
and overall unsatisfactory appearance. The total OS score
was derived by adding the scores on the individual
categories. Burns with optimal outcome received a score of
5. Patients independently assessed their burn appearance
with the VAS and chose the most important of the following
outcomes appearance, function, and lack of pain and/or
itching. Data Analysis—Interobserver correlations were
assessed with Spearman’s (OS) and Pearson’s (VAS)
correlations. Relative importance of outcomes compared
by location (chi-square test). Results: 61 burns were
evaluated. Mean patient age was 37, 27% were female.
Most burns were on the extremities and ranged in size from
12–900 cm square. While practitioner scores were highly
correlated (VAS, r ¼ 0.62 and OS, rho ¼ 0.837), patient and
practitioner scores on the VAS were poorly correlated (0.29
and 0.39). Patient priorities regarding most important burn
outcome differed by burn location (P ¼ 0.04). With facial
burns appearance was most important (80%). With non-
facial burns function was most important (51%). Conclu-
sions: While practitioners agree among themselves on burn
appearance, patients and practitioner do not agree on
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
overall appearance. Appearance is most important to
patients with facial burns and function is more important
to patients with non-facial burns.
226 Evaluation of a New High Viscosity
Octylcyanoacrylate Tissue Adhesive for Laceration
Repair: A Randomized Controlled Trial Adam J Singer,
Philip Giordano, Jeffrey L Fitch, Janet Gulla, Dennis Ryker,
Stuart Chale; State University of New York: Stony Brook, NY,
Orlando Regional Medical Center: Orlando, FL
Objective: Tissue adhesives have recently been approved
for skin closure. Their low viscosity may result in in-
advertent migration. We compared wound infection and
dehiscence rates, short-term scar appearance, and tendency
of the adhesive to migrate after laceration closure with
a high or low viscosity octylcyanoacrylate (OCA). Methods:
Study Design—Randomized clinical trial. Setting—univer-
sity based and community based emergency departments.
Participants—patients with simple traumatic lacerations.
Interventions—patients randomized to laceration closure
with low or high viscosity OCA tissue adhesive. Out-
comes—immediate adhesive migration, wound infection
and dehiscence rates at 14 days and percent of scars with
optimal appearance at 30 days. Data Analysis—proportions
compared with chi-square tests. Results: 84 patients were
randomized to low (n ¼ 42) or high (n ¼ 42) viscosity OCA
tissue adhesive. Groups were similar in baseline patient and
wound characteristics. The high viscosity OCA was less
likely to migrate than the lower viscosity agent (21% vs.
78%, p \ 0.001; OR ¼ 0.3, 95% 0.1 to 0.5). The proportion
of patients that noted a sensation of heat during OCA
application was higher in the high viscosity groups (44% vs.
26% respectively, p ¼ 0.11); however, all such patients in
both groups would use the device again. At 14 days there
were no wound infections in either group. There was one
dehiscence in the high viscosity group. At 30 days the
proportion of patients with optimally appearing wounds
was higher in the high viscosity group (100% vs. 88% in low
and high viscosity groups respectively, p ¼ 0.04). Conclu-
sions: The high viscosity OCA tissue adhesive was less
likely to migrate than the lower viscosity device. Wound
dehiscence and infection rates as well as 30-day cosmetic
appearance were similar between the two tissue adhesives.
227 Development of an Excisional Wound Model
Adam J Singer, Steve A McClain; State University of
New York: Stony Brook, NY, Montefiore Hospital: Bronx, NY
Objective: To develop a porcine model for excisional
cutaneous wounds. Methods: Design—prospective, longi-
tudinal, blinded experiment. Participants—Four isoflurane
anesthetized swine. Interventions—40 standardized exci-
sional wounds (2.5 by 2.5 cm) were created with an electric
dermatome set at a depth of 300, 600, 750, and 900 microns.
Full thickness wounds were created with a surgical blade
(n ¼ 8 for each depth). Wounds were treated with poly-
urethane film. Full thickness biopsies were taken after 1, 2, 3,
4, 5 and 14 days for blinded histopathological evaluation.
Main Outcome—Percent of wound reepithelialization (REP)
calculated by dividing the length of neoepidermis in cross
499
section by the specimen’s diameter (interobserver correla-
tion ¼ 0.99). Data Analysis—ANOVA was used to compare
% REP among wound depths. This study had 80% power to
detect a 33 %-age point difference in REP across groups
(2-tailed alpha ¼ 0.05). Results: There were significant
differences in %REP across wound depths for days 2–5 (P
\ 0.001 for all days). The more superficial wounds (300–600
microns) were mostly reepithelialized by day 4, whereas
wounds ranging in depth from 750–900 microns were
mostly healed by day 5. Full thickness wounds had no
evidence of reepithelialization even after 14 days. Conclu-
sions: We describe an excisional wound model in swine.
Rapid reepithelialization occurs within 3–5 days in wounds
\900 microns.
228 Do Serum Salicylate Levels Detect Unsuspected
Ingestion? Lisa D Mills, Larissa I Velez, Trevor J Mills,
Wilfredo Rivera, Fernando Benitez; Louisiana Statue University
Health Sciences Center at New Orleans: New Orleans, LA,
University of Texas Southwestern: Dallas, TX
Objective: The null hypothesis is that routine serum
salicylate (SAL) levels detect unsuspected SAL intoxication
in Emergency Department (ED) patients with suicide
ideation (SI) or intentional overdose (OD) who deny SAL
ingestion. Methods: This study was conducted at a large,
urban ED that serves as a referral center for psychiatric
emergencies. IRB approval was granted. All patients, over
18 years of age with a chief complaint or diagnosis of OD/
SI, were identified by a computerized patient database.
Protocol at this facility includes testing for serum salicylate
level 4 hours or more from time of ingestion in all patients
with reported OD/SI. Charts were reviewed to determine
time from ingestion to collection of blood sample and time
of observation. Serum SAL level was obtained from
a computerized laboratory database. Results: Ninety pa-
tients (43 women, 47 men) were included. Eighty-one pa-
tients denied ingestion of SAL products. Nine patients
reported ingesting a SAL. Of the 81 patients who denied
salicylate ingestion, none had SAL detected in the serum (4
or more hours post-ingestion). These patients were observed
for a mean of 8.8 hours, which time, no additional SAL
levels were obtained in these patients. In the 9 patients who
reported SAL ingestion, 8 had SAL detected in the serum. A
positive history of SAL ingestion is 100% sensitive and
98.8% specific for detected patients with a positive serum
SAL level. The positive and negative predictive values of
a history of SAL ingestion are 88/9% (CI ¼ 56.5–98) and
100% (CI ¼ 95.5–100). Conclusion: No patients were found
to have positive serum SAL levels if they denied salicylate
ingestion. A history positive for SAL ingestion has an 88.9%
PPV and a 100% NPV for detecting patients with positive
serum SAL levels. Routine SAL levels did not detect un-
reported or asymptomatic SAL ingestion.
229 The Clinical Factors and Outcomes in Patients with
Acute Mesenteric Ischemia in the Emergency
Department Hsien-Hao Huang, Sheng-Chuan Hu, David HT
Yen, Jen-Dar Chen, Chen-Hsen Lee; Taipei-Veterans General
Hospital, National Yang-Ming University: Taipei, Taiwan,
Tzu-Chi Buddhist General Hospital, Hualien: Hualien, Taiwan
500
Objectives: Acute mesenteric infarction is a geriatric emer-
gency with high mortality rate and a continuously diag-
nostic challenge for emergency physicians. The purpose of
this study was to determine initial clinical characteristics of
acute mesenteric infarction and identify the prognostic
factors of this disease in the emergency department (ED).
Methods: From September 1990 through September 2000,
a retrospective review of 124 consecutive patients with
surgical and pathological identification of acute mesenteric
infarction was conducted in a tertiary referral medical
center. Based on the outcomes of hospital admission, all the
patients were categorized into 2 groups, survival and
mortality. Clinical characteristics including demographic
data, predisposing medical diseases, initial presenting signs
and symptoms, laboratory results and radiographic studies
in ED were analyzed for the prediction of outcomes.
Results: The mean age of 124 patients was 71.1 with range
from 25 to 100 years. The overall mortality rate was 50%.
More increase in bandemia, liver and renal function
impairment, amylase, metabolic acidosis, hypoxia, and
septic syndrome were noted in mortality than survival
group patients. In computed tomography with contrast
medium study, only intestinal bowel wall thickening
without obvious mesenteric artery or vein thrombosis,
mesenteric or portal vein gas, and intramural pneumatosis
may indicate better prognosis (P \ 0.05). In logistic
regression analysis, older age (odds ratio [OD], 1.06, 95%
CI, 1.003 to 1.121), bandemia (OD, 1.070, 95 CI, 1.024 to
1.118), and metabolic acidosis (OD, 8.212; 95% CI, 2.582 to
26.117) were significantly associated with high mortality
rate. Conclusions: Multisystem organ dysfuctions were
noted in patients with acute mesenteric infarction. Emer-
gency physicians were suggested to recognize clinical
factors including metabolic acidosis, bandemia and older
age were associated with poor outcomes in patients with
acute mesenteric infarction in ED.
230 Noncontrast Abdominal CT Scans in Patients Being
Evaluated for Right Lower Quadrant Pain Jeannette
M Wolfe, Howard A Smithline, Steven Lee, Brett Coughlin,
Joseph Polino; Baystate Medical Center, Western Campus
Tufts School of Medicine: Springfield, MA
Objective: To determine if contrast is necessary to interpret
an abdominal CT in patients being evaluated for right lower
quadrant pain. Methods: This was a retrospective analysis of
a prospective observational trial comparing oral contrast to
noncontrast abdominal pelvic CT in a convenience sample of
adult patients at a tertiary care academic ED from 9/4/01 to
8/30/02. Patients with trauma, renal colic, pregnancy, need
of IV contrast, or clinically unstable were excluded. In-
dication for CT and location of maximal pain were pro-
spectively recorded on an explicit data sheet. Patients
undergoing CT for RLQ pain or for clinical concern of
appendicitis (if maximal area of pain outside RLQ) were
selected for analysis. Patients had a helical 5 mm cut
noncontrast abdominal pelvic CT followed by 2 drinks of
oral contrast 90 minutes apart and a repeat scan. Radiology
attendings interpreted the scans using explicit data sheets
and were blinded to the results of the matching CT. Clinically
important discordance between the matching scans was
determined by a panel of radiology and emergency medicine
2003 SAEM ANNUAL MEETING ABSTRACTS
attendings. All patients received 30 day follow up and
review of any pathology reports. Results: Forty-two patients
met study criteria: 62% female, mean age 41(95%CI: 36, 46).
In the 8 discordant cases, appendicitis (n ¼ 2), groin mass (n
¼ 1) were interpreted only in the noncontrast group, while
appendicitis (n ¼ 2), bowel wall thickening (n ¼ 2) and
adnexal mass (n ¼ 1) were inter preted only in the contrast
group. Radiology requested additional imaging in 50% of all
noncontrast scans. There were 3 false positive and 3 false
negative scans for appendicitis on the noncontrast scans and
1 false positive and 1 false negative scan for appendicitis on
the contrast scans. Conclusions: Noncontrast abdominal
pelvic CT scan may be inadequate for evaluating patients
with RLQ tenderness and/or suspected appendicitis.
231 Pilot Study to Develop a Decision Rule for the
Selective Use of CT Scan in Undifferentiated
Abdominal Pain Matthew J Scholer, Robert J Vissers,
Branson Page, Valerie J De Maio; University of North
Carolina: Chapel Hill, NC
Objectives: There exist no clear guidelines for the use of
abdominopelvic CT scans (APCT) in assisting with the
diagnosis of undifferentiated abdominal pain (UAP) in the
emergency department (ED). The purpose of this study is to
better identify subsets of patients with UAP whose likeli-
hood of significant findings on APCT is low enough such
that the test might safely be postponed until after hospital
admission or forgone altogether. Methods: The study design
is a prospectively administered survey completed by the
treating physician. The study population is a convenience
sample of adults presenting to a tertiary care teaching
hospital ED in July of 2002 with a chief complaint of non-
traumatic UAP. Demographic, historical, physical exam and
laboratory findings, information related to the patient’s
APCT (if ordered), disposition and diagnosis were recorded
for each patient. Descriptive data and chi square or Fischer
exact comparisons were obtained. Results: 103 patients
were enrolled in the study. 41 patients (40%) received APCT,
6 of which were excluded due to incomplete surveys. 13
patients received non-contrast renal protocol scans and 22
received scans with oral and intravenous contrast. Patients
with hematuria or focal tenderness were more likely to
undergo APCT (p \ 0.05). The APCT was helpful in
determining the etiology of the patient’s abdominal pain
in 49% of patient’s scanned. Of all patients receiving APCT,
those with elevated WBC counts ([11) were more likely to
have the etiology of their abdominal pain determined by the
scan (p \ 0.05). This was, however, true only of patients
undergoing contrasted scans. Patients receiving APCT in the
ED were not more likely to have a diagnosis at the time of
disposition than those that were not scanned (p [ 0.05).
Conclusions: Despite many interesting observations, we
were unable to identify variables that are associated with
significant findings on APCT. It may be possible to better
identify these factors using a larger sample size.
232 Influence of Increasing CT Scan Usage on the
Management of Appendicitis in Adults Steven P
Frei, William F Bond, David M Richardson, Robert K Bazuro,
Gina M Sierzega, Kristen E Koenig, Brian J Belmont, Thomas E
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Wasser; Lehigh Valley Hospital, Pennsylvania State University
College of Medicine: Allentown, PA
Objective: To assess the influence of increasing CT scan
usage on the management of appendicitis. Methods: We
conducted a structured retrospective chart review of ap-
pendicitis cases between January 1999 and December 2001
at a community teaching health network consisting of 3
Emergency Departments. Adult cases were reviewed based
on the final discharge diagnosis of appendicitis and con-
firmation by pathology. Private physician cases and AMA
cases were excluded. Perforation/gangrene rates were de-
termined by pathology. CT scan usage and time to surgery
were recorded. Delay in diagnosis was defined as a time
greater than 20 hours from initial physician exam to sur-
gery or a repeat visit to the ED. Univariate regression
analysis was used to assess the change of variables over
time. Times to surgery with and without CT scan were
compared using Student’s grouped t-test. Results: 420 cases
were reviewed. Overall 194 cases had a CT scan and 226
cases did not. Mean time to surgery with CT scan was 545
min (sd 6 289) and without CT scan was 384 min (sd 6 282).
The difference in means was 160 min (95% CI 105 min to 215
min). The data were subdivided by quarters and subjected
to univariate regression analysis. The proportion of patients
getting a CT scan did increase significantly over the time
period studied from 17% in the first quarter studied to 52%
in the final quarter (slope of regression ¼ .042, 95% CI .015
to .069). Mean time to surgery for all patients did not vary
significantly over the time period studied (slope ¼ 4.23, 95%
CI
10.3 to 18.7). The mean proportion of delay in diagnosis
cases did not change significantly (slope ¼
.001, 95% CI

.009 to .007), nor did the rate of perforation or gangrene
(slope ¼ .006, 95% CI
.008 to .020). Conclusion: In
a community hospital, the increased use of CT scanning
in cases of appendicitis does not appear to influence the
overall time to surgery, the delay in diagnosis rate or the
gangrene/perforation rate.
233 Impact of Abdominal/Pelvic Computed Tomography
with and without Oral Contrast on Emergency
Department Patients Undergoing Appendectomy
Leigh V Evans, Michael J Werdmann, Linda C Degutis, Gail
D’Onofrio; Yale University School of Medicine: New Haven,
CT, Bridgeport Hospital: Bridgeport, CT
Objective: To examine the impact of abdominal/pelvic
computed tomography (CT) on ED patients undergoing
appendectomy. Methods: Patients $18 with the preop
diagnosis of appendicitis at 2 urban, teaching hospitals
during calendar years 1996 and 1999 were included. Site 1
used oral/IV contrast; Site 2 used no contrast. Operative logs
for patients undergoing exploratory laparotomy, diagnostic
laparoscopy, open appendectomy and laparoscopic appen-
dectomy identified all cases of appendicitis. Preop Alvarado
scores were calculated from documented history and
physical findings. All radiologic procedures and operative
and pathology reports were reviewed. Times to triage, CT
scan, operating room (OR) start, and hospital discharge were
recorded. Results: 153 appendectomies (AP) were performed
in 1996 (90 Site 1; 60 Site 2) and 194 in 1999 (125 Site 1; 62 Site
2). There was a significant increase in the number of CTs
501
performed from 1996 to 1999: 28% (43) vs 64% (125), p\0.001.
Mean time to OR was 12.6 hrs with CT and 7.3 hrs without CT
(95% CI 3.2, 7.4). There was no significant difference in time to
OR between oral contrast (13.4 hrs) vs. no oral contrast (11.7
hrs) (95% CI
1.9, 5.4). There was no change between years in
perforation rate 28% (43) vs 22% (42) (95% CI
0.03, 0.16) or
negative appendectomy rate 11% (16) vs 11% (21) (95% CI

0.07, 0.06). In 1999, patients were significantly more likely to
undergo CT (OR 4.6; 95% CI 2.85–7.44). At Site 1, patients $50
years and patients with Alvarado scores \6 were selectively
more likely to undergo CT (OR 5.52; 95%CI 2.23–13.66) (OR
1.96; 95% CI 1.07–3.60). This difference did not occur at Site 2.
Females were not more likely to undergo CT at either site (OR
1.35; 95% CI 0.85–2.15). Conclusion: The use of CTs prior
to operative intervention for appendicitis significantly in-
creased between 1996 and 1999. However, this increase in
use of CT did not result in improvement in negative
appendectomy rates or reduction in perforation rates.
234 Multicenter Controlled Clinical Trial to Evaluate the
Impact of Advanced Life Support on Out-of-hospital
Chest Pain Patients Ian G Stiell, Lisa Nesbitt, George A
Wells, Tammy Beaudoin, Daniel W Spaite, David Brisson,
Graham Nichol, Brian J Field, Marion B Lyver, Douglas P
Munkley, Lorraine G Luinstra, Donna Cousineau, for the
OPALS Study Group; University of Ottawa: Ottawa, Ontario,
Canada, Queens University: Kingston, Ontario, Canada,
University of Western Ontario: London, Ontario, Canada,
Niagara Regional Base Hospital: Niagara Falls, Ontario,
Canada, Ontario Ministry of Health: Toronto, Ontario,
Canada, University of Arizona: Tucson, AZ
Objectives: There is little published evidence regarding the
optimal EMS management of chest pain. Our study tested
the impact of advanced life support (ALS) EMS programs on
chest pain patient outcomes. Methods: This multicenter
before-after controlled clinical trial was conducted in 17
communities (population 20,000 to 750,000) as part of the
Ontario Prehospital Advanced Life Support (OPALS) Study,
which evaluates the impact of EMS programs for multiple
conditions. During the before phase, care was provided at
the BLS-D level. During the after phase, ALS providers
performed endotracheal intubation and administered IV
drugs. Data were collected from ambulance reports, central-
ized dispatch data, ED records, and in-hospital records. Chi-
square and Student’s t-test analyses were performed.
Results: The 4,601 patients enrolled during the two 9-month
BLS and ALS phases were well matched for clinical and
demographic features and had these characteristics: mean
age 66.6 (17–102), female 50.4%, EMS status ‘severe/life
threatening’ 48.7%, ICD-9 final diagnoses: chest pain NYD
17.7%, MI 17.0%, other non-cardiac 15.1%, unstable angina
14.6%, stable angina 9.4%, G.I. 8.6%, respiratory 5.9%,
dysrhythmias 5.8%. During the ALS phase, patients received
these EMS interventions: intubation 0.1%, IV fluid bolus
5.1%, SL NTG 64.4%, SL ASA 49.8%, IV morphine 6.1%, IV
furosemide 4.5%, IV adenosine 0.8%, IV lidocaine 0.3%, IV
atropine 0.3%. There was a 64.7% relative reduction in the
primary outcome, overall mortality, from the BLS to the ALS
phase (5.1% vs 2.8%; P \.001). Other outcomes also showed
improvement from BLS to ALS phase: EMS-judged im-
proved (20.1% vs 50.9%; P \ .0001); admitted (76.7% vs
502
48.9%; P \ .001); discharged to home (65.8% vs 68.7%; P \
.01). A large mortality reduction was seen in the MI
subgroup (19% vs 10%; P \ .001). Conclusions: This is the
largest controlled trial of out-of-hospital chest pain patients
and clearly shows important benefit from ALS programs for
mortality and other outcomes.
235 The Bedside Investigation of Pulmonary Embolism
Diagnosis (BIOPED) Study Marc Rodger, Philip
Wells, Dimitri Makropoulos, Ian G Stiell, Gwynne Jones, Pasteur
Rasuli, François Raymond, Anne Marie Clement, Alan
Karovitch, Helene Djunaedi, Christopher H Bredeson, Mark
Reardon; University of Ottawa: Ottawa, Ontario, Canada
Objectives: Bedside methods to exclude pulmonary embo-
lism (PE) include the Wells Clinical Model, non-ELISA D-
Dimers and alveolar dead space analysis. We sought to test
whether using combinations of bedside tests was as safe
as a standard strategy of diagnostic imaging. Methods:
This triple blind randomized controlled trial enrolled adults
with suspected PE in a tertiary care hospital. Patients were
randomized to initial bedside tests or initial V/Q scan
without bedside tests. All patients had a Wells Clinical
Model score, a non-ELISA D-Dimer and alveolar dead space
analysis but these data were only used in management in
the bedside test group. Patients assigned to the bedside test
group had a sham V/Q performed if 2 of 3 of the bedside
tests were negative; otherwise they had a real V/Q scan.
Further diagnostic testing and management were dictated
by a blinded physician. The primary outcome was recurrent
Venous Thromboembolic (VTE) disease over 90 days in
patients not anticoagulated. Chi-square and logistic re-
gression analyses were performed. Results: Of the 399
patients, 64.4% were ED cases, 65 were anticoagulated after
the initial work-up, and the total VTE rate was 18%. Among
the 334 patients not anticoagulated, the VTE rate was 2.4%
(95% CI 0.6–6.1%) in the bedside test group vs. 3.0% (1.0–
6.8%) in the V/Q scan group (P ¼ 0.76). 5.3% patients with
2/3 bedside tests negative had VTE vs. 24.1% with 2/3
bedside tests positive (p \ 0.0001). 9.9% patients with #4
points on Wells Model had VTE vs. 21.6% with [4 points (p
¼ 0.004). 6.2% patients with negative D-Dimer had VTE vs.
26.5% with positive D-dimer (p \ 0.0001). 12.4% patients
with alveolar dead space fraction #0.15 had VTE vs. 32.1%
with [0.15 (p \ 0.0001). LR analysis demonstrated all 3
bedside tests were independent predictors of VTE. Conclu-
sions: Using a strategy that 2 out of 3 negative bedside tests
excludes PE is as safe as an initial V/Q scan approach and
eliminates the need for diagnostic imaging in 1/3 of
suspected PE patients.
236 Impact of a Clinical Decision Rule and a D-dimer
plus Alveolar Deadspace Measurement to Rule Out
Pulmonary Embolism in an Urban Emergency
Department Jeffrey A Kline, William B Webb,
Alan E Jones, Jackeline Hernandez-Nino; Carolinas Medical
Center: Charlotte, NC
Objective: Test the safety and efficiency of a point-of-care
PE rule-out protocol in an urban ED. Methods: This IRB-
approved study was conducted in two phases over 24
months to measure before and after effect. Phase I
2003 SAEM ANNUAL MEETING ABSTRACTS
established baseline data from Jan-Aug 2001, when only
pulmonary vascular imaging (PVI: CT angiography &
venography or VQ scanning) was available to rule-out PE.
Phase II was implemented during a one-month pilot period,
and data collection began Oct 1, 2001 for all ED patients
with possible PE. The PE rule-out protocol mandated
a published clinical decision rule (CDR) to triage patients
either to PVI or to rapid screening using a whole-blood
D-dimer (SimpliFY) and an alveolar deadspace measure-
ment, both completed in the ED by a respiratory therapist.
Study outcomes: 90-day follow-up for PE, DVT or death;
census adjusted rate (CAR) of ED screening for PE, ED
length of stay (LOS), use of PVI, and rate PE/DVTþ on PVI.
Sample size was estimated to prove safety (N ¼ 1200).
Results: During Phase I, 453 patients underwent PVI (CAR
¼ 0.6% 95% CI: 0.6 to 0.7%), median LOS was 375 min, and
37 of 453 were PE/DVTþ (8%, 6 to 11%). During Phase II, a
total of 1452 ED patients were evaluated for PE in 12 months
(CAR ¼ 1.4%, 1.3 to 1.4%), including 1345 (93%) by the PE
rule-out protocol. The CDR triaged 109 patients directly to PVI
(20 PEþ) and 1236 (92%) to D-dimer/deadspace testing,
which was
/
in 793, of whom, four (0.5%, 0 to 1.3%) had PE
(N ¼ 1) or DVT (N ¼ 3) on follow-up; 8 of 793 died, none with
PE. For the outcome of PE or DVT, final protocol sensitivity
was 67/71 (94%) and specificity was 793/1274 (62%).
During Phase II, the median LOS was 297 min (P ¼ 0.01
M-W U test); 667 ED patients underwent PVI (CAR ¼ 0.62%.
0.57 to 0.67%), and the PE/DVTþ rate on PVI was 12.6% (9 to
15%). Conclusions: Implementation of PE rule-out protocol
was associated with increased ED screening for PE, a very low
rate of PE or DVTafter a negative protocol, decreased ED LOS,
and no adverse effect on PVI use.
237 Public Access Defibrillation Programs without
Training Are Ineffective Richard Neville Bradley,
Wesley H Hamilton, Mark Ryan Boyle, Lynda Mitchell
Schoenstein; University of Texas Medical School at Houston:
Houston, TX, Baylor College of Medicine: Houston, TX,
Memorial Hermann Hospital: Houston, TX
Objectives: Automated external defibrillators (AEDs) are
becoming widely available to the public. Hypotheses:
(primary) using only the instructions from the AED, less
than 75% of the general population can deliver a simulated
defibrillation in less than three minutes; (secondary) less
than 25% can perform all of the steps of basic life support
including initiation of CPR in less than 5 minutes. Methods:
A heavily trafficked pedestrian thoroughfare at a major
US airport was the setting for this prospective survey. The
subjects were consecutive individuals older than 12 years
who came to the study site on Jan. 2–3, 2003. The only
exclusion criterion was previous completion of an advanced
cardiac life support class. After obtaining consent, an in-
vestigator told the subject that he/she was walking down
the concourse and saw a person collapse. The subject was to
demonstrate his/her response without assistance, using
only a telephone and an AED simulator. An investigator
documented the response. Data were analyzed using a one-
sample test of proportions. Results: 30 subjects participated
in the study; one was excluded. Only 8 subjects (28%) (95%
c.i. 13–47%) were able to defibrillate within 3 minutes. Only
1 (3%) (95% c.i. 0–18%) was able to complete a standard
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
AED protocol within 5 minutes. The primary reasons for
inability to shock were placing the electrodes over the
patient’s clothes (62%) or failure to remove the protective
backing from the electrodes (67%). Conclusion: This study
supports the hypotheses. Visual and aural instructions from
the AED are not adequate to facilitate its use by an
untrained individual. As authorities make AEDs more
accessible to the public, they must ensure an effective
educational program is also in place. Primary limitations to
this study are that the use of a training AED on a manikin
may not represent results of using a functioning AED on
a human in cardiac arrest, and the participants may not
reflect the bystanders most likely to provide initial care.
238 Investigation of the Use of Core Practical Objectives
for Standardizing the Experiences of Fourth Year
Medical Students during an Emergency Medicine
Clerkship Jay H Woodland, Gregory Tudor, Marjorie A
Getz; OSF Saint Francis Medical Center: Peoria, IL,
University of Illinois College of Medicine at Peoria: Peoria, IL
Background: EM clerkship students (EMCS) can be guided to
see specific chief complaints (CC) to standardize the clinical
experience (CE) (Gendy et al., 2002). The next steps towards
standardization are to identify key CEs and establish
numbers of each for EMCS to achieve. Core Practical
Objectives (CPOs) are a list of CEs with a suggested number
of each that are explained in detail during the EMCS’
orientation. EMCS then compare their progress to CPO
criteria midway through the rotation to identify unfulfilled
CPOs. EMCS are then expected to pursue CEs to complete
CPOs. Objective: Investigate effects of CPOs to standardize
EMCS experiences by comparing exposure to selected CCs
before/after implementing CPOs. Methods: Retrospective
descriptive study of a 4th year EM clerkship using EMCS’ pt
log encounter forms (LEF) and explicit chart review (ECR)
conducted at a Level 1 Trauma Center with [60,000 ED
visits/yr. LEF were collected from 27 EMCS in 1998 (before
CPOs) and 24 in 2002 (after implementation). CPOs included
wound eval (WE)-3, c-spine x-ray (CSXR)-2, slit lamp exam
(SLE)-2, pelvic exam-4, chest pain (CP)-3, trauma eval-3,
febrile child (FC)-4 and respiratory distress (RD)-4. Some LEF
reviewed for CC and final diagnosis provided enough
information while others required ECR. Results: A chi-
square test of independence was calculated comparing the
proportion of students achieving predetermined criterion
levels. CPOs showing an increase in % of students meeting
criteria comparing 2002 to 1998 were WE, CSXR, SLE, CP, FC
and RD. Significantly more EMCS performed the SLE in 2002
(58%) than in 1998 (22%; contingency corrected chi-square (1)
¼ 5.52, p \ 0.02). Conclusions: CPOs may help standardize
the EM clerkship. Four years after implementing a CPO
program, 6 of 8 showed increases in proportion of students
meeting criteria. Established CPOs may assure adequate
exposure to the most prevalent ED cases, yet allow students
to pursue a variety of other pt presentations. CPOs can be
individualized to any institution.
239 Esmolol Improves Survival Following Prolonged
Ventricular Fibrillation Gregory P Walcott, Sharon B
Melnick, Cheryl R Killingsworth, Raymond E Ideker; University
of Alabama at Birmingham: Birmingham, AL
503
Objective: Studies have shown that there is a large surge
of catecholamines upon reperfusion following prolonged
ventricular fibrillation (VF). Large catecholamine doses
have been shown to have detrimental effects on the myo-
cardium. This study tested the hypothesis that a single
dose of the short-acting b-antagonist esmolol at the time of
reperfusion following prolonged global ischemia, to protect
against the catecholamine surge, will improve survival.
Methods: 16 swine, 36 6 5 kg, were anesthetized with
isoflurane. Following 8 minutes of VF, escalating biphasic
shocks were delivered through self-adhesive defibrillation
electrodes on the left and right anterior chest wall of the
animal. Following successful defibrillation but prior to the
start of CPR, animals were randomized to receive either
esmolol, 1.0 mg/kg, or saline. CPR was then initiated. Epine-
phrine, 0.01 mg/kg, was given every 3 minutes following
defibrillation until the animal’s systolic blood pressure was
50 mm Hg without CPR. Animals were further supported
with supplemental epinephrine if blood pressure sub-
sequently dropped below 50 mm Hg. Animals were started
on dobutamine, 5 mg/kg/min after 1 hour when systolic
blood pressure was \50 mm Hg and stopped after three
hours. The study endpoint was survival at 4 hours.
Results: Seven of eight animals receiving esmolol prior
to reperfusion survived while only three of eight animals
receiving saline survived (chi-square p # 0.05). None of
the animals had return of spontaneous circulation follow-
ing defibrillation with CPR. Duration of CPR was not
different between the survivors of each group (9 6 7
minutes for each). Two survivors from the esmolol group
and one survivor from the control group required do-
butamine support. Conclusion: A single dose of the short-
acting b-antagonist esmolol significantly improved 4-hour
survival in this animal model of prolonged global ischemia
and reperfusion. Further studies are necessary to determine
the precise mechanism of esmolol’s protective effect.
240 Mathematical Model Predicting the Potential Impact
of Various Community Bystander CPR Rates on
Overall Survival from Cardiac Arrest Christian
Vaillancourt, Ian G Stiell, George A Wells, Valerie J De
Maio, for the OPALS Study Group; University of Ottawa:
Ottawa, Ontario, Canada
Objectives: Survival from cardiac arrest remains low.
Bystander CPR is a crucial yet weak link of the chain of
survival for cardiac arrest. We sought to determine the
potential impact of various community bystander CPR rates
on overall survival from cardiac arrest. Methods: We used
descriptive analysis and mathematical modeling of data
prospectively collected within the Ontario Prehospital
Advanced Life Support Study. This study has the largest
population-based cohort of adult out-of-hospital cardiac
arrests in 20 communities with BLS-D and ALS paramedics.
We used the following assumptions from the literature for
our mathematical model: 1) bystander CPR is well-
performed in 50% of cases; 2) the odds of survival with
well-performed CPR compared to technically incorrect CPR
is 3.4; 3) increasing CPR teaching in the community will
increase bystander CPR rates; and 4) improved bystander
CPR rates will be in the well-performed CPR group. We
determined baseline bystander CPR and survival rates for
witnessed and un-witnessed cardiac arrest cases. Victims
504
receiving bystander CPR were divided in two equal groups
and assigned a 3.4 differential survival rate. We varied
bystander CPR rate between 20% and 60%. Results: From
1995 to 2000, there were 7,707 consecutive cardiac arrest
cases: mean age 68.9, 67% male, 37% VF/VT. Bystander CPR
and survival to discharge were: 49% witnessed (23%,6.8%),
and 51% un-witnessed (11%,1.3%). Estimated overall sur-
vival and additional number of lives saved with various
bystander CPR rates are: 20%(4.1%,2), 25%(4.6%,9),
30%(5.1%,17), 35%(5.6%,24), 40%(6.1%,32), 45%(6.5%,39),
50%(7.0%,47), 55%(7.5%,54), 60%(8.0%,62). Conclusion: We
used the largest known multicenter cardiac arrest database
to model the potential impact of various bystander CPR
rates. Community interventions designed to improve
bystander CPR rates could have a significant impact on
survival from cardiac arrest. These results may also be used
for sample size calculation in cardiac arrest research.
241 Angular Velocity of Phase-space Trajectory
Quantifies Change in Ventricular Fibrillation over
Time Lawrence D Sherman, Aron Flag, Clifton W Callaway,
James J Menegazzi, Kristofer C Fertig, David Hostler, Eric Logue;
University of Pittsburgh School of Medicine: Pittsburgh, PA
Objectives: To improve treatments for VF an objective
measure of VF duration is vital. We previously derived
a measure of VF duration, the scaling exponent (ScE). We
noted then that the plot of the waveform in a 3 dimensional
phase-space produced a circular ‘attractor’. Our hypothesis
is that changes in the velocity of rotation of the leading edge
of the attractor over time will correlate with the duration of
VF. This is the Angular Velocity (AV). Methods: 72 domestic
swine were sedated, anesthetized, intubated, paralyzed and
instrumented. VF was induced with a transthoracic shock
and untreated until the ScE reached 1.1, 1.20, 1.30 or 1.40.
Recordings from those allowed to reach ScE of 1.3 and 1.4
(48 total) were used for analysis. A Cþþ program was
written to analyze the rate of rotation of the leading edge of
the attractor in 3 dimensional phase-space over the length of
VF. AV and ScE were calculated at 5 second intervals for up
to 15 minutes. Results: The AV is sigmoidal with an early
rise from 61 rads/sec at 1 minute to 77 at 3 minutes. It then
declines in linear manner to 33 at 12 minutes and again rises
to 45 by 15 minutes (SD þ11). The ScE shows a monophasic
increase from 1.09 to 1.35 over the 15 minutes (SD þ0.07)
with a plateau from 5 to 9 minutes. (See Table 241-1.)
Conclusions: The AV demonstrates a linear decrease from 4
minutes to 10 minutes. The ScE has a plateau from 5 to 9
minutes. Combining these statistics would provide a method
for determining the duration of VF from onset to 15 minutes.
This could allow refinement of treatment strategies focused
on different phases of VF (early versus prolonged).
TABLE 241-1.
Minute of VF
1 2 3 4 5 6 7 8
AV 61 68 77 76 71 63 51
ScE 1.09 1.11 1.12 1.15 1.19 1.19 1.18
2003 SAEM ANNUAL MEETING ABSTRACTS
242 A Location-specific Utility Measure to Guide the
Distribution of Public Access Defibrillation (PAD)
Programs within the Community Valerie J De Maio, Ian G
Stiell, Christian Vaillancourt, George A Wells, Daniel W Spaite,
Lisa Nesbitt, Donna Cousineau, for the OPALS Study Group;
University of Ottawa: Ottawa, Ontario, Canada, University of
North Carolina: Chapel Hill, NC, University of Arizona:
Tucson, AZ
Objective: There is little published data regarding the
strategic placement of PAD programs. We identified a loca-
tion-specific utility measure to guide the implementation of
PAD. Methods: This prospective cohort included all adult,
out-of-hospital cardiac arrests occurring before EMS arrival
in the multicenter, Ontario Prehospital Advanced Life
Support (OPALS) Study. EMS response included firefighter
defibrillation, BLS-D and ALS. The property assessment roll
identified the specific property type for each cardiac arrest
address and the total number of sites, per location type,
within the study boundary. Analyses included frequencies,
incidence rates, and utility scores: i.e., the number of PAD
programs needed to treat (NPNT) one witnessed VF/VT
cardiac arrest during a 5-year period. We estimated the effect
of PAD in those sites with the highest utility using a prior
model that predicts 18% survival to hospital discharge for
cases with a defibrillation response interval of #3 minutes.
Results: From 1995–2000, there were 7,707 cardiac arrests.
Higher utility locations included (cardiac arrests, sites,
incidence rate, NPNT): casinos (28, 2, 14, 0.1); non-acute
hospitals (42, 42, 1, 5); shopping malls (77, 394, 0.2, 9);
nursing/retirement homes (457, 460, 1, 10); hotels (65, 604,
0.1, 19); penal institutions (6, 21, 0.3, 21); golf courses (9, 156,
0.06, 26); recreation/community halls (165, 3206, 0.05, 27);
air/rail/bus terminals (4, 83, 0.05, 42); restaurants/bars (48,
1410, 0.03, 47). The placement of 1502 PAD programs to treat
the 669 cardiac arrests that occurred in the top 5 locations
would have yielded an estimated 87 additional survivors
during the study period. Conclusions: Strategic placement
of PAD programs within those locations with only the
highest utility may lead to clinically important survival
benefits. Location-specific utility measures should be used
to guide the initial placement of PAD programs and the
redistribution of public AEDs already within the community.
243 Effect of Implementation of a Computerized Order
Entry System on Emergency Department Patients’
Length of Stay Andrew T McAfee; Brigham and Women’s
Hospital: Boston, MA
Objective: Computerized ED order entry systems (EDOE)
are gaining popularity. Although such systems clearly
improve compliance and quality of documentation of ED
orders, the effect on operational characteristics is more
9 10 11 12 13 14 15
46 41 37 35 33 33 39 45
1.19 1.20 1.22 1.25 1.29 1.30 1.32 1.35
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
difficult to predict. We set out to analyze the effect of one
such EDOE system on ED length of stay (LOS). Methods:
We analyzed a computerized database of all ED patients
seen in an academic urban medical center. Data were anal-
yzed for 12 months before and 12 months after EDOE im-
plementation on 6/6/2000, in order to reduce seasonal
variability. Prior to the launch date no orders were ele-
ctronic. After the launch date all orders were generated
through the EDOE system. Staff received training over the
previous 3-month period to minimize a learning effect. No
other significant operational changes were made in the ED
during the 2-year study period. LOS was defined as time
of patient triage to the time that the patient physically left
the department. Multivariable linear regression was used.
Results: Pre and post study periods (respectively) compared
as follows: total census 52,555 vs 53,613; mean age 46.4 yrs
(sd 19) vs 46.0 yrs (sd 19); male 39.8% vs 38.9%; white race
50.2% vs 48.5%; higher acuity 46.7% vs 45.4%; Medicare/
Medicaid insurance 31.6% vs 31.9%; admitted 30.6% vs
28.8%; and mean LOS 233 min (sd 151) vs 270 min (sd 173).
A multivariable linear regression model with LOS as out-
come, adjusting for the effects of age, gender, race, acuity,
ambulance use, insurance, and disposition, revealed a signif-
icant post-implementation increase in ED LOS of 39.9 min,
95%CI [37.9, 41.8], a 17% increase on average. Regres-
sion diagnostics revealed adequate model fit. Conclusion:
Implementation of a computerized order entry system
increased average LOS for ED patients in this study. This in-
crease was independent of factors related differences in illness
or demographic characteristics.
244 The Feasibility and Patient Acceptance of
Computer-assisted Asthma Education in the
Emergency Department Joseph Finkelstein, James
Feldman, Clara Safi, Patricia Mitchell, Rajesh Khare; Boston
University Medical Center: Boston, MA
Objective: A COmputer-assisted EDucation (CO-ED) sys-
tem has been developed to provide self-paced patient-
tailored interactive health education using a pocket PC. The
ability of Emergency Department (ED) patients to effectively
use CO-ED for self-education has not been studied. This
study aimed to determine patient acceptance of a palmtop-
based asthma education and whether CO-ED is effective in
changing asthma knowledge in the ED setting. Methods:
A prospective pilot study with convenience sampling of
English speaking patients who presented to the ED of an
urban academic medical center for treatment of an asthma
exacerbation. Enrolled subjects were trained to use CO-ED.
The impact of CO-ED on asthma knowledge was assessed
by asking the previously validated Asthma General Knowl-
edge (AGK, 31-item) questionnaire at baseline and im-
mediately following completion of CO-ED. Mean AGK
pre-post scores were compared using paired t-test. Semi-
structured, in-depth interviews were used for evaluation
of CO-ED acceptance. Results: Of 55 eligible, 5 refused,
unable to participate or left before completing CO-ED. Age
range was 21–68 years (mean 38 6 11), 52% women, 22%
African American, 6% Hispanics, and 9% Whites. 70% had
no computer experience. Comparison of pre-post AGK
scores demonstrated statistically significant increase in
asthma knowledge after using CO-ED from 12 6 17 to 19
505
6 14 (P \ 0.01). Most patients (93%) preferred using CO-ED
as an education tool rather than a brochure. All patients
demonstrated high level of acceptance of user interface
including multimedia content and text font. A majority of
patients (89%) claimed that they would advise other
patients to use CO-ED for disease-specific education. Most
(78%) stated that they learned new information about their
disease using CO-ED. Conclusion: Our results showed that
computer-assisted asthma education can be successfully
implemented in the ED setting in a low income inner city
population with no previous computer skills.
245 A Standardized Communication System (SCS)
Linking the Emergency Department with Primary
Care Physicians: Impact on Continuity of Care Eddy S
Lang, Marc Afilalo, Jean-François Boivin, Ruth Leger, Antoinette
Colacone, Claudine Giguere, Xiaoqing Xue, Alain Vandal,
Stephen Rosenthal, Bernard Unger; Sir Mortimer B. Davis
Jewish General Hospital, McGill University: Montreal, Quebec,
Canada
Objectives: Seamless integration i.e. continuity of care (CC)
between the emergency department (ED) and primary care
physicians (PCPs) depends on accurate and timely sharing
of information. However, for various reasons, EDs inconsis-
tently transmit information about the patients they care for
to PCPs. The objective of this study was to determine the
impact of an electronic communication tool on measures of
CC. Methods: The SCS is an Internet and e-mail-based
application that enables PCPs to receive detailed reports
regarding their patients who have received ED care. We
conducted a prospective, triple-crossover, randomized con-
trolled trial of PCPs’ practices, stratified by age and load of
ED-using patients. While allocated to intervention, PCPs
received reports via the SCS and while in control, mailed
copies of the hand-written ED note. Outcomes were
measured with a patient-specific questionnaire completed
by PCPs 3 weeks after the ED visit of interest. Cluster
analysis was employed for all comparisons. Results: From
June 2001 to May 2002, 2022 ED visits (974 SCS vs. 1048
control) were entered into the trial. The clinical and
demographic characteristics of the patients in each arm were
comparable. The questionnaire response rate was 77%
overall and differed little between intervention and control
periods. SCS resulted in an increase in PCPs’ follow-up
directly related to the ED visit (adjusted OR 0.56, 95% CI
0.38–0.82). PCPs in the intervention arm also reported having
better knowledge of their patients’ ED visits than controls
(adjusted OR 0.16, 95% CI 0.12–0.22). SCS did not reduce
duplication of test ordering at the time of PCPs’ follow-up
(intervention vs. control: all blood-work 13% vs. 11%,
imaging 9% vs. 9%, microbiology 9% vs. 10%, EKGs 3% vs.
4%; all p ¼ ns). Conclusion: Enhanced transfer of in-
formation between the ED and PCPs improves CC primarily
through improved PCPs’ follow-up of ED visits and better
knowledge of the care provided to their patients in the ED.
246 Calculation of the Arterial Partial Pressure of
Oxygen Using Venous Blood Gases and the
Oxyhemoglobin Dissociation Curve Is Inaccurate Paul
Middleton, Anne-Maree Kelly; Joseph Epstein Centre for
Emergency Medicine Research: Melbourne, Australia
506
Objective: To determine whether accurate values for arterial
partial pressure of oxygen may be calculated using oxygen
saturation measured by pulse oximetry, parameters derived
from analysis of venous blood gases and a web-based tool
that utilises a mathematical representation of the oxyhemo-
globin dissociation curve. Methods: Study design: Second-
ary analysis of prospectively cohort data. Participants:
Patients presenting with respiratory illness of a severity
judged to warrant arterial blood gas sampling. Data: Paired
venous and arterial blood gas samples, oxygen saturation
and temperature. Intervention: The arterial partial pressure
of oxygen (ApO2) was calculated using an interactive, web-
based Java tool (http://www.ventworld.com/resources/
oxydisso/dissoc.html) by entering the measured values for
venous pH, pCO2 and temperature into the formula,
together with the oxygen saturation measured by trans-
cutaneous pulse oximetry. Outcome: Comparison of the
calculated ApO2 and actual ApO2 from the arterial blood
gas. Analysis: Bias plot [Bland-Altman] method for de-
termining agreement. Results: Data from 145 patients were
analysed, 109 patients with supplemental oxygen, and 36
patients without. For the group overall, there was poor
agreement with a constant bias of
22.5mmHg and 95%
limits of agreement of
148.4 to 103.4 mmHg. Subgroup
analysis of the groups with and without supplemental
oxygen also showed poor agreement. Conclusion: This
study has found that, with the method studied, there is
insufficient agreement between ApO2 estimated by the tool
and measured values for ApO2 to adopt the technique into
clinical practice.
247 Driver Mortality in Paired Angle Collisions Due to
Incompatible Vehicle Types Cameron S Crandall;
University of New Mexico: Albuquerque, NM
Objective: To measure the mortality associated with in-
compatible vehicle type crashes between passenger cars and
sport utility vehicles in paired T-bone collisions. Methods:
Design: Matched case-control study. Data source: Fatality
Analysis Reporting System (FARS) data from 1999 to 2001.
Subjects: All left front seat positioned drivers involved in
angle (T-bone) collisions of only two vehicles. Crash pairs
were restricted to: (1) passenger cars (‘‘cars’’) and sport
utility vehicles (‘‘SUVs’’), (2) the collision was the most
harmful event, and (3) both the initial and principal impact
points were at 3 or 9 o’clock. Observations: Survival versus
fatal outcome within the matched crash pairs was measured
with matched pair odds ratios and 95% confidence intervals.
Conditional logistic regression adjusted for multiple effects.
Results: From 3,778 paired angle collisions, there were 889
crash pairs between cars and SUVs where either one (but not
both) of the drivers died. Overall, car drivers experienced
greater mortality than did SUV drivers, regardless if they
were in the struck or striking vehicle (odds ratio (OR): 10.0;
95% confidence interval (CI): 7.9, 12.5). Drivers in cars struck
near side by an SUV experienced higher mortality compared
to the SUV driver (OR: 28.9; CI: 22.4, 37.2), as did car drivers
struck far side by an SUV (OR: 16.8; CI: 11.6, 24.3). The
differential mortality persisted after adjustment for restraint
use, air bag deployment, vehicle rollover, traveling speed,
vehicle mass, driver age and driver ejection. Conclusions:
Passenger car drivers in angle collisions experience sub-
2003 SAEM ANNUAL MEETING ABSTRACTS
stantially higher mortality compared to SUV drivers, es-
pecially when struck near side. The popularity of SUVs on
US roadways poses a substantial risk to drivers in smaller
cars while conferring a tremendous safety advantage to SUV
drivers. Vehicle mass explains much, but not all of the
mortality differences. Efforts should be sought to improve
passenger car side impact crashworthiness.
248 Identification of Injury Clusters Using Emergency
Medical Services Dispatch Data and a Geographic
Information System E Brooke Lerner, June D’Agostino,
Manish N Shah; University of Rochester: Rochester, NY,
Rural/Metro Medical Services: Rochester, NY
Introduction: Use of emergency medical services data with
a Geographic Information System (GIS) for public health
has become more common, especially in monitoring for
bioterrorism. These data and methodology could also be
helpful for disease or injury cluster identification and
prevention. Objective: To locate all 9-1-1 requests for aid
due to injury in a Northeastern City and to identify clusters
of specific injury mechanisms that could be investigated by
an injury coalition and form the basis for evidence-based
prevention efforts. Methods: The locations of all 9-1-1
requests for aid due to injury, based on emergency medical
dispatch codes, occurring in the study City over a 3.5 year
period were plotted on a map using ArcGIS. Location
information and dispatch code were obtained from the
dispatch database. Kernel analysis was used to identify
areas with the highest density of injury requests. Injury
dispatch codes were then stratified by type and Kernel
analysis was repeated to identify areas with a high density
of specific codes (i.e, violence, motor vehicle crash, or
bicycle-related). Results: 49,724 requests for aid due to
injury occurred during the study period (1999–2002). 84%
(41,960) of the requests had sufficient location information
to be plotted. Overall, there were 3 injury code clusters
identified within the City. 5,458 requests for aid that were
related to violence were received and 3 areas with a high
density were identified. 4,674 requests for aid that were
related to motor vehicle crashes were received and 2 areas
with a high density of motor vehicle crashes were
identified. 124 bicycle-related requests for aid were received
and 3 areas of high density were identified. Conclusion: 9-
1-1 requests for aid due to injury can be plotted by
geographic location. Clusters of specific injury mechanisms
can be identified. These clusters can then be referred to
a community coalition for evaluation and the establishment
of evidence-based prevention efforts.
249 Survey of Fall History and Fall Risk Factors in
Ambulatory Geriatric Emergency Department
Patients Christopher R Carpenter, Mark D Scheatzle, Joyce
A D’Antonio, Jeffrey H Coben; Allegheny General Hospital:
Pittsburgh, PA
Objectives: To determine the prevalence of and correlated
risk factors for reported falls in the last year in an
ambulatory population of elderly Emergency Department
(ED) patients. Methods: A convenience sampling, cross-
sectional survey of community dwelling elderly patients
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
presenting to an academic ED for any reason except a fall
and discharged to home. History of fall within the past year
and risk factors for falls previously described in community
settings were elicited via a 10 minute standardized in-
terview. A brief functional assessment observing ability to
stand and sit, walk raising feet and turn 180 degrees was also
performed. Results: 263 patients were enrolled. The mean
age was 76 years with 80% Caucasian and 64% female. 39%
reported a fall and 15% fell more than once. Among fallers,
22% were injurious falls with fractures and contusions
predominant. 44% demonstrated a borderline or abnormal
functional assessment test. The risk factors most signifi-
cantly correlated with having fallen within the past 12
months include dementia (OR 3.80), near falls (OR 3.40),
abnormal functional assessment (OR 2.48), ED visits in last
six months (OR 2.30), depression (OR 2.16) and non-drivers
(OR 1.71). The presence of urinary incontinence, cane-
assisted ambulation, objective auditory or visual deficits
and diabetes were not significantly associated with reported
falls. Conclusions: Several previously described fall risk
factors are significantly associated with reported falls in
elderly ED patients. Also, significant risk factors not
previously described include non-driver status and recent
ED utilization. The prospective evaluation of these identi-
fied risk factors will permit the development of an ED fall
risk assessment tool.
250 Smoking Cessation Interventions in the Emergency
Department for Smokers with Chest Pain Bruce
Mark Becker, Beth C Bock, Robert A Partridge; Brown Medical
School: Providence, RI
Objective: Each year over 4 million patients visit ED’s with
chest pain. Although 90% of low risk patients admitted to
Observation Units (OU) will ultimately rule out for
myocardial infarction, their attention is focused on their
health during this time. We examined the efficacy of pro-
viding brief counseling for smoking cessation to smokers
presenting with chest pain admitted to an OU. Methods: A
prospective randomized intervention study of English and
Spanish speaking smokers over 18 years old. These smokers
(n ¼ 365) were given brief physician advice to quit smo-
king and offered nicotine replacement therapy (NRT). Half
of all subjects were assigned to receive a single 45-minute
counseling session using motivational interviewing (MI).
Outcome measures were: quit rates, smoking rates, and
abstinence at 3 and 6 months. Results: Most subjects were
male (54%), 68% were non-Latino whites and average
education level was 11.6 years. Average subject age was
47.8. Most subjects were employed full time (63%) or retired
(21%). Over 90% of those eligible, enrolled. Overall cessa-
tion rates at three and six months were 23.2% and 21.1%
respectively. Subjects receiving the additional counseling
session were significantly more likely to set a quit date while
in the hospital (5% vs. 24.6%, p \ 0.01). At one month
follow-up, subjects given the MI counseling showed higher
confidence (6.1 vs. 5.9, p \ 0.05) and motivation to quit
(4.7 vs. 3.1, p \ 0.01) compared to other subjects. Among
continuing smokers (n ¼ 162) those given MI counseling
smoked fewer cigarettes per day (10.9, SD ¼ 8.0) compared
to other subjects (16.5, SD ¼ 11.6). Conclusions: Admission
to the OU with chest pain may provide a unique opportu-
507
nity for health care workers to intervene with smokers and
help motivate them to quit smoking.
251 A Prospective, Randomized Trial to Evaluate Heliox
as a Delivery Vehicle to Nebulize Albuterol in Acute
Asthma Exacerbations in the Emergency Department
Richard Lanoix, Michael D Lanigan, Michael S Radeos, Joel R
Gernsheimer; St. Luke’s-Roosevelt Hospital Center: New York,
NY, Lincoln Medical and Mental Health Center: New York, NY
Objective: To compare the response of mild to moderate
asthmatics to b-agonists nebulized in a 80:20 helium-oxygen
mixture (heliox), with that of a similar population receiving
b-agonists by a traditional oxygen delivery system. Meth-
ods: A prospective, randomized, double-blind study was
performed in an urban teaching hospital over a two-month
period. Inclusion criteria: Age between 19 and 55 years, with
a mild to moderate asthma exacerbation (PEFR # 80%
predicted). Exclusion criteria: Pregnancy; severe exacerba-
tion requiring emergent intubation; oxygen saturation
#90%; pneumonia or pneumothorax; and history of CHF
or COPD. Patients meeting inclusion criteria were random-
ized to have albuterol nebulized by heliox or oxygen, both at
flow rates of 12Liters/minute. Both groups otherwise
received the same treatment: albuterol treatments every 20
to 40 minutes; prednisone, 60mg orally within one hour of
presentation to the ED; and PEFR and FEV1 measurements
prior to each treatment. All other treatments, such as
Ipratropium bromide or Magnesium sulfate were noted.
Results: 94 patients were enrolled: 48 were randomized to
the control group; and 46 to the heliox group. Baseline
characteristics of patients in both groups, such as age, sex,
race, body mass index, tobacco use, duration of symptoms,
prior intubations, vital signs, oxygen saturation, and initial
% predicted PEFR and FEV1, were similar. There were no
statistically significant differences between the groups
in regards to: Overall improvement in % predicted PEFR
and FEV1; time to best PEFR and FEV1; length of ED stay;
admission rates; inability to complete the study; and return
visits/admissions within two weeks after participation in
the study. Conclusions: Heliox offers no clear benefit in the
management of mild to moderate asthma exacerbations.
252 Intra-muscular vs Oral Methylprednisolone in the
Treatment of Asthma Exacerbations Discharged from
an Emergency Department Michael Lahn, EJ Gallagher,
Polly Bijur; Albert Einstein College of Medicine: Bronx, NY
Background: Asthma exacerbations are commonly treated
with oral glucocorticoid therapy. Previous studies have
suggested but not confirmed the effectiveness of intra-
muscular (IM) glucocorticoid in asthmatics discharged
from Emergency Departments (EDs). Objectives: To com-
pare the effectiveness of IM versus oral methylprednisolone
in adult asthmatic patients treated and discharged from
an ED. Methods: Randomized, double-blinded placebo con-
trol trial of 160mg of depot IM methylprednisolone vs.
eight days of an oral, tapering total dose of 160 mg of
methylprednisolone in adult (ages 18–45) ED patients
treated for an asthma exacerbation and discharged from
the ED. All patients received intravenous methylpredniso-
lone and nebulized albuterol as part of their ED treatment.
508
The primary endpoint was the 10-day relapse rate to an ED
or physician’s office for persistent or worsening asthma
symptoms. A secondary endpoint of 21 day relapse was
similarly examined. An a priori sample size calculation
indicated that 170 patients would be needed to provide
80% power to detect a difference in relapse rate of at least
13.4% at a 2-tailed alpha of .05. Results: One hundred and
ninety patients were enrolled. Three exclusions occurred
due to protocol violations. Follow-up was not completed
on seven patients. One hundred and eighty patients com-
pleted the study and follow-up (96%). The relapse rate at
10 days was nearly identical between the two treatment
groups: (IM: 13/92 relapses, 14.1% vs. Oral: 12/88 relapses,
13.6%. Difference of 0.5%, 95% CI:
9.6% to 10.6%). The
relapse rates at 21 days were also very similar: (IM: 17/92,
18.5% vs. Oral: 20/88, 22.7%. Difference of 4.2%, 95% CI:

16.1% to 7.6%). Conclusions: The relapse rates among ED
asthmatics discharged with IM vs. oral methylprednisolone
do not appear to be clinically or statistically different at 10
and 21 days. IM methylprednisolone appears to be an
effective treatment for asthmatic patients discharged from
an ED.
253 The Relationship of Gender to Asthma Prevalence,
Healthcare Utilization, and Medications in a Large
Managed Care Organization Carlos A Camargo Jr, Michael
Schatz; Massachusetts General Hospital: Boston, MA, Kaiser
Permanente: San Diego, CA
Objective: To define the relation of gender to asthma-related
healthcare utilization and medications. Methods: Comput-
erized data from Southern California Kaiser-Permanente
were used to identify 60,694 asthmatic subjects, ages 2–64
and enrolled continuously during 1999 and 2000. Age-
specific asthma prevalence in 1999 was calculated to identify
ages of male or female predominance. Males (M) and
females (F) were compared on asthma-related healthcare
utilization outcomes (routine clinic visits, emergency de-
partment [ED] visits, and hospitalizations) and inhaled
corticosteroid (ICS) use; comparisons used chi2 and t-test.
Multivariate logistic regression was used to identify 1999
predictors of asthma hospitalization in 2000. Results: The
M:F prevalence ratio was approximately 65:35 at each age
year between 2–13, while it was inverse (35:65) between 23–
64; at ages 14–22, asthma prevalence was relatively similar.
In subjects ages 2–13, males had more ED visits (15.2% vs
13.3%, p \ 0.001) but comparable routine visits (89% vs 89%,
NS) and hospitalizations (4.0% vs 3.6%, NS). Males ages 2–13
used more ICS (49% vs 46%, p \ 0.001). By contrast, females
ages 14–22 had more routine visits (71% vs 76%, p \ 0.001)
and ED visits (14.9% vs 16.8%, p \ 0.05), but still comparable
hospitalizations (2.6% vs 2.6%, NS). Females ages 14–22 used
more ICS (60 vs 63%, p \ 0.01). Finally, in ages 23–64, females
had more routine visits (56% vs 67%), ED visits (10.7% vs
12.2%), and hospitalizations (1.7% vs 2.8%), with all p \
0.001. Adult females also used more ICS (72 vs 75%, p \
0.001). A multivariate model of asthma hospitalization in
ages 23–64 confirmed increased risk among females (OR
1.70, 95% CI 1.35–2.14) and decreased risk for those on ICS
(0.86, 0.81–0.91) Conclusion: Asthma healthcare utilization
and severity appear greater in males ages 2–13, somewhat
greater in females ages 14–22, and definitely greater in
2003 SAEM ANNUAL MEETING ABSTRACTS
females aged 23–64. The mechanisms for these striking
gender differences merit further investigation.
254 Asthma Coaching in the Emergency Department
Sharon R Smith, Marvin Petty, Vanetta Worthy,
Philip Blanks, Robert C Strunk; Washington University
School of Medicine: St. Louis, MO
Background: Follow-up (FU) care after an Emergency
Department (ED) visit for acute asthma decreases morbidity
and mortality. The National Heart, Lung and Blood Institute
recommends FU with the primary care provider within 7
days of an ED visit. We have shown that telephone coaching
2 and 5 days after an ED visit increases FU for children
with asthma. Objective: We evaluated the effect of asthma
coaching during an ED visit for acute asthma on the rate of
FU care for a group of low income, urban children. Methods:
We enrolled a convenience sample of low-income, urban
parents who brought their children to the ED for asthma
treatment. All parents received standardized discharge
instructions, responded to 6 scenarios designed to assess
knowledge and problem-solving skills regarding asthma
symptoms, and received a telephone call 2 weeks later,
during which scenarios were repeated and inquiries were
made about FU care. During the ED visit, parents in the
intervention group met with an Asthma Coach (trained social
worker), who discussed the importance and likely benefits of
FU care. Results: 92 parents were enrolled (50 intervention
group and 42 control group). The groups were similar in
demographics and in responses to the baseline scenarios.
Mean time of coaching intervention was 10.7 minutes (64.1).
84 of 92 parents were successfully contacted 2 weeks
later. The intervention group reported significantly more
FU visits (76.0% intervention vs. 47.6% control; p ¼ 0.0088).
Confirmation by chart audit is pending. There was no
difference in asthma knowledge or problem-solving skills
between intervention and control subjects, nor between those
who obtained and those who did not obtain FU visits.
Conclusion: Asthma coaching in the ED is a brief, simple
intervention that increased the proportion of low-income
urban children reporting a FU visit with their primary care
provider after an acute ED visit for asthma. Asthma coaching
did not improve knowledge of asthma management.
255 Determination of Sample Size Parameters for
Community Intervention Cluster Trials in Cardiac
Arrest Christian Vaillancourt, George A Wells, Ian G Stiell,
for the OPALS Study Group; University of Ottawa: Ottawa,
Ontario, Canada
Objectives: Community interventions to improve survival
from cardiac arrest are becoming more common. Individuals
belonging to a community share characteristics that make
them non-independent. We sought to determine the intra-
class correlation and inflation factor for sample size calcula-
tion of community intervention cluster trials in cardiac arrest.
Methods: We analysed data prospectively collected within
the Ontario Prehospital Advanced Life Support Study. This
study has the largest population-based cohort of adult out-of-
hospital cardiac arrests from 20 communities and 11 base
hospitals with BLS-D and ALS paramedics. We used one-way
analysis of variance to obtain the mean square error among
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
(MSC) and between (MSW) base hospitals for cardiac arrest
survival. We calculated the intra-class correlation (p) using
p ¼ (MSC
MSW)/(MSC þ (m
1) MSW) where m is the
cluster size, the inflation factor (IF) using IF ¼ (1 þ (m
1) p),
and the required sample size (n) to find a 2% absolute
difference in cardiac arrest survival (80% power, two-sided
5% alpha error). The number of clusters required (k) is given
by k ¼ 2n/m. Results: From 1995 to 2000, there were 7,707
consecutive cardiac arrest cases: mean age 68.9, 67% male,
37% VF/VT, 16% bystander CPR, and 4.0% survival to
discharge. Intra-class correlation for cardiac arrest survival
¼ 0.0019 and IF ¼ 2.3. In other words, the sample size
calculation for a community intervention needs to be
multiplied by 2.3 to account for the lack of independence of
individuals within communities. For example, we would
need 8,000 cardiac arrests in 12 communities to find a 2%
difference in survival from cardiac arrest. Conclusion: It is
essential to know the intra-class correlation factor to calculate
the required sample size for community intervention cluster
trials. This factor is often estimated and had not been
published for cardiac arrest research before. Our results can
have major impact on the design and analysis of community
intervention cardiac arrest research.
256 Mortality Benefit of Transfer to Level 1 vs Level 2
Trauma Centers for Head Injured Patients: Analysis
Using Instrumental Variables K John McConnell, Craig D
Newgard, Jerris R Hedges, Melanie Arthur, Richard J Mullins;
Oregon Health & Science University: Portland, OR, Portland
State University: Portland, OR
Background: Patients who are transferred to level 1 trauma
centers are often more severely injured than patients
transferred to level 2 trauma centers, causing a selection
bias in estimates of mortality benefits based on standard
biostatistical methods. Objectives: We used the method of
instrumental variables to account for selection bias and to
determine, for patients presenting to rural hospitals with
severe head injuries, whether there are mortality benefits of
transferring to level 1 trauma centers compared to level 2
trauma centers. Methods: Retrospective cohort study of 536
patients with head injury who initially presented to one of
31 rural hospitals in Oregon and Washington, and were
transferred from the emergency department to one of 15
level 1 or level 2 trauma centers, between 1991 and 1994. We
used a bivariate probit regression to determine the 30-day
mortality benefits of transfer to a level 1 trauma center,
using distance from the original hospital to the nearest level
1 trauma center as an instrumental variable to account for
the selection bias that occurs with the decision to transfer
patients. Predictor variables in this two-equation, joint
estimation included gender, age, Injury Severity Score
(ISS), other indicators of injury severity, and a dummy
variable indicating the transfer was to a level 1 trauma
center. Results: After adjusting for selection bias, transfer to
a level 1 trauma center reduced relative mortality risk by
76.6% (RR 0.234, 95% CI 0.035–0.974) for the average patient
when compared to transfer to level 2 trauma centers.
Conclusions: Patients with severe head injuries who are
transferred from a rural hospital to a level 1 hospital are
likely to have reduced mortality, compared to patients who
are transferred to level 2 hospitals.
509
257 Use of Computer-assisted Attribute Matching to
Estimate Pretest Probability Jeffrey A Kline, Charles L
Johnson, Craig D Newgard, Charles V Pollack; Carolinas
Medical Center: Charlotte, NC, Zframe: Boston, MA, Oregon
Health & Science University: Portland, OR
Background: Pretest probability (PTP) assessment can
provide a basis for resource use in the evaluation of patients
with potential emergent conditions. Current methods of
PTP assessment rely on remembered experience, score from
regression equation coefficients or decision tree analysis.
None of these methods provide the probability of an
outcome among subjects who all have an identical profile
of predictive attributes. Objective: The hypothesis was that
PTP for acute coronary syndrome (ACS) using a novel
method of attribute matching would be more accurate than
a validated method derived from regression analysis.
Methods: The source database contained 60 variables and
45-day ACS outcomes (MI, revascularization or death) that
were prospectively recorded for 15,000 ED patients with
symptoms of ACS. The database was analyzed for outcome
of ACS using classification and regression tree analysis to
select eight nominal attributes: 1. age (in three divisions), 2.
sex, 3. race, 4. known CAD, 5. chest pain reproduced with
palpation, 6. diaphoresis, 7. ST segment depression \
0.5
mm and 8. T wave inversion \
0.5 mm. A Standard Query
Language (SQL) program was written to match each subject
in the database with all other subjects in the database who
shared the exact identities of all 8 attributes. The PTP was
computed as the proportion of matched subjects with
outcome of ACS. PTP was also computed for each patient
using the Acute Cardiac Ischemia Time Insensitive Pre-
dictive Instrument (ACI TIPI). Low risk was defined as PTP
\ 2%. Results: The attribute matching method deemed 2224
of 15,000 patients (15%, 95% CI 14 to 15%) as low-risk for
ACS and one of 2224 (0.05%, 0 to 0.2%) had an outcome of
ACS. ACI TIPI deemed 206 of 15,000 patients (1.3%, 1.1 to
1.5%) as low risk, and one of 206 (0.5%, 0 to 2.7%) had an
outcome of ACS. Conclusion: A computer-assisted method
of matching clinical attributes accurately assessed the
presence of a low pretest probability of ACS in a large
database of ED patients.
258 A Comparison of Research Data Gathered
Prospectively and Retrospectively John T
Nagurney, David FM Brown, Swati Sane, Yuchiao Chang,
Justin B Weiner, Andrew C Wang; Partners Health Care:
Boston, MA, University of Michigan Medical School: Ann
Arbor, MI, Princeton University: Princeton, NJ
Objective: To quantitate the difference between prospec-
tively acquired (pro) and retrospectively acquired (retro)
data. Methods: Type of study: a single-site, bi-directional
comparative study. Setting: a level one 70,000-visit univer-
sity ED. Subjects: adults who were admitted through our ED
with a chief complaint of chest pain (CP). Observations: 12
elements of a typical CP history (hx) as determined by
interview of ED patients to establish a pro database. The
same CP hx elements were then obtained retro through
a review of medical records (MR) by trained, blinded
researchers. Analysis: the pro data set was considered the
criterion or gold standard for a sensitivity-specificity
510
analysis, with the availability of this information in the MR
representing the ‘‘test’’ applied. Kappa statistics (KS) were
also calculated. Results: 104 subjects (of 107 enrolled) were
evaluated, of which 63 % were men; the mean age was 63
years. Three percent of MRs were illegible; the interobservor
KS for chart review ranged from 0.56 to 1.00. The most
accurate data in the MR was for the hx of RFs for CAD.
Sensitivity ranged from .75 (95%CI .60–.90) to .93 (95%CI
.79–1.00); depending on decision rules involving implied
data; specificity ranged from .85 (95% CI .76–.94) to .94
(95%CI .89–.99). Historical data involving best choice among
several items (e. g. location of CP) was much less reliably
captured in the MR review (sensitivities ranged from .13 to
.41.). Among subjects with intermittent CP, the onset of the
most recent episode was accurately recorded in only 14%
(95%CI .05–.23) of cases. Conclusion: Investigators conduct-
ing retro research using MR review need to distinguish
between the relative importance of false negatives and false
positives. They also need to create decision rules between
explicitly stated and implied data elements, and to pay
particular attention to historical items that are less reliably
captured, such as those with multiple possible choices or
that involve timing.
259 Ecstasy’s (MDMA’s) Effect on Oxidative
Phosphorylation in Isolated Rat Liver
Mitochondria Daniel E Rusyniak, Stephany L Scruggs,
Lisa M Kamendulis, James E Klaunig; Indiana
University School of Medicine: Indianapolis, IN
Objective: Methylenedioxymethamphetamine (MDMA) is
a popular rave party drug with usage rapidly on the rise.
Severe intoxications result in a clinical syndrome charac-
terized by marked hyperpyrexia, tachycardia, muscle
rigidity, metabolic acidosis, coagulopathy, and death.
Chemicals that uncouple mitochondrial oxidative phos-
phorylation have a similar presentation. The objective of
this study was to determine if MDMA uncouples oxidative
phosphorylation in isolated rat liver mitochondria. Meth-
ods: Mitochondria were isolated from the livers of adult
male Sprague Dawley rats by differential centrifugation.
Oxidative phosphorylation was measured polarographi-
cally using a Clark oxygen electrode monitored with a
computer generated oxygraph. Rates of respiration, ADP/
Oxygen (ADP/O) ratios and respiratory control ratios
(RCR) were measured from control mitochondria and mito-
chondria with increasing concentrations of MDMA added
(0.1, 0.5, 1.0, 5 mM). Results were obtained for both com-
plex 1 (Glutamate and Malate) and complex 2 (Succinate)
substrates, with dinitrophenol (40nM) used as a positive
control for uncoupling. A one-way analysis of variance
(ANOVA) model was used to assess the effect of MDMA
concentration on the outcome measures. Dunnett’s multiple
comparison procedure was used to compare each of the
MDMA concentrations to the control group. Results: There
were no differences between the rates of respiration, RCR’s
or ADP/O ratios between control and MDMA at con-
centrations from 0.1 to 1.0 mM with either complex 1 or
complex 2 substrates. At the highest MDMA concentration
tested (5.0 mM) there was a significant difference between
state 4 respiration (20 vs 14 nmol O2/mg protein 3 min,
p ¼ 0.0046) and the RCR (3.0 vs 4.3, p ¼ 0.0014) compared to
2003 SAEM ANNUAL MEETING ABSTRACTS
control respectively for complex 1 substrates, and a signif-
icant reduction in the RCR for complex 2 substrate (3.0 vs.
3.74, p ¼ 0.0037). Conclusions: At high concentrations of
MDMA there is evidence for uncoupling of oxidative
phosphorylation.
260 Pharmacokinetic Effects of Co-ingested
Diphenhydramine or Oxycodone on Simulated
Acetaminophen Overdose Anil Goklaney, Michael E
Mullins, S Eliza Halcomb, Alexander Rachmiel, Marco LA
Sivilotti; Washington University: St. Louis, MO, Queens
University: Kingston, Ontario, Canada
Objective: Evidence-based guidelines recommend using
activated charcoal only in the first hour after acute acetamin-
ophen (APAP) overdose. Isolated case reports describe
delayed APAP absorption with overdose of combined-
formulations of APAP and antimuscarinic or opoid agents.
However, no prospective, controlled data exist to support or
refute a delay in APAP absorption in these settings. Our
objective is to determine the effects of diphenhydramine
(DPH) or oxycodone (OXY) on the kinetics of simulated APAP
overdose. Methods: IRB-approved, prospective crossover
study in healthy human volunteers (n ¼ 10). Subjects ingested
5g APAP (day A), 5g APAP þ 250mg DPH (day B), or 5g APAP
þ 0.5mg/kg OXY (day C). Study days occurred in random
order. We obtained serial serum [APAP] hourly (0–8h) and at
24h. The primary outcome was area under the curve (AUC)
for [APAP] from hours 0–8. Secondary outcomes were peak
[APAP] and time to peak [APAP]. Data were analyzed using
same-subject repeated measures ANOVA (with Scheffe
correction for multiple comparisons, SAS version 8.2) and
paired 2-tailed T tests. Results: For APAP alone, the mean
AUC was 318.3 6 82.0 mcg/mL-hrs with a peak [APAP]
71.8 6 11.9 mcg/mL occurring at 1.7 6 0.8 hrs. Compared to
APAP alone, APAPþDPH had a similar AUC 297.7 6 70.4
mcg/mL-hrs with peak [APAP] of 67.6 6 10.4 mcg/mL at
1.1 6 0.3 hrs. However, APAPþOXY had a 27% decrease
in AUC to 232.1 6 74.5 mcg/mL-hrs (p ¼ 0.005) with
a 40% lower peak [APAP] of 42.9 6 13.5 mcg/mL (p \ 0.001)
with a non-significant delay in time to peak [APAP] of
2.4 6 1.4 hrs (p ¼ 0.3) compared to APAP alone. Conclusions:
Diphenhydramine does not appreciably alter APAP absorp-
tion in simulated overdose. Oxycodone has important effects
on APAP absorption and bioavailability. This may have
clinical implications regarding nomogram interpretation and
suggests further study of the utility of activated charcoal
greater than one hour after mixed APAP and oxycodone
ingestion.
261 QT Prolongation and Cardiac Arrhythmias
Associated with Droperidol Use in Critical
Emergency Department Patients Marc Martel, James
Miner, Seth Lashkowitz, Mark Danahy, Joseph Clinton,
Michelle Biros; Hennepin County Medical Center:
Minneapolis, MN
Background: QT prolongation and torsade de pointes (TdP)
have been reported as a complication of droperidol (Drop).
Objectives: To determine the change in the corrected QT
interval (QTc) and the incidence of cardiac arrhythmias in
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
critically ill patients who received Drop. Methods: The
medical records of all critical care ED patients from 1/1/
1997 to 12/31/2001 were hand searched for those who
received Drop and an ECG in the ED. Drop dose, ECG time,
QTc intervals, and cardiac rhythm were reviewed. ECGs
with atrial fib/flutter, right or left bundle branch block,
or paced rhythms were excluded. Data was analyzed in 3
groups, patients with an ECG only before Drop, only after
Drop, and those with ECGs both before and after Drop. Data
was analyzed using descriptive statistics and chi-squared.
Results: 11,583 charts were reviewed, 1172 patients received
Drop, and 396 had both an ECG and Drop in the ED. 44
patients were excluded due to abnormal rhythm, bundle
branch block, or paced rhythm. 96 patients had an ECG only
before Drop (mean 33.3min prior), average dose of 2.75mg,
and mean QTc of 435.0ms (95% CI 428.1–441.9ms). 186
patients had an ECG only after Drop (mean 25.9min after),
average dose of 3.68mg, and mean QTc of 433.3ms (95% CI
427.8 to 438.8ms). 114 patients had ECGs before and after
Drop (mean time 28.2min before, 108.8min after), average
dose of 2.21mg, and mean QTc of 435.7ms (95% CI 426.7–
444.7ms) and 435.8ms (95% CI 427.5–444.1ms) before and
after Drop, respectively. The mean ratio of the QTc before
and after Drop is 1.005 (95% CI 0.985–1.025). 2 patients had
ventricular arrhythmias in the before Drop group, 3 in the
after Drop group, and 4 in the before and after Drop group
(p ¼ 0.5). 1 patient had an unrecorded event of TdP with
a QTc of 466ms after conversion. Conclusions: We detected
no statistical difference in the change of the QTc interval or
occurrence of ventricular arrhythmias in critically ill
patients who received Drop.
262 Analysis of Moonshine for Contaminants Jeffrey D
Ferguson, Christopher P Holstege, Carl E Wolf, Alexander B
Baer, Alphonse Poklis; University of Virginia: Charlottesville,
VA, Medical College of Virginia: Richmond, VA
Objectives: Consumption of moonshine in the past has been
associated with the risk of toxicity from impurities. Ex-
tensive moonshine production continues in the United
States, with over approximately 500,000 gallons produced
annually in individual states. Toxicity from moonshine
contaminants likely continues to be unrecognized. No signif-
icant studies have been conducted to analyze moonshine for
impurities since the 1960s. We hypothesized that moonshine
continues to contain potentially toxic levels of contaminants.
Methods: 48 different still samples of illicitly distilled
moonshine were obtained from law enforcement. An
independent laboratory, blinded to both the moonshine
source and a control sample of ethanol, conducted the anal-
ysis. Lead content was determined using atomic absorption
spectrophotometry with a graphite tube atomizer. Alcohol
content, including ethanol, methanol, and ethylene glycol,
was determined using gas liquid chromatography with
flame ionization detection. Results: Ethanol content ranged
from 10.5% to 66.0% with a mean value of 41.2%
and stardard deviation (SD) of 15.9%. Lead was found in
measurable quantities in 43 of 48 samples with values
ranging from 5 to 599 parts per billion (ppb) with a mean
value of 80.7 ppb (SD 123.1 ppb). A total of 28 of 48 (58%) of
samples had levels above EPA water guidelines of 15 ppb.
Methanol was found in only one sample at 0.11%. No
511
samples were found to contain measurable levels of ethyl-
ene glycol. Conclusions: Illicitly distilled alcohol was found
to have elevated lead content in the majority of moonshine
samples. Extrapolations based on the above moonshine lead
content suggest chronic abusers of moonshine could attain
toxic lead levels. Emergency medicine physicians should
consider lead toxicity in the differential diagnosis when
evaluating moonshine abusers.
263 Glibenclamide as a Treatment for Severe Verapamil
Toxicity Jason Chu, Theodore C Bania, Eric Perez,
Deepti Pisupati; St. Luke’s-Roosevelt Hospital Center:
New York, NY
Background: Severe verapamil (VER) toxicity causes shock
from vasodilation, decreased cardiac output and bradycar-
dia. Intravenous sulfonylureas increase blood pressure
in vasodilatory shock from hypoxia, endotoxemia, and
hemorrhage in animal studies. The effect of sulfonylureas
in verapamil-induced shock has not been previously
evaluated. Objective: To evaluate the effect of glibencla-
mide (GLB) as a treatment for severe verapamil toxicity.
Methods: Seven dogs were instrumented to measure
systolic (SBP) and diastolic blood pressures (DBP), cardiac
output (CO), pulmonary artery pressures and glucose. VER
toxicity, 50% decrease in mean arterial pressure (MAP ¼ 1/
2SBP þ 2/3DBP), was induced with VER at 6mg/kg/hr
and maintained for 30 minutes by titrating the VER rate.
The VER rate was changed to 4 mg/kg/hr and the animals
were observed for 1.5 hours until their hemodynamics
reached a steady state. At this time, the animals received
intravenous GLB (0.15mg/kg) hourly for a total of 3 doses.
Measurements 5 minutes before GLB were compared to
immediately after GLB and at 5 and 10 minutes after GLB.
Data were analyzed using a paired t-test and alpha ¼ 0.05.
Results: GLB increased SBP following the third dose of
GLB: immediately after GLB ¼ 5.3 mmHg, CI 1.8–8.9), 5
minutes after GLB ¼ 7.6 mmHg, CI 4.5–10.7, and 10
minutes after GLB ¼ 14.3 mmHg, CI 3.4–25.2. GLB also
increased MAP at this time: immediately after GLB ¼ 2.5
mmHg, CI 1.0–3.9, 5 minutes after GLB 4.2 mmHg, CI
2.6–5.8, and 10 minutes after GLB 6.3 mmHg, CI 3.3–9.4.
There were no significant changes in the DBP, CO, and
systemic vascular resistance after any GLB administration.
Two animals expired before the third GLB administration.
Glucose was greater than 60 mg/dL at all times. Conclu-
sions: GLB increased SBP and MAP after 3 doses in this
animal model of severe VER toxicity. Further investigation
is required to determine the optimal dose of GLB for the
treatment of VER toxicity.
264 Jimsonweed (Datura stramonium) Seed Extract as
a Protective Agent in Severe Organophosphate
Poisoning Theodore C Bania, Jason Chu, Dallas Bailes,
John Smith, Mellanie O’Neil; St. Luke’s-Roosevelt/Columbia
University: New York, NY, Metropolitan Hospital/New
York Medical College: New York, NY
Background: Treatment of patients following an organo-
phosphate (OP) exposure can deplete a hospital’s entire
supply of atropine. Given the possibility of multiple severe
512
exposures after a terrorist attack using (OP) nerve agents,
there exists a need for either greater atropine stores or the
development of alternative antidotes. Jimsonweed (Datura
stramonium) contains atropine and other anticholinergic
compounds and is common and readily available. It is used
recreationally for its central anticholinergic effects and is
made easily into an extract by boiling its parts. The extract
has rapid onset of effects and may be useful for treatment of
OP poisoning. Objective: To determine if pretreatment with
an easily stored and prepared Datura seed extract (DSE) will
increase survival following a severe OP poisoning. Meth-
ods: Datura stramonium seeds were collected, crushed and
then heated in water to make a 2 mg/ml atropine solution
(100 seeds contain approximately 6 mg of atropine or .007
mg/seed). Male Wistar rats were randomized to pretreat-
ment with either saline (n ¼ 10) or 7.5 mg/kg DSE (n ¼ 10)
given as a single intraperitoneal injection 5 min prior to
a subcutaneous injection of 25 mg/kg dichlorvos. The
endpoint was time to death recorded by a blinded observer.
Results: The Kaplan-Meier estimates of the 24 hour survival
rate was 90% (95% CI ¼ 60% to 98%) for the DSE pretreated
group and 10 % (95% CI ¼ 2% to 40%) for the control group.
The log-rank test revealed a statistically significant differ-
ence between the survival rates over time (P ¼ 0.0002).
Median survival time was 22 min 30 sec for the control
group and greater than 24 hours for the DSE pretreated
group. Conclusion: Pretreatment with DSE at doses of 7.5
mg/kg significantly increases survival following severe
dichlorvos exposure. DSE may be useful as an alternative
treatment in acute, severe OP poisoning. Future studies
should include treatment with DSE post OP exposure and
via the gastric route.
265 The Predictive Validity of the Canadian Triage and
Acuity Scale (CTAS) Rob Stenstrom, Eric J Grafstein,
Grant D Innes, Jim M Christenson; Providence Health Care:
Vancouver, British Columbia, Canada
Background: The Canadian Triage and Acuity Scale (CTAS)
has been shown, in various emergency department studies,
to have good reliability. No studies to date have assessed the
association between CTAS level and outcomes such as
utilization and patient disposition. Objective: To establish
the predictive validity of the CTAS in relation to patient
disposition, ED length of stay (LOS), hospital LOS (for
admitted patients) and utilization (lab tests and imaging)
based on a large administrative dataset. Methods: This
retrospective cohort study was conducted at St. Paul’s
Hospital, a Canadian tertiary care institution with 45,000
visits yearly. On arrival to the ED, all patients are assigned
a CTAS level (from 1 to 5) by the triage nurse. ED LOS,
hospital LOS, and patient disposition, were assessed for
over 70,000 patient visits between October 2000 and October
2002. As a proxy for utilization, the proportion of patients
having any imaging (CT scan, ultrasound, X-ray) or
a complete blood count (CBC) was established for each
CTAS level. Results: Multivariate ANOVA for mean ED
LOS and hospital LOS by CTAS level rendered statistically
significant results for ED LOS. Chi-square and trend
analyses for proportion of patients admitted, having a
CBC, or any imaging were significant (Bonferonni correction
for multiple comparisons used).
2003 SAEM ANNUAL MEETING ABSTRACTS
CTAS 1 2 3 4 5 P-Value
Mean ED
LOS (hrs) 5.7 4.0 3.5 2.1 1.7 \.0001
Admitted 54.9% 35.2% 23.9% 11.6% 2.8% \.0001
Any imaging 38% 35% 36.3% 24.9% 14.4% \.0001
CBC 46.1% 47.9% 39.8% 11.6% 6.1% \.0001
Conclusion: Based on this sample of over 70,000 patient
visits the CTAS has excellent predictive validity for clinical
and utilization outcomes.
266 Characteristics of Primary Care Practices Affect
Patients’ Emergency Department Use Robert A
Lowe, J Russell Localio, Donald Schwarz, Sankey Williams,
Lucy Tuton, Staci Maroney, David Nicklin, Harold I Feldman;
Oregon Health & Science University: Portland, OR,
University of Pennsylvania: Philadelphia, PA
Objective: Much attention has been focused on decreasing
emergency department (ED) use. Most previous research
has studied characteristics of patients seeking ED care,
finding that poor, under-insured, and non-White patients
are more likely to use the ED, but these studies have not led
to successful policy changes. We sought to measure the
association between characteristics of primary care practices
serving Medicaid patients and ED utilization by these
patients. Methods: Cohort study of 57,850 patients under
age 65 who were enrolled in a single Medicaid HMO in
Southeastern Pennsylvania from August 1, 1998 to July 31,
1999 and received care in 353 primary care practice sites.
Predictor variables were practice site characteristics, ascer-
tained by data collection at each site. The outcome measure
was the rate of ED use, adjusted for patient characteristics,
as obtained from HMO administrative data. Results: On
average, patients made 0.80 visits to the ED per person per
year. ED use was 2% lower for every hour after 5 PM that
a practice was open on weekdays (RR 0.98, 95% CI 0.97–
0.99). Medicaid patients assigned to practices with a higher
proportion of Medicaid patients had greater ED utilization
rates. A higher ratio of the number of active patients
per clinician-hour of practice time was also associated with
more ED use. Equipment for the care of asthmatic patients
was associated with ED use rates, but the direction of the
association depended on the type of equipment. Rates were
higher when nurse practitioners and physician assistants
were part of the treatment team. Conclusion: Primary care
practices that are open more evening hours have lower ED
use by their Medicaid patients. Practices that are over-
stressed, as measured by higher patient load and higher
proportion of Medicaid patients, have greater ED use. Some
of these associations suggest interventions that should be
studied for their ability to reduce ED use.
267 The Prevalence and Effect of Information Gaps in
the Emergency Department Andrew Stiell, Alan
Forster, Ian G Stiell, Carl van Walraven; University of Ottawa:
Ottawa, Ontario, Canada
Objectives: Information gaps (IG) occur when previously
collected information is unavailable to a physician who
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
is currently treating a patient. This study measured the
prevalence and impact of IG for patients presenting to the
ED. Methods: This prospective cross-sectional survey was
conducted in a teaching hospital ED on a stratified sample
of adult patients. A trained research assistant interviewed
ED attending and housestaff physicians immediately after
patient assessment to determine if there was previously
collected information that was not available in the ED. The
physicians identified what data was missing, why it was
required, and its importance to the patient’s care on a
5-point Likert scale. We reviewed patient charts to measure
severity of illness and determine if the patient was referred
to the ED by a community physician. Multiple linear re-
gression was used to determine if IG were associated
with ED length of stay. Results: Information was collected
for 1002 visits (983 patients) over an 8-week period. At least
one information gap was identified in 323 (32.2%, 95% CI
29.4%–35.2%) of ED visits. IG most commonly comprised
hospital record (36.9%), laboratory (23.3%), medication
(13.4%), and physician record (9.2%) data and were felt to
be essential to patient care 47.8% of the time. Patients with
IG were more likely to: be older (60 vs 48 yrs), have arrived
by ambulance (34.1% vs 20.9%), have triage level ‘emergent’
(15.5% vs 7.5%), be in a monitored bed (26.6% vs 12.4%),
have a cardiovascular diagnosis (23.8% vs 9.7%), and be
admitted (24.8% vs 11.3%); all p-values \.0001. After ad-
justing for important confounders, ED length of stay was 1.2
hours longer for patients with IG (p \ .0001). Conclusions:
IG were present in one-third of ED patients, most common
in the sickest patients, and independently associated with
prolonged stay in the ED. IG could have huge implications
to the patient and the health care system and future research
should identify strategies to decrease IG.
268 Reasons Why Patients Leave without Being Seen
from the Emergency Department Brian H Rowe,
Channan Peter, Michael Bullard, Arif Alibha, Duncan Saunders;
University of Alberta: Edmonton, Alberta, Canada
Objectives: Recently, patients leaving without being seen
(LWBS) by a physician have become an important emer-
gency department (ED) concern; however, research into this
problem has been limited. The purpose of the present study
was to determine the acuity level, reasons, and outcomes of
patients who LWBS at two EDs. Methods: This prospective
study, contacted all patients who LWBS at two Canadian
EDs during six 7-day sampling periods in the summer of
2002. Following medical record review, a telephone ques-
tionnaire with the patient or guardian was completed up to
14 days after the original visit or 6 attempts. Results: 8531
patients registered and 395(4.6%) LWBS during the sam-
pling periods. Of these, 361 were confirmed LWBS cases;
46% were female and the mean age was 37. An urgent triage
score was assigned to 26% of these LWBS. Median patient
arrival in the hours before and during arrival was 11 (IQR: 9,
13) and median delay to seeing an MD for a triage-matched
control was 79 minutes (IQR: 44, 135). Follow-up contact
was made with 261(72%) and 245(94%) agreed to partici-
pate. The most common reason for LWBS in adults was ‘‘fed
up with waiting’’ (49%) and in children was ‘‘feeling better’’
(44%). Overall, 60% of LWBS cases sought alternative
medical attention for their symptoms; of the patients who
513
did not seek any medical attention, 28 (29%) were triaged
as urgent. Six patients were hospitalized and two of those
required urgent surgery after seeking subsequent medical
attention. One patient who did not follow up with a
physician died four days after ED registration. Conclu-
sions: The majority of LWBS results from impatience during
periods of peak ED volumes. Many patients seek alternative
medical care within one week of their presentation and,
while rare, complications do occur. While most ED LWBS
cases are minor and low-risk ailments, further research is
required to determine methods of reducing LWBS, espe-
cially ‘‘high risk’’ patients.
269 A Comparison of Two Methods for Biosurveillance
of Respiratory Disease in the Emergency
Department: Chief Complaint vs ICD9 Diagnosis
Code Melissa Mocny, Dennis George Cochrane, John R Allegra,
Trang Nguyen, Richard T Heffernan, Julie Pavlin, Jonathan
Rothman; New York State Department of Health: Albany, NY,
Morristown Memorial Hospital Residency in Emergency
Medicine: Morristown, NJ, New York City Department of
Health and Mental Hygiene: New York, NY, Walter Reed
Army Institute of Research: Silver Springs, MD, Emergency
Medical Associates of New Jersey Research Foundation:
Livingston, NJ
Objectives: ICD9 diagnosis code (ICD9) and patient’s chief
complaint (CC) have both been advocated for surveillance
of emergency department (ED) visits to detect or mitigate
a bioterror attack. However, few studies exist comparing
these two methods. The objective of this study was to see if
two existing ICD9 and CC respiratory algorithms identified
similar patients and patterns of illness when applied to the
same ED database. Methods: Design: Retrospective analysis
of a computerized database of ED visits. Setting: 15 New
Jersey EDs located in urban and suburban areas with annual
ED volumes from 20,000 to 65,000. Participants: Consecutive
patients seen by ED physicians, January 1999 to November
2002. Protocol: A CC respiratory illness algorithm was
developed by the New York City Department of Health and
extended by the New York State Department of Health. An
ICD9 respiratory illness algorithm was supplied by the
ESSENCE project. Applying each method, we prepared
time-series graphs of illness and also calculated a Kappa
statistic for agreement. We also analyzed the patient visits
for which the methods disagreed. Results: There were
2,250,922 patient visits in the database. Visual inspection of
the time-series graphs demonstrated good agreement re-
garding seasonal variations in incidence of respiratory
illness. However, the Kappa statistic showed only fair
agreement between the two methods (Kappa ¼ 0.37).
Subgroup analysis revealed that many patients presenting
with a non-respiratory CC (e.g. ‘‘fever’’) fell into the
respiratory ICD9 group at final diagnosis. Also, the methods
differed in terms of diagnostic targets. Conclusion: These
existing CC and ICD9 methods identified similar seasonal
variations in respiratory illness. The lack of agreement
between the two methods was due both to the different
information captured in the CC and ICD9, and also to
the different diagnostic targets included in the two
algorithms. Further work needs to be done to evaluate
these methods.
514
270 Emergency Medicine Patients’ Access to Healthcare
(EMPATH) Study: Reasons for Seeking Care in the
Emergency Department Lynne D Richardson,
Deborah Fish Ragin, Ula Hwang, Rita K Cydulka
Dave Holson, Christopher Richards, Leon L Haley Jr,
Bruce Becker, Steven L Bernstein; Mount Sinai School of
Medicine: New York, NY, Yale-New Haven Medical Center:
New Haven, CT, MetroHealth Medical Center/Case Western
Reserve University: Cleveland, OH, Queens Hospital Center:
New York, NY, Oregon Health & Science University: Portland,
OR, Emory University School of Medicine: Atlanta, GA,
Brown Medical School: Providence, RI, Newark Beth Israel
Medical Center: Newark, NJ
Objective: To identify the reasons patients seek care in EDs
rather than other health care settings. Methods: This cross
sectional observational study was conducted at 30 U.S.
hospitals selected to allow stratification by geographic
region and by hospital and patient demographics. Data,
collected during one 24-hour period at each site, were
obtained through a structured interview, administered to
all consenting adult patients who sought treatment during
that period, and a chart review conducted on all presenting
patients during the same time interval. Demographic,
clinical and insurance data were collected. In the interview,
21 carefully worded statements designed to capture a range
of possible reasons for seeking care in the ED were read to
the patient who then indicated their level of agreement (on
a 3-point Likert scale) with each statement as a reason for
that ED visit. Correlational analyses were conducted to sort
and consolidate responses to these 21 items in order to
construct more robust measures of patients’ reasons for
coming to the ED. Results: 1,547 patient interviews and
1,956 chart reviews were completed on a diverse sample of
patients who were 53.5% female; 56.5% white, 24.8% African
American, 6.1% Hispanic, 1.9% Asian American and 10.2%
other, mixed or missing; mean age was 48.0 years. Analysis
revealed four types of reasons for patients seeking care in
the ED which were consistent across all geographic areas:
95.9% Medical Necessity (e.g. ‘‘too sick to go anywhere
else’’, ‘‘it’s a medical emergency’’); 88.8% ED Preferred
(‘‘better care in ED’’, ‘‘can get everything done here’’); 86.3%
Convenience (‘‘ED only place open’’, ‘‘no appointment
needed’’) and 29.9% Affordability (‘‘cannot afford anywhere
else’’, ‘‘no insurance’’). Conclusions: These findings suggest
that, for most patients, ED utilization is not driven by a lack
of other affordable options, but rather by the scope, quality
and availability of ED services as compared to other sources
of health care.
271 Stages of Change Are Predictive of Response to
a Brief Intervention for Alcohol Problems in Young
Adult Emergency Department Patients Luba Leontieva,
Arshadul Haque, James C Helmkamp, Samuel D
Swisher-McClure, Peter Ehrlich, Janet M Williams,
Kimberly A Horn; West Virginia University Center for Rural
Emergency Medicine: Morgantown, WV
Objectives: The goal of this study was to determine if
baseline stages of change (pre-contemplation, contempla-
tion, preparation, and action) are predictive of the
effectiveness of a brief intervention for young adults
identified as having self-reported alcohol problems during
2003 SAEM ANNUAL MEETING ABSTRACTS
their emergency department (ED) visit. Methods: From
August 1998 through December 2000, the Alcohol Use
Disorders Identification Test (AUDIT) was administered to
all consented ED patients aged 18–29 years. A brief
motivational intervention was provided to screen-positive
patients (AUDIT score [5 out of 40). Outcome was
measured as a decrease at 3-month follow-up in the
scores within the AUDIT domains of alcohol intake,
harm-related behavior, and dependency symptoms. Logis-
tic regression was used to analyze the predictability of
stages of change among the AUDIT domains at 3-month
follow-up. Results: Sixty percent (805/1304) of the screen
positive patients were successfully followed at 3 months.
Of the 805 followed up patients, 48% were pre-contem-
plators, 24% were contemplators, 5% were in the
preparation stage, and 23% were taking action. Compared
to patients in the pre-contemplation stage, those in the
action stage were over twice as likely to reduce their
alcohol intake (OR ¼ 2.2, 95%CI ¼ 1.1–4.7), nearly three
times as likely to reduce their alcohol-related harm
behavior (OR ¼ 2.8, CI ¼ 1.6–4.9), and almost four times
more likely to decrease their dependency symptoms (OR
¼ 3.6, CI ¼ 1.9–6.6). Compared to pre-contemplation
patients, those in the contemplation stage were nearly
twice as likely to reduce their alcohol-related harm (OR ¼
1.9, CI ¼ 1.0–3.3) and those in the preparation stage were
more than twice as likely to reduce their dependency
symptoms (OR ¼ 2.2, CI ¼ 1.1–4.3). Conclusions: Stages
of change at baseline appeared to be significant predictors
for young adults in reducing alcohol intake, alcohol-
related harm, and dependency symptoms following a brief
intervention.
272 Randomized Controlled Trial of an Emergency
Department-based Interactive Computer Program
to Prevent Alcohol Misuse among Injured Adolescents
Ronald F Maio, Jean T Shope, Frederic C Blow, Mary Ann
Gregor, Jennifer S Zakrajsek, James E Weber, Michele M
Nypaver; University of Michigan: Ann Arbor, MI, Hurley
Medical Center: Flint, MI
Objectives: The emergency department (ED) may be an
ideal place to deliver interventions to prevent adolescent
alcohol-related injury. Use of a computer may facilitate such
interventions. Hypothesis: an ED-based laptop computer
intervention reduces the normative age-related increase
of alcohol misuse (AM) compared to standard of care.
Methods: Design: Randomized controlled trial. Setting:
Community teaching hospital and university medical center.
Subjects: 14–18 years of age, presenting with a minor injury
(Triage Class [ 2); intoxicated patients were excluded; 10/
11/99–4/14/01; Both controls (C) and experimental (E)
subjects completed a computer-based questionnaire; E also
completed a laptop-based interactive computer program to
affect alcohol use/misuse. Measures: Alcohol Misuse Index
(AMIdx): at baseline (T0), 3 (T3) and 12 months (T12) (T3 and
T12 via phone, interviewers blinded), Demographics, injury
severity score (ISS). Analysis: Repeated measures analysis,
statistical significance p \ 0.05; alpha 1.96; power 0.80, effect
size (ES) 0.10. Results: 329 subjects were randomized to E
and 326 to C; 295 E (89.7%) and 285 C (87.4%) completed 3
month and 12 month follow-up. Mean age 16.0, 15.9; AMIdx:
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
2.2, 2.0; ISS: 1.8, 1.8; Males: 66.8%, 66.3% for E and C
respectively. The AMIdx for both groups decreased by about
30% of baseline at T3; at T12 the AMIdx increased in both
groups rising above baseline for C (þ2.4%), yet still below
baseline values for E (
15.2%), however, this was NS (ES
0.06). The subgroup of 17–18 year olds showed a group by
time interaction (p ¼ .02), with the groups at T0 and T3 very
similar. From T0 to T12 the AMIdx for E was down
0.94 (CI
¼
1.93, 0.04) p ¼ .06 and for C was up 1.06 (CI ¼
0.11,
2.24) p ¼ .08. Conclusion: No significant reduction in AM
was noted for both groups, however, these data suggest
a potential benefit among 17 and 18 year olds.
273 Linking Emergency Department Patients with
Alcohol and Other Drug Problems to Treatment
Gail D’Onofrio, Linda C Degutis; Yale University:
New Haven, CT
Objective: To determine if Health Promotion Advocates
(HPAs) as part of a Project ASSERT model can effectively
link ED patients with alcohol and drug (AOD) problems to
specialized treatment programs. Methods: 3 HPAs (2.6
FTEs) are available 8am–11pm Monday-Friday, 8am–8pm
Saturday and 8am–4pm on Sunday. They identify patients
with alcohol and drug problems by completing health needs
surveys, or through ED staff or patient self-referrals. The
HPAs perform Brief interventions in AOD dependent
patients with the goal of negotiating enrollment into a STP.
Results: 10,572 patients were screened and evaluated for
AOD problems from 12/99–11/01. 49.0% were male. Mean
age was 41.0 SD 6 15.7. 43.0% were white, 30.6% black, 23.2
Hispanic, and 3.0% other. Of the 48.8% (5162) who reported
alcohol consumption, 25.6% (1324) exceeded the NIAAA
recommendations for at-risk drinking by either quantity/
frequency/binge criteria or 1 positive CAGE response.
23.9% (1233) were dependent ($2 CAGE positive) and
13.4% (1420) patients reported illicit drug use. Of these 59.0 %
reported use of cocaine/crack; 37.0% Heroin; 20.6% mari-
juana. 1343 AOD dependent patients were referred. Follow-
up data is presented below:
1 year 2 year Total
Referred to STP 719 624 1343
Contact made 293 (40.8%) 518 (83.0%) 811(60.0%)
Enrollment 227 (77.5%) 484 (93.4%) 711 (87.6%)
Conclusion: ED patients with AOD problems linked to
treatment by HPAs were likely to enroll in a program.
274 Can Trained Health Educators Provide Screening,
Brief Intervention and Referral Services in an
Academic Teaching Hospital Emergency Department?
Theodore C Chan, Dennis Kelso, James V Dunford, Gary M
Vilke; UC San Diego: San Diego, CA, Altam Associates:
San Diego, CA
Objective: Nationwide, alcohol use accounts for a large
portion of ED visits. We examined the feasibility of a
Screening, Brief Intervention and Referral (SBIR) program
515
conducted by health educators in an academic ED. We
hypothesized that such a program could screen a large
portion of patients with little impact on ED length of stay
(LOS), and with greater success when compared to
physician screening. Methods: Design—Prospective exper-
imental before-after clinical trial. Setting—University urban
trauma center and teaching hospital. Subjects—All adult ED
patients able to complete verbal SBIR screening test
(AUDIT—Alcohol Use Disorders Identification Test) by
trained health educators (available 12 hours a day) com-
pared with historical controls. Study—We prospectively
collected data during the first month of the program (post-
SBIR) on the number of ED patients eligible for screening,
patients actually screened, screening results, ED census and
LOS. We compared this data with the month prior to the
start of the program (pre-SBIR), as well as with historical
data from a previous 1-month trial in which ED physician
faculty & housestaff underwent training to perform alcohol
dependence screening (MD-screen). Statistical analysis was
conducted using 95% confidence intervals (CI) and chi-
square testing (STATA). Results: There was no difference
between pre-SBIR and post-SBIR periods in terms of ED
census or mean LOS. With SBIR, 907 of 931 eligible patients
were successfully screened. More patients were screened
during the post-SBIR period (93.0% [CI 91.2–94.5%] vs 36.2%
[CI 34.3–38.1%], p \ 0.001), and more patients were
determined to be at risk for alcohol dependence (26.0% [CI
22.9–28.7%] vs. 4.3% [CI 3.1–5.8%], p \ 0.001) when com-
pared with the MD-screen period. Conclusions: Use of
health educators to conduct alcohol screening in the ED
resulted in more patients being screened and determined to
be at risk for alcohol dependence. SBIR screening did not
impact mean ED LOS.
275 Syncope and Electrocardiograms: What
Abnormalities Are Most Significant and How
Sensitive Is It for Acute Myocardial Infarction (AMI)?
Daniel A McDermott, James V Quinn, Jonathan G Zaroff;
University of California, San Francisco: San Francisco, CA
Objectives: Among patients presenting with syncope to: 1)
Determine the specific EKG abnormalities associated with
all serious outcomes and 2) Determine the sensitivity and
specificity of an initial EKG for predicting AMI. Methods:
Emergency physicians determined the presence of an
abnormal EKG (new changes and/or non-sinus rhythm)
as they prospectively evaluated patients with syncope. All
patients were followed to determine if they had suffered
a serious outcome (death, AMI, arrhythmia, PE, stroke,
SAH, significant hemorrhage or any condition causing
a return ED visit and hospitalization for a related event).
Specific EKG’s abnormalities {unstable rhythm, SVT, RBBB,
LBBB, paced rhythm, significant and non specific ST seg-
ment changes, interval variants, presence of ectopy or
Q-waves} were noted. Variables were assessed using chi-
square and logistic regression analysis to determine sig-
nificant associations with all serious outcomes. The sen-
sitivity and specificity of the initial EKG to predict the sole
outcome of acute AMI was also assessed. Results: 684 pa-
tients were evaluated, 219 had abnormal EKG’s, 50 of 219
suffered serious outcomes. An unstable rhythm (predefined
as a serious outcome), significant ST segment changes OR ¼
516
3.74 (95%CI 1.2–11.9) and the presence of a LBBB (old or
new/complete or partial) OR ¼ 2.28(95%CI 1.02–5.1) were
most likely to be associated with serious outcomes.
Considering all 684 patients, only 21(3.0%) were determined
to have had an AMI, over half being non-Q wave. An initial
EKG classified as abnormal was 67% (95%CI 44%–84%)
sensitive and 69% (95%CI 68%–70%) specific with a negative
predictive value (NPV) of 98.5% (95%CI 97.4%–99.3%) for
predicting AMI. Conclusion: In syncope patients with
abnormal EKG’s, those with unstable rhythms, significant
ST segment changes and LBBB are more likely to be asso-
ciated with serious outcomes. The EKG has low sensitivity
for predicting AMI, but has a high NPV because of the low
incidence of MI among patients with syncope.
276 Upwardly Concave ST Segment Morphology Is
Common in Acute Left Anterior Descending
Coronary Artery Occlusion Stephen W Smith; Hennepin
County Medical Center: Minneapolis, MN
Background: ST elevation (STE) in anterior precordial leads,
in association with upwardly convex morphology (CVxM) or
straight morphology (SM), is associated with anterior acute
myocardial infarction (aAMI). Upwardly concave morphol-
ogy (CCvM), is characteristic of pseudoinfarction patterns
such as early repolarization. Objective: The hypothesis was
that aAMI frequently presents with CCvM; thus, CCvM
cannot be relied upon to exclude aAMI. Methods: Retro-
spective review of diagnostic ECGs of consecutive patients
presenting to our ED who were diagnosed with aAMI,
underwent emergent primary percutaneous coronary in-
tervention, had proven left anterior descending coronary
artery occlusion and no bundle branch block. On leads V2–
V6, a straight line was placed from the J-point to the T-wave
inflection. CCvM was defined as the presence of any area
below this line in all 5 leads. CVxM was defined as any area
above the line in at least one lead. SM was defined by no area
above the line in any lead, and no area below the line in at
least one lead. ‘‘Non-concave’’ morphology (NCCvM) was
defined as CVxM or SM. Thus, NCCvM was defined as no
area below the line in one or more leads. Borderline STE
(BSTE) was defined if the ECG did not have 2 consecutive
leads with [2mm of STE (as measured at the J-point and
relative to the PR segment). Data was analyzed with
descriptive statistics. Results: 37 patients were identified
who met the inclusion criteria and whose records were
available for review. 18 of 37 (49%) had CCvM. 19 (51%) had
NCCvM, 8 with CVxM, and 11 with SM. 14 of 37 (38%) had
BSTE. Of these 14, 6 (43%) had NCCvM and 8 (57%) had
CCvM; 8 of 37 (22%) had both BSTE and CCvM. Conclusion:
A clinically significant proportion (49%) of patients with
acute LAD occlusion have a CCvM. In our institution, 22% of
patients with acute LAD occlusion had both BSTE and
a CCvM. Concave morphology does not exclude acute LAD
occlusion, even in patients with BSTE.
277 Relationship between Time to ECG Acquisition and
Adverse Cardiac Events in Patients with Unstable
Angina or Non ST Elevation Myocardial Infarction
Deborah B Diercks, J Douglas Kirk, Christopher J Lindsell, Judd
E Hollander, Charles V Pollack, James W Hoekstra, W Brian
Gibler; University of California, Davis Medical Center:
2003 SAEM ANNUAL MEETING ABSTRACTS
Sacramento, CA, University of Cinncinnati: Cincinnati, OH,
University of Pennsylvania: Philadelphia, PA, Pennsylvania
Hospital: Philadelphia, PA, Ohio State University: Columbus,
OH
Background: Recent guidelines for the management of
unstable angina (UA) and non-ST segment elevation myo-
cardial infarction (NSTEMI) recommend that an electrocar-
diogram (ECG) be obtained within 10 minutes of arrival to
the emergency department (ED). Objective: To determine the
clinical impact of a delay in time to ECG acquisition in
patients with UA/NSTEMI. Methods: We analyzed the
presentation to ECG time for patients included in a pro-
spective registry of undifferentiated chest pain patients who
presented to eight community or university EDs. Patients
with the diagnosis of UA/NSTEMI based on the ED
physician’s clinical impression or elevated cardiac injury
markers were included in the analysis. Logistic regression
was used to determine the relationship between time to ECG
acquisition and the occurrence of adverse cardiac events
which included death or recurrent myocardial infarction
within 30 day follow-up. Multivariate analysis was done to
adjust for ED treatments (aspirin, heparin, beta-blocker,
nitroglycerin, and glycoprotein-IIb/IIIa inhibitors) and the
liklihood of ischemia using an acute cardiac ischemia-time
insensitive predictive instrument (ACI-TIPI) score. Results:
Of the 1249 patients who met the criteria for UA/NSTEMI,
median age was 62 yrs, SD 21. Median time to ECG acq-
uisition was 17 minutes (IQR 31.8 minutes). Adverse events
were found in 29 patients (2.3%). After adjusting for ED
treatment and ACI-TIPI score, a delay in ECG acquisition
over 10 minutes was an independent predictor of adverse
events. Every minute delay over 10 minutes resulted in a 0.3%
(OR 1.003, 95% CI 1.00–1.006) increase in death or recurrent
myocardial infarction. Conclusion: In patients with UA/
NSTEMI, an increase in time from presentation to ECG
acquisition significantly increases the risk of death or re-
current MI.
278 Ratio of T Amplitude to QRS Amplitude Best
Distinguishes Acute Anterior MI from Anterior Left
Ventricular Aneurysm Stephen W Smith, Megan Nolan;
Hennepin County Medical Center: Minneapolis, MN
Objectives: Reperfusion therapy for acute myocardial in-
farction (AMI) is indicated in the presence of ST elevation
(STE) and ischemic symptoms. Previous MI may present
with persistent STE, or ‘‘left ventricular aneurysm’’ (LVA)
morphology that mimics AMI. Hypothesis: a high ratio of T-
wave (TW) amplitude (TA) to QRS amplitude (QRSA) best
distinguishes AMI from LVA. Methods: All patients (pts)
with ‘‘diastolic distortion’’ (LVA) in the echocardiography
database were retrospectively identified; all who had
presented to the ED with ischemic symptoms and STE of
at least 1 mm in 2 consecutive leads and ruled out for acute
LAD occlusion were selected. ECGs were compared with 37
consecutive anterior AMI (aAMI) with proven acute LAD
occlusion. Bundle branch block was excluded. Measure-
ments (MMT) of STE at the J-point (JP) and 60 milliseconds
after the JP, and of T-, Q-, R-, and QRS amplitudes were
recorded. Various MMTs and ratios were compared. Data
was analyzed by descriptive statistics and t-test. Results: 22
pts with LVA met the inclusion criteria. Neither Q-wave
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
presence, absence, nor depth, nor STE at the J-point,
distinguished AMI from LVA. All other STE and TW MMTs
and ratios resulted in statistically significant differences
between aAMI and LVA. The best discriminator was TA to
QRSA ratio, misclassifying (MC) only 4 of 59 cases. For aAMI
and LVA, respectively, mean (695% CI) ratio of highest
TA:QRSA ratio in leads V1–V4 for each ECG was 1.1 (0.31)
and 0.25 (0.05), (p \ 0.015). If any single lead had a TA:QRS
ratio [ 0.36, 35 of 37 were aAMI. If no lead had a ratio [0.36,
20 of 22 were LVA. Ratio of TA sum to QRSA sum in V1–V4
performed identically: for aAMI and LVA, respectively, the
mean ratios were 0.54 (.086) and 0.16 (.024), (p \ 0.05). MMTs
and ratios using ST segment and Q-waves, respectively, had
MC rates from 9–16 and 19–21 out of 59 pts. Conclusion: TA
to QRSA ratio best distinguishes aAMI from LVA in ECGs
that meet STE criteria for reperfusion therapy.
279 A Model for Drug Effects on Intracranial Pressure
at Altitude Alan B Storrow, Christopher J Lindsell;
University of Cincinnati: Cincinnati, OH
Objective: To develop a model for the effect of prophylactic
drug use on intracranial pressure (ICP) during altitude
exposure. Methods: ICP was recorded by subdural micro-
sensor once per minute in 2 groups of New Zealand white
rabbits during randomized hypobaric chamber induced
altitude exposures. Rabbits received either drug (Group 1:
dexamethasone, verapamil or caffeine, Group 3: nimodipine)
or saline (control) in a blinded crossover fashion. Rabbits
were taken from ambient barometric pressure to an equiv-
alent of 16,000 feet (Group 1, n ¼ 18) or 18,000 feet (Group 3, n
¼ 8) over 2 hours, and then remained at altitude for 1 hour. A
96 hour medication washout occurred between exposures.
Mixed models were developed to determine the effect of
altitude and drug during ascent, and at altitude. Parameter
estimates (95% CI) are given. Results: Overall, baseline ICP
(mmHg) was 7.61 (7.43, 7.78). Dexamethasone increased
baseline ICP by 0.53 (0.24, 0.82) and verapamil decreased
baseline ICP by
0.68 (
0.97,
0.39). During ascent, the
change in ICP for each 10,000 foot increment was: a) control
0.17 (0.02, 0.31), b) dexamethasone
0.35 (
0.61,
0.09), c)
verapamil
0.23 (
0.49, 0.03), d) caffeine
0.32 (
1.82, 1.18),
and e) nimodipine 0.54 (0.27, 0.80). Effects of caffeine and
verapimil were not significant. At altitude, ICP was 8.18
(8.01, 8.35). Pretreatment with caffeine, dexamethasone or
verapamil resulted in significant decreases in ICP compared
to controls:
1.36 (
2.61,
0.11),
0.93 (
1.17,
0.69) and

1.67 (
1.90,
1.43), respectively. Nimodipine increased
ICP, 0.52 (0.25–0.78). Conclusion: During ascent ICP tends to
increase in controls, pretreatment with dexamethasone
reversed this change while nimodipine amplified it. Dexa-
methasone, caffeine and verapamil decreased ICP at altitude.
Nimodipine increased ICP at altitude. While the clinical
significance of the modest changes in ICP is unclear, this
model may prove valuable for further study with different
ascent rates, altitudes, and drugs.
280 Vasopressin vs Glucagon to Treat Beta-antagonist
Toxicity in a Porcine Model Christopher L Obetz,
Joel S Holger, Kristin M Engebretsen, Tanya L Kleven,
Carson R Harris; Regions Hospital: St. Paul, MN
517
Objective: We compared the efficacy of vasopressin (VP)
and glucagon (GL) in a porcine model of beta-blocker
toxicity. Our primary outcome was survival over 4 hours.
Methods: Sixteen pigs were anesthetized with isofluorane
and nitrous oxide, and underwent tracheostomy. A Swan-
Ganz catheter and an arterial line were placed. Each pig
received a 1 mg/kg bolus of propranolol i.v. followed by
continuous infusion at 0.25 mg/kg/minute throughout the
protocol. Toxicity was defined as a 25% decrease in the
product of heart rate (HR) and mean arterial pressure
(MAP), at which point 20 ml/kg normal saline was rapidly
infused. Each pig was randomly assigned to receive either
VP or GL after the saline bolus. The VP group received
a continuous infusion at 0.0028 U/kg/minute which was
titrated up to a maximum of 0.014 U/kg/minute to main-
tain HR-MAP product [75% of baseline. The GL group
received a 50mcg/kg bolus followed by continuous infu-
sion at 150mcg/kg/hour. HR, MAP, systolic BP (SBP),
cardiac output (CO), glucose, and pH were monitored for
4 hours from toxicity or until death. A Kaplan-Meier
survival curve was constructed. Results: No differences
were found throughout the 4 hour survival curves between
the two groups (log-rank test 0.059, p ¼ 0.81). One pig
survived at 4 hours (VP group). No overall differences
were identified in MAP, systolic BP, cardiac output, or HR.
However, over the first hour MAP and SBP were
significantly higher in the VP group (p ¼ 0.004, p ¼ 0.006,
respectively). Glucose and pH levels did not differ signifi-
cantly at any time. Conclusions: In this beta-blocker toxicity
model, there were no differences in the survival curves
between vasopressin- and glucagon-treated pigs during
a 4 hour analysis period. No overall differences were noted
in MAP, systolic BP, cardiac output, HR, pH, or glucose
levels, although vasopressin treatment yielded higher MAP
and systolic BP early in resuscitation.
281 Ethnic Differences in the Home Management of
Poisonings Gregory Luke Larkin, Larissa I Velez, John J
Zielinski, Wilfredo Rivera, J Greene Shepherd, Sean Fleming,
Daniel C Keyes; University of Texas Southwestern Medical
Center at Dallas: Dallas, TX, North Texas Poison Center:
Dallas, TX
Objective: To evaluate differences in knowledge and
awareness in the management of poisonings by ethnicity.
Methods: Stratified random sample of residents in Dallas
County, Texas, USA. A random digit dial survey of 900
citizens was conducted: 300 White (W), 300 Black (B) and
300 Hispanic (H). The respondents were asked the following
open-ended question in English or Spanish: ‘‘If someone
you know accidentally or intentionally swallows something
that is poisonous, what are the first three things you would
do?’’ The top three choices were recorded for every
respondent. The data were stratified by ethnicity and
differences of proportion, odds ratios (OR) and 95%
confidence intervals were calculated. Results: The top three
choices varied by ethnicity and the top five overall choices
for the 900 respondents are presented below (Table 1).
Calling 911 was the most popular countermeasure and did
not differ significantly by ethnicity. Hispanic respondents
were one third as likely as Whites and half as likely as
Blacks to call the Poison Center (p \ 0.00001). Hispanics
518
were also more than twice as likely to go to the ED than
White or Black respondents (p \ 0.00001). Exclusive and
independent of suggesting ipecac or inducing vomiting,
Blacks and Hispanics were significantly more likely to ‘‘give
milk’’ than Whites (OR: 10.7 (4,31) B v. W and 8.9 (3.3, 26) H
v. W).
Priority Actions White % Black % Hispanic %
Call 911 68.0 69.7 62.7
Go to the ED 15.1 17.7 35.0*
Induce vomiting 21.0 16.7 17.0
Give milk 1.8 16.7 14.3*
Call Poison Center 46.3 28.7 17.7*
*p \ 0.0001
Conclusions: Disparities in health seeking behavior and
toxicologic education have implications for poison center
and ED resource utilization. In our study population,
Hispanics were the least likely to call the PC for advice
and were the most likely to directly access an ED in cases of
poisoning.
282 Effects of Physostigmine Following Cessation of
Chronic GHB Administration in Mice Theodore C
Bania, Jason Chu, Mellanie O’Neil, Amanda Batisti;
St. Luke’s-Roosevelt/Columbia University: New York, NY
Background: Physostigmine(PHYSO)is an arousal agent
controversially used to treat coma following gamma-
hydroxybutyrate(GHB)overdoses. Chronic GHB users with
withdrawal symptoms take more GHB to relieve symptoms
resulting in coma. The effect of PHYSO given to chronic
GHB users who overdose on GHB is unknown. Objective:
To determine if there is increased toxicity to physostigmine
following cessation of chronic, large dose use of GHB.
Methods: 8 mice had a subcutaneous mini-pump implanted
and 7 controls had similar sized shams placed. Pumps
delivered 5.6 gm/kg-day of gamma-butyrolactone (GBL)
continuously over 7 days. On day 8, a reversal dose of
PHYSO was given intraperitoneally every 15 min (0.1 mg/
kg-dose for dose 1–16(3 hours), 0.2 mg/kg-dose for dose 16–
20 (1 hour), 0.3 mg/kg-dose for dose 20–36 (4 hours) or until
persistent seizures or death. Prior to each dose the mice
were assessed by a blinded observer for ptosis, lacrimation
(LAC), fasiculations (FASC), tremors, or seizures and
monitored continuously for time of death. Data was anal-
yzed using a Kaplan Meier-log rank and Mann-Whitney U
tests. This study is powered to detect a 10-fold difference in
100% lethal dose (LD100) of PHYSO. Results: 8/8 GBL
treated mice and 6/7 controls survived the 7 days of
pretreatment. 0/8 GBL treated and 1/6 controls survived
the PHYSO dosing (mean LD100 of PHYSO: GBL ¼ 4.32
mg/kg, control ¼ 4.88 mg/kg, p ¼ 0.55) (median survival:
GBL ¼ 378 min, control ¼ 375 min). The median time to
signs are: ptosis: GBL ¼ 150 min, control 120 min, p ¼ 0.4;
LAC: GBL ¼ 150 min, control ¼ 95 min, p ¼ 0.36; FASC: GBL
¼ 45 min, control ¼ 30 min, p ¼ 0.9; tremor, GBL ¼ 315 min,
control ¼ 300 min, p ¼ 0.12. Seizures occurred in 2/8 GBL
treated and 1/5 non-surviving controls and occurred im-
mediately before death. Conclusion: We were unable to
2003 SAEM ANNUAL MEETING ABSTRACTS
detect a 10-fold increase in LD100 of PHYSO following
cessation of chronic, large dose administration of GBL in
mice. Further studies are needed before PHYSO can be
safely administered to patients with coma from GHB.
283 Mechanism of Protective Effects of Datura
Stramonium in Organophosphate Poisoning
Theodore C Bania, Jason Chu, John Smith, Dallas Bailes,
Mellanie O’Neil; St. Luke’s-Roosevelt/Columbia University:
New York, NY, Metropolitan Hospital/New York Medical
College: New York, NY
Background: Organophosphate poisoning (OP) produces
cholinergic symptoms and death via muscarinic, nicotinic
or central nervous system effects, but the progression of
symptoms has not been described. Objectives: (1) Describe
the development of muscarinic and nicotinic symptoms in
rats with OP. Datura seed extract (DSE) contains several
anticholinergic agents and significantly increases survival in
a rat model of severe OP. It is not known if the protective
effects are centrally or peripherally mediated. (2) Determine
the mechanism of the protective effects of DSE by mea-
suring the delay in onset of OP symptoms. Methods: Datura
stramonium seeds were used to make an extract equivalent
to 2 mg/ml atropine solution. Rats were randomized to
pretreatment with saline (n ¼ 6) or 5 mg/kg DSE (n
¼ 7) given by intraperitoneal injection 5 min before a sub-
cutaneous injection of 25 mg/kg dichlorvos. The time to
onset of signs (salivation (SLV), head tremor (HT), wide
stance (WS), total body fasciculations (TBF), total body
tremor (TBT), tonic clonic movement (TCM), and death (D) )
were recorded by a blinded observer and analyzed using
Kaplan-Meier estimates and log rank test and is powered to
find a 10 fold difference in median survival time. Results:
The median time to signs in seconds was: SLV (Saline ¼ 120,
DSE ¼ 224, p ¼ .19), HT (Saline ¼ 400 , DSE ¼ 400 , p ¼ .84),
WS (Saline ¼ 296, DSE ¼ 477, p ¼ .79), TBF (Saline ¼ 221,
DSE ¼ 412, p ¼ .32), TBT (Saline ¼ 184, DSE ¼ 349, p ¼ .64),
TCM (Saline ¼ 580, DSE ¼ mean [24 hours, p ¼ .65), D
(Saline ¼ 867, DSE ¼ 946, p ¼ .42). Conclusions: Muscarinic
signs occurred first followed by nicotinic signs then death in
the untreated rats. When compared to DSE animal, all the
controls developed peripheral cholinergic signs earlier. We
were unable to detect a difference in the time to onset of
these signs. This and the delay in onset of tonic-clonic
movement [24 hours for the DSE group implies a centrally
mediated protective effect for DSE treatment.
284 Severe Gamma-hyroxybutyric Acid Withdrawal in
an Animal Model Theodore C Bania, Jason Chu, Tom
Ashar, Mellanie O’Neil, Gregory Press, Patricia M Carey; St.
Luke’s-Roosevelt/Columbia University: New York, NY
Background: Abrupt cessation of frequent and nearly
continuous dosing with Gamma-hydroxybutyrate (GHB)
and related compounds results in a severe withdrawal
syndrome. Optimal therapy is unknown. There are no
animal models of chronic dosing of GHB resulting in severe
GHB withdrawal. Objective: To develop a model of GHB
withdrawal that results in severe withdrawal with seizure,
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
high withdrawal scores or death that can be used in eval-
uating therapy. Methods: Rats were administered the GHB
precursor gamma butyrolactone (GBL) every 3 hours via
intraperitoneal catheter (IP). Nutrition was supplemented
by gastric tube feedings. 23 rats were treated with GBL
for 6 days. Prior to each dose, rats were assessed for level of
intoxication which determined the dose of GBL (coma, loss
of righting, severe ataxia ¼ 0 mg/kg, moderate ataxia ¼ 350
mg/kg day 1–2, 450 mg/kg day 3–6, mild ataxia, sedation
and neutral ¼ 700 mg/kg day 1–2, 900 mg/kg day 3–6). 6
controls were treated with IP saline every 3 hours for 6 days.
9, 12, 24 and 48 hours after the last dose of GBL, the rats
were scored using a 16 point ethanol withdrawal scale
rating behaviors, response to handling, neurological signs,
seizure and death. An ethanol withdrawal score of [20
indicates severe withdrawal. Scores were compared to con-
trols using the Wilcoxon Sign Rank test. Results: 15/23
GBL treated and 6/6 control survived 6 days of treatment.
During GBL dosing, 9/23 of the rats developed withdrawal
and 2 had seizures. 10/14 surviving GBL treated rats
developed severe withdrawal (peak score [ 20 or seizure or
death during withdrawal). The mean withdrawal score for
the GBL group increased above control by 3.7 at hour 9 (p ¼
0.022), 8.7 at hour 12 (p ¼ 0.000), 7.7 at hour 24 (p ¼ 0.000)
and 7.7 at hour 48 (p ¼ 0.001). Conclusion: Severe
withdrawal can be induced by administering GBL IP every
3 hours for 6 days and may be used to evaluate therapy for
the GHB/GBL withdrawal syndrome.
285 In Vitro Binding of Lithium Carbonate to Prussian
Blue and Activated Charcoal In-Hei Hahn, Deepti
Pisupati, Shannan Tarrer, George Slavin, Robert S Hoffman,
Theodore C Bania; St. Luke’s-Roosevelt Hospital Center: New
York, NY, New York City Poison Control Center, Department of
Health: New York, NY
Objective: Prussian Blue (potassium ferric hexacyanofer-
rate) has been described as an effective chelating agent for
thallium. By mechanism of potassium ion-exchange, Prus-
sian Blue might serve as an ion-exchange adsorbent for
elements other than thallium. Lithium has similar chemical
properties to potassium. The purpose of this experiment
was to determine if Prussian Blue has any binding affinity
for lithium. Methods: A standard aqueous solution of
lithium carbonate was agitated at 258C with Prussian Blue at
lithium:adsorbent ratios ranging from 1:100 to 1:100,000 as
well as a solutions of 1:1000 with 50 g of activated charcoal
and 1:1000 plus 18.7 mg activated charcoal added. After
thorough agitation, the mixtures were suction filtered.
Supernatant lithium concentrations were measured by
atomic absorption spectrophotometry and compared to the
prepared lithium standard curve. Results: The adsorptive
capacity of Prussian Blue can be seen by measuring the
decrease of absorption values. The lithium:Prussian Blue of
1:100,000 and 1:1000 plus 50 g activated charcoal both
showed a decrease in absorbance readings of 89.9%. The
lithium:Prussian Blue of 1:100, 1:1000, and 1:1000 plus 18.7
mg of activated charcoal demonstrated a range of only 4–7%
decrease in atomic absorption values. Conclusions: This in
vitro study demonstrates that Prussian Blue with or without
activated charcoal has some binding affinity for lithium
which is concentration-dependent. The quantities of Prus-
519
sian Blue necessary for binding are greater than would be
physiologically feasible to administer in vivo. The decreased
atomic absorption of the solution containing activated
charcoal may represent a synergistic effect of charcoal and
Prussian blue or may represent an ability of charcoal to bind
lithium independently.
286 Characterization of the Pharmacokinetic and
Pharmacodynamic Interaction between Gamma-
hydroxybutyrate and Ethanol in the Rat Diederik K Van
Sassenbroeck, Peter De Paepe, Frans M Belpaire, Walter A
Buylaert; Heymans Institute of Pharmacology, University of
Ghent: Ghent, Belgium, University Hospital of Ghent: Ghent,
Belgium
Objective: Ethanol has been reported to enhance the
hypnotic effect of gamma-hydroxybutyrate (GHB). It has
been hypothesized that this is due to a pharmacokinetic (PK)
interaction. In order to clarify the nature of the interaction
we studied the PK and pharmacodynamics (PD) after co-
injection of GHB and ethanol in rats. Methods: Rats
instrumented with intravascular catheters received combina-
tions of different doses of GHB and ethanol. Blood was
sampled at regular times to measure the GHB and ethanol
plasma concentrations (Cp) by HPLC and the depth of
hypnosis induced by both drugs was measured by means of
the startle (SR) and righting reflex (RR) and a reaction to
a painful tail clamp (TC). IRB for animal research approved
the study. Data (means 6 SD) were compared with ANOVA
with P ¼ 0.05. Results: In a first series rats received a bolus of
GHB (400 mg/kg, i.v.) in addition to different doses of
ethanol targeting steady-state Cp (300–3000 mg/ml, n ¼ 12)
or saline (n ¼ 15). PK analysis of GHB Cp with a two-
compartment model with Michaelis-Menten elimination
showed no dose dependent differences in the area under
the curve (P ¼ 0.39). In a second series, the nature of the PD
interaction was studied using an interaction model (in-
teraction parameter S [ 0 means synergy, S ¼ 0 additivity,
S \ 0 antagonism). The model was applied for the loss of SR,
RR, and TC in rats receiving combinations of steady state Cp
of ethanol (1000–3000 mg/ml) and GHB (200–1400 mg/ml).
For the RR, synergy was observed at high ethanol Cp
([2 mg/ml, S ¼ 10) and additivity at lower Cp. For the SR,
antagonism was observed at ethanol Cp below 1mg/ml (S ¼

1.49) and additivity at higher Cp. For the TC reaction,
a slight but significant antagonism was found at all com-
bined Cp (S ¼
0.32, P \ 0.05). Conclusions: The interac-
tion between ethanol and GHB in the rat cannot be explained
by the PK. PD interactions between GHB and ethanol in
the rat occur and the nature varies with the reflexes stud-
ied and the Cp of ethanol.
287 Hemodyamic Effects of Cyanide Toxicity Frank
McGeorge, Julius Pham Cuong, David Huang, Emmanuel
Rivers; Henry Ford Hospital: Detroit, MI
Objective: To characterize the hemodynamic, oxygen trans-
port, oxygen utilization, and lactic acidosis changes seen in
acute cyanide toxicity and the response to treatment with
sodium thiosulfate. Methods: Design: Prospective experi-
520
mental study. Study Subjects: Five conditioned canines.
Observations: Changes in blood pressure, heart rate, oxygen
delivery, oxygen consumption, oxygen saturation, oxygen
consumption, and lactic acid production were monitored
before and after lethal injections of cyanide were given.
These same parameters were measured after administration
of the antidote, sodium thiosulfate. Results: After an initial
delay, the blood pressure decreased as the cyanide levels
increased. The heart rate was also initially maintained, but
rapidly decreased as the cyanide levels increased. The
delivery of oxygen correlated with the heart rate, decreas-
ing as cyanide levels increased. Oxygen consumption was
maintained until near lethal levels of cyanide were reached.
All parameters slowly corrected with the administration
of sodium thiosulfate. Lactate levels correlated directly to
cyanide levels (r2 ¼ 0.85). Base deficit levels also correlated
directly to cyanide levels (r2 ¼ 0.83). Conclusions: In cyanide
toxicity, routine vital signs show little change until late in the
disease process. Hemodyanic effects of cyanide are mostly
due to myocardial suppression/toxicity, as evident by de-
creased oxygen delivery. Lactate and base deficit levels are
rapid and easily measured surrogates to cyanide levels.
288 A Standardized Intoxication Scale vs Breath Ethanol
Level as a Predictor of Observation Time in the
Emergency Department James R Miner, Chris McCoy,
Michelle Biros; Hennepin County Medical Center:
Minneapolis, MN
Background: The current standard for the assessment of
patient’s with ethanol (ETOH) intoxication is through breath
ETOH levels. Intoxication has been defined clinically but
there are few scales to standardize the determination.
Objective: To compare a standardized intoxication scale
(IS) used to define a patient’s level of intoxication to
a patient’s concurrent breath ETOH levels as predictors of
total observation time required in the ED. Methods: This was
a prospective observational study of a convenience sample of
patients who presented to the ED with a chief complaint of
altered mental status or ETOH intoxication between 6/11/02
and 9/1/02. The IS was a 9 point scale, 0 ¼ normal exam,
4
unresponsive, and 4 extremely agitated. When ETOH was
detected by Breathalyzer, the patient was entered in the study
and a IS score was recorded by an examiner independent
from the treating physician. During the subsequent observa-
tion, an IS was obtained every hour with an additional breath
ETOH level. Total time in the department (TID), diagnosis,
disposition, and complications were also recorded. The
absolute value of the IS at presentation, the breath ETOH
level at presentation, and the TID were compared using
ANCOVA and Spearman’s rank correlation analysis. Re-
sults: 85 patients were enrolled. The mean absolute IS score at
presentation was 1.83 (95% CI 1.59 to 2.07). There was an
association between the IS and TID (p ¼ 0.047), but no
correlation was found between the initial breath ETOH and
the IS score (p ¼ 0.48), or the initial breath ETOH and TID
(p ¼ 0.83). Conclusion: The IS was associated with a patient’s
TID, but the initial breath ETOH was not. Furthermore, these
values were not predictive of one another. Assuming that
observation time required by a patient with ETOH in-
toxication corresponds to a patient’s true level of clinical
2003 SAEM ANNUAL MEETING ABSTRACTS
intoxication, the IS is predictive of a patient’s clinical level of
intoxication, while the breath ETOH level is not.
289 Diagnosing Pupillary Dilation by Measurement:
More Specific than Gestalt Judgment Michael D
Witting; University of Maryland: Baltimore, MD
Objective: To compare the specificity of simple measure-
ment versus gestalt judgment in diagnosing pupillary
dilation in a model of sympathomimetic overdose. Meth-
ods: In each participant, 4 eye drops were instilled in each
eye: placebo in one and a dilute phenylephrine (PE) solution
in the other. The eye to receive active drug was chosen by
randomization. After 1 hour, emergency care providers—
attendings, residents, registered nurses (RNs), physicians’
assistants (PAs)—judged whether the pupil was dilated and
measured each pupil in bright light ([54,000 lux). Measure-
ments were taken using a modified Haab scale, noting the
minimum pupillary diameter. No more than two providers
assessed the same pupil. Pupils larger than 3.6 mm in diam-
eter, using measurements by the same observer who pro-
vided the gestalt judgment, were considered dilated by
measurement. Specificity values were calculated for gestalt
judgment of dilation and for diagnosing dilation by
measurement. Results: There were 136 pupillary assess-
ments - 68 in placebo eyes and 68 in PE eyes. Of these, 24
were done by attendings, 42 by residents, 62 by RNs, and 8
by PAs. These assessments were taken from 101 different
participants. The degree of dilation was moderate; median
bright-light measurements were 2.7 mm for placebo eyes
and 3.6 mm for PE eyes. On the one hand, the specificity of
gestalt judgment was 0.68 (95% CI 0.55–0.78), with similar
values across types of observer (0.77 for attendings, 0.68 for
residents, 0.66 for RNs, and 0.5 for PA). On the other hand,
the specificity of simple measurement was 0.94 (95% CI
0.85–0.98). The likelihood ratio for a positive test was 2.5
(95% CI 1.7–3.5) for gestalt judgment versus 7.3 (95% CI 2.7–
19) for simple measurement. Conclusion: In a model of
sympathomimetic overdose, pupillary size [3.6mm in
bright light has higher specificity than gestalt judgment in
diagnosing pupillary dilation.
290 Diazepam Attenuates Acute Central Respiratory
Depression from Acute Organophosphate
Poisoning Steven B Bird, Romolo J Gaspari, Karl A
Barnett, Eric W Dickson; University of Massachusetts
Medical School: Worcester, MA
Objective: Current evidence suggests that mortality from
acute organophosphate poisoning (OP) is partially mediated
through CNS respiratory center depression. However, the
exact mechanism of OP-induced central respiratory de-
pression remains unknown. We propose the following
paradox: that OP-induced respiratory center depression is
due to a relative over-stimulation of CNS respiratory
centers. Methods: To test our hypothesis, Wistar rats (n ¼
56) were randomized to receive prophylaxis with either
saline (controls), atropine (5 mg/kg IM), the peripherally
acting anticholinergics glycopyrrolate (GLY, 4.5 mg/kg IM)
or ipratropium bromide (IB, 75 mg nebulized) or the CNS
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
respiratory center attenuator diazepam (1 mg/kg IM). To
determine if a dual CNS/peripheral cholinergic mechanism
is responsible for animal death, two additional cohorts
received combination treatment with diazepam plus either
IB or GLY. All treatments were completed 5 min prior to OP
with 25mg/kg subcutaneous dichlorovos. Differences in 10-
min and 24 hour mortality were assessed by Fisher Exact
Test. Results: Dichlorvos poisoning resulted in profound
fasciculations without obvious seizure in all cohorts. In
controls and animals treated with peripherally acting
anticholinergics (IB or GL), fasciculations were followed
by sedation and respiratory arrest (0% 10-min survival in all
cohorts). In contrast, pretreatment with either atropine or
diazepam significantly improved 10-min survival (100%
and 38%, respectively). Although GLY or IB afforded no
protection when given alone, when given in conjunction
with diazepam they significantly improved survival (both
groups 88% at 24 hours), suggesting a dual CNS/pulmo-
nary muscarinic mechanism of poisoning. Conclusion: OP-
induced central respiratory depression can be attenuated by
the central respiratory depressant diazepam, supporting the
hypothesis that dichlorovos evokes central respiratory
depression by paradoxically over stimulating CNS respira-
tory centers.
291 A Prospective Evaluation of Abbreviated Oral N-
acetylcysteine (NAC) Therapy for Acetaminophen
Poisoning Steven B Bird, Jennifer L Mazzola, D Eric Brush,
Edward W Boyer, Cynthia K Aaron; University of
Massachusetts Medical School: Worcester, MA
Objective: To prospectively evaluate the efficacy of an
abbreviated course of oral N-acetylcysteine (NAC) therapy
in acetaminophen poisoning. Methods: Since July 1997 we
have treated patients with serum acetaminophen concentra-
tions above the Rumack-Matthew nomogram treatment line
(150 mcg/mL at 4 hours post-ingestion) with 24–48 hours of
oral NAC, provided that both the LFTs are within normal
limits and serum acetaminophen concentration is below 10
mcg/mL at 24 hours post-ingestion. If either of these con-
ditions is not met, the patient receives standard NAC ther-
apy. Only those patients admitted to our University hospital
within 24 hours of ingestion were included. Primary
outcomes were death at 30 days or need for liver trans-
plantation. Secondary outcomes were severe hepatotoxicity
(ALT or AST [ 1000 IU/L), or any LFT value of [2 times the
upper limit of normal. Abbreviated NAC therapy was
defined as #12 doses. Patients were followed-up by phone,
computer search of hospitalizations and lab values, or
contact with primary physician. Massachusetts’ death and
transplant records were also queried to identify any patient
not accounted for. Results: Thirty-three patients (6 men and
27 women) received abbreviated NAC therapy. Mean age
was 21.2 years. The mean number of NAC doses was 7.1
(range 4 to 11). Two patients were lost to 30-day follow-up.
No deaths or transplants were discovered upon transplant
data or death certificate review. One patient had mild
elevation of ALT (111 IU/L) during NAC therapy that
returned to normal by hospital discharge. Conclusion:
Abbreviated NAC therapy (\12 doses) appears safe and
effective for those patients with acetaminophen poisoning
who have normal LFTs and a serum acetaminophen con-
521
centration of less than 10 mcg/mL at 24 hours after
ingestion. A larger prospective investigation of this therapy
is warranted.
292 Cytoprotective Effects of Intraperitoneal Amifostine
on a-Amanitin Toxicity in Mice Brandon Wills,
Nairmeen Haller, David Peter, Lynn J White; Akron General
Medical Center: Akron, OH, Calhoun Research Laboratory:
Akron, OH
Background: Despite supportive measures, mortality from
ingestions of the mushroom Amanita phalloides remains as
high as 20% with many surviving patients requiring liver
transplantation. A variety of treatments for Amanita in-
gestion have been evaluated, yet other than supportive
measures, no effective therapy has been identified. The drug
amifostine may improve survival from a-amanitin toxicity,
not by direct antagonism of the toxin, but rather by con-
ferring cytoprotective effects on hepatocytes at risk for
secondary cell death. Amifostine protects against lipoperox-
idation and interferes with the cross linking of DNA. These
characteristics make it attractive for potentially attenuat-
ing ongoing hepatic necrosis. Objective: To determine
whether amifostine is an effective post-exposure therapy for
a-amanitin, the primary lethal toxin in Amanita phalloides.
Methods: Swiss mice (n ¼ 30 in all groups) were given an
approximate LD75 dose of intraperitoneal (i.p.) a-amanitin.
Amifostine was administered i.p. in three dosing groups: 50
mg/kg (cumulative dose 250 mg/kg); 100 mg/kg (500 mg/
kg); and 200 mg/kg (1600 mg/kg). Controls received equal
volumes of i.p. sterile 0.9% saline. Mice were monitored and
time of death recorded. At day 7 survival was assumed and
the remaining mice were euthanized. Qualitative histologic
comparisons of hepatic and renal toxicity were performed.
Results: At day 7, only 10% of the control mice survived.
Survival in the amifostine 50, 100, and 200 mg/kg groups
was: 20%; 20%; and 3% respectively. No statistically
significant differences were detected in Kaplan-Meier
survival between the control group and those receiving 50
or 100 mg/kg; however, there was a statistically significant
decrease in survival for the group receiving 200 mg/kg (p ¼
0.0002). Conclusion: These data suggest that amifostine may
provide some improvement with cumulative doses between
250 and 500 mg/kg; however higher doses may result in
subsequent toxicity and decreased survival.
293 Effect of Oral Calcium Disodium EDTA on Iron
Absorption in a Human Model of Mild Iron
Overdose Michael Habibe, Michael J Matteucci, David A
Tanen, Kristi Robson, Robert H Riffenburgh, Accursia A
Baldassano; Naval Medical Center San Diego: San Diego, CA
Objective: Animal models have suggested that the admin-
istration of CaNa2EDTA (EDTA) may be effective in
reducing the absorption of iron after an oral iron overdose.
We designed this study to determine the effect of orally
administrated EDTA with or without activated charcoal
(AC) on iron absorption after a mild iron overdose in
healthy human volunteers. Methods: A randomized, cross-
over study was conducted in 8 healthy human volunteers.
All subjects ingested 5 mg/kg of elemental iron in the form
522
of ferrous sulfate. One hour post ingestion, subjects were
randomized to receive 35 mg/kg EDTA, EDTA plus 50
grams of AC, or placebo. Serial iron levels were obtained
at baseline and every hour for the first 6 hours, then at 8,
12 and 24 hours. A two-week washout was used between
study arms. The Kruskal-Wallis test was used for the fol-
lowing comparisons between treatment groups: baseline
serum iron levels, area under time-concentration curves
(AUCs) from baseline to 12 hours and baseline to 24 hours,
and peak iron levels. Results: Baseline serum iron levels did
not differ among the three treatment groups (p ¼ 0.844).
AUCs were not different among groups (p ¼ 0.746 for 12 hr,
p ¼ 0.925 for 24 hr). AUC medians (with 95% binomial
confidence bounds) for control, EDTA, EDTAþAC groups,
respectively, for 12 hr were: 2813 (2298, 3561), 2570 (1669,
3476), 2654 (2125, 3600); and for 24 hr were: 4083 (3488,5314),
4139 (2666, 5547), 4274 (3336, 5577). Peak serum iron levels
did not differ among treatment groups (p ¼ 0.481). Peak
iron level medians in mg/dl (with 95% binomial confidence
bounds) were for control: 329 (253, 382), for EDTA: 271 (184,
375), and for EDTAþAC: 285 (229, 352). Conclusion: Orally
administered EDTA did not significantly reduce iron
absorption when administered one hour post iron ingestion
during the 12 or 24 hour period following mild iron over-
dose in healthy human volunteers.
294 The Emergency Severity Index Triage Instrument
Predicts Resource Consumption Paula Tanabe,
Rick Gimbel, Paul Yarnold, James G Adams; Northwestern
University, Feinberg School of Medicine: Chicago, IL
Objectives: Unlike current triage systems used by most
ED’s, a validated triage tool has the potential to offer insight
into ED processes and outcomes. Such insight could
theoretically be used to help optimize ED operations. Our
objective was to analyze the relationship between ESI triage
levels and the following ED process and patient elements:
patient length of stay in the ED and hospital, ED resource
consumption, hospital admission rates for patients with
suicidal/homidical ideation and the ability of triage vital
signs to predict hospital admission. Methods: We conducted
a population-based cohort study of 403 randomly selected
ED records of patients who presented to a large academic
medical center. Twenty-seven variables from the ED record
were abstracted including triage level, vital signs and chief
complaint of suicidal or homicidal ideation. Dependent
variables blindly assessed included ED and hospital length
of stay, ED resources used, and admission status of patients
with suicidal or homicidal ideation. The relationship be-
tween ESI level and each of the dependent variables was
determined. The ability of vital signs to predict hospital
admission was assessed with Oda analysis. Results: Mean
resource use decreased monotonically as a function of ESI
level, 1(5), 2(3.89), 3(3.3), 4(1.22), and 5(0.20). Vital signs
were not significantly associated with hospital admission.
Ninety per cent of patients with suicidal/homicidal idea-
tion were admitted to the hospital. The ED average length of
stay (minutes) per ESI Level was as follows: 1(195), 2(255),
3(304), 4(193), and 5(98). ESI level 1–3 patients all had an
average hospital length of stay of approximately 4 days.
Conclusions: The ability to predict ED resource demands
according to ESI triage level can help optimize resource
2003 SAEM ANNUAL MEETING ABSTRACTS
management. Vital signs are not helpful in predicting the
likelihood of hospital admission.
295 Waiting Time Correlates with Patient Walk-out Rates
But Not with Patient Satisfaction Scores Gretchen K
Lipke, Anthony Cauci, Brian K Nelson; Mayo Clinic:
Jacksonville, FL, Texas Tech University: El Paso, TX
Objectives: 1) To correlate patient satisfaction scores by
Press-Ganey survey (PSS) and the rate of patients leaving
without being seen (LWBS) with waiting times. 2) To
ascertain if notification of probable waiting time could
modify patient ratings. Methods: Total registrations be-
tween 10am to 7pm and the number LWBS were collected
daily for three weeks. In week 1, patients were given no
information at triage about probable waits. Expected overall
ED waiting times were posted outside the triage window
and updated hourly the second week. During the third
week, patients were individually notified of the expected
waiting time for their triage class and ED section. Press-
Ganey surveys were tracked by visit day and reviewed for
the second and third weeks to score patient satisfaction with
the ED visit and with physician care. Models of LWBS and
PSS were generated using week (WK), average waiting time
(WT), number of registrations (REG), wait estimates (EST)
and estimate accuracy (EA) as predictors. Results: LWBS
was correlated with WT, REG, WE. Multiple stepwise
forward linear regression of correlated predictors gave
a relation of LWBS ¼ 1.8 þ 2.5dREG (r2 ¼ .47, p ¼ .007).
PSS was not related to the predictors except for a weak trend
with EA (r2 ¼ .08, p ¼ .054). Conclusions: Prolonged WT
explained almost ½ of the LWBS rate but did not adversely
affect PSS. Attempts to estimate WT at triage were generally
accurate but did not strongly affect PSS.
296 The Children’s Health Insurance Program (CHIP): A
Multicenter Trial of Outreach through the
Emergency Department James A Gordon, David Blumen-
thal, Carlos A Camargo Jr, for the Emergency Medicine Network;
Massachusetts General Hospital: Boston, MA, MGH/Partners
Institute for Health Policy: Boston, MA, Harvard Medical
School: Boston, MA
Objective: In 1997, the U.S. government funded the
Children’s Health Insurance Program (CHIP). Although
beneficial, the multi-billion dollar initiative has had pro-
blems finding and enrolling uninsured children. Because
such children are more likely to receive care in emergency
departments (EDs), we performed a multicenter trial to
evaluate the effectiveness of CHIP outreach in the ED
setting. Methods: Prospective before-after trial of CHIP
outreach among uninsured children (age 18 and under)
presenting to 8 EDs across the U.S. in 2001–2002. Consec-
utive subjects were enrolled for a control period (4–14 days)
followed by a matched intervention period in which sites
were randomized to either: (a) handing out CHIP applica-
tions, or (b) posting the toll-free CHIP outreach number. The
primary outcome was state confirmation of insurance status
at 90 days. Data analysis used chi-square and logistic reg-
ression, and formally tested for interaction. Results: We
enrolled 296 uninsured children who were followed by
both phone interview and state records (145 control, 151
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
intervention). Compared to controls, those receiving any
intervention were more likely to have state health insurance
at 90-day followup (30% vs 43; p \ 0.05). This effect was
more pronounced among the 251 non-whites (28% vs 46%; p
\ 0.01) than among the whites (36% vs 26%; p ¼ 0.46), with
evidence for interaction (p ¼ 0.08). In a multivariate model
(adjusting for age, sex, race, household income, parent’s
education, and current public assistance), the intervention
doubled the likelihood of CHIP enrollment (odds ratio 2.2;
95%CI, 1.2–3.6; interaction p \ 0.05). Conclusion: Brief
insurance outreach in the ED appears to be an effective
CHIP enrollment strategy, particularly for minority chil-
dren. Adopted nationwide for the millions of uninsured
children seen annually in the ED, this inexpensive strategy
could initiate insurance coverage for hundreds of thousands
of additional children each year.
297 Prospective Confirmation of Casemix-independent
Increased Inpatient Length of Stay in Patients with
Long Total Emergency Department Time Drew B
Richardson; The Canberra Hospital: Canberra, ACT, Australia
Objective: Access Block (AB) refers to the situation where
patients in the ED are unable to gain timely access to ap-
propriate inpatient beds. AB has been associated with
adverse effects on ED function and with increased inpatient
ward length of stay (LOS) which is seen as an adverse effect
because of the opportunity cost of lost bed-days in a fixed
resource environment. This study aims to prospectively
confirm the increased average ward LOS in AB patients, in
a setting where AB is identified at the time of admission.
Methods: Prospective descriptive study of all patients
admitted to a ward bed through a mixed adult/paed
tertiary hospital ED over 21 weeks in 2002. Admission was
defined as starting at the time of leaving the ED for the
ward. Standard definitions were used: LOS ¼ days from
admission to discharge, or 1 if same day, AB ¼ total ED time
more than 8 hours, DRG ¼ Australian National Diagnosis
Related Group version 4 assigned by trained coders after
discharge. National DRG averages were used to derive
Caseweight and Predicted LOS, and the difference between
LOS and predicted LOS was calculated. Results: 4576
admissions had valid data (98.6%), and AB patients had
a longer LOS (6.36 days vs 5.74 days, P ¼ 0.01) with the
following means (95% C.I):
AB No AB
Number 1430 3146
Caseweight 1.17 (1.12–1.23) 1.32 (1.26–1.38)
Predicted LOS 5.10 (4.87–5.31) 5.22 (5.04–5.40)
LOS-Predicted 1.26 (0.91–1.61) 0.51 (0.28–0.74)
Subgroup analysis confirmed previous findings that the
access block effect of increased LOS was concentrated in
those with AB whose time of admission was outside office
hours (0800–1800 Mon-Fri). Conclusions: Increased inpa-
tient LOS in access block patients is confirmed in this
prospective series. After accounting for casemix, the
additional LOS amounts to an excess of 1070 bed-days in
523
21 weeks. The resource implications represent a major
adverse effect of access block occurring outside the ED.
298 Characterizing Payments for Emergency Department
Visits: Do the Uninsured Pay Their Way? Alexander
C Tsai, Joshua H Tamayo-Sarver, Rita K Cydulka, David W
Baker; Case Western Reserve University School of Medicine:
Cleveland, OH, MetroHealth Medical Center: Cleveland, OH,
Northwestern University Feinberg School of Medicine:
Chicago, IL
Objective: We sought to describe the distribution of out-of-
pocket and third-party payments received for emergency
department (ED) visits, to determine the extent to which the
uninsured pay their ED charges, and to assess the financial
burden on the uninsured resulting from excessive out-of-
pocket payments. Methods: We used 1999 data drawn from
the Medical Expenditure Panel Survey, a national probabil-
ity sample of the U.S. civilian non-institutionalized popula-
tion. The unit of analysis was the ED visit, excluding visits
by persons aged 65 years and older, as well as visits at VA
facilities, visits covered under flat fee arrangements, and
visits which resulted in hospital admission. We limited our
analysis to those either uninsured or covered by public
or private insurance. We determined the respondent’s in-
surance status at the time of the ED visit by assigning to
that visit the insurance status recorded by MEPS for that
month. Results: Out-of-pocket payments for ED visits
by the uninsured were concentrated at both extremes. For
12.1% of ED visits by the uninsured, the full charge was
paid exclusively out of pocket, but 51.7% had no payments
out of pocket. For uninsured persons below poverty level,
a single out-of-pocket payment exceeded 5% of annual
family income for 7.2% of ED visits. The difference between
those who did and did not try to pay their ED charges
was not related to age, race, gender, education, income, or
employment. Third-party payments were made for 45.0%
of ED visits by the uninsured. Conclusions: A substantial
proportion of the uninsured pay their ED charges out of
pocket, resulting in financial burdens especially for those in
the poorest income brackets. Third-party payments account
for a surprising proportion of payments for persons self-
reported to be uninsured, suggesting a need for further
research on characterizing the uninsured. Legislative rem-
edies should be considered to alleviate the financial burden
of excessive out-of-pocket payments by the uninsured.
P
299 Factors Associated with Patients Who Leave
without Being Seen James V Quinn, Steven K
0.001 Polevoi, Nathan R Kramer, Michael L Callaham; University
ns of California, San Francisco: San Francisco, CA
0.001
Background: Patients who leave without being seen (LWBS)
by an attending physician can be an indicator of patient
satisfaction and quality for emergency departments (ED).
Objective: To develop a model to determine factors as-
sociated with patients who LWBS. Methods: A case-cross
over design to determine the transient effects on the risk of
acute events was utilized. Over a four-month period, time
intervals when patients LWBS were matched (within two
weeks), according to time of day and day of the week,
with time periods when patients did not LWBS. Factors
524
considered were percentage of ED bed capacity (patients/
available treatment beds), inpatient floor capacity, ICU
capacity, number of house staff and other practitioners,
and the characteristics of the attending physician in charge
including, age, experience, full or part time status, board
certification and the completion of a residency in emergency
medicine (EM). McNemar’s test, Wilcoxon Signed Ranks
test and conditional logistic regression analysis with back-
ward elimination were used to determine significant
variables. Results: 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 greater than 100%. This association in-
creased with increasing capacity. Other significant factors
were older age (p [ 0.01) and completion of an EM
residency (p [ 0.01) of the physician in charge. When factors
were considered in a multivariate model, ED capacity
greater than 140% OR ¼ 1.77 (95%CI 1.18–2.67) and non
completion of an EM residency OR ¼ 1.90 (95%CI 1.22–2.97)
were most important. Conclusion: ED capacity greater than
100% capacity 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 EM training appear to be important when
using LWBS as a quality indicator.
300 Accuracy of Laceration Length Estimation Michael J
Lemanski, Fidela S J Blank, Howard A Smithline, Philip L
Henneman; Baystate Medical Center: Springfield, MA
Objective: To determine how well Emergency Medicine
(EM) attendings and residents estimate the length of
lacerations. Method: Prospective, multi-center, observa-
tional survey, consisting of 2 dimensional line drawings
representing 30 lacerations (10 linear, 10 curvilinear, and 10
stellate) varying in length from 0.5 cm to 13 cm. Each
provider estimated the length of each laceration in centi-
meters, without the use of any measuring device. Estimated
lengths were considered correct for measurement purposes
if they were within 0.5 cm of the actual length. Estimated
lengths were considered correct for billing purposes if they
would have received the same CPT-4 billing code. Results: A
total of 81 providers (50 attendings and 31 residents) from 5
emergency departments completed the survey form (95%
response rate). Of the 47 attendings who listed their training,
67% completed an EM residency and 94% were EM board
certified. Attendings were in practice a median of 13 years
(IQR: 8–19). Forty-four percent of attendings and 55% of
residents reported that they always estimate laceration
length without a ruler. For each laceration type, the percent
(with 95% confidence intervals) of estimates that were
correct for measurement purposes, correct for billing
purposes, as well as estimates that would have led to over
and under billing according to CPT-4 billing codes are:
Correct Correct Over Under
Measure Billing Billing Billing
Linear 54% (50, 57) 66% (63, 70) 18% (16, 21) 15% (13, 18)
Curvilinear 48% (44, 51) 62% (58, 65) 26% (23, 29) 13% (11, 15)
Stellate 36% (33, 39) 59% (55, 62) 31% (28, 35) 10% (8, 13)
2003 SAEM ANNUAL MEETING ABSTRACTS
Conclusion: Emergency physicians frequently misestimated
the length of laceration line drawings. This may lead to
inaccurate billing.
301 Emergency Medicine Patients’ Access to Healthcare
(EMPATH) Study: Racial/Ethnic, Gender and Age
Related Differences in Emergency Department Use
Lynne D Richardson, Deborah Fish Ragin, Ula Hwang, Rita K
Cydulka, Dave Holson, Christopher Richards, Leon L Haley Jr,
Bruce Becker, Steven L Bernstein; Mount Sinai School of
Medicine: New York, NY, Yale-New Haven Medical Center:
New Haven, CT, MetroHealth Medical Center/Case Western
Reserve University: Cleveland, OH, Queens Hospital Cener:
New York, NY, Oregon Health & Science University:
Portland, OR, Emory University School of Medicine: Atlanta,
GA, Brown Medical School: Providence, RI, Newark
Beth Israel Medical Center: Newark, NJ
Objectives: To examine reasons why patients seek care in
EDs and explore the impact of barriers to healthcare access
for minority patients. Methods: 30 U.S. hospitals stratified
by geographic region and by hospital and patient demo-
graphics were chosen to participate in this cross-sectional
observational study. Demographic, clinical and insurance
data, collected for a 24-hour period at each site, were ob-
tained through chart review and a structured interview
administered to all consenting adult patients who sought
treatment during that period. Patients’ reasons for coming
to the ED were assessed in the interview by their level
of agreement (on a 3-point Likert scale) with 21 carefully
worded statements designed to capture a range of possible
reasons for seeking care in the ED. Correlational analyses
were employed to consolidate highly correlated responses
and to construct more robust measures of patients’ reasons
for coming to the ED. Chi-square statistic was used to
examine racial/ethnic, gender and age differences. Results:
1,547 patient interviews and 1,956 chart reviews were
obtained. Our diverse respondents were 53.5% female,
56.5% white, 24.8% African American, 6.1% Hispanic, 1.9%
Asian American and 10.2% other, mixed or missing; mean
age was 48.0 years (range ¼ 18–99). Significantly more
minority patients reported financial reasons for seeking care
in EDs than did white patients in 4 of 5 regions: Northeast
(NE), p \ .01; Mid-Atlantic (MA) p \ .03; Southeast, p \ .03;
Midwest (MW), p \ .04. In some regions minority patients
were also more likely to attribute their ED visit to medical
necessity: MA, p \ .001; Northwest (NW), p \ .04; MW,
p ¼ .078. Younger patients were more likely to use the ED
due to affordability than older patients in 3 regions: NW,
p \ .001; MW, p \ .05; MA, p ¼ .053. There were no gender
differences. Conclusion: Results suggest that economic
barriers to healthcare access disproportionately impact
minority and younger patients and increase their reliance
on the ED for care.
302 Effect of Treatment Guidelines for Odontalgia on
Number of Emergency Department Visits Marek
Ma, Christopher John Lindsell, Edward Charles Jauch, Arthur
Martin Pancioli; University of Cincinnati College of Medicine:
Cincinnati, OH
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Objectives: After extensive input from academic and
community dentists/oral surgeons, and a review of the
dental literature, we implemented guidelines emphasizing
the use of NSAIDs for routine dental pain. Patients were
also provided with information about effective nonprescrip-
tion pain medications and a list of Health Department
dental clinics. We hypothesized that guidelines would
decrease narcotic prescriptions, ED visits for tooth pain,
and recidivism for tooth pain. Methods: Guidelines were
implemented in a tertiary-care teaching hospital with 161,
181 ED visits during the two-year period of our study. This
retrospective, observational study used primary ICD-9
codes to identify visits for odontalgia (dental caries, pulpitis
and unspecified disorder of the teeth) during the year prior
to and the year following guideline implementation. The
proportion of patients filling prescriptions for narcotics in
our system was determined from inpatient and outpatient
pharmacy records. Proportions were compared using the
z-ratio. 95% confidence intervals were computed using the
score-method. x2 and t-tests were used to compare de-
mographics. Results: There were 5931 visits for odontalgia
during the study. Mean age was 32.5 (SD 10.0) years. 54.7%
were white and 50.2% were male. Age and gender did not
differ between before and after guideline implementation
(P [ 0.2). The proportion of visits with odontalgia decreased
from 4.3% (CI 4.2–4.5) to 3.1% (CI 3.0–3.2) (P \ 0.001). In
contrast, the proportions of visits for back pain, ankle sprain
and arm lacerations were stable. The proportion of patients
filling narcotic prescriptions for tooth pain decreased from
29.6% (CI 28.1–31.2) to 9.5% (CI 8.5–10.7) (P \ 0.001). There
were significantly more (408) recidivists prior to guideline
implementation than after (150) (P \ 0.001). Conclusions:
We conclude that implementation of our guidelines signif-
icantly reduced the proportion of odontalgia related visits,
number of filled narcotic prescriptions, and recidivism.
303 Comparison of Physician’s Choice of Charting
Template to ICD9 Codes for Biosurveillance Using
an Emergency Department Electronic Medical Records
Database Dennis George Cochrane, John Raymond Allegra,
Jonathan Rothman; Morristown Memorial Hospital Residency in
Emergency Medicine: Morristown, NJ, Emergency Medical
Associates Research Foundation: Livingston, NJ
Objectives: Syndromic biosurveillance is often performed by
tracking patterns of ICD9 code utilization, but ICD9 codes are
frequently not available in real time. The ED physician’s
choice of electronic charting template is available for anal-
ysis before the patient leaves the ED. Previously, we
demonstrated that templates and ICD9 codes generated
similar seasonal patterns, but we did not determine to what
extent these two techniques identified the same patients. The
objective of this study was to quantify the level of agreement
between these two techniques. Methods: Design: Retrospec-
tive analysis of a computerized database of Emergency
Department (ED) visits. Setting: 15 New Jersey EDs located
in urban and suburban areas. These included teaching and
non-teaching hospitals with annual ED volumes from 20,000
to 65,000. Participants: Consecutive patients seen by ED
physicians, January 1999–October 2002. Protocol: Two of the
authors reviewed all ICD-9 codes and all templates used
during this period and chose by consensus those related
to each of nine syndromes. For each of the syndromes, we
525
generated counts of patient visits selected by ICD9 code and
by physician’s choice of template. We used the kappa statistic
to characterize the level of agreement between the two
techniques. Results: There were 1,729,866 patient visits in the
database. Kappa calculations for the filters showed near
perfect agreement for the ‘‘asthma’’ (0.82), ‘‘chest pain’’ (0.81)
and ‘‘headache’’ (0.82) filters. There was excellent agreement
for the ‘‘skin’’ (0.6), ‘‘any GI’’ (0.74) and ‘‘diarrhea’’ (0.69)
filters. There was moderate agreement for the ‘‘respiratory’’
(0.52) and ‘‘fever’’ (0.49) filters and only fair agreement for the
‘‘weak’’ (0.34) filter. Conclusion: There was moderate to near
perfect agreement between ICD9 code and physician’s choice
of charting template for 8 of the 9 syndromes examined. This
data further validates the use of physician’s choice of
electronic charting template for biosurveillance.
304 The Effect of Bedside Registration on Patient
Encounter Times in an Urban Academic Emergency
Department Kevin M Takakuwa, Frances S Shofer, Christian
Boedec, Iris M Reyes; University of Pennsylvania Health
System: Philadelphia, PA
Objective: Bedside registration (BR) is the process of
registering an Emergency Department (ED) patient in the
treatment care area instead of the traditional triage or
waiting room area. The goal is that by being seen by a nurse
and/or physician sooner, ED care can be initiated earlier
leading to a decrease in total patient encounter time. Our
hypothesis was that BR would decrease the time from triage
to room (TTR) but not from room to disposition (RTD).
Methods: This was a prospective cohort study of all patients
registered in our urban academic ED. BR was instituted in
November 2001 at our ED. In this study we looked at the
month prior to initiating the process of BR (October 2001)
and at subsequent one-month intervals for five months by
our four triage classifications (critical, acute, urgent, non-
urgent). We excluded all patients seen in our fast track area
since those patients were not registered by BR. Data were
analyzed by 2-way ANOVA using type II sums of squares to
adjust for differences in our monthly census. Results: A
total of 18,223 patient encounters were analyzed for this
study. There was a significant difference in TTR time after
BR began across triage classifications (p \ 0.0001). The mean
monthly TTR time decreased after BR began from 59 min
to 42, 44, 50, 53 and 48 min, respectively. There were no
differences in TTR time for critical patients who are always
taken directly from triage into the patient care area. The
decrease in TTR times occurred mostly within the first two
months for our acute, urgent, and non-urgent groups before
returning toward the baseline. There was no difference for
mean RTD time after BR started across triage classifications
(p ¼ 0.79). Conclusions: BR had no effect on TTR time for
our critical triage classification but did decrease for our
acute, urgent and non-urgent patients for about 2–3 months
after which the effect seemed to disappear. As expected, BR
had no effect on RTD times across all triage classifications.
305 Ambulatory Care Sensitive Emergency Department
Visits: A National Perspective Robin M Weinick,
John Billings, Joshua M Thorpe; Agency for Healthcare
Research and Quality: Rockville, MD, New York University:
New York, NY, University of North Carolina: Chapel Hill, NC
526
Objectives: We use a newer, rigorously-developed method-
ology for determining the urgency of emergency department
(ED) visits, and apply it to nationally representative data in
order to provide an overview of the factors associated with
non-emergent visits to the ED. Methods: An algorithm was
developed by a panel of ED physicians, based on in-
formation abstracted from a sample of more than 5,500 ED
records. It classifies use into seven categories: Non-emergent;
Emergent–Primary care treatable; Emergent–ED care re-
quired–Preventable/avoidable; Emergent–ED care re-
quired–Not preventable/avoidable; Injury; Mental health;
and Drug or alcohol related. For some analyses, these
categories are collapsed into ambulatory care sensitive ED
visits (ACS-ED) (including the first three categories) and
non-ACS-ED (capturing the remaining categories). We apply
this algorithm to the ED component of the 1997–2000
National Hospital Ambulatory Medical Care Survey
(NHAMCS), a national sample survey of visits to hospital
emergency departments (n ¼ 93,109). In addition, we use
logistic regression to assess the characteristics associated
with ACS-ED visits. Results: 56 percent of all visits were
ACS-ED visits, with ACS-ED visits being most likely among
children under age 5, Medicaid patients, and those visiting
public hospitals. Compared with the period from noon to
4:00 pm, children under age 18 were 2.35 times (odds ratio,
C.I. 2.00–2.77) as likely to have an ACS-ED visit between
midnight and 6:00 am, and 2.13 times as likely (C.I. 1.75–2.59)
to have one between 6:00 and 9:00 am. No such differences
were found for adults. Children and adults ages 65 and over
were more likely to have ACS-ED visits on the weekends,
and all age groups were more likely to have such visits in the
fall and winter. Conclusions: The increased likelihood of
ACS-ED visits among children between midnight and 9:00
am and on weekends suggests that after-hours clinics may be
helpful for reducing ACS-ED visits among children.
306 Development and Implementation of a Relative
Value Scale for Teaching in Emergency Medicine:
The Teaching Value Unit (TVU) Naghma S Khan, Harold K
Simon; Emory University School of Medicine: Atlanta, GA,
Children’s Healthcare of Atlanta: Atlanta, GA
Background: Relative value units exist to standardize the
measurement of clinical productivity. However, limited
objective measures exist for non-clinical activities, specifi-
cally teaching. Objectives: To develop an objective measure
of teaching productivity linked to a performance-based
incentive plan. Methods: Teaching activities were identified
prior to the 1998–1999 academic year. Teaching Value Units
(TVU’s), objective measures for quantifying teaching activ-
ities were developed. TVU’s were assigned to each activity
based on an estimation of time needed to complete the
assignment and weighted for importance to the teaching
mission. Each physician was allocated teaching time based
on past performance and future goals. Targeted TVU’s
necessary to meet expectations were proportionate to
allocated teaching time. Teaching productivity was defined
as a percentage of targeted TVU’s achieved and incentive
dollars for teaching were distributed based on this percent-
age, weighted for the teaching load of each individual. Future
teaching time was adjusted based on prior years perfor-
mance. Results: Teaching productivity was evaluated over
a 3-year period. In Year-1 mean TVU’s allocated/physician
2003 SAEM ANNUAL MEETING ABSTRACTS
were 181 units (Range: 25–449). Four of 18 physicians (22%)
met expectations. The mean individual TVU’s achieved were
54% of expected (range of 0–114%). By Year-3 mean TVU’s
allocated/physician were 179 (range: 45–629). Twelve of
22 physicians (55%) met expectations. The mean individual
TVU’s achieved were 82% of expected (range: 11%–146%).
Between Year-1 and Year-3, the group productivity increased
from 73% to 88% and the mean individual productivity in-
creased from 54% to 82% (p ¼ 0.01). Conclusions: The TVU-
based system enabled objective quantification and on-going
monitoring of a broad range of teaching activities, and
assisted in future allocation of teaching time. The TVU-based
system linked to an incentive plan helped to increase both
individual and group teaching productivity.
307 Total Daily Patient Care Time as a Measure of
Emergency Department Overcrowding Drew B
Richardson; The Canberra Hospital: Canberra, ACT,
Australia
Objective: Overcrowding causes ED dysfunction because
of excessive staff workload but it is not well defined. In
Australasia, patients are triaged by a 5 point scale, which
prescribes a waiting time threshold for each category, and
ED performance is measured as the proportion of patients
waiting less than their time threshold. This study aimed to
use a multivariate approach to identify the causes of ED
waiting time performance, and to seek a threshold for
inadequate performance. Methods: Retrospective descrip-
tive multivariate analysis of daily activity data from a
tertiary mixed age ED in 2000, a period of negligible change
in staffing. Patient care time (PCT) was calculated for each
presentation and then proportions were ascribed to the day
(midnight–midnight) during which the care was provided.
This corresponds to the mean daily occupancy with patients
being treated. ED performance (proportion seen within
threshold) was the dependent variable, and presentations,
admissions, proportion of low acuity patients, proportion
aged over 65, daily PCT, and access block (proportion of
admissions spending more than 8 hours in ED) were the
independent variables. Results: 51166 cases were included.
On initial analysis, PCT had the strongest association with
performance (r ¼
0.58) but daily presentations, admis-
sions, discharges, and access block were significantly
associated. On multivariate modeling, only PCT and
presentations were significant, accounting for 40% of the
variance in performance. Subgroup analysis showed a linear
relationship between daily PCT and performance at differ-
ent levels of daily presentations. Average performance was
69% on the 27 days with more than 432 hours of PCT
(equivalent to mean daily occupancy of 18) compared to
83% otherwise. Conclusion: Of the elements studied, daily
total patient care time is the best predictor of waiting time
performance. This simple measure has potential to be a
useful marker of overcrowding, and a threshold can be
established.
308 Prospective Confirmation That Total Daily Patient
Care Time Can Measure Emergency Department
Overcrowding Drew B Richardson; The Canberra Hospital:
Canberra, ACT, Australia
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Objective: The total daily patient care time (PCT ¼ time
from treatment start to departure from ED), which is
equivalent to the mean daily occupancy with treated
patients, has been shown to be associated with ED waiting
time performance. In Australasia, patients are triaged by a 5
point scale, which prescribes a waiting time threshold for
each category, and ED performance is measured as the
proportion of patients waiting less than their time threshold.
This study aimed to prospectively assess total daily PCT as
a predictor of waiting time performance in an ED which has
been collecting patient care time data in real time since May
2002. Methods: Prospective descriptive study of daily
activity data from a tertiary mixed age ED for 26 consecutive
weeks. Patient care time (PCT) was calculated for each
presentation and then proportions were ascribed to the day
(midnight–midnight) during which the care was provided
at the end of each day. Performance was defined as the
proportion of patients seen within their triage threshold
on each day. Days were categorised as ‘‘Low’’ or ‘‘High’’
depending on whether the daily PCT exceeded 18 patient-
days, and ‘‘good’’ or ‘‘bad’’ depending on whether
performance was 70% or more. Results: 25316 cases were
included. 39% of 71 low PCT days had bad performance,
compared to 88% of 110 high PCT days (P \ 10E-12 Chi
square). Daily PCT was strongly correlated with perfor-
mance (r ¼
0.55) and subgroup analysis showed an almost
linear relationship between daily PCT and performance at
different levels of daily presentations. Conclusion: Daily
total patient care time is shown to be a good predictor of
daily waiting time performance. ED performance is poor
above a threshold which may indicate overcrowding.
309 Relationship between Total Daily Patient Care
Time and Performance as a Measure of Emergency
Department Efficiency Drew B Richardson; The Canberra
Hospital: Canberra, ACT, Australia
Objective: In Australasia, patients are triaged according to
a 5 point scale, which prescribes a waiting time threshold for
each category, and the proportion of patients waiting less
than their threshold is a major performance measure. Total
daily patient care time (PCT—corresponding to mean daily
occupancy with patients under treatment) has been shown
to be a good predictor of waiting time performance. This
study aimed to identify changes in the relationship between
daily PCT and performance over time during a period of
increasing demand and practice improvements, but little
change in staffing. Methods: Retrospective descriptive
study of daily activity in a mixed adult/paed tertiary ED
over 5 consecutive 6 month terms from Jan 1999. PCT was
calculated for each presentation and then proportions were
ascribed to the day (midnight–midnight) during which the
care was provided. Daily access block was calculated as the
proportion of admissions spending more than 8 hours in
ED. For each term the correlation and the line of best fit
between daily ED performance (proportion seen within
triage threshold) and daily PCT was calculated. Results:
126477 cases were included. Daily presentations increased
by 5%, access block by 170% and total patient care time by
30% in the period. Daily PCT was most strongly associated
with performance (r \
0.48 in all terms). The slope of the
relationship between PCT and performance decreased over
527
the 5 terms from
4.0%/patient-day to
1.9%/patient-day,
but the overall performance was highest in the middle term.
Conclusions: This study confirms that daily total patient
care time (mean daily occupancy) is the best predictor of
waiting time performance over the medium term, but shows
that the relationship changes in the longer term. The slope of
the relationship between PCT and performance can be used
as a measure of efficiency. Peak efficiency was achieved at
the end of the period studied, but peak performance in the
middle because of increasing demand.
310 The Inter-rater Reliability of Triage in an Acute Care
Emergency Department Setting Eric J Grafstein,
Grant D Innes, Julie Westman, Jim M Christenson, Anona
Thorne; Providence Health Care: Vancouver, British Columbia,
Canada, Centre for Health Evaluation and Outcome Studies:
Vancouver, British Columbia, Canada
Background: Triage reliability studies typically use hypo-
thetical scenarios and weighted kappa scores where agree-
ment within one level is considered satisfactory. If triage
category is used to define comparative ED case-mix groups,
agreement on exact triage level and the major system in-
volved is important. We have previously developed a
computerized presenting complaint list linked to the 5-level
Canadian Triage and Acuity Scale (CTAS). Our hypothesis
was that a computerized menu that links presenting
complaints to preferred triage levels (PC-linked triage)
would provide high triage reliability. Objectives: To assess
inter-rater reliability of PC-linked triage using the CTAS in
a real-time clinical setting, considering agreement on exact
triage level and the major system involved. Methods: This
prospective study was conducted at St. Paul’s Hospital,
a Canadian inner-city academic centre. The on duty triage
nurses assessed a convenience sample of ED patients and
entered a presenting complaint and a PC-linked triage level.
A second nurse, blinded to the triage assignment, concur-
rently observed the patient interview and independently
entered the same information on a dummy terminal. Each
nurse also assigned a subjective triage level without PC-
linking. Results: Between August and November 2002, 15
pairs of nurses triaged 265 patients. Study patients matched
actual ED case mix closely, with 1%, 13%, 36%, 33% and 18%
in levels 1–5 respectively. Kappa statistics were 0.74 (95% CI
0.68–0.80) for PC-linked triage (exact level) agreement and
0.80 (95% CI 0.69–0.91) for agreement on the major system
involved. Agreement between the subjectively assigned
acuity levels and PC-linked triage levels was 0.55 (95% CI
0.51–0.59). Using subjective triage, nurses assigned fewer
patients to levels 1, 2 and 5. Conclusions: PC-linked triage
reliability is high in a real-time clinical setting. Nurses
triaging subjectively are more likely to cluster patients in
triage levels 3 and 4.
311 Impact of Ambulance Transportation on the Use of
Resources in the Emergency Department Adrian
Marinovich, Jonathan Afilalo, Marc Afilalo, Bernard Unger,
Antoinette Colacone, Claudine Giguere, Ruth Leger, Xiaoqing
Xue, Elizabeth MacNamara; Sir Mortimer B. Davis Jewish
General Hospital: Montreal, Quebec, Canada
528
Objective: Ambulance diversion is sometimes used to
manage emergency department (ED) overcrowding. Our
objective was to determine how ambulance transportation
is associated with the use of various resources in the ED.
Methods: Retrospective administrative database review of
visits to a Montreal tertiary care hospital ED over one year,
from April 2000 through March 2001. Resource-use measures:
consults and radiology/imaging tests (excluding plain-film
X-rays) ordered from the ED, ED length of stay, and
admission to the hospital from the ED. Results: During the
study interval, 39,674 patients made 59,142 visits to the ED. Of
all visits, 15.6% were by ambulance. Ambulance visits were
more likely than non-ambulance visits to be made by older
patients (68 years old [95% CI: 67.7–68.6] vs. 47 [46.8–47.2]), by
female patients (59% female vs. 55%) [odds ratio (OR): 1.18
(95% CI: 1.13–1.23)], to be triaged more urgently (2% non-
urgent vs. 44%) [OR: 0.021 (0.0183–0.025)], and to occur
during off-hours (47% between 5pm and 9am vs. 43%) [OR:
1.19 (1.14–1.25)]. Ambulance visits were more likely than
non-ambulance visits to result in consults (56% with consults
vs. 20%) [OR: 5.15 (4.92–5.40)] and imaging tests (20% with
tests vs. 12%) [OR: 1.90 (1.79–2.01)], to have a longer length of
stay [13.2 hours (13.0–13.5) vs. 5.9 (5.9–6.0)], and to result in
hospital admission (40% admitted vs. 10%) [OR: 6.01 (5.71–
6.32)]. In multivariate models that accounted for the effects of
age, sex, home origin of visit, triage level and ED stretcher
use, ambulance transportation had independent associations
with greater use of consults, longer length of stay, and more
hospital admissions, but was not independently associated
with use of imaging tests. Conclusions: This preliminary
study indicates that patients transported by ambulance
generally use more resources in the ED.
312 Emergency Department Volume and Patient
Acuity as Factors in Patients Leaving without
Treatment Jason T McMullan, Frederick H Veser; Medical
University of South Carolina: Charleston, SC
Objectives: Any patient that leaves the emergency de-
partment (ED) without being seen by a physician represents
a liability to himself and the hospital. Waiting room time,
ED volume, and total hospital admissions through the ED
have been linked to patients who leave without treatment
(LWT); these studies, however, were done at large trauma
centers with annual ED censuses above 75,000 and staffed
by several physicians. This study investigates if volume
and acuity influence the rate of patients leaving without
treatment from a community hospital emergency depart-
ment with an annual census of less than 20,000 and staffed
by a single attending physician. Methods: Using a retro-
spective ED census review, patient volume, numbers of
admissions, and LWTs were recorded for 12-hour intervals
over a one-year period. Patient acuity is defined as the
number of patients requiring ED resuscitation efforts and/
or admission to the hospital. Patient-specific information
(demographics, chief complaint, etc.) was not collected.
Results: Over a twelve-month period, 629 of 18,664 patients
absconded from the emergency department (3.4%). Median
volume was 23 patients per 12-hour shift; median acuity
was 3 patients per shift. When total volume exceeded 25
patients per shift, there were significantly more LWTs than
at low patient volumes (0.68 vs. 0.28 per shift, p \ .05).
2003 SAEM ANNUAL MEETING ABSTRACTS
When acuity exceeded 4 patients per shift, LWTs were also
significantly greater (1.5 vs. 0.56 per shift, p \ .001). Of 730
total shifts, 349 had total volume greater than 25 and 162
had acuity of 5 or more. Conclusions: Increasing patient
load and patient acuity caused LWT rates to rise in this
single attending physician staffed community hospital ED
with an annual census of less than 20,000. Thresholds of 25
patients per shift and acuity of five or more patients per shift
were associated with significant increases in LWTs, suggest-
ing possible per physician maximum patient loads before an
increased risk of LWT patients.
313 Headache Patients: Who Does Not Come to the
Emergency Department? Peter L Lane, Cristina M
Nituica, Barbara Sorondo; Albert Einstein Medical Center:
Philadelphia, PA
Objective: According to the National Headache Founda-
tion, over 28 million Americans suffer either headache or
migraine, equate to nearly 13 percent of the population,
and cost the nation’s economy approximately $13 billion
a year. The purpose of this study is to identify and com-
pare the characteristics of patients who use the emergency
department services for headache/migraine (H/M) care,
with those who use other type of healthcare service for the
same condition. Methods: Design: population-based, ob-
servational, cross sectional study. Setting:1996 Medical
Expenditures Panel Survey (MEPS) data. Subjects: All pa-
tients who have self-reported H/M as a medical condition
during 1996. Observations: Age, gender, race/ethnicity,
total annual income, work status, educational level, in-
surance status, perceived medical (PHS) and mental health
status (PMS) were identified and compared between
headache sufferers that use the ED and headache suffers
who those who use other source of care for the same con-
dition. Regression model was use to identify factors related
to the use of ED as a source for medical care. Results: 1327
people were identified as having H/M as medical con-
dition, 46 (3.5%) had at least one ED visit. The two groups
are not statistical different in terms of age, gender, in-
surance status, having a primary care provider (PCP), and
satisfaction with the PCP. Predictors for using the ED as
source for medical care were: PHS (p ¼ 0.01) and PMS
(p ¼ 0.02), having difficulty getting medical care (p ¼
0.023), having more than three ED (p \ 0.001) and more
than 8 (p \ 0.001) office visits for other medical reason
than H/M. Additionally in the adult population ($18
years old) lower annual income (p ¼ 0.012), not being
employed (p ¼ 0.012), lower education level were
predictors for ED utilization. Conclusions: People with
lower income, less educated, unemployed, having diffi-
culty getting medical care, having multiple ED and office
visits, are more likely to use ED as source of medical care
for H/M.
314 Variability of Admission Practice Patterns among
Emergency Physicians Robert H Baevsky, Jin Pyun,
Howard A Smithline, Fidela J S Blank, Philip L Henneman;
Baystate Medical Center: Springfield, MA
Objectives: Determine the variability across board certified
emergency physicians (EPs) on the percent of admitted
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
patients who rule-in for acute myocardial infarction (AMI).
Methods: A blinded, prospective observational trial at
a university tertiary referral center from May 2001–May
2002. All ED patients admitted to the adult telemetry unit to
rule-out AMI were prospectively followed to determine the
presence of AMI within 24hrs (using ESC/ACC definition).
Exclusion criteria included an ED ECG diagnostic for acute
ischemia or infarct, elevated initial troponin, or an ED
diagnosis of AMI or unstable ACS. Variables recorded
included: patient demographics, admission and discharge
diagnoses, serologies, and ECGs interpreted by cardiolo-
gists. Additionally, EPs were surveyed as to their perceived
AMI rule-in rate. Although no apriori sample size was
determined, collection of data over a one yr period was felt
to minimize any transient variability in admitting patterns.
Data were analyzed using Spearman’s correlation coeffi-
cient. Results: During the 13 month study period, 94,350
patients were seen by 22 full time, board certified EPs in the
adult ED with a 16% overall admission rate (OAR). Of the
2,275 (2.4%) patients admitted to telemetry (TAR) for rule-
out AMI, 439 (19%) developed an AMI within 24hrs upon
admission. There were no differences between EPs on
admitted patients’ gender, age, or race. Median(IQR) data
for EPs are shown:
Yrs at Yrs in
Rule-In Rate OAR TAR Hosp Practice
21%(17–23%) 17%(15–19%) 2%(2–3%) 10(3–19) 12(7–19)
EP rule-in rates ranged from 10% to 29% with no correlation
to OARs (p ¼ 0.38), TARs (p ¼ 0.82), years at the hospital (p
¼ 0.55) or years in practice (p ¼ 0.90). On the survey, the
median estimated rule-in rate was 10% (IQR:4.5–15%) with
no correlation to the EPs’ actual rule-in rate (p ¼ 0.17), OAR
(p ¼ 0.41) or TAR (p ¼ 0.47). Conclusion: There was an
observed three-fold variation in AMI rule-in rates for EPs
treating comparable patients.
315 The Overcrowded Emergency Department:
Perception vs Reality Timothy J Reeder, Deeanna L
Burleson, Herbert G Garrison; Brody School of Medicine at
East Carolina University: Greenville, NC, Pitt County
Memorial Hospital: Greenville, NC
Objectives: To study perceptions of physicians and nursing
staff about real-time demands and capacity of an Emergency
Department (ED). To utilize ED data to calculate proposed
demand ratios called Real-time Emergency Analysis
of Demand Indicators (READI) scores. To compare these
objective READI scores with ED staff perceptions of demand
and capacity. Methods: This prospective study utilized
a computerized clinical management system to provide data
about ED demand and capacity. Physicians and staff charge
nurses were surveyed about perceptions of the real-time
ED demand and capacity. These results were compared to
mathematical READI scores which are proposed to objec-
tively assess ED demand. Kappa scores were utilized to
measure intra-rater reliability between the physicians’ and
nurses’ assessment of demand and between the staff
assessments and the READI scores. Results: Kappa scores
529
of the perception of excess demand between two physician
groups was 0.392, between the one physician group and
charge nurses was 0.453, and between a second attending
physician group and charge nurses was 0.243. Comparing
respondents who indicated demand had or had not exceeded
capacity, one of the READI ratios, the Bed Ratio, demon-
strated a significant difference in the mean 0.245 (95% CI
0.153–0.336) between groups. Conclusions: Real-time data
may be utilized to help predict ED demand and resource
needs. The subjective assessment of excess ED demand did
not correlate between physician groups or between physi-
cians and charge nurses. Although there was a trend toward
predicting excess demand with one of the READI score, these
scores did not correlate to staff perceptions. Further work
must be done to refine these objective measures.
316 Who Should Be Estimating Your Patient’s Weight
in the Emergency Department? Jill Corbo, Michael
Canter, Diana Grinber, Polly Bijur; Jacobi Medical Center,
Albert Einstein College of Medicine: Bronx, NY, Albert
Einstein College of Medicine: Bronx, NY
Background: Medical personnel are required to estimate
patients’ weight rapidly and accurately to give doses of
pharmacological agents that are weight-based. Inaccurate
estimates of weight may result in administration of either
sub-therapeutic or, in other cases, toxic doses of medications.
Objective: To test the primary hypothesis that patients’
weight estimates are more accurate than those of physicians
or nurses; secondarily, to assess if position of the patient at
time of estimation influences accuracy of the estimate.
Methods: A prospective observational study of adults
presenting to an urban ED during one month. Patients
unable to stand were excluded. The patient, physician, and
nurse caring for the patient were independently asked to
estimate the patient’s weight, with the patient in the same
position (supine or standing). Patients were then weighed.
Results: A convenience sample of 464 patients was enrolled.
The mean measured weight was 180.1 pounds with a
standard deviation of 50.2 (range 92–405 pounds).The best
estimate of patient’s weight was from the patients: mean
difference between patient estimates and actual weight was

1.2 pounds [95%CI,
2.5 to 0.1]. The physicians and nurses
had larger underestimates:
7.9 pounds [95%CI,
10.5 to

5.4] and
8.6 pounds [95%CI,
11.3 to
5.9], respectively.
Weight was estimated within 10% of actual weight by 98% of
patients, 49.6% of physicians, and 50.9% of nurses. Position
of the patient at time of estimation influenced the accuracy of
the estimates. The mean difference between physician
estimates and actual weight for supine patients was
3.2
and
13.3 pounds for standing patients; for nurses the
difference was
3.3 and
14.8 pounds for supine and
standing, respectively. Conclusion: When a patient is unable
to be weighed, the patient’s own weight estimate should be
used. If neither is possible, the physician or nurse should
estimate the patients’ weight in the supine position.
317 Emergency Code Systems and Disaster Preparedness
in Level-1 Trauma Centers in the US Robert E
Antosia, H Range Hutson, Andrew Chang, Jennifer Leaning;
Beth Israel Deaconess Medical Center: Boston, MA, Brigham
530
and Women’s Hospital: Boston, MA, University of California
at Irvine: Orange, CA, Harvard School of Public Health:
Boston, MA
Objectives: The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) requires all Hospitals
to have an Emergency Code System (ECS) in place, but there
is no standard ‘‘code nomenclature’’ required. The purpose
of our study was to determine the ECS in place at all Level-1
Trauma Centers (L1TCs) in the U.S., assess our current state
of disaster preparedness, and identify barriers to improve-
ment. Methods: The American Hospital Association (AHA)
supplied the names of all 211 L1TCs. All L1TCs were sur-
veyed from Sep–Nov, 2002 with a questionnaire mailed to
both Emergency Medicine (EM) and Trauma Surgery (TS)
Directors. Chi-square test and Kappa Statistic were used.
Results: 206 L1TCs responded (97.6%). The overall response
rate was 87.0% (EM ¼ 86.4%; TS ¼ 87.6%). The most
common ECS for Fire was ‘‘Code Red’’ (74.2%); Cardiopul-
monary arrest, ‘‘Code Blue’’ (61.2%); Infant abduction,
‘‘Code Pink’’ (53.3%); and Disaster, ‘‘Code Yellow’’
(15.9%). The majority (74.2%) favored adopting a universal
color-coded ECS. Most also felt their Institutions’ level of
disaster preparedness was good–very good (71.6%), but
17.9 % reported it was fair–poor. Overall, 63.4% perceived
the U.S. preparedness as only slightly improved since the
events of 9/11/01; however, respondents who were aware
of JCAHO’s 2001 revised standards for Emergency Man-
agement were more likely to report improvement (p \
0.001). The most commonly cited barriers included in-
adequate funding (70.7%) and inadequate staff education
(57.5%) while the most vulnerable areas identified were
over-crowded Emergency Departments (EDs) 84.0% and
lack of available inpatient beds (83.0%). The correlation
between EM and TS was relatively poor (k ¼ 0.33, 95%
CI 0.14–0.53). Conclusions: A universal color-coded ECS
should be adopted and implemented to simplify training
and minimize confusion. We also recommend that issues
including lack of funding, over-crowded EDs and lack of
available inpatient beds at L1TCs should be further
addressed.
318 Patterns and Factors Associated with ‘‘Increased’’
and ‘‘Intensive’’ Emergency Department Utilization:
Implications for Allocating Resources Jennifer P Ruger,
Chris J Richter, Lawrence M Lewis; Washington University
School of Medicine: St. Louis, MO, Washington University
School of Social Work: St. Louis, MO, Siteman Cancer Center:
St. Louis, MO
Objectives: To define two new measures of ED utilization:
‘‘increased utilization’’ (volume $110% of mean daily
census) and ‘‘intensive utilization’’ (volume $110% mean
daily census & high acuity (triage A or B)). To identify
patterns and factors associated with, ‘‘increased’’ and
‘‘intensive’’ utilization and relate to throughput times and
patient disposition. Methods: Retrospective, cross-sectional
study of all 2001 patients seen at urban academic hospital
ED. Data from hospital clinical and financial records.
Multivariate logistic regression identified factors associated
with ‘‘increased’’ and ‘‘intensive’’ utilization. ANOVA and
chi-squared tests used for bivariate analyses. Results: 15,815
(20%) of patient-visits occurred on ‘‘increased’’ utilization
2003 SAEM ANNUAL MEETING ABSTRACTS
days, 6,057 (39%) of these were Acuity A or B. 63 of 365 days
met ‘‘increased’’ utilization criteria. Percentage of Acuity
A & B patients did not differ between ‘‘increased’’ and
‘‘normal’’ days, although number of these patients was
higher on ‘‘increased’’ compared to ‘‘normal’’ days (96 vs.
82, P \ 0.05). Factors most strongly associated with ‘‘in-
creased’’ utilization included: arriving on Monday (adjusted
odds ratio [OR], 92.4, 95% CI, 78.8–108.3), or Tuesday (OR,
13.9, CI, 11.8–16.5), in January (OR, 34.8, CI, 29.7–40.7), or in
April (OR 24.4; CI, 20.9–28.6), in a motor vehicle crash (OR,
1.2; CI, 1.0–1.4), or sustaining fall 0to10 feet (OR 1.3; CI,
1.1–1.5). ED length of stay increased for all patients on
‘‘increased’’ days (311 vs. 302 minutes, P \ 0.001) and
percentage of left without being seen (10% vs. 7%, P \ 0.001)
was greater on ‘‘increased’’ vs. ‘‘normal’’ utilization days.
LOS was almost 20% higher (359 vs. 302 minutes; P \ 0.001)
for ‘‘intensive’’ vs. ‘‘normal’’ utilization periods. Conclu-
sion: ‘‘Increased utilization’’ showed a predictable pattern
of daily and monthly trends and a greater average number
of higher acuity patients on those days. Length of stay and
percentage left without being seen was greater for ‘‘in-
creased’’ utilization days.
319 Improving Accuracy of Triage of ‘‘Borderline’’
Patients Jennifer P Ruger, Chris J Richter, Lawrence
M Lewis; Washington University School of Medicine:
St. Louis, MO, Washington University School of Social Work:
St. Louis, MO, Siteman Cancer Center: St. Louis, MO
Background: Improving accuracy of triage of ‘‘borderline’’
patients, those presenting with conditions not clearly
emergent or non-urgent, would improve the quality and
efficiency of ED care. Little is known about factors
associated with an increased likelihood of admission to
the hospital when triaged as non-emergent. Objectives:
Identify factors associated with hospital admission for
patients triaged as non-emergent. Methods: Retrospective,
cross-sectional study of all patients seen in 2001 at an urban
academic hospital ED. Data obtained from hospital clinical
and financial records. We reviewed all patients triaged as
Level ‘‘C’’ (the middle category of our A–E Triage system).
Main Outcome Measures: Admitted to the hospital when
triaged as non-emergent (‘‘C’’). Multiple logistic regression
models identified factors associated with hospital admission
among non-emergent patients. Results: 47% of patient visits
were triaged Acuity C. Factors associated with hospital
admission for these patients included: age 41–64 (adjusted
odds ratio (OR), 1.6; 95% confidence interval (CI), 1.38–1.89),
age $65 (OR, 2.62; CI, 2.13–3.24), presenting complaints of
sickle-cell crises (OR, 3.79; CI, 2.38–6.04), fall 0–10 feet (OR,
1.97; CI, 1.41–2.76), abdominal pain (OR, 1.86; CI, 1.61–2.14),
shortness of breath (OR, 1.72; CI, 1.32–2.23) and weak or
dizzy (OR, 1.41; CI, 1.10–1.80). Combining age $65 and
presenting complaints with an OR[1 (creating ‘‘Cþ’’ triage
category) resulted in a 63% admission rate—higher than the
44% rate for emergent Level ‘‘B’’ patients and the average
10% for non-emergent Level ‘‘C’’ patients. Conclusions:
Admission rates for Level ‘‘Cþ’’ patients were significantly
higher than both Level ‘‘B’’ and Level ‘‘C’’ patients.
Augmenting existing triage information with these simple
criteria can improve the ability to detect severe illness
requiring admission.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org 531

320 Establishing a Predictive Model for Emergency personnel and 20 ED support staff (G1-102 G2-56). Scenarios
Physician Clinical Workload Robert Stenstrom, were alike until event 4. Events were 1-unexplained sick
Grant Innes, Eric Grafstein, Jim Christenson; St. Paul’s patients, 2-media report new bug, 3-system overwhelmed,
Hospital: Vancouver, British Columbia, Canada 4-agent identified, 5a-remote site staff treatment, 5b-onsite
staff treatment, 5c-onsite staff and family treatment.
Background: Emergency department (ED) physician staffing
requirements should be based on clinical workload. Factors
that predict the physician time necessary to care for patients
Event 1 2 3 4 5a 5b 5c
have not been well described. Objective: To develop
a multivariable linear regression model to establish which Group 1 84 80 62 Scenario 1 85 41 35 88
clinical, demographic and setting variables have the strongest Scenario 2 44 31 22 59
Group 2 75 84 57 Scenario 1 82 55 48 86
association with time needed to treat patients. Methods: A
Scenario 2 38 38 34 70
research assistant (RA) followed 22 emergency physicians
(EP) for 32 day, evening and night shifts at a busy (45000 pts
per year) inner city ED. The RA recorded the exact amount of
Conclusions: As a BT event develops fewer health care
EP time spent performing clinical, teaching, departmental
providers will come to work. Determination of the agent is
and communication functions for 585 patient visits. The RA
a major decision point for providers to return to or stay
also recorded candidate predictor variables: gender, age,
away from work. Onsite treatment of staff and their family
mode of arrival, CTAS level (Canadian Triage and Acuity
increases staffing compared to treating staff only (onsite or
Scale), language, vital signs, GCS, co-morbidity, prior visits,
offsite). These factors should be considered when designing
housing status, need for procedure, and whether a resident or
a terrorism response plan.
student was involved in care. Association between the
variables (and 5 pre-determined 2-way interactions) and
total EP time per patient (dependent variable) was assessed
322 Emergency Waiting Room Care: Are Some of Our
via multiple linear regression. Results: Assumptions un-
Emergency Patients Being Poorly Cared For? Eric J
derlying multiple linear regression were valid for these data.
Grafstein, Grant D Innes, Rob Stenstrom, Jim M Christenson,
Colinearity between variables was minimal. 539 of 585
Garth Hunte; Providence Health Care: Vancouver, British
patients (92%) had complete data for all candidate predictor
Columbia, Canada
variables. The regression equation for total physican time per
pt (TFT) was derived using a forward stepwise selection Background: ED overcrowding creates a situation where
procedure (F-to-enter 0.05): TFT ¼ 30.6 þ 10.3(procedure some ED patients are triaged to and cared for in the waiting
required [Y/N])
3.5(CTAS level [1–5]) þ 3.4(ambulance room/hallway (WR). Objectives: To compare baseline
arrival)
1.1(GCS[3–15] ) þ .1(age [years])
.05(n of previous characteristics, ED utilization and adverse outcomes in pa-
visits) þ2.4(female gender) þ .32(age 3 CTAS interaction). tients with WR care versus those triaged to an acute care
This model predicted 30.5% of the variance in physician time bed (ACB). Our hypothesis was that patients managed in the
per patient (F[14,524] ¼ 19.4; P \ .0001). Conclusions: This WR would have more adverse events. Methods: A retro-
study identifies the predictor variables that are most asso- spective cohort study at St. Paul’s Hospital, a Canadian,
ciated with ED physician workload. After validation in other tertiary centre with 45,000 annual visits. By linking physician
settings, these data will help predict ED manpower needs. order entry and administrative databases, we reviewed all
patients who required an ACB from November 2000 to
November 2002. We used Chi-square analysis and t-tests to
321 The Terrorist Attack: Will We Respond? James I compare patients cared for exclusively in WR versus those
Syrett, William H Livingston, Sarah J Paris, Richard Russoti, whose entire care was in an ACB. Results: 34,226 patients
Eric A Davis, John G Benitez; University of Rochester: required an ACB. Of these, 5,355 (15.6%) had their entire care
Rochester, NY in WR, 5,341 (15.6%) were triaged to WR and later transferred
to an ACB, and 23,530 (68.7%) were triaged directly to an
Introduction: Terrorism Response Plans often call for ACB on arrival. WR patients were younger, lower acuity, and
Health Care Providers (HCPs) to report to work. Objective: seen less quickly than ACB patients. WR patients had shorter
The hypothesis is that HCPs will refuse to work during ED length of stay (LOS) and left without being seen (WBS) or
a bio-terrorism (BT) attack, family duties and availability of against medical advice (AMA) more often. WR patients were
treatment will change work availability. Methods: Survey of more likely to return requiring hospitalization within 7 days
HCPs required to respond to a BT attack. Two groups (revisit-admit) than ACB patients.
determined: G1-married and/or with children; G2-single/
no children. Two scenarios were presented, developing over
several days: 1-release of non-transmissible agent/proven ACB WR
treatment; 2-release of a transmissible agent/unproven Characteristic (n ¼ 23530) (n ¼ 5355) p
treatment only. At critical time points participants were AGE (years) 50.4 42.6 \.0001
asked to decide whether they would go to work (Yes/ % LEVEL 1/2 27.3 11.8 \.0001
Probably Yes/Undecided/Probably No/No). Follow up TIME TO MD (hrs) 0.75 0.85 \.0001
questions considered the effect of three treatment plans. ED LOS (hrs) 4.3 2.8 \.0001
Those answering yes or probably yes were assumed to LEFT WBS 0.3% 9.6% \.0001
report to work. Results: 164 surveys were issued. (100% LEFT AMA 1.3% 7.6% \.0001
response, 6 incomplete and excluded). Surveys were re- REVISIT-READMIT 1.35% 1.79% .018
ADMISSION RATE 37.5% 6.8% \.0001
turned from 45 EM physicians, 29 ED nurses, 64 EMS/Fire
532
Conclusions: Triage nurses accurately identified patients
who could safely be managed in the WR. High left WBS/
AMA rates suggest lower patient satisfaction but we failed to
show clinically important differences in revisit-admit rates.
323 Does Physician Order Entry Reduce Emergency
Department Length of Stay (LOS) in an
Overcrowded Emergency Department? Grant D Innes,
Eric J Grafstein, James M Christenson, Roy Purssel, Robert
Stenstrom; Providence Health Care, St. Paul’s Hospital:
Vancouver, BC, Canada, Vancouver Hospital: Vancouver, BC,
Canada, University of British Columbia: Vancouver, BC,
Canada
Objective: The practice of holding admitted patients in
the ED reduces stretcher availability and limits access to
emergency care. When ED stretcher occupancy is above
100% and sick patients are treated in waiting rooms (WR),
reducing ED LOS improves throughput and care access
for waiting patients. In November 2000, we instituted ED
physician order entry (POE), which reduces process times
and expedites testing for WR patients. Our hypothesis was
that the change to POE would reduce ED LOS, especially for
patients treated in the WR. Methods: A controlled before-
after study conducted at St. Pauls Hospital (SPH), an inner
city Vancouver teaching centre. The before cohort included
all patients discharged from the SPH ED from June 10–Nov
10, 2000. The POE (after) cohort included all patients
discharged from June 10–Nov 10, 2001. Concurrent control
data was gathered from a nearby teaching hospital with
similar volume and triage mix that did not implement POE.
The primary outcome was ED LOS for discharged patients.
Results: The POE and before cohorts included 19,225 and
22,191 patients respectively. Age (42.8 vs. 41.9), gender
(62.5% vs. 61.3% male) and disease spectrum were similar in
the two groups. During the study period, ED overcrowding
and gridlock increased: The mean daily n of admitted
patients held in the (22-bed) ED rose from 17.6 to 20.7 and
ED LOS (wait time) for admitted patients rose from 11.6 to
31.5 hrs. ED LOS for discharged patients rose by 36 minutes
(17%) at the control hospital and 12 minutes (8%) at the POE
hospital (p \ .001). ED LOS fell by 18 minutes for WR pa-
tients treated at the POE site. We are unaware of con-
founding variables to explain these findings. Conclusions:
We believe POE expedites patient care, particularly in non-
traditional locations, and mitigates the negative impact of
overcrowding on ED LOS.
Table Before After
SPH ED LOS (hrs): 2.4 2.6
SPH LOS for WR pts 3.4 3.1
Control hospital LOS 3.6 4.2
324 Financial Effects of Emergency Department
Admissions Compared to Electives within Surgical
Diagnosis Related Groups (DRGs) at 11 Hospitals in
Suffolk County, NY Mark C Henry, Henry C Thode Jr,
Stephen P Havasy; State University of New York:
Stony Brook, NY
2003 SAEM ANNUAL MEETING ABSTRACTS
Objective: Munoz and colleagues (1985) documented that
patients admitted through the emergency department (þER)
incurred higher hospital charges than patients who were not
admitted through the ED (
ER) in selected surgical DRGs. If
financial incentives were to guide priority for bed assign-
ments, ED admissions may be less desirable than electives.
Our study was structured to test the hypothesis that mode
of admission, (through the ED vs. not through the ED), is
a financial identifier for hospital charges within a DRG for
a variety of hospitals in Suffolk County, NY. Methods:
Setting—12 hospitals in Suffolk County, NY. Design—Re-
trospective review of administrative database including
DRGs, mode of admission, and hospital charges. Hospital
charges for all admissions (n ¼ 4445) within 9 surgical DRGs
(001, 049, 075, 107, 148, 209, 210, 215, 305) for the calendar
year 1996 were examined and mean charges calculated.
Patients in each DRG were then divided by identifer (þER
vs.
ER) and mean charges calculated by mode of ad-
mission within a DRG. We computed the percent difference
between identifiers. As per Munoz, a positive response
(positive identifier) was considered a greater than 20%
difference between identifiers within a DRG. Cells with less
than 4 patients were excluded from the analysis. The
remaining 51 DRG pairs were anayzed. Results: Within all
8 DRGs, admission through the ED (þER) had higher
hospital charges than admissions not through the ED (
ER).
(Range:
9% to 265%) For 38 of 51 þER was a positive
identifier ([20% difference in charges). In two cases ad-
missions not through the ED were associated with higher
charges than through the ED. Conclusion: For the 9 surgical
DRGs, admission through the ED is usually associated with
higher hospital charges. Negative financial incentives to
admit emergencies may contribute to boarding emergency
admissions in emergency departments and giving bed
priority to elective admissions.
325 Early Return as a Predictor of Recidivism in Patients
with Cholelithiasis Lisa D Mills, Trevor J Mills,
Shameem Nazeer; Louisiana State University Health Sciences
Center at New Orleans: New Orleans, LA, University of Texas
Southwestern: Dallas, TX
Objective: To determine patterns of recidivism in Emer-
gency Department (ED) patients with suspected cholelithi-
asis (CL). Methods: This IRB approved, prospective study
was conducted at a county hospital from 6/01 to 6/02.
Patients, age 18 to 65 years, evaluated for cholecystitis were
consecutively enrolled. These patients were followed by
a computerized triage system to identify repeat visits. Prior
visits to other EDs were included in data analysis. Number
of visits, time between visits, diagnosis and disposition were
recorded. Data was analyzed using a two-sided Fisher’s
Exact test with SPSS software. Results: One hundred fifty-
seven patients were enrolled. Thirty percent (46/157)
had multiple ED visits for abdominal pain. Patients with
multiple visits were significantly less likely to have an acute
process (cholecystitis, biliary pancreatitis or choledo-
cholithiasis) on the first visit than patients with only one
visit (p \ 0.000). Eighty percent (37/46) of the patients with
multiple visits to the ED were determined to have CL. In the
group with CL, patients with 2 visits in a 31day period had
a significantly increased chance of having 3 or more total
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
visits compared to patients whose visits were farther apart
(p ¼ 0.001). Patients with CL were significantly more likely
to be admitted on subsequent visits than patients with other
causes of abdominal pain (p \ 0.000). Number and size of
gallstones did not correlate with number of visits (p ¼ 0.06).
Conclusion: This study identifies patterns of presentation
among patients with multiple visits to the ED for CL. These
patients were less likely to have an acute process on the first
visit. Patients with 2 visits in 31 days were likely to have 3 or
more visits to the ED. This study indicates that same-visit
cholecystectomy in patients with one early return visit may
affect health care savings.
326 A National Estimate of Characteristics of Uninsured
Patients Who Seek Emergency Department
Care Peter Louis Lane, Barbara Sorondo, Cristina Magdalena
Nituica; Albert Einstein Medical Center: Philadelphia, PA
Objective: The Census Bureau estimated that 44.3 million
Americans were uninsured in 1998. The purpose of this
study was to characterize the uninsured (UI) population
that visited the Emergency Department (ED). Methods:
Descriptive, cross-sectional study using data from the
Medical Expenditure Panel Survey (MEPS) from 1996 to
1998. Demographic and socioeconomic characteristics were
analyzed and compared between the insured (I) and the
uninsured (UI). Results: Of 47,208 people surveyed, 9,129
(14.38%; 95%CI 13.64–15.12) reported having one or more
ED visits from 1996 to 1998, representing 127,316,777 million
persons nationwide. The mean age for the UI was 29.32; 95%
CI(28.46–30.17), and 52%, 95%CI (49.22–54.75) were female.
54.8% of the UI perceived their health status as very good to
excellent compared with 61% of I patients (p \ 0.001, 95%CI
¼
0.09 to
0.04). 39.6% of the UI patients perceived
themselves to have good mental health status compared
with 45.2% among I patients (p \ 0.001, 95%CI ¼
0.11 to

0.05). 32.1% of the UI had no educational degree compared
with 18.6% among I patients (p \ 0.001; 95%CI ¼ 0.11 to
0.16).70.2% of the UI were employed vs 62.7% of the I (p \
0.001, 95%CI ¼ 0.05 to 0.11). There were no statistical
differences between the groups in terms of the frequency of
ED visits. The three most frequent conditions in the two
groups were: UI -injuries and poisoning, respiratory and
gastrointestinal diseases (39.63%, 12.44%, 8% respectively);
I -injury and poisoning, respiratory and cardiovascular
diseases (31.2%, 12%, 9.54%). Conclusions: There were no
differences between I and UI patients in terms of the
frequency of ED visits. The UI were more likely to be young,
and female. UI patients had less education, but were more
likely to be employed. The UI were more likely to perceive
both their health and mental health status as poor when
compared with the I patients. Further analyses will evaluate
the clinical characteristics and the charges associated with
UI ED care.
327 Diabetes Education and Emergency Department
Recidivism Paul Vanderbeek, Tao Nguyen, Craig
Stanger, John J Kelly, Barbara Sorondo, George Gudrock;
Albert Einstein Medical Center: Philadelphia, PA
Objective: The purpose of this study was to evaluate the
benefit of the diabetic education program for patients
533
admitted to the Emergency Department Observation Unit
(OU). It was hypothesized that patients receiving diabetic
education would have fewer repeat ED visits for hypergly-
cemic events. Methods: Design: descriptive retrospective
data analysis. Study population: uncomplicated hyperglyce-
mic patients admitted to the OU at an inner city Level I
Trauma Center from November 19, 2001 to November 19,
2002 with an ICD9 code of 790.6 and 250.0. We compared two
groups, a control group defined as those not seen by
the certified diabetic educators (CDE), and a study group
defined by those seen by the CDE. The incidence of
recidivism of those patients who did not receive diabetic
education was compared to those who did. We defined
recidivism as return visits to the ED for hyperglycemic
episodes within a 6 month period of the initial OU admission.
Results: A total of 132 admissions to the OU with diagnosis
of uncomplicated hyperglycemia were analyzed. Of those, 37
did not meet inclusion criteria, as they had a period of
observation of less than 6 months. This left 95 patients that
were enrolled in the study. Thirty six patients were included
in the study group. The rate of recidivism for the control
group was 9.8%, compared to the study group rate of 16.7%
(p ¼ 0.35). In the study group, 15 patients had a range of one
to six additional outpatient classes or telephone instructions
beyond the initial OU teaching. No statistical significance
was found when comparing the recidivism of patients with
single versus multiple interventions, and when comparing
the type of intervention. Conclusion: The recidivism rate did
not change in the group receiving the educational interven-
tion as compared to the control group. There was no
relationship between the numbers of interventions and the
recidivism rate. Further analysis will be done when more
data is collected.
328 Methodologic Issues in the Classification of Race/
Ethnicity in Clinical Research Gabrielle C Hunter,
Sunghye Kim, Jessica L Hohrmann, Sunday Clark, Carlos A
Camargo Jr; Massachusetts General Hospital: Boston, MA
Objective: A primary goal of ‘‘Healthy People 2010’’ is the
elimination of racial disparities in healthcare. To address
this problem, and monitor progress, accurate reporting and
analysis of race/ethnicity data are crucial. We examined one
aspect of this complex issue; approaches to categorizing
a person’s ‘‘race’’. Specifically, we compared a ‘‘traditional’’
approach (1 question with 5 options [W, B, H, A, other], with
a single ‘‘race’’ assigned by the interviewer) versus the 2000
US Census approach (2 questions asked of each individual;
1 on race and 1 on Hispanic status). In our prospective
multicenter study, we hypothesized that there would be
high interrater agreement between the two approaches.
Methods: For two 24-hour periods, we interviewed pts age
$18 years presenting to 4 Boston EDs. Exclusion criteria
included severe illness and emotional disturbance (n ¼ 224).
For subjects classified or self-identified as multiracial (e.g.,
Hispanic black), a single race/ethnicity was assigned to
each patient (e.g., Hispanic)—as is often done in research
studies. Data analysis used the Kappa statistic. Results: Of
754 eligible pts, 530 (70%) were interviewed. Using the
traditional approach, interviewers identified patients with
the following race distribution: 63% W, 14% B, 21% H, 2% A,
and 1% other. When patients were asked to identify their
534
race, we obtained this distribution: 60% W, 14% B, 20% H,
2% A, and 4% other. Overall interrater agreement between
the two classifications systems was high, with 91.2%
agreement, a Kappa statistic of 0.84 (p \ 0.001). We next
examined agreement within subgroups to determine
whether these classifications were consistent across age
groups, sex, education levels, and place of birth. Agreement
was [85% for all subgroups except those born outside the
US, where agreement was 84%, with Kappa 0.76 (p \ 0.001).
Conclusion: The traditional classification of race/ethnic
categories appears to yield a similar distribution to the new
US Census approach started in 2000.
329 A Comparison of Three Methods for Defining Acute
Myocardical Infarction John T Nagurney, Orlando
Heredia, Swati Sane, Sarah C Lewis, Ik Kyung Chang; Partners
Health Care: Boston, MA, Washington University School of
Medicine: St. Louis, MO, Stanford University: Palo Alto, CA
Objective: To compare three methods of defining acute
myocardial infarction (AMI): the traditional 1985 WHO
criteria, the recent 2000 ESC/ACC criteria, and chart criteria
(CC). Methods: type of study: single-center, retrospective
descriptive study. Setting: a level one 70,000-visit university
ED. Subjects: any adult admitted to the hospital through our
ED over a three month period with at least one elevated
cardiac biomarker (TnI, TnT, CKMB) recorded in the hos-
pital database. Observations: all laboratory data, medical
records, and ECG results were reviewed. Published criteria
for WHO 1985 (1985) and ESC/ACC 2000 (2000) definitions
of AMI were applied to each subject by two trained, blinded
coders. A subject was considered positive (pos) by CC if the
medical record indicated that they had sustained an AMI
during that admission. Analysis: a multi-rating system
kappa statistic was calculated, as well as the percent overlap
among criteria, with 95% confidence intervals. An inter-
observor kappa statistic on the two abstractors for key
variables was also determined. Results: Preliminary results
show that there were 399 eligible subjects, and data avail-
able on 396. Among them, all three criteria were pos in 15%
((95% CI 11–19%), negative (neg) in 27% (95% CI 23–31%),
and disagreed in 58% (95% CI 53–63%). The multi-rating
system kappa statistic for all 3 criteria was 0.19(95% CI 0.14–
0.25). There were 277 subjects who were 2000 criteria pos.
Among them, 21% (95 % CI 16–26%) were pos by all three
criteria but 52% (95% CI 46–58%) were neg by both 1985 and
CC. An additional 16% (95% CI 12–20%) were CC pos and
1985 neg and 11% (95% CI 7–15%) were 1985 pos and CC
neg. Conclusion: The agreement for the definition of AMI
among the new 2000 ESC/ACC criteria, traditional 1985
WHO criteria, and providers (CC) is poor. These new 2000
ESC/ACC criteria appear to include large numbers of
patients who would not be considered to have had an AMI
by traditional criteria or by their providers.
330 Impact of Informed Consent Requirements on
Cardiac Arrest Research in the United States:
Exception from Consent or from Research? Graham
Nichol, Ella Huszti, Jennifer Rokosh, Andrea Dumbrell, Jessie
McGowan, Lance Becker; University of Ottawa: Ottawa, ON,
Canada, University of Chicago: Chicago, IL
2003 SAEM ANNUAL MEETING ABSTRACTS
Objectives: Experimental research in patients with life-
threatening illness is challenging since such patients can not
provide consent. The Food and Drug Administration pre-
viously addressed the issue of consent in these populations
by stating criteria for waiver or exception from informed
consent. Therefore, we systematically reviewed the origin of
randomized trials of interventions for patients in sudden
cardiac arrest to assess the impact of these regulations.
Methods: Studies were identified by using a priori struc-
tured literature searches of English language MEDLINE and
EMBASE from 1992 to June 2002. Included were studies that
used random allocation in humans in sudden cardiac arrest
at the time of enrollment. Excluded were duplicate publica-
tions. Changes over time in the number of US trials, number
of non US trials and proportion of trials of US origin were
compared by using Poisson and linear regression analysis.
Randomized trials of interventions for atrial fibrillation
were evaluated as concurrent controls. Results: Of 426
eligible cardiac arrest studies, 47 trials (11 percent) were
included. The number of US cardiac arrest trials tended to
decrease by 15 6 7 percent annually (p ¼ 0.054) over the
duration of the study period. The proportion of all cardiac
arrest trials that were of US origin decreased by 17 6 6
percent annually (p ¼ 0.037). Of 1770 eligible atrial
fibrillation studies, 140 (8 percent) were included. The
number of atrial fibrillation trials of US origin has not
significantly changed (p ¼ 0.48). The proportion of all atrial
fibrillation trials of US origin has not significantly changed
(p ¼ 0.38). Conclusions: The number and proportion of
cardiac arrest trials of US origin has declined during the last
decade while the number and proportion of atrial fibrilla-
tion trials of US origin has not changed. The decline in US
cardiac arrest trials is temporally associated with changes in
consent requirements. This may limit Americans’ access to
innovative beneficial interventions.
331 Risk Factors for Hyponatremia among Runners in
the Boston Marathon Christopher S Almond, Elizabeth
B Fortescue, Andrew Y Shin, Rebekah Mannix, David S Greenes;
Children’s Hosital: Boston, MA
Objectives: The objective of our study was to identify risk
factors for exercise-associated hyponatremia in marathon
runners. Methods: Official participants in the 2002 Boston
Marathon were recruited prospectively at an exposition 1–2
days before the race. Subjects completed a survey describing
demographic information and training history. Following
the race, runners provided a blood sample and completed
a questionnaire detailing fluid consumption during the race.
Pre- and post-race weights were measured. We determined
a priori that age, female gender, smaller body surface area
(BSA), poorer conditioning, longer race times, lower per-
centage of weight loss, and consumption of predominantly
free water should be considered as potential risk factors for
hyponatremia. Chi-square and unpaired t-tests, along with
binary logistic regression techniques were employed.
Results: Of 741 runners enrolled, 481(64%) had blood
drawn after completing the marathon. Subjects had a mean
age of 39 6 9 years. 165 (34%) were female. Mean race time
was 219 6 48 minutes. Mean serum sodium was 140 6 4.8
mEq/L. Sixty-two (13%) subjects developed hyponatremia
(serum sodium less than 135 mEq/L). Three subjects (1.2%)
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
had serum sodium values less than 120 mEq/L. On
univariate analysis, female gender, race time $4 hours,
BSA # 50th%ile (1.8 meters-squared), #5 marathons run
previously, and post-race weight $ pre-race weight were
associated with hyponatremia. On multivariate analysis,
hyponatremia was associated with race duration $4 hours
(OR 2.7, 95% CI 1.4 to 5.1), female gender (OR 3.4, 95% CI 1.2
to 9.7) and post-race weight $ pre-race weight (OR 4.0, 95%
CI 2.1 to 7.7). Conclusion: Exercise-associated hyponatremia
occurred in approximately 13% of subjects completing the
Boston Marathon. Female runners and runners with slower
race times are at higher risk. Our findings also suggest that
excess fluid consumption before or during marathoning
may contribute to the risk of hyponatremia.
332 New Jersey Heating Oil Company Responses to
Questions Regarding Carbon Monoxide Poisoning
and Hyperbaric Oxygen Therapy Marc A Bornstein,
Paul Szucs, Donald Alves; Morristown Memorial Hospital:
Morristown, NJ
Objectives: Carbon monoxide (CO) is the most common
cause of death from acute poisoning in the United States.
The objective was to determine if New Jersey (NJ) heating
oil companies provide accurate information regarding CO
poisoning and its potential treatment with hyperbaric
oxygen (HBO) therapy. Secondary objective was to de-
termine the availability of this information to the public.
Methods: The study design was an observational cross-
sectional telephone survey of NJ heating oil companies. The
first 400 oil companies listed in the NJ yellow pages on
excite.com were called. Callers identified themselves as
physicians performing research on carbon monoxide poi-
soning. A script of 10 questions was posed to the most
knowledgeable employee available regarding carbon mon-
oxide poisoning. Results: Completed surveys were obtained
for 232 of the 400 calls made (58%). Failure to obtain
completed surveys was the result of incorrect phone listings,
answering machines and the refusal to answer questions.
Thirty five percent of responders denied any risk of CO
poisoning from oil burning furnaces. CO was reported to
have an odor by 27%. Thirty percent were unfamiliar with
any symptoms of CO poisoning. If a CO detector alarmed,
only 21% recommended turning off the furnace and/or
leaving the scene. The recommended treatment was fresh
air or oxygen for 52% of responders. Of the completed sur-
veys, 18% were familiar with HBO chambers and only 5%
knew that HBO is a potential treatment for CO poisoning.
Three percent knew the location of a HBO chamber. Only
10% of the NJ heating oil companies surveyed had an
available brochure on CO poisoning. Conclusions: NJ
heating oil companies do not uniformly provide accurate
information regarding CO poisoning. The majority of NJ
heating oil companies surveyed are not familiar with HBO
therapy or its applications in CO poisoning. Information on
carbon monoxide poisoning and HBO therapy is not readily
available from NJ heating oil companies.
333 Child Passenger Fatalities Involving Drinking
Drivers Patricia C Ramos, Cameron Crandall;
University of New Mexico: Albuquerque, NM
535
Objectives: Motor vehicle collisions involving alcohol are
a leading cause of mortality for children over age one in the
United States. This study examines characteristics of child
passenger fatalities involving drinking drivers to identify
trends and opportunities for injury prevention. Methods:
Design/Setting/Participants. Epidemiological analysis of
1991–2000 Fatal Analysis Reporting System (FARS) data of
crashes involving child passenger deaths. This is a retrospec-
tive cohort study. Interventions/Observations. Study authors
employed SAS, version 8.2, for statistical analysis using
multiple imputed blood alcohol concentration (BAC) values
provided by the National Highway Traffic Safety Adminis-
tration (NHTSA). Main outcome measures are driver,
passenger and crash characteristics (e.g. age, use of
restraints, driver BAC, single versus multiple vehicle col-
lisions). Comparison is made to previously reported FARS
data (1985 to 1996) using revised multiple imputed BAC
values. Results: In 1991–2000, there were 17,381 child
passenger deaths, with 4,519 (26%) involving a drinking
driver (95% confidence interval 24–28%). Among these
drinking driver-related child passenger deaths, 62% were
unrestrained and 38% were killed in single-vehicle collisions.
In 66% of these fatalities, the child was riding with
the drinking driver. The proportion of child passenger deaths
involving drinking drivers declined over the past sixteen
years, from 32% (95% confidence interval 29–35%) in 1985, to
23% (95% confidence interval 20–26%) in 2000. The pro-
portion of child passenger fatalities involving a child trans-
ported by a drinking driver also declined over this period.
Conclusions: Revised NHTSA data show that drinking
drivers contribute to one in four child passenger deaths in
the United States. Most of these fatalities involve a child
being transported, unrestrained, by a drinking driver.
Aggressive public health interventions are needed.
334 From Poppy Fields to Potter’s Field: Increased
Mortality after Nonfatal Heroin Overdose Christine
S O’Brien, Cameron S Crandall, Patrick E McKinney;
University of New Mexico: Albuquerque, NM
Objectives: To determine the follow-up mortality of patients
presenting to an urban Emergency Department (ED) for
nonfatal heroin overdose. Methods: Design: Nonconcurrent
prospective. Setting: Urban, university-affiliated teaching
hospital. Subjects: ED charts for all 419 patients presenting
to the ED 2/94–3/96 with opiate use key words (e.g., heroin,
opiate, narcotic, OD, IVDA) in the chief complaint or final
diagnosis fields of our ED patient database were reviewed
for inclusion. ED chart review confirmed opiate overdose
history and yielded 90 subjects who survived to discharge,
thus comprising the cohort. Observations: Subjects were
linked to state mortality files using names and date of birth.
Person-time was calculated between the overdose ED visit
and the date of death or end of follow-up (1/02). Persons
not found in the state mortality files were presumed alive.
All cause age- and gender-specific mortality rates were
calculated using death data as the numerator and person-
time as the denominator. The observed number of deaths
was compared to the expected number using 1998 county
specific age and gender mortality rates, calculating age-
adjusted standardized mortality ratios (SMR). Results: 16 of
90 subjects died in follow-up (10/65 male; 6/25 female), on
536
average 2.7 years after the ED visit. The average age at death
was 41.4 years. The overall mortality rate was 3,028 deaths/
100,000 person-years. The annual mortality risk was 3.0%
and was uniform over time. The overall SMR was 8.4 (95%
CI: 5.1, 13.0). For men, the SMR was 6.0 (95% CI: 3.1, 10.6).
For women, the SMR was 18.2 (95% CI: 7.8, 35.8). Most
subjects died of an opiate overdose (31%), trauma (25%), or
hepatitis (19%). Few (6%) died of AIDS. Conclusions: The
mortality of narcotic users is striking. Effective, ED-based
interventions targeting this high-risk population are ur-
gently needed. Gender specific risks must be further studied
and interventions aimed at those factors identified be
prioritized.
335 Identification of Cardiac Arrest Clusters Using
Historical Data and a Geographic Information
System E Brooke Lerner, Rollin Fairbanks, Manish N Shah,
Kumar Ilangovan; University of Rochester: Rochester, NY
Introduction: Use of emergency medical service data with
a Geographic Information Systems (GIS) for public health
has become more common, especially in monitoring for
bioterrorism. These data and methodology could also be
helpful for disease cluster identification and prevention.
Objective: To locate all out-of-hospital cardiac arrests
(OHCA) in a Northeastern City and to identify clusters of
OHCA and clusters of patients who did not receive by-
stander CPR in order to identify locations that would benefit
from prevention efforts. Methods: The locations of all adult
OHCA of cardiac etiology occurring in the study City over
a 4-year period were plotted on a map using ArcGIS.
Location information was obtained from patient care reports
and included street address and zip code. Descriptive data
related to patient treatment and transport were also
abstracted. Kernel analysis was used to identify areas with
the highest density of OHCA. OHCA that did not receive
bystander CPR were selected and Kernel analysis was
repeated to identify areas with a high density of no
bystander CPR. Results: 461 OHCA occurred during the
study period that met the inclusion criteria. 94% of the
OHCA had sufficient location information to be plotted.
Two clusters of OHCA were identified. EMS or First
Responders started CPR (i.e., no bystander CPR) for 339
patients (74%). Kernel analysis revealed 3 areas with a high
density of no bystander CPR; these areas coincided with the
OHCA cluster sites. They were also in areas that according
to the census had lower median household incomes
($20,928; $19,240; $8,613) than the City median ($27,123).
Conclusion: OHCA can be plotted by geographic location.
Clusters of OHCA can be identified, which could be used to
guide resource allocation. Clusters of OHCA that did not
receive bystander CPR can also be identified and used
to direct education programs. Census data can be super-
imposed on this information to identify characteristics of
cluster locations.
336 At Risk Drinking among Injured Older Adults
Presenting to the Emergency Department
Samuel A McLean, Frederic C Blow, Maureen A Walton,
Kristen L Barry, Ronald F Maio, Steven R Knutzen;
University of Michigan: Ann Arbor, MI
2003 SAEM ANNUAL MEETING ABSTRACTS
Background: Injured patients presenting to the ED have
been identified as an important group in which to target
alcohol screening and intervention. The rate of at risk
drinking in this group is unknown. Objective: To determine
the rate of at risk drinking among injured older adults
presenting to the ED. Methods: Cross-sectional survey of
injured adults presenting to a university hospital ED 8/99–
2/02. Injured patients were prospectively identified; con-
senting, cognitively intact patients completed survey via
hand-held computer including questions regarding quan-
tity/frequency of alcohol use. Major trauma patients were
excluded. Demographic and injury information and patient
medications were obtained from the medical record. Older
adults were defined as those 60 years of age or older;
patients who exceeded NIAAA quantity/frequency guide-
lines for adults 65 years of age or older were defined as at
risk drinkers. Analysis utilized Student’s t for continuous
variables, and frequency (95% CI) and chi-square analysis
for categorical variables. Results: 4476 patients were
enrolled, 284 [6%(6–7%)] were older adults. 275(97%) lived
independently, 114(40%) were male. Fall (66%) was the most
common injury mechanism, the most common injury types
were fracture/dislocation (34%), laceration (23%), and
contusion/abrasion (23%). 30(11%) patients were admitted.
31 older adults [11%(8–15%)] were at risk drinkers. Injury
mechanisms and mean ages of at risk drinkers (67 years)
and non at risk drinkers (70 years) were not significantly
different. At risk drinkers were more likely to be male (71%
vs. 36%, p # .001). Among at risk drinkers, 10 [30%(17–
51%)] were taking one or more medications which may
cause a moderate or severe drug interaction with alcohol.
Conclusion: Approximately 1 in 10 injured older adults
presenting to our ED are at risk drinkers, a significant
minority of such patients are taking medications which may
result in a moderate or severe adverse drug reaction with
alcohol.
337 Emergency Medical Services Responses to Shootings
and Stabbings as Predictors of Homicide Jamie K
Hensen, Stephen W Hargarten, Clare E Guse, Peter M Layde;
Medical College of Wisconsin: Milwaukee, WI
Objectives: To determine if localized escalating violence as
measured by Emergency Medical Services (EMS) responses
to shootings and stabbings can be used as a predictor of
homicide events. Methods: Design: A retrospective pop-
ulation-based case-control study. Setting: urban. Subjects:
Records of EMS responses to shootings or stabbings be-
tween 12/1/98 and 12/31/00 (n ¼ 2,244) were obtained
from the Fire Department Computer Aided Dispatch
Incident Response Master File. Homicide data from 1/1/
99 through 12/31/00 were obtained from the Medical
Examiner’s Office, (n ¼ 250). Groups of 50 controls per
homicide event (n ¼ 12,500) were randomly sampled from
the 2000 Census for the city and assigned an index date
corresponding to the date of the event. Observations:
Homicides, controls and EMS responses were assigned
latitude and longitude coordinates using ArcView GIS 3.2a.
The distances between each homicide and each EMS
response and between each control and each EMS response
were calculated. Time and distance were used to examine
the predictive utility of different temporal and spatial mea-
sures. Analyses were performed using a logistic regression
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
model while controlling for demographic factors. Results:
A zhomicide event was more likely than controls to have
EMS activity on the same day within one mile of the homi-
cide victim’s injury address (OR ¼ 1.9; 95%CI: 1.7–2.2).
An increase in EMS activity in the days leading up to
a homicide event was observed at 15–30 (OR ¼ 1.1; 95%CI:
1.06–1.13), 8–14 (OR ¼ 1.1; 95%CI: 1.1–1.2), 3–7 (OR ¼ 1.2;
95%CI: 1.1–1.3) and 1–2 days (OR ¼ 1.3; 95%CI: 1.1–1.4).
Conclusions: A relationship between EMS responses to
shootings and stabbings and homicide events is suggested.
Additional examination of EMS responses 6 to 24 hours
prior to homicide events is needed to further define this and
may suggest that space-time clustering of EMS responses
should trigger a broader community and law enforcement
response to potentially preempt homicide events.
338 Instant Disposition: Validation of an Admission
Prediction Model Jonathan A Handler, Craig F Feied,
Julie Sundaram, Paul Yarnold, Michael Gillam, James G Adams,
Robert C Soltysik; Northwestern University Medical School:
Chicago, IL, Evanston-Northwestern Healthcare: Evanston, IL,
MedStar Health: Washington, DC
Objectives: Emergency departments (ED) suffer from long
waits and overcrowding. Real-time disposition prediction at
triage may enable resource planning and patient satisfaction.
We previously derived a model to predict admission (ADM)
at triage. This study attempts to validate the model by
comparing predicted ADM likelihood with actual disposi-
tion. Methods: We performed a retrospective analysis of
prospectively collected data on all ED patients during a 3-
month period (n ¼ 15,255). Patients not admitted to or
discharged from our hospital (e.g. transfers) were excluded.
The previously derived model incorporates four variables
(triage score, age, # of prior ED visits, # of prior ADMs from
ED) to predict ADM likelihood. In this analysis, admission
likelihood was compared to the actual ADM status in order to
assess validity. Individual patient classification performance
and Type I error for the resulting goodness-of-fit was assessed
using Fisher’s exact test. Overall performance of the model
was compared to triage score (TS) alone as well as historical
ADM rate (HAR). Results: 72.1% of patients were correctly
classified, with an ADM prediction sensitivity of 85.1%,
specificity of 66.9%, and a relatively strong Effect Strength for
Sensitivity of 52.0% (0% ¼ chance). For individual patients,
the model (11 categories) predicts ADM with finer granular-
ity than TS (5 categories) or HAR (1 category), and the
model’s range of predicted ADM rates (2%–71%) is 25.5%
greater than that of TS alone (1%–56%). For undifferentiated
patient cohorts, the model, TS, and HAR comparably predict
the total number of admissions. The HAR performs un-
reliably, and often poorly, on partially differentiated cohorts
(e.g. moderately ill waiting room patients). Conclusions: The
model predicts admission with a relatively strong validity,
significantly better than chance, and with finer granularity
than TS or HAR. This tool may improve hospital resource
planning and allocation, as well as patient satisfaction.
339 The Use of Electronic Clinical Practice Guideline
Resources in Two Canadian Emergency
Departments Brian H Rowe, Michael J Bullard,
David P Meurer, Ian Colman, Brian R Holroyd; University of
537
Alberta: Edmonton, Alberta, Canada, University of Alberta
Hospital: Edmonton, Alberta, Canada
Objectives: Access to valid clinical practice guideline (CPG)
information in the emergency department (ED) has the
potential to improve practice efficiency and patient care.
This study examined the use of electronic CPG applications
by emergency physicians. Methods: Desktop computers
containing an ED tracking system were widely available to
all staff in two linked EDs. In addition, EM-specific desktop
CPG materials including decision tools, order sets, full care
maps, and discharge instructions were accessible using an
intranet website (eCPG). Access was provided to 38 full-
time EM staff over a 20 month study. Staff use was doc-
umented using a web counter, database (n ¼ 2267) and end
of session questionnaires (n ¼ 840) using a 7-point Likert
scale. Descriptive and comparative analyses are reported (p
\ 0.05). Results: All physicians accessed the tools at least
once over the study, with over 5500 ‘‘hits’’ recorded to the
site. Most (88%) physicians used 1 application per site visit
of which many (64%) preferred the defaulted templates.
Overall, the most common resource accessed was the
outpatient information in 1138 cases (50%), followed by
decision tools in 603 cases (27%), and order sets in 526 (23%)
cases; over seven 3-month periods, use of all applications
increased (p \ 0.0001). The respondents reported that they
found the resources easy to find (6/7; IQR ¼ 5,7) and helpful
(6/7; IQR ¼ 5,7). Physicians felt more confident with the
care they delivered (6/7; IQR: 4,6) and felt that the
application improved the quality of care they provided
(6/7; IQR: 4, 6). Finally, most physicians felt satisfied both
with the information contained in the document (6/7; IQR:
5, 7). Conclusions: An intranet based EM-specific eCPG site
was used widely by pediatric and adult physicians in busy
EDs. Overall, physicians felt the eCPG information was
valid and helped them practice better medicine in the ED.
Further research is required to determine if access to eCPGs
improves patient outcomes.
340 Documentation of Emergency Medicine Resident
Procedures Using a Personal Digital
Assistant David R Lane, Steven B Bird, Robert S Zarum;
University of Massachusetts Medical School: Worcester, MA
Background: Personal Digital Assistants (PDAs) have been
integrated into daily practice for many emergency physi-
cians and residents. Few objective data exist that quantify
the effect of PDAs on documentation. Objective: The
objective of this study was to determine whether use of
a PDA would improve emergency medicine resident
documentation of procedures and patient resuscitations.
Methods: Twelve first-year residents were provided a Palm
V (Palm, Inc., Santa Clara, CA) PDA. A customizable patient
procedure and encounter program was constructed and
loaded into each PDA. Residents were instructed to enter
information on patients who had any of 20 procedures
performed, were deemed clinically unstable, or on whom
follow-up was obtained. These data were downloaded to
the residency coordinator’s desktop computer on a weekly
basis for 36 months. The median number of procedures and
encounters performed per resident over a three year period
were then compared with those of 12 historical controls
from the previous residency class that had recorded the
538
same information using exclusively a handwritten card
system for 36 months. Medians of both groups were
compared using the Mann-Whitney U test with Bonferroni
correction for multiple comparisons. Results: Median
documentation of three procedures significantly increased
in the PDA vs handwritten groups: conscious sedation 24.0
vs 0.03; thoracentesis 3.0 vs 0.0; and ED ultrasound 24.5 vs.
0.0. In the handwritten cohort, only the number of
cardioversions/defibrillations (26.5 vs 11.5) was statistically
increased (p ¼ 0.001). Conclusions: Use of a PDA did not
significantly change EM resident procedure or patient
resuscitation documentation when used over a three-year
period. Statistically significant differences between the
handwritten and PDA groups likely represent alterations
in the standard of ED care over time. This favorable
comparison and the numerous other uses of PDAs may
make them an attractive alternative for EM resident
documentation.
341 Can an Artificial Neural Network Predict the Need
for Hospital Admission Using Routine Triage
Data? Wayne A Satz, Jacob W Ufberg, Jennifer Harris;
Temple University Hospital: Philadelphia, PA
Objective: In the setting of emergency department (ED)
overcrowding and inpatient bed shortages, effective ED
resource allocation hinges on rapid identification and
queuing of patients requiring admission. We hypothesized
that an artificial neural network (ANN) utilizing informa-
tion easily obtained during ED triage can predict hospital
admission for patients in the ED waiting area more
accurately than logistic regression (LR). Methods: This
study took place at a busy, inner city ED. Data was collected
retrospectively from triage components of the charts of 142
waiting area patients classified by the triage nurse as
‘‘urgent.’’ The data collected included a modified emer-
gency severity index score (ESI), vital signs, past medical
history, age, chief complaint risk score (CC risk), number of
medication allergies, and medications. The 6 most sensitive
categories using LR criteria of p \ 0.25 (age, ESI, past
medical history, CC risk, allergies, and medications) were
used to train the ANN and LR. After training and cross-
validation, an unexposed set of 22 patients was then used to
test the ANN and LR. Results: Overall 44 of the 142 patients
(31%) in the training set were admitted. After training of the
ANN and LR, ANN identified 86% of admissions in the test
group vs. 71% of admissions for LR (p ¼ NS). ANN
predicted 87% of discharges in the test group vs. 73% of
discharges for LR. The sensitivity of ANN for predicting
admission was 86% vs. 73% for LR. Conclusion: In this
study ANN performed at least as well as LR in predicting
admission using routine triage data. Larger studies may
show ANN to be superior to LR in predicting hospital
admission. Future studies should evaluate whether use of
an ANN to predict admission results in earlier hospital bed
disposition.
342 Evaluation of Triage Nurse Satisfaction with
Training and Use of an Electronic Triage
Tool Michael J Bullard, David P Meurer, Shirley Pratt,
Brian R Holroyd, Brian H Rowe; University of Alberta:
2003 SAEM ANNUAL MEETING ABSTRACTS
Edmonton, Alberta, Canada, Grey Nun’s Community
Hospital: Edmonton, Alberta, Canada
Objectives: The Canadian Triage and Acuity Scale (CTAS) is
a nationally recognized triage standard; however, applica-
tion of CTAS in busy EDs by multiple users reduces
reliability and limits validity. This study was designed to
determine if an electronic, complaint-based triage tool
(eTRIAGE) could be easily learned and rated satisfactory
by nurses in a busy urban ED. Methods: 9 volunteer triage
nurses each received 2 hours of didactic teaching, 2 hours of
mentoring during their first eTRIAGE shift, and access to
a free time training module. A satisfaction questionnaire was
completed at the end of each shift (using a 7-point Likert
scale). All eTRIAGE shift data were captured in a database
for analysis with traditional paper triage interactions
randomly captured for time comparison with eTRIAGE en-
counters. Users were categorized based on self-reported PC
experience into novice (NOV) or experienced (EXP) com-
puter users. Results: The study nurses were experienced
(median age 45) with 24 (IQR: 21,25) years of nursing.
Overall, 2122 eTRIAGE encounters were recorded over 67
shifts; only 112 (5.2%) encounters had a nurse override the
eTRIAGE score. EXP users rated eTRIAGE more favorably
than NOV users with respect their: comfort using (5.88 vs
4.76), ease (3.96 vs 3.05), helpfulness (3.76 vs 3.18), in-
terference with patient interaction (2.60 vs 4.08), and in-
creased triage time (4.44 vs 5.21). Measured triage times
(minutes/patient) were similar for paper-based (2.45m) and
eTRIAGE (EXP ¼ 2.42m vs. NOV ¼ 2.85m). Conclusions:
eTRIAGE was easily learned even by novice users and speed
was at least comparable to paper-based triaging. The tool also
satisfied nursing perceptions of patient acuity, as 5% of
encounters resulted in an override of the eTRIAGE score.
The database provides search and reporting capabilities. If
ongoing studies confirm both reliability and validity,
templated electronic triage should be adopted in place of
paper-based triage relying on nurse memory and experience.
343 Development of a Computerized System to Reduce
Medical Errors: A Pilot Study Adam J Singer,
Melina J Lo-Giudice-Khwaja, Ishan S Khwaja, Robert F
Kelly; State University of New York: Stony Brook, NY
Objective: A recent report of the Institute of Medicine has
brought attention to medical errors, many of which are
errors of omission in the ED. We developed a computerized
system aimed at reducing the number of errors of omission
in the ED. Methods: Design-retrospective observational.
Setting-university based ED with 75,000 annual visits.
Participants-random sampling of medical records of pa-
tients discharged from ED during a 1-month period.
Intervention-a computerized program was developed that
captured multiple clinical and laboratory data, including
demographics, vital signs, hematology, chemistry, toxicol-
ogy, and electrocardiographic information. Abnormal
values were defined for each of the 77 data points using
standard references. The computer program was designed
to alert the physician to any abnormal findings, emphasiz-
ing sensitivity over specificity, and required their acknowl-
edgment prior to disposition. In the first phase of our study,
data was abstracted retrospectively from medical records
and entered into the computerized program. All abnormal
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
values identified were reviewed by two investigators to
determine their relative clinical significance. Data analysis-
descriptive statistics used. Results: 242 medical records
were reviewed. Abnormal findings were identified in 157
cases (65%), of which 43 were considered potentially clin-
ically significant and not addressed in the ED including 32
cases of elevated blood pressures, 2 cases of hypotension,
one case of thrombocytopenia, and two cases of renal insuf-
ficiency, one case of anemia, 4 cases of tachydyshythmias,
one case of bradycardia. Telephone follow-up did not reveal
any deaths or major disabilities resulting from these
omissions. Conclusions: A computerized system aimed at
identifying errors of omission in the ED was tested. 43
potentially significant omissions were identified from 157
cases. Further prospective evaluation of this system is
ongoing to determine its utility in the ED.
344 Supporting Clinical Practice at the Bedside Using
Wireless Technology Michael J Bullard, Brian Rowe,
David P Meurer, Ian Colman; University of Alberta: Edmonton,
Alberta, Canada
Objectives: Despite studies that show improvements in
both standards of care and outcomes with the judicious
application of clinical practice guidelines (CPG), clinical
utilization remains low. This randomized trial examines
the use of a wirelessly networked mobile computer (MC) by
physicians at the bedside with access to an ED information
system, decision support tolls and other software options.
Methods: Each of 10 volunteer Emergency Physicians were
randomized using a matched pair design to work 5 shifts
in their standard fashion and 5 shifts with a wireless net-
worked laptop computer. Work pattern issues and electronic
template use were compared using end-of-shift satisfaction
questionnaires and reviewing the database for electronic
template usage. Repeated measures ANOVA was used to
examine between shift differences. Results: 99% compliance
with post-shift questionnaires was achieved. Using a 7 point
Likert scale (MC values first) MC shifts were rated as being
as fast (5.04 vs 4.54; p ¼ 0.128) and convenient (5.08 vs 4.14;
p ¼ 0.071) as desk top computers. Overall, physicians rated
MC to be less efficient (3.18 vs 4.30; p ¼ 0.015) but resulted
in more frequent use of CPG forms (4.10 vs 3.47; p ¼ 0.034)
without impacting on doctor-patient communication (2.78
vs 2.96; p ¼ 0.512). During the study period, physicians
demonstrated more frequent use of CPGs during shifts
assigned to the mobile computer compared to the desktop
(3.6 vs 2.0; p ¼ 0.033). The major concerns of the study
physicians were the size of the computer and cart and the
limited number of CPGs available on-line. Conclusions: The
MC technology permitted physicians to rapidly access
information at the bedside and use the CPG tools more
frequently. Patients appeared to accept physician’s use of
information technology to assist in decision making. The
major limitations remain MC size and portability, requiring
ongoing development of new computer technology.
345 Multicenter Prospective Validation of the Canadian
CT Head Rule Ian G Stiell, Catherine Clement, George
A Wells, Robert Brison, R Douglas McKnight, Michael Schull,
Brian H Rowe, Jonathan A Dreyer, Glen Bandiera, Jacques Lee,
539
Iain MacPhail, Howard Lesiuk, for the CCC Study Group;
University of Ottawa: Ottawa, Ontario, Canada, Queens
University: Kingston, Ontario, Canada, University of Toronto:
Toronto, Ontario, Canada, University of Western Ontario:
London, Ontario, Canada, University of British Columbia:
Vancouver, British Columbia, Canada, University of Alberta:
Edmonton, Alberta, Canada
Objectives: The Canadian CT Head Rule (CCHR) for use of
CT was previously derived in a cohort of 3,121 patients and
stratifies minor head injury patients into High-, Medium-,
and Low-Risk categories, based upon 7 clinical criteria. This
study prospectively and explicitly evaluated the accuracy,
reliability, and acceptability of the CCHR. Methods: This
prospective cohort study was conducted in 9 tertiary care
EDs and enrolled adult minor head injury patients with
witnessed loss of consciousness, amnesia, or confusion and
a GCS score of 13–15. More than 350 physicians completed
15-item data forms and interpreted the CCHR status for
patients prior to diagnostic imaging. In some cases 2nd
physicians performed interobserver assessments. The out-
come standards were ‘need for neurological intervention’
and ‘clinically important brain injury’. Analyses included
kappa coefficient, sensitivity, and specificity with 95% CIs.
Results: The 2,588 patients enrolled over 30 months had
these characteristics: mean age 38.4 (range 18–99), male
69.3%, ambulance arrival 76.9%, clinically important brain
injury on CT 8.2%, unimportant injury 3.6%, neurological
intervention 1.6%, death 0.2%. The five CCHR High-Risk
Criteria classified patients for neurological intervention (N
¼ 41) with sensitivity 100% (95% CI 91–100), specificity
65.4% (63–67), and would have required CT for 35.7%. The
seven CCHR High- and Medium-Risk Criteria classified
patients for 212 important brain injuries with sensitivity
100% (95% CI 98–100), specificity 41.0% (39–43), and would
have required CT for 62.4%. The kappa value for MD inter-
pretation of the CCHR was 0.80 (0.76–0.92). MDs under-
estimated the risk in 7.1% and were uncomfortable applying
the rule in 7.7%. Conclusions: The CCHR has proven to be
an accurate, reliable, and acceptable decision rule for the use
of CT in minor head injury. Widespread implementation
would stabilize or decrease use of CT, decrease health care
costs and ensure optimal patient outcomes.
346 San Francisco Syncope Rule (SFSR) vs Physician
Judgment for Predicting Patients with Serious
Outcomes James V Quinn, Ian G Stiell, Karen L Sellers,
Daniel A McDermott, Michael A Kohn, George A Wells;
University of California, San Francisco: San Francisco, CA,
University of Ottawa: Ottawa, Ontario, Canada
Objective: The causes of syncope are usually benign, but
are occasionally associated with significant morbidity and
mortality. This study compares a clinical decision rule and
physician judgment when predicting serious outcomes in
patients with syncope. Methods: In a prospective cohort
study, attending emergency physicians evaluated patients
presenting to a university teaching hospital with syncope
or near syncope. When possible a second physician also
evaluated patients. As part of their evaluation, physicians
were asked to predict the chance (0–100%) of the patient
developing a predefined serious outcome. All patients were
followed to determine whether they had suffered a serious
540
outcome within seven days of their ED visit. Analyses
included sensitivity and specificity for a low risk judgment
threshold, and comparison of areas under the receiver
operating characteristic curve (ROC) with 95% confidence
intervals. Kappa coefficients were used to measure ob-
server agreement. Results: During the 20-month study
there were 684 visits for syncope, 79 resulting in serious
outcomes. Of the patients to whom the physicians assigned
a probability of serious outcome of 2% or less, 5 went on to
develop serious outcomes. The sensitivity of this low risk
2% threshold was 94% (95%CI 86%–98%), with a specificity
of 41% (95%CI 40%–42%). Agreement for this determina-
tion of risk was only fair, kappa ¼ 0.44 (95%CI 0.34–0.54).
The SFSR predicted the 5 patients with serious outcomes
classified as low risk by physician judgment and had good
overall sensitivity 96% (95%CI 92%–100%) and specificity
62% (95%CI 58%–66%). The area under the ROC was 0.90
(95%CI 0.86–0.94) for the SFSR and was significantly better
(p ¼ 0.01) than physician judgment 0.82 (95%CI 0.77–0.88).
Conclusions: The SFSR performed better than phys-
ician judgment when predicting which patients with syn-
cope will develop serious outcomes. This suggests great
potential for the rule to help with physician decision
making.
347 Community-acquired Pneumonia (CAP) Decision
Guidelines: Are the Pneumonia Patient Outcomes
Research Team (PORT) Guidelines a Reliable Tool for
Predicting Morbidity in the Immunosuppressed (IS)
Population? Ambreen Khalil, Ming C Ding, Eric
Nuermberger, Paul Auwearter, Richard E Rothman;
The Johns Hopkins University: Baltimore, MD
Introduction: Current ACEP guidelines rely on the PORT
criteria for risk stratification and disposition decisions, with
outpatient or brief observation unit-based (\24 hr) treat-
ment, recommended for pts in PORT classes I, II, III
(associated mortality 0.1–2.8%). It remains unclear whether
the PORT guidelines can be applied to the immunosup-
pressed (IS) population, as this group was excluded in the
initial derivation cohort. Objectives: The hypothesis was
that there is no difference in morbidity (defined here by the
proxy measure, length of study, LOS) between immunocom-
petent (IC) and IS pts assigned to low-risk PORT groups.
Methods: Prospective, observational study in urban univer-
sity hospital with 55,000 pt visits/yr. Inclusion: consenting
pts; age [ 18 yr; new infiltrate; ATS confirmatory findings.
Exclusion: Hospitalization \ 2 wks. IS definition: HIVþ with
CD4 \ 200/mm); organ transplant recipient; pt receiving
IS therapy. T-test and Mann-Whitney Wilcoxon used to
calculate mean and median LOS. Descriptive data collected
for IS pts with LOS [ median. Results: 283 pts consented
(90%); mean age 48 yr (S.D. 15.7); 152 (54%) female; 209 (74%)
black; 97 (34%) were IS. Overall mean and median LOS was
greater in IS vs IC pts–7d vs 4.8d (p ¼ 0.01) and 4d vs 3d (p ¼
0.058), respectively. IS pts in low-risk PORT groups (I, II, III)
had significantly greater median LOS compared to IC pts, 3d
vs 2d (p ¼ 0.009). Most common complications in IS pts with
LOS [ 3d were: hypoxemia (N ¼ 26), pancytopenia (N ¼ 20),
transfer to ICU (N ¼ 14) and death (N ¼ 6). Conclusions:
IS pts differ significantly from their IC counterparts with
regard to LOS. The IS in low-risk PORT classes (I, II and III)
2003 SAEM ANNUAL MEETING ABSTRACTS
have increased morbidity vs their IC counterparts suggest-
ing PORT criteria may be insufficient for guiding admission
decisions in the IS. Ongoing study will define prognostic
factors associated with increased morbidity in the IS,
important for decision guidelines in this population.
348 Validation of a Model to Identify Women with
Chest Pain in Need of Additional Diagnostic
Testing after an Initial Negative Emergency Department
Evaluation for Cardiac Ischemia Deborah B Diercks,
J Douglas Kirk, Frank D Sites, Frances S Shofer, Judd E
Hollander; University of California, Davis Medical Center:
Sacramento, CA, University of Pennsylvania: Philadelphia, PA
Background: Diagnostic testing of women with suspected
coronary artery disease (CAD) is challenging due to its poor
specificity. Objective: Validate a previously derived model
identifying women who would benefit from further
evaluation of CAD after an initial negative ED evaluation
for ischemia. Methods: A retrospective analysis of women
from a prospective registry of patients who presented to
a university ED with chest pain from 7/99–3/02. This site
was independent from the derivation site. Subjects were
excluded if the initial ECG or cardiac injury markers were
consistent with infarction or ischemia. CAD was defined as
subsequent elevation of cardiac injury markers, a positive
diagnostic study, or death during the 30 day follow-up
period. Predictors of CAD and their weighted value were
hypertension (2), history of CAD (2), hypercholesterolemia
(1), age $60 (3), high clinical suspicion(6). Low risk was
defined as a score # 4, moderate risk [4 and \ 10, high risk
$10. Chi square analyses and logistic regression were used
for group comparisons. Results: The validation set com-
prised 2440 women, mean age 50 yrs, SD12. Compared with
the derivation set, the validation set was younger (diff –9
yrs, 95% CI–2.2—12), less likely to have a history of CAD
(OR 0.7, 95%CI 0.5–0.8), and less often considered at high
clinical suspicion (OR 0.7, 95%CI 0.6–0.8). A final diagnosis
of CAD was found in 8/1523(.5%), 30/618(5%), and 55/393
(14%) in the low, moderate and high risk groups re-
spectively. The relative risk of CAD was greater in the
moderate risk group (OR 10, 95% CI 5–22) and high risk
group (OR 35, 95% CI 16–74) compared with the low risk
group. Conclusion: We successfully validated a model that
utilizes cardiac risk factors and clinical suspicion for risk
stratification in women after an initial negative ED eval-
uation. These data suggest this model can identify women
who are high risk and would therefore benefit from compre-
hensive diagnostic testing to identify CAD.
349 Yield of Head Computerized Tomography in Patients
with New Onset Seizure David A Guss, William
Mower, Jerome R Hoffman; University of California at San
Diego: San Diego, CA, University of California at Los Angeles:
Los Angeles, CA
Introduction: Head computerized tomography (HCT) is
typically ordered for patients with new onset seizure, but the
diagnostic yield of this approach is uncertain. Objective:
Determine the yield of HCT in patients presenting to the ED
with a primary complaint of ‘‘new seizure.’’ Methods: The
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
National Emergency X-ray Utilization Study II (NEXUS II)
is a multicenter, prospective observational study of all ED
patients for whom head computerized tomography (HCT)
scanning was ordered by the examining clinician. Clinicians
prospectively recorded patient demographic data, the in-
dication for HCT, and 22 physical findings. Final HCT
reading was collected on every patient. In this sub-study of
NEXUS II, we analyzed findings among those patients for
whom ‘‘new seizure’’ was the recorded indication for HCT.
Study design: Prospective, observational. Study sites: 23 EDs
from a geographic cross section of the US. Measures:
Indication for HCT, age, gender, HCT findings. Results: Of
28,320 subjects enrolled in NEXUS II, the indication was
‘‘new seizure’’ in 1640, and this was the sole documented
indication in 948. Subject age ranged from 36 days to 100
years, with a mean of 38.6 years, and 585 were male. HCT was
abnormal in 51 (35 males), and abnormalities included acute
subdural hematoma (SDH) in 6, chronic SDH in 4, sub-
arachnoid hemorrhage in 7, cerebral contusion in 3, in-
tracranial hemorrhage in 8, mass lesion in 3, cerebral infarct
in 10, tumor in 5, cerebral edema in 2, and other in 9. Six
patients had more than one abnormality. Conclusion: 5.4% of
patients undergoing HCT for a ‘‘new seizure’’ have a signif-
icant abnormality on the scan. This suggests a reasonable
yield of HCT in this group. Further studies will be required to
determine if clinical criteria can identify if there is a subset of
such patients in whom HCT can be safely withheld.
350 Can the Urine Dipstick Safely Screen Patients for IV
Contrast? Christopher Stromski, Donna Allmon, Seth
Fagerlie, James Reed; St. Luke’s Hospital: Bethlehem, PA
Objective: A measurement of renal function is often
required prior to the administration of IV contrast to ED
patients. Determination of creatinine (CRE) often delays
performance of the study and increases ED time and cost. A
recent study found that the urine dipstick was an effective
screening tool for elevated CRE in the ED patient with
severe hypertension. We sought to determine if the absence
of hematuria and proteinuria on urine dipstick identifies
patients who can safely receive IV contrast. Methods: This
retrospective chart review was performed in a community
teaching hospital with an ED residency. Two hundred fifty
consecutive patients receiving abdominal and pelvic CTs
were reviewed. Demographic data (age, sex, chief complaint
and medical problems) were noted on a standardized data
collection sheet, as were results of the urine dipstick and
serum CRE. Renal failure was defined as a CRE of greater
than 1.5 mg/dL, which is often used as the upper limit for
contrast administration. Results: Of 250 consecutive charts
reviewed, 179 had both a CRE and urine dipstick performed
and recorded in the ED. Of these, 17 patients had a CRE
greater [1.5 mg/dL and 47 had a CRE [1.2 mg/dL. These
were associated (p \ .01) with the demographic character-
istics of age [62, male gender, hypertension and CHF, but
none of these characteristics were sufficiently sensitive or
specific to identify or eliminate patients with renal failure. A
negative urine dipstick for proteinuria and hematuria was
100% sensitive in identifying patients without renal failure
(NPV ¼ 100%). Even with renal failure defined as any
abnormal CRE ([1.2 mg/dL) the NPV was 92.5%. Conclu-
sion: In this derivation set, a negative urine dipstick was
541
100% sensitive in identifying ED patients in whom IV
contrast could be safely administered, obviating the need for
serum tests of renal function. These findings should be
tested in a confirmation set.
351 Does Body Mass Index Affect the Interpretation of
Noncontrast Abdominal Pelvic CT Scans? Jeannette
M Wolfe, Howard A Smithline, Steven Lee, Brett Coughlin,
Joseph Polino; Baystate Medical Center, Western Campus Tufts
School of Medicine: Springfield, MA
Objective: Intra-abdominal fat helps to outline abdominal
structures on CT scan. We hypothesize that CT scans on
patients with a high body mass index (BMI) do not require
oral contrast for accurate interpretation. Methods: A pro-
spective observational trial of a convenience sample of 100
adult patients at a tertiary care academic emergency
department having an abdominal pelvic CT from 9/4/01
to 8/30/02. Patients with trauma, renal colic, pregnancy,
need of IV contrast, or clinically unstable were excluded.
Enrollment was limited to two patients per weekday. Height
and weight were recorded and BMI was calculated. Patients
had a helical 5 mm cut noncontrast abdominal pelvic CT
followed by 2 drinks of oral contrast 90 minutes apart and
a repeat scan. Radiology attendings interpreted the scans
using explicit data sheets and were blinded to the results of
the matching CT. Clinically important discordance between
the matching scans was determined by a panel of radiology
and emergency medicine attendings. Agreement was
measured by the kappa statistic. A relationship between
discordance and BMI was assessed by stratifying BMI by
quartile and performing a nonparametric test for trend.
Results: Of 112 patients approached, all consented and 100
completed the protocol. Patients had a mean age of 50
(95%CI: 46, 53), a median BMI of 27 (IQR: 24, 33), and 65%
were female. Twenty-one had discordant interpretations
between noncontrast and contrast scans, kappa ¼ 0.58
(95%CI: 0.07, 0.72). The percent of discordant scans by BMI
quartile was: 24%, 38%, 17%, 8% (p ¼ 0.08, test for trend).
Conclusions: This study did not demonstrate a statistically
significant relationship between obesity and the ability to
interpret a noncontrasted abdominal pelvic CT scan. The
distinction between intraperitoneal fat content and extra-
peritoneal subcutaneous fat was not assessed and needs
further evaluation.
352 A Comparison of the Accuracy of Helical CT, Scout
CT, Digital Radiography, Plain Film Radiography,
Fluorography and Film-screen Mammography for the
Diagnosis of Radiolucent Foreign Bodies Using a
Chicken Leg Model Scott DePue, Jamal Bokhari; Yale
University: New Haven, CT
Objectives: To evaluate the efficacy of various easily
obtained and non operator specific radiographic methods
for the detection of radiolucent foreign bodies (FB) in
wounds. Methods: Chicken legs were used a model for the
human thenar eminence. The chicken legs were punctured
with linear FB or had a 2cm 3 2cm deep laceration placed
through skin, fat and muscle with non linear FB inserted. FB
used included tempered auto glass, windshield auto glass,
542
household glass fragments, plastic toothpicks (TP), wood TP
and cactus spines. Chicken legs were evaluated by plain
film radiography soft tissue view (KVP 53, MAS 2.5), digital
radiography (Digital Ektagraph 60 KVP, 3 MAS), film-screen
mammographic technique (25 KVP 70 MAS no compres-
sion), Scout CT view at 3 levels (KV120 Ma 10; KV 120 MA
40 and KV 120 Ma 60), axial helical CT (KV 120 MAS 10
1 Sec) and fluoroscopy (KV 75 MAS 0.1–0.3) by a board-
certified radiologist. Images were reviewed independently
by 2 board-certified radiologists. Results: Plain film radiog-
raphy soft tissue view, digital radiography, and fluoroscopy
did not detect wood or plastic TP or cactus spines.
Mammographic technique was 100% sensitive and specific
for the diagnosis of glass FB, closely followed by scout CT at
80 MAS and helical CT (sens .833; spec .083). Mammogra-
phy, scout CT at 60 MAS and helical CT all had intermediate
sensitivity for wood TP or cactus spines. Only helical CT
was able to detect plastic TP. No technique used adequately
detected cactus spines. Axial helical CT was able to detect all
FB tested with history and entry wound marking (utilizing
air contrast around the foreign body to delineate it) to
a reasonable level of accuracy (sens .75–1.0). Conclusions:
Helical CT should be used to evaluate wounds when there
is a high suspicion for glass, plastic, wood or biologic FB
contamination, using scout CT or plain films to rule out
metallic or radiopauqe FB. Mammography has a role in
small glass FB of body parts amenable to this technique.
353 Efficacy of Parenteral Dexamethasone to Prevent
Relapse after Emergency Department Treatment of
Acute Migraine Jeffrey S Jones, Michael D Brown, Michelle
Bermingham, Jan Anderson, Jacque Perrin; Spectrum Health
Hospital-Butterworth Campus: Grand Rapids, MI
Objectives: Studies indicate that up to 66% of migraine
patients will suffer recurrent headaches after abortive
therapy. Our objective was to evaluate the effectiveness of
parenteral steroids in reducing the incidence of migraine
headache recurrence 48 hours after discharge from the ED.
Methods: This was a randomized, double-blind, controlled
trial of adult migraine patients evaluated in the ED of
a community teaching hospital over a 24-month study
period. Eligible patients met the International Headache
Society’s diagnostic criteria for migraine headache and had
a headache severe enough to require parenteral therapy.
After abortive therapy (antiemetics, analgesics), patients
were administered either parenteral dexamethasone (20 mg/
2mL) or placebo. Patients were contacted by telephone 48
hours after discharge and asked whether they had suffered
a recurrent headache. These were categorized as class A
(provoking another physician visit), class B (interfering with
daily activity but not provoking another physician visit),
class C (requiring self-medication but not limiting daily
activity) or class D (requiring no treatment). Discrete
variables were analyzed with the chi-square test. Results:
Seventy-five patients met the inclusion criteria; five patients
were lost to follow-up, leaving 70 in the study sample. The
treatment groups were similar with regard to baseline
characteristics, headache duration, and abortive therapy. At
follow-up, 12% (4/34) of those receiving dexamethasone had
severe (classes A and B) headache recurrence; 29% (10/34)
had mild (classes C and D) recurrence; and 59% (20/34) had
2003 SAEM ANNUAL MEETING ABSTRACTS
no recurrence. Similarly, 19% (7/36) in the placebo group
had severe headache recurrence; 28% (10/36) had mild
recurrence; and 53% (19/36) had no recurrence. These rates
of recurrence were not statistically significant (p ¼ 0.675).
Conclusions: These results suggest that parenteral dexa-
methasone does not decrease the incidence of recurrent
headache following ‘‘successful’’ ED treatment.
354 Inhalation of High-flow Oxygens as a Treatment
for Migraine Headache in the Emergency
Department Robert Stambaugh, John Sisson, Charles
Erdman; Naval Medical Center Portsmouth: Portsmouth, VA
Objective: Migraine headache is a common complaint in the
Emergency Department. We hypothesized that inhalation of
one hundred percent oxygen for thirty minutes would cause
a clinically significant (25%) reduction of pain for patients
with migraine headache. Methods: This study was a pro-
spective, randomized, controlled, double-blinded trial using
high-flow inhaled oxygen as the treatment group and in-
haled air as the control group. It was conducted between
December 2001 and April 2002 in the ED of a military
hospital. A convenience sample was enrolled into the study
using a computer generated randomization scheme. In-
clusion criteria were all patients 18 to 65 years old with
a previous diagnosis of migraine headaches who presented
to the ED complaining of a ‘‘typical migraine headache’’.
Exclusion criteria included: patients triaged as ‘‘urgent’’ or
‘‘emergent’’, patients with altered mental status, febrile
patients, and patients with COPD. A visual analog scale
(VAS) was used to rate headache pain before and after
treatment. The change in pain score as measured by the VAS
(in mm) was assessed by a two factor repeated measures
analysis of variance (ANOVA). Change in VAS from before
intervention to after intervention between the Air and
Oxygen groups was the test of interest. Analysis of co-
variance (ANCOVA) was also used to compare VAS scores
after intervention adjusted for VAS scores before interven-
tion. Results: Forty-six patients completed the study, with 23
in each group. The Air group recorded a mean pain level of
84.7mm þ/
13.2mm SD on the VAS before intervention and
81.3mm þ/
15.3mm SD after intervention. The Oxygen
group showed a mean of 76.1mm þ/
15.5 SD prior to
intervention and a mean of 60.4mm þ/
29.4mm SD after
intervention. The Oxygen group had, on average a 21%
decrease in pain compared to a 4% decrease for the Air
Group (p ¼ 0.031 by ANCOVA). Conclusion: Inhalation of
high-flow oxygen caused a statistically significant reduction
in the pain of migraine headache.
355 Prevalence of Post Dural Puncture Headache
after Emergency Department Performed Lumbar
Puncture Rawle A Seupaul, William E Hauter, Geoffrey
G Somerville, Chad D Viscusi, Andrew J Shepard, Brian
A Robinson; Indiana University School of Medicine:
Indianapolis, IN, Methodist Hospital of Indiana: Indianapolis, IN
Objectives: Post dural puncture headache (PDPH) is
a common complication following lumbar puncture (LP).
To our knowledge there have been no studies describing the
prevalence of PDPH in the emergency department (ED)
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
setting. The anesthesia literature shows that the use of small
gauge ($22 ga) noncutting needles markedly reduce the
rate of PDPH (2–5%). However, noncutting needles are not
commonly used in the ED. This study describes the
prevalence of PDPH in the ED using Quinke cutting needles
typically used in the ED. Methods: Design: Prospective
observational multicenter trial with consecutive enrollment.
Setting: Two large urban EDs with an emergency medicine
training program. Subjects: All consenting adult patients
(age $18) undergoing diagnostic LP in the ED. Patients
were excluded if they were incarcerated or had a LP
performed within the prior 5 days. Observations: Only
cutting needles (20 or 22 gauge) were used for ED LP.
Patients were followed up via phone interview to determine
if a complication occurred. PDPH was defined as any head-
ache that worsened with positional change and improved
upon laying supine. Results: 72 patients were enrolled and
56 were contacted for follow-up. Ages ranged from 18–94
with 41% men. The overall prevalence of PDPH was 17.9%.
LPs performed with a 20 gauge needle (16) had a PDPH
prevalence of 37% versus 10% for those performed with a 22
gauge needle (40) (p ¼ .024 using Fisher’s exact test). The
absolute risk reduction was 0.27 resulting in a number
needed to harm of 4 (95% CI 2–17). Conclusions: ED LPs
using 20 gauge cutting needles had a significantly higher
PDPH rate than those performed with a 22 gauge cutting
needle. The overall PDPH rate was higher than that
reported in the anesthesia literature using small gauge
noncutting needles. Further prospective evaluations are
needed to compare small gauge cutting needles with like
noncutting needles in an ED setting.
356 Smaller Cerebral Aneurysms Cause More
Extensive Subarachnoid Hemorrhage Following
Rupture Stephen M Russell, Ke Lin, Sigrid A Hahn, Jafar J
Jafar; Mt. Sinai School of Medicine: New York, NY, New York
University School of Medicine: New York, NY
Objective: To determine the relationship between cerebral
aneurysm size and the volume of subarachnoid hemorrhage
(SAH). Methods: One hundred consecutive patients pre-
senting with an acute SAH diagnosed by computed
tomography (CT) scan within 24 hours of their ictus, and
subsequently confirmed to be aneurysmal in origin by
catheter angiography, were included in this study. The data
was collected prospectively in 32 patients and retrospec-
tively in 68. The volume of SAH on the admission CT scan
was graded in a semi-quantitative manner from 0 to 30,
according to a previously published method. Results: The
mean aneurysm size was 8.3mm (range 1–25mm). The mean
volume of SAH was 15.0 (range 0–30). Regression analysis
revealed that smaller aneurysm size correlated with more
extensive SAH (r2 ¼ 0.23, p \ 0.0001). Other variables in-
cluding gender, age, parenchymal or ventricular hemor-
rhage, multiple aneurysms, history of hypertension, and
aneurysm location were not statistically associated with
a larger volume of SAH. Conclusions: Smaller cerebral
aneurysm size is associated with a larger volume of SAH.
This may have important implications as it has been dem-
onstrated that larger volume subarachnoid hemorrhages are
associated with worse clinical outcomes.
543
357 Emergency Department Electrical Cardioversion
of Patients with Atrial Fibrillation: A
Multi-institutional Experience John H Burton,
David R Vinson, Kate W Drummond, J J McInturff, Tania D
Strout; Maine Medical Center: Portland, ME, Kaiser
Permanente Medical Centers: Sacramento, CA, Kaiser
Permanente Medical Centers: Roseville, CA, St. Vincent
Hospital: Worcester, MA
Objective: Electrical cardioversion (EC) of emergency
department (ED) patients (pts) with atrial fibrillation (AF)
has not been well investigated. The objective of this study
was to identify the outcomes and complications associated
with ED EC for AF pts. Methods: This retrospective health
records survey investigated a consecutive cohort of ED AF
pts who underwent EC in four separate EDs during a 42-
month period. Trained personnel reviewed medical records
for pre-defined variables that included demographics,
clinical descriptors, medical interventions, complications,
and ED return visits within 7 days. Data were analyzed
using descriptive statistics with comparisons between
groups assessed by Mann Whitney and Chi-square analysis
as appropriate. Results: The study population consisted of
367 pts (mean age ¼ 63 years, range 20–93). Duration of AF
was less than 48 hours in 98% of the cohort. Thirty-five
percent of pts (130) underwent rate-control intervention(s)
prior to EC. Agents utilized for procedural sedation and
analgesia (PSA) were methohexital (49%), etomidate (39%),
midazolam (8%), and propofol (4%). The EC waveform was
monophasic in 75% of pts and biphasic in 25%. Electrical
cardioversion was successful in 312 (85%) pts. No correla-
tion was noted between EC success and age (p ¼ 0.15),
duration of AF (p ¼ 0.84), antecedent ED heart rate control
(p ¼ 0.33) or EC waveform (p ¼ 0.24). Complications were
noted in 19 pts (5%): 16 attributed to PSA and 3 attributed to
EC. Three hundred twelve (85%) pts were discharged to
home from the ED: 281 following EC success and 32 with EC
failure. Thirty-eight pts (10%) returned to the ED within 7
days, 25 (7% of total cohort) due to relapse of AF.
Conclusion: In this multi-center cohort, AF ED pts had
high rates of EC success, infrequent hospital admission, and
few complications—the majority attributed to PSA. Proper
selection criteria and long-term outcomes associated with
ED EC deserve future study.
358 A Prospective, Randomized Trial of an Emergency
Department Observation Unit for Acute Onset Atrial
Fibrillation Wyatt W Decker, Deepi G Goyal, Eric T Boie,
Peter A Smars, Douglas L Packer, Thomas D Meloy, Andy J
Boggust, Annie T Sadosty, Dennis A Laudon, Nicola E Schiebel,
Joseph K Lobl, David O Hodge, Win-Kuang Shen; Mayo
Clinic–Mayo Foundation: Rochester, MN
Objectives: We compared an Emergency Department
Observation Unit (EDOU) protocol for the management of
acute onset atrial fibrillation (AF) to routine hospital
admission. Methods: This IRB-approved prospective, ran-
domized study was performed in a tertiary referral center
ED between September 1999 and December 2002. Adult
patients presenting to the ED with AF of \ 48 hours
duration and without hemodynamic instability or other
conditions requiring hospitalization were eligible to partic-
ipate. Participants were randomized to either care in the
544
EDOU or routine inpatient care. The EDOU protocol
included heart rate control, 6 hours of cardiac monitoring,
and reassessment. Those still in AF after a 6-hour ob-
servation period were electrically cardioverted and ob-
served for two more hours. Those in sinus rhythm (SR) after
the observation period were discharged home with cardi-
ology follow-up within 3 days while those still in AF were
admitted. All patients were followed for 6 months for
adverse events, recurrent AF, and return visits. Results: 156
patients were enrolled and data analysis has been per-
formed on the initial 75 patients. 34 of the 75 patients were
randomized to the EDOU and 41 to routine care. 88% (28) of
EDOU patients converted to NSR, vs. 95% (39) in the routine
care group (P ¼ 0.39). The median length of stay was 10 vs.
24 hours (P \ 0.001) for EDOU and routine care patients
respectively. Seven EDOU patients required inpatient
admission. 26% (9) of the EDOU group had recurrence of
atrial fibrillation during follow-up vs. 34% (14) of the
routine inpatient care group (P ¼ 0.62). There were no
significant differences between the groups in the frequency
of hospitalization, number of tests/procedures, or adverse
events during followup. Conclusion: An 8-hour EDOU
protocol that includes electrical cardioversion appears to
be a viable alternative to routine hospital admission for
patients with acute onset of AF, and results in a shorter
initial length of stay.
359 Emergency Department Presentations of Atrial
Fibrillation (AF) in Alberta, Canada Barry M
Diner, Niko Yiannakoulias, Brian R Holroyd, Michael Bullard,
Carol H Spooner, Rhonda Rosychuk, Larry Svenson, Donald
Schopflocher, Brian H Rowe; University of Alberta:
Edmonton, Alberta, Canada, Alberta Health and Wellness:
Edmonton, Alberta, Canada
Objectives: Atrial fibrillation (AF) is the most common
sustained arrhythmia and the most common arrhythmia
seen in the emergency department (ED); however, the
burden of acute AF on EDs is virtually unknown. This
study examines the epidemiology of AF presentations to the
ED using a provincial database. Methods: All patients
presenting to Alberta EDs were eligible for inclusion. Data
were derived from a population of patients treated at
Alberta EDs in 17 health regions over 1 year (fiscal 00/01).
Data were extracted from computerized abstracts coded
similarly across all regional EDs contained within the
Ambulatory Care Classification System (ACCS) database.
Diagnostic categories are recorded using ICD-9 coding by
medical record nosologists in each hospital and represented
the primary physician discharge diagnostic code. Descrip-
tive statistics, crude and adjusted presentation rates are
reported. Results: Over 1 year, 1.7 million ED visits were
recorded; 3270 (0.2%) patients aged [17 made 5023
presentations to the ED during this period with a diagnosis
of AF. Males (1691; 52%) and females were similarly
represented. The elderly ([60 years) accounted for 76%
of all cases of AF. Daily variation was high with peak
presentations occurring at 5 PM. The provincial presentation
rate was 1.0/1000 persons with a prevalence of 1.5/1000.
Patients experienced frequent relapses of AF in the first 30
days and one year (16.4% and 32.8%, respectively). The
proportion experiencing TIA within the 365 days after an AF
2003 SAEM ANNUAL MEETING ABSTRACTS
presentation was 1.5%; the proportion of patients experi-
encing CHF was 9.6%. Approximately 60% of all patients
were discharged and 9.7% were admitted to ICU. Conclu-
sions: Discharge for acute AF is common, reflecting the
outpatient treatment of this disease in Canada. Recurrence
and complications are also frequently observed; however,
TIAs are less common than reported elsewhere. Further
research is needed to understand the role of outpatient
treatment of AF on these outcomes.
360 Emergency Department Patients with Acutely
Decompensated Congestive Heart Failure: Is
Discharge a Safe Disposition? Allison V Brewer, John H
Burton, Tania D Strout; University of Vermont College of
Medicine: Burlington, VT, Maine Medical Center: Portland, ME
Objective: Few investigations have reported the outcomes
associated with Emergency Department (ED) patient (pt)
visits for acutely decompensated congestive heart failure
(AD-CHF). The objective of this study was to examine the
rates of unscheduled return ED visits and hospital admis-
sion in a cohort of AD-CHF pts discharged from the ED to
outpatient follow-up. Methods: This retrospective health
records survey investigated a consecutive cohort of pts with
the primary diagnosis of ED-CHF, treated during the
calendar year 2000, in a tertiary-care ED. Trained personnel
reviewed medical records for pre-defined variables that
included demographics, clinical descriptors, and medical
interventions as well as unscheduled ED return visits
and clinical outcomes at 7 and 30 days. This study was
conducted with approval from the institutional review
board. Data were analyzed using descriptive statistics.
Results: A total of 552 AD-CHF encounters were reviewed.
Four hundred sixty-two (84%) patients were admitted to
hospital. Ninety pts, with a mean age of 73 years (range 49–
99), were discharged to outpatient follow-up. Of these 90
pts, 27 (30%) had no previously documented CHF history.
At 7 days post-discharge, 15 (17%) pts returned to the ED for
an unscheduled visit. Ten of these pts required hospital
admission. At 30 days post-discharge, 39 (43%) pts returned
for an unscheduled ED visit with 2 deaths and 19 pts
requiring hospital admission. Conclusion: In this cohort of
AD-CHF pts discharged from the ED, approximately half
either died or returned for unscheduled evaluation within
one month. Discharge of AD-CHF pts from the ED may
represent an elevated risk disposition for this pt population.
361 A Randomized Trial of Bolus Nitroglycerin for the
Treatment of Acute Congestive Heart Failure Phillip
Levy, Aaron Hexdall, Peter Gordon, Chritian Boeriu, Raed
Arafat; Bellevue Hospital Center/NYU School of Medicine: New
York, NY, Mures County Hospital: Targu Mures, Romania
Objective: We hypothesized that the use of bolus in-
travenous (IV) nitroglycerin (NTG) therapy in addition to
standard care in the treatment of acute congestive heart
failure (CHF) would lead to improved clinical outcomes
without an increase in serious, adverse events. Methods:
Designed as a prospective, randomized, placebo controlled,
double blind trial, this study was conducted from July 2000
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
to Sept. 2002 at Mures County Hospital, in Mures County,
Romania. This is a university affiliated, tertiary care referral
center with an annual ED census of 20,000. Inclusion criteria
was a clinical diagnosis of acute CHF, a systolic blood
pressure $140 mmHg, age $18, and ability to provide
informed consent. Exclusion criteria were cardiopulmonary
resuscitation or immediate intubation. Demographic and
historical information was obtained and all enrolled patients
were given AHA standard treatment. If not improved, the
following protocol was initiated: IV NTG and concurrent
administration of a bolus of 1–3 cc from a syringe containing
either D5W or NTG (1 mg/cc). The syringe contents were
pre-randomized by coin-flip. Repeat bolusing of 1–3 cc
every 3–5 minutes was permitted (up to 15 cc), as was IV
NTG titration. The primary outcomes were incidence of
intubation and hypotensive events. Appropriate statistical
and univariate analysis of continuous or categorical vari-
ables between groups were applied. Results: 40 patients
were enrolled, 60% male and 40% female. 52.5% received
bolus NTG, 47.5 % placebo. The average age was 68.
Overall, 4 (10%) were intubated, 1 of which received bolus
NTG (p ¼ 0.33; OR ¼ 0.27, 95% CI 0.01–3.41) and 3 patients
had transient hypotension, 2 of which received bolus NTG
(p ¼ 1; RR ¼ 1.81, 95% CI 0.13–50.1) The mean bolus NTG
dose was 9.95 mg (95% CI 7.68–12.22). Conclusions: This
study suggests that the treatment of acute CHF with bolus
NTG is safe and efficacious. Larger studies are needed
however, before this form of therapy can be fully advocated.
362 Derivation of a Prediction Rule to Identify Low Risk
Patients with Heart Failure Thomas E Auble,
Margaret Hsieh, William Gardner, Gregory F Cooper,
Roslyn A Stone, Julie B McCausland, Donald M Yealy;
University of Pittsburgh: Pittsburgh, PA
Objectives: Prognostic uncertainty for patients presenting
with heart failure (HF) contributes to wide variation in
hospital admission rates. ED providers greatly overestimate
the risk of poor outcomes in HF patients and are more likely
to discharge them to more intense care settings. We sought
to derive a clinical prediction rule based on data available in
the ED to identify patients with HF who are at low risk of
inpatient death or serious medical complications (SMC).
Methods: We performed a retrospective database analysis of
all 1999 discharges from acute care hospitals in PA with
a primary ICD-9-CM code of HF. The data were obtained
from two statewide databases of hospital discharge data
and key clinical findings. We included for analysis the first
hospitalization of patients $18 years of age who were
admitted from the ED. We used recursive partitioning to
build an algorithm to identify patients at low risk of
inpatient death or SMC but were discharged alive. SMCs
were acute myocardial infarction (AMI), reperfusion ther-
apy (RT), nonsurgical mechanical ventilation (MV), ventric-
ular fibrillation (VF), or resuscitation efforts including CPR
(RE). Results: The 33533 HF patients were largely white
(83.1%), female (54.6%) and $65 years of age (80.2%).
Overall, 4.5% died during hospitalization and 6.8% had
a SMC but were discharged alive. The 2-path prediction rule
classified 15.9% of all patients as low risk; of these 5343
patients, 0.4% died (95% confidence interval [CI], 0.3–0.6)
and 2.1% (95% CI, 1.7–2.5) had a SMC but were discharged
545
alive (AMI ¼ 0.8%, RT ¼ 0.8%, MV ¼ 0.4%, VF ¼ 0.1%, RE ¼
0.2%). Conclusion: We developed a heart failure prediction
rule using variables available in the ED that identifies
patients at low risk of death or serious medical complica-
tions during hospitalization. If validated, this rule could
improve ED provider prognostic estimates and initial inten-
sity of care decisions for patients diagnosed with HF.
363 Symptoms of Acute Stress Disorder in Medical
Students Completing an Urban Emergency
Department Rotation Trevor J Mills, Derek Isenberg,
Lisa D Mills, James Moises, Micelle Haydel; Louisiana State
University Health Sciences Center: New Orleans, LA, Tulane
Medical School: New Orleans, LA
Objective: To determine the types of stressors and the
prevalence of symptoms of acute stress disorder (ASD) in
medical students completing an Emergency Medicine (EM)
rotation. Methods: The study was conducted at a high
volume, teaching hospital over 6-months (7–12/2002). All
medical students completing an EM rotation were eligible for
inclusion. At the end of the rotation, anonymous surveys
were distributed. The surveys included questions about the
number of prior EM rotations, intended future specialty,
a question asking to ‘‘describe the most stressful situation(s)
which you encountered during your EM rotation’’ and the 18
questions that compose the screening tool for ASD. The ASD
survey is a validated instrument, designed to assess
symptoms of acute stress immediately following a traumatic
event. It includes 5 subcategories: peri-trauma dissociation,
post-trauma dissociation, intrusive thoughts, avoidance and
hyperarousal. Scores of 56 or greater are diagnostic of acute
stress disorder. Results: Thirty-seven of 56 medical students
responded to the survey. Eighty-one percent (30/37) reported
that this was their first EM rotation, sixty percent (22/37)
reported EM to be their future specialty. Thirty-three students
reported a significant, stressful event during their EM
rotation. Of those with a stressful event, forty-two percent
(14/33) reported that their stressful event involved the care of
a critically ill patient. Seventy-nine percent (26/33) of
students with a stressful event reported at least one symptom
of ASD. The mean ASD score was 23.1. The highest score was
39. When comparing mean ASD scores, the variables: type of
stressor, first EM rotation and future specialty were not
statistically significant (p greater than 0.05). Conclusion:
There are a high percentage of medical students who report
symptoms of ASD as a direct result of their EM experience.
Student directors may consider ASD education and counsel-
ing services as part of the EM orientation.
364 Medical Clearance of Emergency Patients with
Psychiatric Complaints: Can the Emergency Provider
Predict the Usefulness of Screening Laboratory
Studies? Charlotte A Newman, Stephanie Stokes-Buzzelli;
Henry Ford Hospital: Detroit, MI
Objective: To analyze the ability of emergency providers
(EPs) to predict the value of screening labs in patients (pts)
presenting with psychiatric complaints. The cost and utility
of these labs were also addressed. Methods: Prospective,
546
observational analysis of psychiatric patients in an urban
teaching hospital ED over 8 months. Included were pts $18
yrs presenting with a psychiatric chief complaint. Evalua-
tion included: medical history (Hx), physical exam (PE), and
labs including CBC, lytes, alcohol, UA, and urine drug
screen. After the Hx and PE, but before having lab results,
EPs completed a questionnaire indicating whether or not the
pt required labs to be medically cleared (MC). Lab results
were then compared to the EPs prediction. Results: 169 pts
were enrolled. EPs judged 83 pts (49%) to not need further
testing (MCþ) while 86 pts (51%) required further testing
(MC-) before being considered MC. 11 pts (6.5%) were
found to need medical intervention, 4 pts from MCþ and 7
pts from MC
(p ¼ 0.38). Lab abnormalities were treated in
the ED and did not affect final disposition. 3 pts (1 from
MCþ, 2 from MC
) were declared not MC and admitted.
Lab results played no role in this decision. The specificity
and sensitivity of EPs in predicting MC with respect to labs
was 0.64 and 0.50, respectively. The odds of having an
abnormal lab result was 3.6 3 greater if there was an
abnormal PE (p \ 0.05). The cost of the labs ordered in the
MCþ group was $22,000. Conclusion: In this first pro-
spective study of routine lab testing for MC, there was a low
rate of abnormal labs that could not be accurately predicted
by EPs. These labs were clinically insignificant and did not
affect pt final disposition but did add to the cost of the ED
visit. Mandating routine lab testing for all pts presenting to
the ED with a psychiatric chief complaint is of low yield and
may not be necessary.
365 Intimate Partner Violence among Men Presenting
to a University Emergency Department Cherlin E
Johnson, Julie Gorchynski; University of California, Irvine
Medical Center: Irvine, CA
Objective: We sought to establish the prevalence, define the
nature, and identify demographics of intimate partner
violence (IPV) towards men presenting to a university
emergency department (ED). Methods: This survey study
was conducted at a tertiary, academic, level I trauma center
with an ED that has 36,500 visits per year, from September
2001 until January 2002. The confidential written survey
consisted of 16 questions previously validated in the
Colorado Partner Violence Study, Index of Spouse Abuse
and the Conflict Tactics Scale. This survey was randomly
administered in English, Spanish and Vietnamese to men 18
years of age and older who presented to the ED, day or
night, 7 days a week. Odds Ratio (OR) with 95%CI were
calculated when appropriate and a p-value of 0.05 was set
for significance. Results: The prevalence rate of male IPV
was 24% in our study population (82/346). Among the men
who experienced some form of abuse specified as either
physical, emotional, or sexual the prevalence was calculated
to be 15.6% (54/346), 13.6% (47/346) and, 2.6% (9/346),
respectively. Education, income, age and race did not
demonstrate an association for any one variable to be a
risk factor for intimate partner abuse (p [ .05) with the
exception of increased risk of IPV among unemployed
men in the relationship (p \ .04, OR 0.592). IPV towards
men was found to affect both heterosexual as well as
homosexual relationships, 89% and 11% respectively. Over-
all, 10.4% (8/77) of the men surveyed had received medical
2003 SAEM ANNUAL MEETING ABSTRACTS
treatment as a result of IPV by their intimate partner within
the past year. Conclusion: The prevalence of IPV among our
study population was 24%, an astonishingly high value.
In our study of 346 men, IPV crossed all socioeconomic
boundaries, racial differences and educational levels for
both men and women regardless of the sex of the partner.
Initial research into this topic has demonstrated the need for
community resources, support groups, public awareness
and education of IPV in men.
366 Underdiagnosis of Child Abuse in Emergency
Departments Seth Kunen, Paul Hume, John N Perret,
Cris V Mandry, Tina R Patterson; Earl K. Long Medical Center:
Baton Rouge, LA
Objectives: To determine: 1) the incidence and types of
child abuse in four ED’s; 2) the extent of child abuse coding
errors; 3) the number of suspicious but non-diagnosed cases
of fractures and dislocations in children two and under.
Methods: We surveyed ICD-9 child abuse diagnoses (995
codes) and E-codes of 21,203 patients 18 and under attending
four ED’s over a six-month period. In a subset of 7,827
infants two and under, 127 had fractures and dislocations
that were not diagnosed as abuse. Of these 127 infants, we
randomly selected 50 and had physicians rate the injuries as
not suspicious, moderately suspicious, or highly suspicious
of child abuse. Results: Among ED patients age 18 and
under, 57 or .27% were diagnosed with child abuse (well
below the national rate of about 1.12%). Of these 57 cases,
55% were diagnosed with physical abuse; 28% with sexual
abuse; 7% with neglect; and 10% with unspecified abuse.
More than 25% of the child abuse cases were improperly
coded (e.g., only E-codes were given and no 995 codes).
Approximately 30% of the infant cases with fractures and
dislocations were rated as highly suspicious of abuse.
Conclusions: It is likely that more than 75% of all child
abuse cases presenting to ED’s are being missed, and many
of these missed cases involve fractures and dislocations in
infants. These results indicate that residency programs need
to better train residents how to recognize symptoms of child
abuse and how to question parents who give implausible
explanations of their children’s injuries. The high coding
error rate could lead to significant underestimates of child
abuse rates in ED’s, since abuse cases documented only by
E-codes would be missed in epidemiological studies that
select cases using only ICD 995 abuse codes. The failure
to diagnose child abuse in the present is also a failure to
protect the child in future, since a substantial percentage of
undiagnosed abused children will be reabused in the future.
367 Insurance without Care: Unreliable Access to
Emergency Department Follow-up Care Brent R
Asplin, Karin V Rhodes, Lauren Crain, Arthur L Kellermann,
Nicole Lurie; Regions Hospital and HealthPartners Research
Foundation: St. Paul, MN, University of Chicago Hospitals:
Chicago, IL, Emory University: Atlanta, GA, RAND:
Arlington, VA
Objective: Insurance status is known to affect access to
primary care for patients with nonurgent conditions. We
studied the effect of insurance (INS) status on appointment
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
(APPT) rates for ED conditions requiring urgent follow-up
care. Methods: We called randomly selected primary care
clinics in 9 U.S. cities. Callers identified themselves as
patients needing an ED follow-up APPT for an urgent con-
dition. The same person called each clinic twice with the
same clinical vignette. The caller’s INS status was randomly
varied. In one call, the caller had private INS; in the other
the caller had either Medicaid (MED) or was uninsured.
The primary outcome was APPT rate within 7 days. Two
multilevel regression models (call within clinic within city)
were fit to predict APPT success. The first model used
private vs. MED call pairings; the second private vs.
uninsured. INS type and vignette were fixed factors at the
call level. A random intercept modeled differences by city.
Results: Overall, 39% of 804 callers received APPTs. In the
private vs. MED pairings, 51% of 184 private and 28% of 234
MED callers got APPTs. INS status was associated with
APPT success in the adjusted model [F(1,414) ¼ 26.3, p \
.001]. In the private vs. uninsured pairings, 59% of 186
private and 22% of 200 uninsured callers got APPTs. INS
status was associated with APPT success in the adjusted
model [F(1,382) ¼ 73.4, p \ .001]. Uninsured callers willing
to pay full cash price (mean ¼ $95; range ¼ $0–$500) had
a 50% APPT rate. Vignette was not associated with APPT
success in either model. APPT success varied by city in the
private vs. MED model (p ¼ .054). Conclusions: Only half
of privately insured patients with serious conditions got
a follow-up APPT within one week of ED discharge.
Medicaid and uninsured patients were even less likely to
have timely access to follow-up care. Full cash payment
increased uninsured APPT rates. These data raise serious
concerns about access to care after ED visits for all patients.
368 Care without Coverage: Do Uninsured Patients
Receive Care Comparable to Insured Patients in an
Academic Emergency Department? Faber A White, Daniel
K French, Frank L Zwemer Jr; University of Rochester Strong
Memorial Hospital: Rochester, NY
Objective: Are there disparities in ED care related to
patients’ insurance status? A recent Institute of Medicine
(IOM) report ‘‘Care Without Coverage’’ compared admit-
ted patients with traumatic and acute cardiovascular diag-
noses and found that uninsured patients received fewer
hospital services than insured patients. Do these dis-
parities actually begin in the ED? We studied patients in
an academic ED, hypothesizing that insurance status
would result in no difference in the measures of ED care
for patients presenting with similar complaints and di-
agnoses. Methods: Retrospective comparison of patient
care in an academic tertiary referral center (80,000 annual
visits) for period Jan 1- June 30, 2001 utilizing electronic
databases. IOM definitions were matched as closely as
possible: age (18–64 years); insured (any insurance, in-
cluding Medicaid); uninsured (no insurance); and diagno-
ses (traumatic injuries (‘‘trauma’’) and acute cardiovascular
disease). We then compared measures of patient demo-
graphics, acuity, and ED resource utilization. Results: For
patients presenting with trauma and cardiovascular dis-
ease (n ¼ 3,899, 3,431 insured and 468 uninsured),
uninsured more likely to be younger (32.2 vs. 39.5 yrs,
p \ .001) and male (71.3% vs. 57.3%, p \ .001). In terms of
547
acuity, uninsured less likely to arrive by EMS (42.9% vs.
48.9%, p ¼ .016) and require admission (9.8% vs. 27.2%,
p \ .001). Regarding ED resource utilization, no significant
difference in number of lab tests ordered, percentage of
patients receiving consults, or total ED charges; however,
uninsured received fewer radiographic studies (2.68 vs.
3.51, p \ .001). For admitted patients, no difference in the
percentage admitted to intensive care units. Conclusion: In
evaluating insurance status for a specific group of high-
acuity patients, there were no significant differences in ED
care except for fewer radiographic studies for uninsured
patients. Insurance status does not significantly affect care
in an academic ED.
369 Nonurgent Emergency Department (ED) Visits:
Patient Characteristics and Barriers to Primary
Care Johnathan Afilalo, Adrian Marinovich, Marc Afilalo,
Antoinette Colacone, Claudine Giguère, Ruth Léger, Bernard
Unger; Sir Mortimer B. Davis-Jewish General Hospital
Emergency Department: Montreal, Quebec, Canada
Background: ED overcrowding is at the forefront of the
medical and political agendas and diversion of nonurgent
(NU) patients (pts) has been entertained as a management
strategy. Prior to policy changes a clear understanding of the
reasons why these pts are not seeking care at a primary care
provider (PCP) before presenting to the ED is essential. This
study compares NU pts to urgent and semi-urgent (USU)
and describes the NU pt reasons for not seeking care at
a PCP before presenting to the ED. Methods: Cross-sectional
study with sequential sampling in 5 tertiary care hospitals
EDs (Oct. 19 1999 to May 26 2000). Data on past medical
history, social support, awareness and utilization of health-
care, ED visit, referral, Activities of Daily Living (ADL),
socio-demographics, were obtained. The NU group were pts
triaged as code 5 while USU were pts coded 2,3,4 using the
Canadian Triage & Acuity Scale. Pts reasons were structured
into the Andersen Behavioral Model (ABM) for health care
utilization. Only comparisons producing P-value \ 0.05 are
shown. Results: Of 2348 pts approached 1804 (76%)
accepted to participate. NU (n ¼ 454) were younger than
USU (n ¼ 1329) (mean age 43 vs. 49 years). NU pts had
better health (number of prior conditions; 3.1 vs 2.87) and
functioning (ADLs;1.92 vs 1.87), were less likely to arrive by
ambulance (4% vs 22%), reported less specialist care (38% vs
48%) and were less often admitted from the ED (4% vs 24%).
While 70% of NU pts compared to 75% USU pts were
followed by a PCP, only 22% of NU pts and 27% USU pts
sought PCP care before presenting to the ED. The reasons
given by NU pts for not seeking PCP care were: accessibility
(34%), referral/follow-up to the ED (19%), familiarity with
(19%), perception of need (16%), and trust of the ED (10%).
Conclusions: The NU pt clientele is a heterogeneous group
and that there are significant issues to be considered prior to
implementation of diversion strategies.
370 Do Electronic Linkages between the Emergency
Department and Primary Care Physicians Reduce
Resource Utilization in the Emergency Department?
Results of a Randomized Controlled Trial Eddy S Lang,
Jean-François Boivin, Ruth Leger, Antoinette Colacone, Claudine
Giguere, Xiaoqing Xue, Alain Vandal, Stephen Rosenthal,
548
Bernard Unger; Sir Mortimer B. Davis Jewish General Hospital,
McGill University: Montreal, Quebec, Canada
Objectives: The lack of communication between emergency
departments (EDs) and primary care physicians (PCPs) is
cited as a cause of inefficiency in ED care. Despite this, few
EDs consistently transmit data about the patients they care
for to PCPs. We hypothesized that as a result of enhanced
follow-up, electronic communication would reduce resource
utilization in the ED. Methods: The Standardized Commu-
nication System (SCS) is a secure, e-mail and Internet-based
application that enables PCPs to receive detailed reports
including laboratory and imaging data as well as consulta-
tions, disposition and follow-up information regarding their
patients who have received ED care. We conducted a pro-
spective, triple-crossover, randomized controlled trial of
PCPs’ practices, stratified by age and load of ED-using
patients. While allocated to intervention, PCPs received
reports via the SCS and while in control, mailed copies of
the hand-written ED note. Outcomes of interest were 14-day
revisit rates, admission rates upon revisit and ED length of
stay (LOS) as well as consultation requests and test ordering
in the ED. The study was designed with 0.80 power to detect
a 25% reduction (a ¼ .05) in revisit rates. Cluster analysis
was employed for all comparisons. Results: 2022 ED visits
(974 SCS vs. 1048 control) were entered into the trial. The
clinical and demographic characteristics of the patients in
each arm were comparable. The SCS intervention did not
reduce 14-day revisit rates (adjusted OR 1.10, 95% CI 0.80 –
1.51). There was also no difference in admission rates upon
revisit (25% with SCS vs. 27% controls; p ¼ ns) nor in ED
LOS (9.3 hrs. with SCS vs. 9.4 hrs. controls; p ¼ ns).
Consultation requests (16% SCS vs. 15% controls; p ¼ ns)
and test ordering (84% SCS vs. 85% control; p ¼ ns) were
also unaffected by the intervention. Conclusions: In
comparison with mailed copies of the ED chart, electronic
communication between EDs and PCPs does not reduce
resource utilization in the ED.
371 Increased Psychosocial Risk Communication with
Computer Screening: Impact on Patient
Satisfaction Karin Verlaine Rhodes, Elizabeth Louise
Anliker, Melinda Drum, Richard Frankel, David S Howes,
Wendy Levinson; University of Chicago Hospitals: Chicago,
IL, Richard Roudebush VA Medical Center: Indianapolis, IN,
University of Toronto: Toronto, ON, Canada
Objective: To assess the effect of a patient self-administered
computer health risk survey, (Promote Health) on com-
munication regarding psychosocial risks and patient satis-
faction. Methods: A randomized-controlled trial was
conducted at two EDs, an urban medical center and
a suburban community hospital. Consenting non-urgent
female patients between the ages of 18–65 were randomized
to usual care or to Promote Health, which generates a patient
risk summary for the treating physician. The ED visits of all
patients were digitally audiotaped and independently coded
for primary outcomes of discussion of intimate partner
violence (IPV), depression, and alcohol/drug abuse. Patients
completed an exit questionnaire at the end of the visit rating
their overall care from poor (1) to excellent (5). Results:
1298/2159(60%) of eligible patients consented. To date, 558/
2003 SAEM ANNUAL MEETING ABSTRACTS
898(64%) audiotapes have been coded. Of patients with
coded audiotapes, 482(86%) completed Exit Questionnaires.
There was a significant increase in rates of discussion of at
least one psychosocial risk factor in the Promote group 84/
265(32%) compared to the Control group 69/289(24%), p ¼
.040, mainly attributable to communication regarding IPV at
the urban site (Promote 62/119(54%), Control 50/135(38%),
p ¼ .010) and depression at the suburban site (Promote 16/
146(11%), Control 6/154(3.9%), p ¼ .019). The two sites dif-
fered in overall rates of psychosocial communication, urban
site, 119/258(46%) versus the suburban site 37/300(12%),
p ¼ .000. Patients who were asked about psychosocial risks
were more likely to rate their care as excellent, p ¼ .019.
Likewise, the lowest ratings were associated with lack of
discussion of psychosocial risk, p ¼ .057. Conclusions:
Providing patient health risk information increased provider
rates of inquiry regarding major psychosocial risk factors.
When it occurred, this communication was associated with
increased patient satisfaction.
372 Acute Stress Disorder and Major Depressive
Episode Diagnoses among Emergency Department
Staff Involved in the Response to the World Trade
Center Tragedy Jeremy D Sperling, Phillip D Levy,
Joanna Garritano, William Chiang; Bellevue Hospital Center/
NYU Medical Center: New York, NY
Objectives: The role of Emergency Medicine (EM) health
professionals in disaster situations places them at significant
risk for psychological sequelae. The mental health needs of
these individuals are often overlooked. This study was
undertaken to characterize the psychological impact of such
a disaster and the subsequent incidence of DSM-IV defined
acute stress reactions, specifically acute stress disorders
(ASD) and major depressive episodes (MDE). Methods:
Two to three weeks after the September 11 World Trade
Center (WTC) attack, an anonymous questionnaire was
distributed to the EM staff at one of New York City’s major
trauma centers. Demographic information was requested as
well as the amount of time spent engaged in specific
activities during the first 72 hours after the attack. The
questionnaire assessed the psychological state of the re-
spondent by asking about 54 subjective symptoms. These
symptoms were correlated to DSM-IV defined criteria for
either ASD or MDE. Appropriate statistical and univariate
analysis of continuous or categorical variables between
groups were applied. Results: A total of 155/194 (79.9%)
eligible staff members completed questionnaires. Of those
completing the survey, 39.3% were nurses, 29.7% were
residents, 24.5% were attending physicians and 6.5% were
medical students. The majority of respondents were female
89 (57.4%). 14.2% of respondents met criteria for ASD; 30.9%
for MDE. A diagnosis of ASD or MDE was not associated
with level of training, position, age or time spent at the
hospital or Ground Zero. Patients with MDE were more
likely to be female (p ¼ 0.006; RR ¼ 2.23, CI 95% 1.24–4.24).
Conclusions: ED personnel are at risk for acute psycholog-
ical reactions to traumatic events. Because it is difficult to
predict who will develop a stress reaction, all EM personnel
should be considered at risk and targeted for psychological
interventions, such as debriefings and counseling.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
373 Use of Complementary/Alternative Medicine among
Emergency Department Patients: A Prospective
Multicenter Study Sunghye Kim, Karla N Munoz, Josef E
Braun, Arpi Doshi, Katherine T Wayland, Jessica L Hohrmann,
Sunday Clark, Michael S Radeos, Carlos A Camargo Jr;
Massachusetts General Hospital: Boston, MA, Lincoln Medical
Center: Bronx, NY
Objective: Two-thirds of Americans are thought to have
used a complementary/alternative medicine (CAM) at some
point in their lives. Convenience samples in two single-
center studies suggest that 43–56% of ED patients (pts) have
used CAM. Our goal was to describe the CAM use by
consecutive ED pts. Methods: For two 24-hour periods, we
interviewed consecutive pts age 18þ presenting to 4 Boston
EDs. Exclusion criteria included severe illness and emo-
tional disturbance (n ¼ 224). Trained interviewers assessed
pt use of prescription meds, ever/recent (within past year)
use of supplements and herbal ‘‘remedies’’ (e.g., St. John’s
wort), and ever/recent use of complementary/alternative
‘‘therapies’’ (e.g., acupuncture). Data analysis used chi2.
Results: Of 754 eligible pts, 530 (70%) were interviewed. Of
these 530, ‘‘ever’’ use of CAM (remedy or therapy) was
reported by 57% (95%CI, 53–61), while 37% (33–42) reported
use in the past year. Corresponding figures for remedies
were 34% (30–39) and 21% (17–24), and for therapies
46% (42–50) and 28% (24–32). On an ‘‘ever’’ basis, the most
commonly tried remedy was ginseng (14%) and therapy
was chiropractic (23%). During the past year, corresponding
items were ginseng and Echinacea (both 7%) and relaxation
techniques such as meditation (10%). Most patients had
a primary care provider (PCP) and not an alternative
medicine provider (AMP): 92% PCPþ/AMP
, 7% PCPþ/
AMPþ, 0% PCP
/AMPþ, and 1% PCP
/AMP
. 89%
reported that they would be comfortable discussing CAM
with their PCP, ED physician, or ED nurse, but only 34%
reported that they had ever discussed CAM with one of
these providers. While provider characteristics and comfort
levels did not differ by site (all p [ 0.05), ever CAM usage
was lower at one site (57%, 65%, 58%, and 39%; p ¼ 0.004).
Conclusion: CAM usage is common among ED patients.
Given the growing evidence of benefits and hazards from
popular CAM remedies and therapies, ED staff should feel
comfortable raising this health issue with their patients.
374 Prevalance of Hunger and Its Effects on English
and Spanish Speaking Emergency Department
Patients Michelle H Biros, Karen Resch, Pamela Hoffman;
Hennepin County Medical Center: Minneapolis, MN,
Children’s Hospital: Minneapolis, MN, University of
Minnesota Medical School: Minneapolis, MN
Background: Because of food insecurity, some ED patients
must choose between buying food and medication. The
relationship between hunger and ethnicity has not been
described in ED patients. Objective: To compare the
prevalence of hunger and its health effects among English
and Spanish speaking patients. Methods: A validated
survey about hunger, choosing between food and medicine,
and adverse health outcomes related to food insecurity was
administered to a convenience sample of adult non-critically
ill ED patients or parents of non-critically ill children.
549
Surveys were administered in English and Spanish from
January to August 2001. Relationships between outcomes
and demographics were summarized by odds ratio and 95%
CI. Logistic regression was used for multivariate analysis.
Results: 501 subjects completed the survey in English and
315 in Spanish. Mean age was 33.8 6 13yrs: 25.4% were
white, 25.5% African American/ black, 38.6% Hispanic, and
10% other. Overall, 24.9% reported not having enough to eat
at least once in the preceding 12 months. 10% reported that
they had gotten sick because they could not afford medicine,
resulting in an ED visit; of these, 73% resulted in a hospital
admission. Hunger was predicted by illicit drug use (OR ¼
5.95), income \ $10K (OR ¼ 3.02), Hispanic ethnicity (OR ¼
2.38) and chronic health problems (OR ¼ 1.88). Choosing to
buy food instead of meds was predicted by no insurance
(OR ¼ 3.20), chronic health problems (OR ¼ 2.36) and low
income (OR ¼ 2.22). Getting sick because of buying food
instead of meds was predicted by lack of insurance (OR ¼
3.29), chronic health problems (OR ¼ 2.63), low income (OR
¼ 2.27) and African American race (OR ¼ 1.93). Conclu-
sions: The ED patients in this urban setting have high rates
of hunger and choosing to buy food instead of meds may
result in ED visits and hospitalization. Ethnicity/race and
low income may predict hunger and subsequent ill health
effects.
375 Increasing the Identification of Depression in an
Inner City Population Sandie Torres, Steven Nazario,
Marianne T Haughey, Yvette Calderon; Jacobi Medical Center,
Albert Einstein College of Medicine: Bronx, NY
Objectives: Depression is a major cause of morbidity and
mortality in the U.S. As many as 50% of cases are un-
recognized by their PCP’s and the underprivileged that
rely on emergency departments for primary care may be at
an increased risk for undetected depression. The purpose of
our study was to compare ED physician practice with
a simple screening tool for the detection of depression in
patients presenting to an urgent care setting with somatic
complaints. Methods: This prospective observational study
included all patients over 18 years of age presenting to an
urgent care clinic staffed by ED physicians in an urban
public hospital during an 8-week period. Patients present-
ing with a chief complaint of depression and those with
clinical instability were excluded. For patients with multiple
visits during the study period, only the first visit was
included. Subjects consenting to participate completed
a previously validated two-question screening tool for
depression. Those identified by the tool, or by the physician,
as depressed were referred for evaluation by social workers
for possible psychiatric referral. A questionnaire adminis-
tered to the patients, physicians, and social workers
recorded self-reported or solicited depressive symptoms,
the provider’s diagnostic assessment of depression, and the
need for psychiatric referral. Results: Of the 230 patients
enrolled, 150 reported depressive symptoms on the ques-
tionnaire. Physicians identified 29 of the 150 symptomatic
patients as depressed. 37 patients agreed to further
evaluation by SW and of these, the screening tool alone
identified 25 patients. SW evaluation found that 21 patients
of 25 (84%) required further psychiatric care (Chi Square, p
¼ 0.001). Conclusion: Depressive symptoms are common
550
among patients presenting to urgent care settings with
somatic complaints. Depression is under-detected and
under-treated in this population. A simple screening tool
can aid in identifying these patients for further evaluation.
376 Increased Rate of Anxiety Related Visits to Selected
New Jersey Emergency Departments Following the
September 11, 2001 Terrorist Attacks David Joseph Adinaro,
John Allegra, Dennis G Cochrane, Greg Cable; Morristown
Memorial Hospital: Morristown, NJ, Atlantic Health System:
Florham Park, NJ
Objectives: Our goal was to examine the effect of the
September 11, 2001 terrorist attacks on the daily rate of
anxiety related complaints to selected emergency depart-
ments (EDs) in New Jersey. Methods: Design: Retrospective,
cohort study of ED diagnoses. Setting: 15 New Jersey EDs
located in urban and suburban areas within a 50-mile radius
of the World Trade Center. These included teaching and
non-teaching hospitals with annual ED volumes from 20,000
to 65,000. Subjects: Consecutive patients seen by ED
physicians in these hospitals over a six year period, 1996–
2001. Protocol: Three of the authors reviewed all ICD9 codes
used during this period and chose by consensus those
related to anxiety. Models were constructed of the vari-
ation in daily rates of anxiety related diagnoses. We used
graphical methods, Box-Jenkins modeling and time series
regression to determine the differential effect of the days
September 11 to 14 on daily rates of anxiety related
complaints. We controlled for effects of long-term trend,
day of the week and season on the daily series within each
year. All tests of statistical significance were conducted at
alpha ¼ 0.05. Results: There were a total of 2,911,300 patient
visits in the database for the six calendar years. The primary
ED diagnosis was anxiety-related for 25,855 (0.9%). The
daily rate of anxiety related complaints during September 11
to 14 in 2001 was 46% larger than the mean rate during the
remainder of the July 11 to December 11, 2001 period (p ¼
0.0001). During the other years of the study, the differential
effect of September 11 to 14 was small (both positive and
negative) and was not statistically significant. Conclu-
sion: We found a large increase in the rate of anxiety related
visits to selected EDs in New Jersey the 4 days following
September 11, 2001. Future planning for the aftermath of
terrorist attacks should include the expectation of increased
ED usage for anxiety related complaints in areas near the
terrorist attacks.
377 Patient Satisfaction and Physician Dress in the
Emergency Department Siu Fai Li, Marc Haber,
Adrienne Birnbaum; Jacobi Medical Center/AECoM: Bronx, NY
Background: To determine if patients’ evaluations of EM
physicians are influenced by their manner of dress. Past
studies concerning patient responses to physicians’ style
of dress have been limited to clinic / in-patient settings, or
were limited to preference by photographs. There is one
study of patients’ attitude toward ED physician attire, done
in the UK, where patients did not show any preference of
dress. We wish to determine if patient preferences are
2003 SAEM ANNUAL MEETING ABSTRACTS
influenced by physicians’ dress in our clinical setting, a U.S.
urban hospital. Methods: A cross-section, convenience sam-
ple of patients. Physician dress was recorded. Patients were
asked to determine on a 100 mm VAS their evaluation of
physician appearance, satisfaction, and professionalism.
Dress styles were recorded as scrubs, dress shirt/pants, or
mixed. We estimated 56 patients were needed to detect
a 10% difference between groups based on an estimated
mean of 75, sd of 10, 2-tailed alpha of .05, beta of .2.
Comparison of scores between groups was done using one-
way ANOVA, or Kruskal-Wallis when variances were
unequal. Comparison of variances was done using the F
test. Correlation between physician appearance and satis-
faction or professionalism was done using Pearson’s rho.
Results: 117 patients were surveyed. Physician dress style
was 56% scrubs, 26% mixed, and 17% dress. There were no
differences between patients’ evaluation of appearance,
satisfaction, or professionalism between the three groups
(Table 1). There was poor correlation between ratings on
dress and physician satisfaction (r2 ¼ .42) or professionalism
(r2 ¼ .32). Conclusions: Physicians’ dress style in the ED
does not affect patients’ evaluations of their performance.
TABLE 1. Patients’ Evaluation of Physicians Based
on Different Dress Styles
Appear. Satisf. Profess. (mean 6 sd)
Scrubs 90 6 11 90 6 10 90 6 9.9
Mixed 84 6 16 86 6 16 89 6 11
Dressed 87 6 14 88 6 9.8 90 6 9.6
p \ .08 p \ .69 p \ .86
378 Troponin I Degradation with Increasing Duration of
Global Ischemia Brian Scott Palmer, Peter J Reiser,
Mark G Angelos; The Ohio State University: Columbus, OH
Background: The myofibrillar protein cardiac troponin I
(cTnI) is particularly susceptible to cleavage during reperfu-
sion and is thought to play an important role in post ischemic
contractile dysfunction. cTnI degradation has been noted
after ischemia and reperfusion, but the effect of ischemia
alone on cTnI breakdown has not been well characterized.
Objective: To determine the nature of cTnI breakdown after
increasing durations of global ischemia. Methods: Sprague
Dawley rat hearts were perfused with oxygenated Krebs-
Henseleit solution including 5.5 mM glucose and 0.2 mM
octanoic acid. Hearts were subjected to no ischemia, or to 15,
20, 25, or 30 minutes global ischemia (n ¼ 6/group) and freeze
clamped without reperfusion. Protein separation was probed
with a cTnI specific antibody on Western blots and quanti-
tated densitometrically. Group analysis was performed with
ANOVA using post hoc Tukey testing. Results: Four distinct
degradation bands including one doublet were seen in
all ischemic groups at the end of ischemia. These bands
correspond to molecular weights of approximately 25–27 kD
(bands 1 and 2), 20 kD (doublets) and 17 kD for band 5.
With increasing duration of ischemia, 2 of the 4 bands
increased compared to the 15’ group (p 6 0.05) and 2 bands
did not change significantly. Total degradation products
increased significantly as ischemia time increased from 15’
to 25’ (p 6 0.05) and then leveled off at 30’ ischemia.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Conclusions: Significant cTnI degradation occurs during
global ischemia, preceeding reperfusion, and is proportional
to the duration of ischemia. Protective therapy directed
toward preservation of cTnI must start prior to reperfusion.
379 A Predictive Instrument for Reperfusion Therapy for
Acute Myocardial Infarction David M Kent, Robin
Ruthazer, Joni R Beshansky, John L Griffith, Cindy L Grines,
Thomas Aversano, Robert Zalenski, Harry P Selker; Tufts-New
England Medical Center: Boston, MA, William Beaumont
Hospital: Royal Oak, MI, Johns Hopkins Hospital: Baltimore,
MD, Wayne State University: Detroit, MI
Objective: As reperfusion therapy, primary coronary in-
tervention (PCI) has been shown to yield superior outcomes
to thrombolytic therapy (TT) in acute myocardial infarction
(AMI). Yet in most settings TT remains the standard of care.
Starting with the Thrombolytic Predictive Instrument (TPI)
that makes real-time, patient-specific predictions of out-
comes with TT, we sought to add estimates of the expected
incremental benefits of PCI compared to TT, and also
estimates of the procedure-related delay that would nullify
these benefits. Methods: We developed a database of 3006
patients who received either TT or PCI for AMI from both
registry and clinical trial data. We used this database to
modify the TPI’s logistic regression equations in order to
make predictions for patients treated either with TT or with
PCI, the ‘‘Reperfusion TPI’’ (R-TPI). We then validated the
R-TPI on an independent dataset (The C-PORT Trial).
Results: In addition to the TPI equation, the new predictive
model required variables to account for the differential
treatment impact of PCI (compared to TT), an interaction
between PCI-effect and baseline TPI risk, door-to-treatment
time, and a new variable for age. Predictions were then
obtained on patients in the C-PORT trial with complete data
(n ¼ 337). The mean predicted mortality for those in the TT
arm was 6.3% (observed 6.0%). The mean predicted
mortality for the PCI arm was 4.5% (observed 3.9%). The
area under the ROC on this validation dataset was 0.87.
There was considerable variation in the expected incremen-
tal benefit of PCI compared to TT across this population.
Similarly, the door-to-balloon time expected to nullify this
benefit ranged from 0.3 to 4.3 hours (median 1.7, inter-
quartile range 1.3–2.3). Conclusions: The R-TPI accurately
predicts mortality in patients with AMI receiving either PCI
or TT. Installed in an electrocardiograph as is the TPI, such
an instrument may be useful in selecting which patients
benefit most from PCI compared to TT.
380 Brief Anoxia Induces Myocardial Ischemic Tolerance
by an Opioid-independent Mechanism Eric W
Dickson, David J Hirsch, Chad E Darling, Charles His, David J
Blehar, Karin Przyklenk; University Of Massachusetts Medical
School: Worcester MA
Background: Intermittent brief ‘‘preconditioning’’ (PC)
ischemia has been shown to render the heart resistant to
a subsequent sustained ischemic insult. The mechanism
responsible for this protective effect is multifactorial and
incompletely resolved, but includes opioid receptor activa-
551
tion. Using the rabbit model, we tested the hypotheses that
intermittent in vivo whole-body anoxia, without focal
myocardial ischemia: (1) will elicit a cardioprotective re-
sponse similar to that achieved with conventional PC
ischemia; and, if so, that (2) opioid receptor stimulation
contributes to anoxia-induced PC. Methods: Anaesthetized,
intubated New Zealand White rabbits (n ¼ 33) were
randomized to receive three 4-min bouts of brief anoxia
interspersed with 5 min normal ventilation or time-matched
standard ventilation (controls). Upon completion of the
in vivo PC/control period, the hearts were excised and
assessed for ischemic tolerance on a modified Langendorff
apparatus (40 min global ischemia þ 2 h reperfusion). To
assess the contribution of opioid receptor stimulation, 2
additional control and PC cohorts received the nonspecific
opioid antagonist naloxone (10mg/kg) prior to the in vivo
intervention phase. Infarct size (IS: delineated by tetrazo-
lium staining and expressed as a % of the total left ventricle)
was compared among the 4 groups by ANOVA. Results:
Intermittent whole-body anoxia evoked profound cardio-
protection: IS in the anoxia group averaged 22þ8%,
significantly smaller (p \ .01) than the value of 51þ3%
seen in controls. Pretreatment with naloxone had no effect
on infarct size in control hearts (IS of 63þ5% in naloxone þ
control group), and, had no inhibitory effect on anoxia-
induced PC (IS of 20þ7% in naloxone þ anoxia group: p ¼
.75 vs anoxia; p \ .01 vs controls). Conclusions: Inter-
mittent, in vivo whole-body anoxia evokes significant
myocardial ischemic tolerance. However, our results fail to
support the concept that this anoxia-induced cardioprotec-
tion is mediated via an opioid-dependent mechanism.
381 Influence of Time on Epinephrine and Vasopressin
Efficacy during Cardiopulmonary Resuscitation
from Ventricular Fibrillation W Taylor Muhly, Clifton W
Callaway, James J Menegazzi, Eric Logue Logue; University of
Pittsburgh School of Medicine: Pittsburgh, PA
Objective: Recent guidelines advance vasopressin (vaso) for
use as a pressor during cardiopulmonary resuscitation
(CPR). Prior studies suggest that vasopressin is more
effective than epinephrine (epi) after prolonged cardiac
arrest, but question its usefulness during brief cardiac ar-
rest. We hypothesized that the efficacy of vasopressin and
epinephrine for increasing coronary perfusion pressure
(CPP) is equivalent after short duration cardiac arrest but
differs after prolonged cardiac arrest. Methods: Design: A
blinded, randomized, laboratory experiment. Subjects:
Twenty immature mixed-breed swine. Interventions: After
a short (5 minute) or long (10 minute) arrest interval, CPR
was initiated using mechanical ventilation and chest
compressions. Following 2 minutes of CPR, drug (40U vaso
or 0.1 mg/kg epi) was administered, and up to three rescue
shocks were delivered 5 minutes into the resuscitation.
Measurements and Outcomes: The primary outcome, DCPP
(maximum CPP
minimum CPP during the 3 min of
resuscitation following drug administration), was calculated
during the final 0.2 seconds of the relaxation phase of each
compression. The DCPP was compared between groups
using ANOVA with drug and duration of arrest as factors.
Secondarily, return of spontaneous circulation (ROSC) for $
30 seconds was analyzed using Fisher’s exact test. Results:
552
Vaso produced greater increases in CPP at both short (DCPP
¼ 33.8 6 5.47 mmHg vs. 17.30 6 7.19 mmHg) and long
(DCPP ¼ 42.93 6 7.84 mmHg vs. 12.56 mmHg 6 7.96) arrest
durations relative to epi (drug: F(1,16) ¼ 52.17, P \ 0.001).
ROSC occurred in 5/5 short vaso and 3/5 short epi, and
4/5 long vaso and 1/5 long epi (p ¼ NS). Conclusions:
Vasopressin produced greater increase in CPP after both
brief and prolonged cardiac arrest. Vasopressin may be
a superior drug for increasing CPP during cardiac arrest
regardless of duration.
382 L-arginine, the Substrate for Nitric Oxide, Is
Significantly Low in Acute Vasoocclusive Sickle
Cell Crisis Bernard L Lopez, Allyson A Kreshak, Claudia
R Morris, Samir K Ballas, Linda Davis-Moon, Xin L Ma;
Jefferson Medical College: Philadelphia, PA, Children’s
Hospital Oakland: Oakland, CA
Objective: Vasoocclusive crisis (VOC) is the most common
presentation of adult sickle cell patients in the ED. Our
prior studies demonstrated an inverse relationship between
nitric oxide (an endogenous vasodilator) metabolite (NOx)
levels and pain scores during VOC, suggesting that an NO
deficiency may result in vasoconstriction with resultant
ischemia and pain. Our prior study (AEM 2002; 9:409) of 34
subjects revealed low L-arginine (l-arg, the substrate for NO
formation) and NO levels in VOC. We report the final data
of the largest l-arg study in adult VOC. Methods: Patients [
18 years presenting to the ED with uncomplicated, typical
VOC had plasma l-arg and NO levels obtained prior to
treatment. L-arg was measured using ion-exchange chro-
matography and NOx was measured by an NO-specific
chemiluminesence technique (SIEVERS 280I NO analyzer).
Excluded were those with atypical pain or acute, co-existing
illness. Pain was measured prior to and at the end of ED
treatment using a 100 mm visual analog scale (VAS).
Subjects were divided into a persistent pain group (DVAS
\ 13 mm) and an improved pain group (DVAS $ 13 mm).
Results: 50 subjects with VOC had a significantly low
plasma l-arg level (29.78 mM 6 11.21, p \ 0.05 vs. steady-
state control ¼ 41.16 mM 6 5.04) and significantly low
plasma NOx (12.33 mM 6 10.28, p \ 0.05 vs steady-state
control ¼ 25.2 mM 6 2.6). Neither L-arg nor NOx levels
could predict the clinical course of VOC—there was no
difference in either measurement between the persistent
pain and the improved pain groups nor between those
admitted and discharged from the ED. Conclusions: L-arg,
the substrate for NO, is significantly low in adult VOC
patients in the ED. However, this low l-arg level is still ten
times higher than the km of the enzyme NO synthase.
Serum l-arg levels alone, therefore, cannot explain low NO
levels in VOC and suggest that other mechanisms such as
altered intracellular transport may play a significant role.
383 Prospective Validation of the Canadian Pulmonary
Embolism Score with Subjective Pre-test Probability
and D-dimer Testing Christopher Kabrhel, Andrew T
McAfee, Samuel Z Goldhaber; Massachusetts General
Hospital and Brigham and Women’s Hospital, Harvard
Affiliated Emergency Medicine Residency: Boston, MA
2003 SAEM ANNUAL MEETING ABSTRACTS
Objectives: The Canadian Pulmonary Embolism Score
(CPES) was developed by Wells et.al. to identify patients
whose probability for pulmonary embolism (PE) was
sufficiently low to forego imaging. The CPES was derived
from a restricted population of inpatients and outpatients,
and has not been independently validated. The CPES was
developed without concomitant measurement of d-dimer.
We examined the validity of the CPES, with and without
d-dimer, in an undifferentiated emergency department (ED)
population. Methods: From Aug. 2001 to Sept. 2002,
physicians in an academic urban ED prospectively com-
pleted the CPES each time they began to work-up PE by
ordering a d-dimer, CT scan, PA-gram, V/Q scan, or venous
US. Physicians were blinded to the results of the score.
PE was defined as a positive PA-gram, CT scan, or high-
probability V/Q scan. The CPES at various cutoff levels and
its individual elements were compared to the diagnosis of
PE. Results: 625 patients were enrolled. Mean age was 48
years, 74% were women, 46% were discharged, and 10%
had PE. Diagnostic work-up was as follows: d-dimer 89%,
CT 43%, V/Q 18%, PA-gram 3%. Patients with PE had
a mean clinical score of 4.5, 95%CI [3.8–5.2] compared to 2.3
[2.1–2.5] (t-test, p ¼ 0.00) for those without PE. 21.2% of
patients with CPES [ 4 had PE, 5.7% of patients with CPES
#4 had PE (OR 4.1[2.4–7.1]). 16.7% of patients with CPES
$2 had PE; 3.9% of patients with CPES \ 2 had PE (OR 4.3
[2.3–8.2]). In an age and gender adjusted multivariable
logistic regression model of CEPS, only 3 of the 7 data
elements were significant: malignancy (OR 1.9 [1.02–3.6]);
pulse [ 100 (OR 2.1 [1.2–3.7]); and subjective pre-test as-
sessment of PE as most likely diagnosis (OR 3.0 [1.7–5.3]).
With the addition of the d-dimer result to the model, only
the subjective assessment of PE remained significant (OR 2.8
[1.4–5.6]). Conclusions: The CPES was validated with sub-
jective pre-test probability contributing the most to the score
when combined with the d-dimer result.
384 The Vexatious Vital: A Comparison of Clinical vs
Electronic Measurement of Respiratory Rate in
Triage Paris B Lovett, Jason M Buchwald, Kai Stürmann,
Polly Bijur; Beth Israel Medical Center: New York, NY, Albert
Einstein College of Medicine: Bronx, NY
Background: Of all the vital signs, only Respiratory Rate
(RR) is still measured clinically. The authors’ experience at
multiple centers is that RR recorded in triage shows low
variability and accuracy. Objectives: To assess the method,
duration, variability and accuracy of triage nurses’ mea-
surements of RR (RNRR). To compare this with electronic
measurement of RR (ERR) using transthoracic impedance
plethysmography (TTIP), and with the W.H.O. gold stand-
ard (GSRR) of auscultation for 60 sec. Methods: 483 con-
secutive patients presenting to an urban teaching ED were
enrolled in this prospective study. Researchers observed
triage nurses to assess how long and by what method they
measured RNRR. ERR was measured simultaneously.
Nurses were not aware that their RNRR measurements
were being observed. In Phase II, RNRR and ERR were
compared with GSRR in an additional 187 subjects.
Results: RNRR was recorded in 92.9% of subjects, with
observation the only method witnessed. 91% of RNRR
measurements followed a recording period of 0–15 sec.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org 553

Neither RNRR nor ERR was accurate: RNRR sensitivity Conclusions: Age [ 50, neck pain and vomiting were
for detecting low RR (\12) was 0 (95%CI 0–0.10) against related to the outcome of SAH and should be sought in all
GSRR. RNRR sensitivity and specificity for detecting high patients presenting with an acute headache. Although relief
RR ([22) were 0.48 (0.33–0.64) and 0.83 (0.75–0.89). ERR of headache was statistically more common in the benign
sensitivity and specificity against GSRR for detecting low headaches, it does not rule out SAH.
RR were 0.29 (0.08–0.64) and 0.98 (0.93–0.99) and for de-
tecting high RR were 0.33 (0.19–0.51) and 0.91 (0.84–0.95).
Nurses’ sensitivity in detecting tachypnea was greater in
patients over 65; no other significant demographic asso-
ciation emerged. RNRR showed low variance (13.1) com- 386 Prospective Assessment of the Accuracy and
pared with ERR (27.6) and GSRR (31.4). Conclusions: There Reliability of the Eight Clinical Criteria in the
isn’t time for nurses to spend 60 seconds recording RR in Canadian C-spine Rule Ian G Stiell, Jonathan Dreyer,
triage. Neither triage nurses nor TTIP provided reliable R Douglas McKnight, Iain MacPhail, Glen Bandiera, Catherine
measurements of RR. EDs should examine the possibility Clement, Jacques Lee, Daniel Cass, Brian H Rowe, Robert Brison,
of adopting a trimodal approach to measuring RR (brady- Michael Schull, Howard Lesiuk, for the CCC Study Group;
pneic, normal, tachypneic), or perhaps even abandon triage University of Ottawa: Ottawa, Ontario, Canada, Queens
measurement of RR until an accurate electronic modality is University: Kingston, Ontario, Canada, University of Toronto:
identified. Toronto, Ontario, Canada, University of Western Ontario:
London, Ontario, Canada, University of British Columbia:
Vancouver, British Columbia, Canada, University of Alberta:
Edmonton, Alberta, Canada
385 The Value of History in the Diagnosis of Objectives: We recently prospectively validated the accu-
Subarachnoid Hemorrhage for Emergency racy, reliability, and acceptability of the Canadian C-Spine
Department Patients with Acute Headache Jeff J Perry, Rule (CCR) in a cohort of 8,283 patients. In this study, we
Ian G Stiell, George A Wells, Melodie Mortensen, sought to evaluate the accuracy and reliability, separately, of
Howard Lesiuk, Gordon Wallace, Marco Sivilotti, Atul Kapur; each of the 8 high-risk and low-risk clinical criteria within
University of Ottawa: Ottawa, Ontario, Canada the CCR. Methods: This prospective cohort study was con-
Objective: It is unclear which ED patients with an acute ducted in 9 tertiary care EDs and involved alert (GCS 15)
headache require investigation for SAH. This study de- and stable adult trauma patients at risk for neck injury.
termined the value of history and resolution of headache for Physicians performed standardized clinical assessments and
predicting SAH. Methods: This 2-year prospective cohort completed data forms for patients who then underwent
study was conducted at 3 university tertiary care EDs. radiography to determine the outcome, clinically important
Adults with an acute headache peaking within 1 hour and c-spine injury. 130 patients were independently examined
without neurological deficit were enrolled. Excluded were by a 2nd MD. Patients were followed by a 14-day telephone
recurrent headaches of similar type, trauma, or previous interview. We conducted chi-square, odds ratio, and kappa
SAH/brain neoplasm. Emergency physicians completed coefficient analyses. Results: Among the 8,283 patients, the
data forms prior to investigation. The outcome, SAH, was mean age was 37.6 (range 16–100), 52.3% were male, 67.2%
defined as SAH on CT, xanthochromia in the CSF, or the were injured in a MVC, and 2.0% had clinically important
presence of red blood cells in the last tube of CSF with cervical spine injury. This table shows % of injury and non-
positive cerebral angiography. Patients were asked historical injury patients with findings, P-value, unadjusted odds
questions and to rate their pain on a scale of 0–10; 0 ratio, and kappa coefficient:
represented no pain and 10 the worst. Analysis included
univariate and multivariate logistic regression. Results: The CRITERIA INJURY NO-INJURY P-VALUE O.R. KAPPA
589 enrolled patients had a mean age of 42.9 years, were
HIGH-RISK
mostly women (60.6%), and had mean peak pain of 8.5 (SD
- Dangerous
¼ 2.1). Anti-migraine treatment was given to most patients
mechanism 69.2% 18.3% \.0001 10.0 —
(83.9%); total pain relief was associated with benign head- - Age 65 years 24.3% 7.2% \.0001 4.2 —
aches versus SAH (p ¼ 0.031); however 6.1% of patients - Paresthesias 22.5% 12.2% \.0001 2.1 0.81
with total pain relief had SAH. We compared patients with LOW-RISK
and without SAH and determined their unadjusted and - Simple rear-
adjusted odds ratios (** P \ 0.05): end MVC 1.2% 23.1% \.0001 0.03 0.97
- Sitting position
in ED 5.9% 34.6% \.0001 0.12 0.70
FEATURE %SAH %NO-SAH UNADJ-OR ADJ-OR - Ambulatory at
any time 40.8% 62.2% \.0001 0.42 0.86
Age over 50 67.5 26.8 5.7 7.8**
- Delayed onset
Female 62.5 60.5 1.1 0.6
neck pain 18.6% 38.2% \.0001 0.37 0.74
Worst Headache 92.5 77.1 3.7 1.9
- Absence midline
Exertion 17.5 9.3 2.1 1.3
tenderness 16.0% 39.8% \.0001 0.29 0.52
Transient LOC 15.0 4.1 4.2 2.3
Neck Pain 75.0 32.3 6.3 5.4**
Vomiting 60.0 28.9 2.7 2.7** Conclusions: The 3 high-risk and 5 low-risk CCR criteria
Awoke with Pain 5.1 19.8 0.2 0.3
showed very good interobserver agreement and very strong
Occipital 25.0 13.1 2.2 1.1
association with c-spine injury. The excellent accuracy and
554 2003 SAEM ANNUAL MEETING ABSTRACTS

reliability of the CCR is based upon the strength of its Objectives: The Canadian CT Head Rule (CCHR) is
clinical components. designed to improve the efficiency of ED management of
minor head injury patients. This economic analysis esti-
mated the potential cost savings to the Canadian health care
387 Prospective Evaluation of the Classification system with widespread use of the CCHR. Methods: This
Performance Accuracy of Neck Rotation and economic analysis used a probabilistic-based decision
Flexion in Potential C-spine Injury Patients Ian G Stiell, analytic model comparing current clinical practice to that
Mary Eisenhauer, Mark Reardon, James R Worthington, assuming 100% uptake of the CCHR. Cost savings were
Brian Holroyd, Catherine Clement, Daniel Cass, Gary assessed from a Canadian health care system perspective.
Greenberg, Michael Schull, Robert Brison, Brian H Rowe, The sensitivity and specificity of the rule were estimated by
Erica Battram, for the CCC Study Group; University of Ottawa: combining data from the derivation (N ¼ 3,121) and
Ottawa, Ontario, Canada, Queens University: Kingston, validation (N ¼ 2,588) studies. For our base analysis, current
Ontario, Canada, University of Toronto: Toronto, Ontario, CT ordering rate was estimated to be 80.2%. Sensitivity
Canada, University of Western Ontario: London, Ontario, analyses assumed rates of 90% and 100%. Cost data were
Canada, University of British Columbia: Vancouver, obtained from provincial health care fee schedules, hospital
British Columbia, Canada, University of Alberta: cost accounting systems and the literature. The probabilistic
Edmonton, Alberta, Canada model employed Monte Carlo simulation that was based on
Objectives: We recently validated The Canadian C-Spine 5,000 replications. We estimated the expected values for
Rule (CCR) for radiography in alert and stable trauma potential cost savings and reduction in CT rates. Results: In
patients. The CCR calls for evaluation of active neck rotation our base analysis, based upon the high-risk criteria and an
if patients have none of 3 high-risk criteria and at least 1 of 5 absolute reduction in CT use of 44.5% (from 80.2% to 35.7%),
low-risk criteria. This substudy prospectively evaluated the the expected cost savings per patient was $27.52 (95%
accuracy of rotation and flexion for ruling out c-spine injury. credibility interval $6.75–$44.34). For analysis based on the
Methods: This prospective cohort study was conducted in 9 medium risk criteria and an absolute reduction in CT use
tertiary care EDs and involved alert (GCS 15) and stable of 17.8 %, the expected cost savings per patient was $17.56.
adult trauma patients at risk for neck injury. More than 350 The total annual cost savings, assuming 200,000 minor head
physicians completed standardized examinations for active injury cases per year, would be $5.5 million based on the
rotation and flexion and recorded their findings on data high risk strategy and $3.5 million based on medium risk.
forms. Patients underwent radiography to determine the Results were sensitive to the rate of use of CT in current
outcome, clinically important c-spine injury. Analyses practice. Assuming CT rates of 90 and 100%, the expected
included sensitivity, specificity, and descriptive statistics, annual cost savings were $7.3 million and $9.5 million,
with 95% CIs. Results: 5,442 patients were enrolled over 30 respectively. Conclusions: Widespread use of the CCHR is
months and had these characteristics: age range 16–100, expected to lead to cost savings as low as $3.5 million per
male 50.6%, ambulance arrival 51.9%, important c-spine year or as high as $9.5 million. Future studies should
injury 0.6%, unimportant injury 0.2%, CCR low-risk 68.8%, evaluate the potential economic impact of the CCR in other
medium-risk 4.0%, high-risk 27.2%. For patients capable of countries.
rotation or flexion, the accuracy and probability of injury,
stratified by risk category, were:
389 Impact of a ‘‘STEMI Alert’’ System on Reperfusion
TEST/RISK SENS SPEC NPV 95%CI PROB 95%CI Strategy and Door-to-balloon Time Steven T Turner,
Marian Lawson, Lawrence Gimple, Chris A Ghaemmaghami;
ROTATION
University of Virginia: Charlottesville, VA
Low- .50 .80 1.0 1.0–1.0 .0003 .000–.002
Medium- 1.0 .59 1.0 .97–1.0 .000 .000–.04 Objective: Mounting evidence supports the expeditious use
High- .59 .82 .99 .98–.98 .01 .004–.02 of primary percutaneous coronary intervention (PCI) as
Total .61 .84 1.0 .99–1.0 .003 .001–.006 a superior strategy over fibrinolysis for acute ST-segment
FLEXION
elevation myocardial infarction (STEMI). Lack of coordina-
Low- .50 .84 1.0 1.0–1.0 .0003 .000–.002
tion between ED and interventional cardiology teams may
Medium- 1.0 .51 1.0 .97–1.0 .000 .000–.05
High- .78 .78 .99 .99–1.0 .006 .001–.06 result in the default selection of fibrinolytic (lytic) strategies
Total .77 .81 1.0 1.0–1.0 .002 .001–.004 or delays in the performance of PCI. We hypothesized that
an integrated, multidisciplinary ‘‘STEMI Alert’’ model could
place several clinical processes in parallel resulting in
Conclusions: Both rotation and flexion demonstrate 100% a higher utilization of PCI-based strategies and decreased
negative predictive value and can be considered accurate times from ED arrival to first intracoronary balloon inflation
techniques for evaluating cervical spine injury in alert and [Door-to-Balloon Time (DBT)]. Methods: The study was
stable patients. For patients classified as low-risk by the CCR conducted at a university hospital with 24-hr on-call
and capable of neck rotation, the probability of injury is 0.03%. interventional cardiology services. A ‘‘STEMI Alert’’ pro-
gram combining ED management and activation of cardiac
cath lab services via group paging and parallel processing
388 Economic Evaluation of the Potential Impact of the was initiated. Prospectively collected data on pts present-
Canadian CT Head Rule Douglas Coyle, Ian G Stiell, ing to the ED with STEMI from the first 8 months of the
George A Wells, Catherine Clement, for the CCC Study Group; program (AFTER) were compared to data abstracted from
University of Ottawa: Ottawa, Ontario, Canada the records of consecutive STEMI pts presenting in the
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
8 months prior to starting the new program (BEFORE).
Primary endpoints were: selection of initial management
strategy [lytic, PCI, or CCU management(CCU)] and DBT.
Data analysis was performed using Fisher’s exact and
Student’s t-tests. Results: 47 BEFORE and 67 AFTER pts
were identified. Initial management strategies were distrib-
uted as follows:
BEFORE AFTER
Lytic 5 (10.6%) 1 (1.5%)
PCI 31 (66.0%) 50 (74.6%)
CCU 11 (23.4%) 16 (23.8%)
In pts undergoing PCI, mean DBT was reduced from 141.7
mins (BEFORE) to 110.4 mins (AFTER) [p ¼ 0.0195 (95% CI
5.2–57.4 mins)]. Conclusions: An integrated, multidisciplin-
ary ‘‘STEMI alert’’ model employing parallel processes can
promote PCI-based over fibrinolytic strategies and can sig-
nificantly reduce times to PCI-based reperfusion therapy for
patients presenting to the ED with acute STEMIs.
390 An Assessment of the Prognostic Value of Exercise
Treadmill Testing Utilizing the Duke Score in Risk
Stratification of Emergency Department Chest Pain Unit
Patients Gregory G Johnson, Wyatt W Decker, Joseph K Lobl,
Dennis A Laudon, Jennifer J Hess, Christine M Lohse, Amy L
Weaver, Deepi G Goyal, Peter A Smars, Guy S Reeder; Mayo
Clinic: Rochester, MN
Objectives: Exercise treadmill testing (ETT) has been a
standard for evaluating outpatients at risk for cardiovascu-
lar (CV) events. Few studies demonstrate the prognostic
utility of ETT in an emergency department chest pain unit
(CPU) or have used the Duke score (DS) [exercise duration

5x ST deviation
4x treadmill angina index] to grade ETT
performance. The authors assess the utility of the DS in the
CPU to predict CV events. Methods: This retrospective
study enrolled consecutive CPU patients from November
2000 to October 2001 with chest pain. Patients were required
to reside in a ten county area surrounding the tertiary ref-
erral center and grant research authorization. They were
retrospectively followed for one year to identify CV events
defined as death, myocardial infarction, unstable angina,
acute congestive heart failure, stroke, arrhythmia, and
cardiac revascularization. Those undergoing ETT were
stratified into low (DS $ 5) and moderate/high (DS \ 5)
risk groups. A logistic regression model was fit to evaluate
differences in risk of having a CV event within one year
between the DS $ 5, DS \ 5, and no ETT groups. Results:
During the study period, 1048 patients entered the CPU
with 800 meeting inclusion criteria. Of these, 599 patients
received an ETT and 201 had contraindications or failed the
CPU protocol prior to stress testing. The CV event rates were
1.5% (7/454), 17.9% (26/145), and 19.9% (40/201), respec-
tively, among those with DS $ 5, DS \ 5, and those who did
not undergo an ETT. Patients who did not undergo ETT
were 10.5 times (95% CI, 4.4–24.7) more likely to experience
a CV event compared to patients who had a DS $ 5. Patients
with DS \ 5 were 11.2 times (95% CI, 4.7–26.8) more likely
555
to have a CV event. Conclusions: Patients with DS $ 5
developed minimal CV events when compared to those with
DS \ 5. The DS appears to be effective in risk stratification
of chest pain patients entered into the CPU.
391 Coronary Artery Calcification Scanning in Patients
Presenting to the Emergency Department with Chest
p Pain: Do We Need a Negative Scan? Dennis A Laudon,
0.042 Thomas R Behrenbeck, Larry F Vukov, Jerome F Breen; Mayo
0.219 Clinic: Rochester MN
0.568 Background: Electron Beam Computed Tomography
(EBCT) detection of coronary artery calcification (CAC) as
a surrogate for coronary atherosclerosis has been well
validated. In patients presenting with chest pain to the
Emergency Department (ED) CAC scanning has been
shown useful in distinguishing between a cardiac and
non-cardiac etiology. Low specificity using a 0 score as the
threshold criterion impedes ED management of these
patients. This study tested the hypothesis that low positive
scores can be used safely in the ED setting and achieve cost
savings. Methods: 262 patients with an intermediate
probability of chest pain were prospectively enrolled. All
patients underwent CAC scanning (GE-Imatron-150Ò), inde-
pendent of conventional cardiac testing, including enzyme
determination, stress testing (TMET, stress echocardio-
graphy, nuclear imaging, coronary angiography). 43 patients
had positive test results (enzymatic MI ¼ 9, TMET ¼ 9,
stress echo ¼ 5, nuclear imaging ¼ 5, and coronary angiog-
raphy ¼ 15), documenting a cardiac origin of chest pain.
Results: No events (MI, sudden cardiac death, or CABG)
were recorded in patients with negative CAC testing.
Results are shown in the table. ROC analysis yielded an
optimal CAC threshold score of 31, with a sensitivity of
82.4%, a specificity of 82.9%, a positive predictive value of
41.8%, and a negative predictive value of 96.9%. Cost
analysis showed a 50% reduction versus a 0-score threshold
with a total cost reduction of 21%.
Sensitivity Specificity PPV NPV
CAC Score % % % %
[0 94.1 57.0 24.6 98.5
[50 73.5 86.0 43.9 95.6
[100 52.9 93.0 52.9 93.0
[400 29.4 97.8 66.7 90.3
Conclusion: 1) Low non-zero CAC scores can be used safely
to distinguish between cardiac and non-cardiac origin of
symptoms. 2) Significant cost savings can be achieved using
low non-zero scores.
392 Ischemia-modified Albumin (IMA) Is Useful in Risk
Stratification of Emergency Department Chest Pain
Patients Charles V Pollack Jr, W Frank Peacock IV, Richard W
Summers, Francis M Fesmire, Brian R Holroyd, J Douglas Kirk,
Teresa M Mannion; Pennsylvania Hospital, University of
Pennsylvania Health System: Philadelphia, PA, Cleveland Clinic
Foundation: Cleveland, OH, University of Mississippi Medical
Center: Jackson, MS, University of Tennessee College of
556
Medicine: Chattanooga, TN, University of Alberta: Edmonton,
AB, Canada, University of California-Davis Medical Center:
Sacramento, CA
Objective: Ischemia-modified albumin (IMA) is a novel
highly sensitive, fairly specific biomarker of myocardial
ischemia. Using the ED portions of abstracted records of
patients entered into a prospective study for chest pain
syndrome suggestive of ACS, the utility of IMA in
making risk stratification decisions at ED presentation
was projected. ED cardiac risk assessment (CRA) was then
compared to hospital course including radionuclide
myocardial perfusion imaging. Methods: After receiving
standardized training on IMA test performance, 6 aca-
demic EPs from varied geographic regions and ED
settings reviewed 251 records that included demographics,
pain history, cardiac risk profile, 12-lead ECG, and pre-
sentation necrosis markers. A risk level was assigned to
each patient based on the reviewer’s clinical practice. After
2 weeks, without access to previous results, and in ran-
dom order, the patients were evaluated again based on the
same data plus presentation IMA. Analysis included mea-
suring the impact of IMA on CRA and inter- and intra-
observer agreement on CRA and reassessment. Results:
The study population was at aggregate low risk, with
a 10% frequency of ACS. The intraclass correlation
coefficient for both CRAs across the 6 evaluators was
0.517 without IMA and 0.665 with IMA. Intrarater reli-
ability ranged from kappa 0.80–0.98. Paired t-test analysis
indicated that all 6 evaluators adjusted their CRAs
concordantly with IMA. Without IMA, a total of 66 ‘‘very
low risk’’ CRAs (consistent with expeditious discharge
home) were made. With IMA, 236 CRAs were ‘‘very low
risk.’’ No patients with negative IMA were found to have
ACS; NPV was 100%. In patients with negative IMA, an
average of 55% were downgraded in the second CRA;
39% remained the same, and 6% were upgraded. Corres-
ponding numbers for positive IMA were 5%, 35%, and
60%. Conclusion: IMA is useful in the presentation risk
stratification of chest pain in the ED, and with minimal
training is used relatively consistently by EPs.
393 Emergency Evaluation of ICD Discharges Ranjan K
Thakur, Prashant Kumar, Sid Shah; Michigan State University:
Lansing, MI, Saginaw Cooperative Hospitals, MSU: Saginaw, MI
Introduction: Implantable cardiac defibrillators (ICD) are
commonly utilized for malignant ventricular arrhythmias.
These patients often present to the emergency department
(ED) for evaluation after ICD discharges. Their ED evalua-
tion is varied and no standards exist. Hospital readmission
for evaluation affects quality of life as well as increases cost.
Objectives: 1) To determine concordance between patient’s
report of ICD discharge and its confirmation, 2) Identify
hypokalemia or sub therapeutic drug concentrations as
potential cause for ICD shock and 3) Assess correlation
between ICD discharge and cardiac enzymes elevation.
Methods: A retrospective chart review was conducted of all
patients presenting with complaints of ICD discharge to
Ingham Medical Center and Sparrow Hospital Emergency
Department between February 1997 to May 2002. Patients
were excluded if adequate documentation was not available.
Results: Out of a total of 90 charts, 73 had adequate docu-
2003 SAEM ANNUAL MEETING ABSTRACTS
mentation for review. On ICD interrogation, appropriate
discharge was observed in 63%, inappropriate shock in 27%
and combination of inappropriate and appropriate in 10%.
Four % had no discharge despite complaints. Hypokalemia
was present in 10%. Cardiac enzymes were elevated in 4%
of patients. Of the medications for which drug levels were
routinely available, were checked in 56 % of patients and
were found to be therapeutic in 87.5 % of them. Conclusions:
Two thirds of the patients presenting to the ED with
complaints of ICD discharge had appropriate discharges.
No correlation was found between electrolyte disturbances,
sub therapeutic drug level concentrations, elevation of
cardiac enzymes and ICD discharges. None of the para-
meters evaluated in the current study were predictive of
discharging the patients directly from the ED.
394 Patients with Diabetes Can Undergo Immediate
Exercise Treadmill Testing in a Chest Pain
Evaluation Unit Deborah B Diercks, J Douglas Kirk, Nancy
Onesko, Ezra A Amsterdam; University of California, Davis
Medical Center: Sacramento, CA
Background: The evaluation of patients with diabetes in
a rapid assessment chest pain evaluation unit (CPEU) is
controversial due to their higher risk for acute coronary
syndrome (ACS). Objective: To describe our experience with
diabetic patients in our CPEU who underwent immediate
exercise treadmill testing (IETT) to exclude ACS. Methods:
This is a retrospective analysis of consecutive patients re-
ferred to a CPEU who underwent IETT from 1/94 to 11/01 in
a university hospital. Study patients had an ECG that was
normal or nondiagnostic and a single set of normal cardiac
markers on initial evaluation in the ED. An abnormal IETT
was defined as either an inadequate heart rate response
without ischemia (nondiagnostic) or ECG changes consistent
with ischemia (positive). Criteria for a final diagnosis of
ACS included evidence of ischemia by stress scintigraphy or
echocardiography, myocardial infarction, angiographic ste-
nosis [ 50%, or cardiac related death during 30 day follow-
up. Differences between subject groups were tested using
one-way analysis of variance and Chi-square; odds ratios
(ORs) and 95% confidence intervals (CIs) are given. Results:
The cohort comprised 252 (14%) diabetic and 1532 (86%)
non-diabetic patients, mean age 51 years SD 12. Of the 1784
patients enrolled, 113 (45%) diabetics and 460 (30%)
nondiabetics had abnormal exercise tests. There were no
complications during IETT. After adjusting for age, history of
CAD, tobacco use, hypertension and gender, diabetes was
still an independent predictor of abnormal IETT results (RR
1.6, CI 1.2–2.2). Diabetic patients also had more evidence of
ACS during follow up (RR 2.6, CI ¼ 1.68–4.1). No deaths or
MI occurred in either group. Conclusion: Despite a higher
rate of abnormal IETT’s, diabetic patients with chest pain can
be safely evaluated by IETT in a CPEU.
395 The Value of the TIMI Risk Score in the Risk
Stratification of Patients with Undifferentiated
Chest Pain Deborah B Diercks, J Douglas Kirk, Frances S
Shofer, Ezra A Amsterdam; University of California, Davis
Medical Center: Sacramento, CA, University of
Pennsylvania: Philadelphia, PA
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org 557

Background: A recently developed risk stratification tool, segments from HC rabbit with MnTE-2-PyP5þ (a superox-
the Thrombolysis in Myocardial Infarction(TIMI)risk score, ide dismutase mimic) completely blocked superoxide-
has been used to aid in the assessment of patients with acute initiated light production (28.2 6 3.6, P \ 0.01 vs. vehicle).
coronary syndrome (ACS). Its use in the risk stratification Pre-incubation of the vascular segments with diphenyle-
of an undifferentiated chest pain population has not been neiodonium, a selective NADPH oxidase inhibitor, but not
reported. Objective: To assess the value of the TIMI risk oxypurinol, a selective xanthine oxidase inhibitor, inhibited
score for risk stratification of an undifferentiated population superoxide production (32.8 6 6.8, P \ 0.01 vs. vehicle and
of chest pain patients presenting to the emergency depart- 105 6 19.5, NS vs. vehicle, respectively). Moreover, in vivo
ment(ED). Methods: A retrospective analysis of a prospec- treatment of HC rabbits with rosiglitazone, a PPARgamma
tive observational registry of patients presenting to a agonist that retards atherosclerosis formation, also reduced
university ED with symptoms suggestive of ACS was superoxide production (44.3 6 10.1, P \ 0.01 vs. HC).
performed. The TIMI risk score is a sum of 7 variables Conclusion: Our study provides direct evidence that
including: age $65, aspirin use within 7 days, 2 episodes of superoxide production in vascular tissues from HC animals
angina in 24hrs, $3 cardiac risk factors, ST-segment is markedly increased. NADPH oxidase, but not xanthine
deviation on initial electrocardiogram, elevated cardiac oxidase, is likely the major source of superoxide anion
markers, and a prior history of CAD $50%. Patients with generation under this pathological condition. Therapeutic
incomplete TIMI risk score criteria were excluded. Adverse interventions that inhibit NADPH oxidase activity, such as
cardiac events included a new or recurrent myocardial PPARgamma agonist, may have clinical application in
infarction, revascularization, or cardiac related death within hypercholesterolemic patients.
the 30 day follow-up period. Results: Of the 3766 registry
patients, 2744 were included in the analysis. Mean age was
56 yrs, SD 14.6 and 48% were males. Adverse events were
found in 274 patients(10%). The relationship between TIMI 397 Comparative Pharmacokinetics of a
risk score and adverse cardiac events is shown in Table Hemoglobin-based Oxygen Carrier L Bruce
395-1. Conclusion: These data suggest the TIMI risk score Pearce, Virginia T Rentko, Paula F Moon-Massat, Maria
can stratify the risk of adverse cardiac events in an S Gawryl; Biopure Corporation: Cambridge, MA
undifferentiated chest pain patient population. Its utility in
Objective: To determine the pharmacokinetics of a hemo-
disposition decisions warrants further study.
globin-based oxygen carrier (HBOC-201, Biopure Corp.,
Cambridge, MA) in the rat and dog compared to human.
Methods: Eighteen Sprague-Dawley rats and 18 beagle
dogs, divided into 3 equal groups, received 8.5, 21 or 42.5
396 Hypercholesterolemia Enhances Aortic Superoxide mL/kg HBOC-201 (0.13 6 0.01 g/mL hemoglobin (Hb)) at 7
Anion Production by NADPH Oxidase Clinton mL/kg/hr IV. Blood samples were collected predosing,
Keilman, Ling Tao, Hui-Rong Liu, Erhe Gao, Bernard L Lopez, immediately and 1, 2, 4, 8, 12, 18, 24, and 30 hours after
Theodore A Christopher, Tian-Li Yue, Xin L Ma; Thomas dosing, and twice daily for 2 additional days. For rats, blood
Jefferson University: Philadelphia, PA, Albert Einstein Medical withdrawn (;1 mL) was replaced with saline subcutane-
Center: Philadelphia, PA, GlaxoSmithKline Pharmaceuticals: ously. Total and plasma Hb were measured by oximetry
King of Prussia, PA while high performance size exclusion chromatography
determined HBOC molecular components ([octomer, octo-
Objective: Anti-oxidant treatment has been demonstrated mer, and tetramer). Results: The pharmacokinetics of
to improve endothelial function in hypercholesterolemic HBOC-201 and its molecular components were consistent
(HC) animals and retard atherosclerosis formation. The with a first order mechanism for all species and similar to
aims of the present study were to 1) obtain direct evidence human (Table). For all species, total plasma Hb clearance
that HC increases superoxide generation; 2) determine the (Cl), volume of distribution (Vss), and elimination half-life
molecular source(s) that produces superoxide in HC (t1/2) showed a significant dependence on dose.
vascular tissue; and 3) search for therapeutic interventions
that may inhibit superoxide generation in HC. Methods:
Male New Zealand rabbits were fed with normal rabbit diet Dose (mL/kg) Species Vss(ml/kg) t1/2(hr) Cl(ml/kg/hr)
(Control) or 1% high cholesterol diet (HC) for 8 weeks. 4.1 Human* 40 6 12 16.1 6 2.1 1.65 6 0.4
Superoxide production was determined by lucigenin-en- 8.5 Dog 62 6 6 19.8 6 2.4 2.01 6 0.1
hanced chemiluminescence from freshly harvested carotid 8.5 Rat 53 6 10 7.5 6 1.6 5.41 6 1.0
artery segments and expressed as relative light units (RLU) 21.0 Dog 79 6 11 30.6 6 4.9 1.75 6 0.2
per second per milligram vessel dry weight (RLU/s/mg). 21.0 Rat 66 6 8 10.7 6 1.9 4.31 6 0.7
Data were analyzed with ANOVA. Results: HC markedly 42.5 Dog 87 6 11 43.1 6 11.1 1.46 6 0.2
42.5 Rat 88 6 11 15.2 6 4.1 4.43 6 0.8
increased superoxide generation (98.5 6 7.2 vs. 50.5 6 7.2
in Control, P \ 0.01). In vitro incubation of the vascular *Hughes GS, et al. Crit Care Med 1996;24:756–764.

TABLE 395-1.
TIMI risk score 0/1 2 3 4 5 6/7
Adverse cardiac events (%) 33/1554 (2%) 65/651 (10%) 85/351 (24%) 60/143 (42%) 26/36 (72%) 5/9 (55%)
558
Conclusions: The basic pharmacokinetic profile, first order
kinetic elimination by a saturable process, is consistent
across species. The most noteworthy species difference is
the shorter half-life in the rat vs. the dog or man. The
pharmacokinetics of HBOC-201 in the dog may be more
predictive of HBOC-201 behavior in humans.
398 Anti-apoptotic Effects of the PPARgamma Agonist
Rosiglitazone on Aortic Endothelial Cells in
Hypercholesterolemic Rabbits Tiffany Gillis, Qi-Zhong
Mo, Hui-Rong Liu, Ling Tao, Erhe Gao, Bernard L Lopez,
Theodore A Christopher, Tian-Li Yue, Xin L Ma; Thomas
Jefferson University: Philadelphia, PA, Albert Einstein Medical
Center: Philadelphia, PA, GlaxoSmithKline Pharmaceuticals:
King of Prussia, PA
Objectives: Activation of PPAR receptors, a family of
nuclear receptors found in many organ systems, has been
shown to produce protective effects on the cardiovascular
system via anti-inflammatory and anti-atherosclerotic me-
chanisms. This study focuses on elucidating a possible anti-
apoptotic effect by rosiglitazone (ROSI) on rabbit aortic
endothelial cells (ECs) via activation of the PPARgamma
receptor. Methods: Male New Zealand rabbits were
assigned to one of the following groups: Control (C, normal
diet), High Cholesterol (HC, 1% cholesterol diet for 8
weeks), or High Cholesterol diet plus ROSI (4mg/kg/day
for the last 5 weeks). Rabbit aortic ECs were analyzed by
TUNEL assay to determine the apoptotic index (AI, %).
Western blot analysis was utilized to detect levels of p-Akt,
and immunohistochemistry was used to detect nitrotyrosine
(a footprint of peroxynitrite formation) and inducible nitric
oxide synthase (iNOS) expression in aortic endothelial cells
(EC). ECs were identified with an EC-specific antibody
(anti-CD146). Data are analyzed with ANOVA. Results: HC
resulted in significant reduction in Akt phosphorylation (an
anti-apoptotic signal), increase in iNOS expression and
peroxynitrite formation (pro-apoptotic nitrosative stress),
and increase in aortic EC apoptotic death (29.9 6 3.9% vs.
19.8 6 1.1% in C, P \ 0.01). Treatment with ROSI restored
Akt phosphorylation (3.5-fold increase over HC), inhibited
iNOS expression and peroxynitrite formation, and attenu-
ated HC-induced EC apoptosis (11.1 6 0.8%, P \ 0.01 vs.
HC). Conclusion: Our data demonstrate that ROSI exerts an
anti-apoptotic effect on aortic ECs in HC rabbits via
preservation of an anti-apoptotic signal, Akt phosphoryla-
tion and inhibition of a pro-apoptotic signal, iNOS
expression and peroxynitrite formation. These results may
have profound clinical implications for the prevention of
vascular injury in hypercholesterolemic patients by the
selective activation of PPARgamma receptors.
399 Does Specialty Training Affect Outcomes and
Complications of Temporary Transvenous Pacing in
the Acute Care Setting? Robert H Birkhahn, Theodore J
Gaeta, John Tloczkowski, Todd A Mundy, Joseph J Bove; New
York Methodist Hospital: Brooklyn, NY
Objective: To compare the success and complication rate
associated with temporary transvenous pacemaker (TVP)
insertion between physicians trained in either Emergency
2003 SAEM ANNUAL MEETING ABSTRACTS
Medicine or Cardiology. Methods: A retrospective chart
review of all patients with a billing code for TVP insertion at
our institution between 7/99 and 6/02. Patients were
excluded if the indication for pacing was asystole. Cases
were reviewed by two physicians certified in Emergency
Medicine and categorized by the specialty training of the
attending physician providing direct supervision. Power
estimations suggested that given an alpha of 0.05 and a 3:1
ratio of TVP insertions, a sample size of 95 would provide an
80% power to detect a difference of 5% in the complication
rate between specialties. Results: During the review period,
10 EM faculty and 8 Cardiologists directly supervised 124
of the 135 TVP inserted in 131 patients. 24 were placed for
asystole, leaving a total of 111 cases (24 EM, 74 Cardiology, 8
unsupervised) for review. TVP was successful in 97% (108/
111) of the attempts with no statistical difference based on
specialty. Complications were seen in 21% (CI 3%,38%) of
the TVP inserted by EM attendings, including: multiple
attempts(1), arterial puncture(1), failure to capture(1), line
sepsis(2), and pacemaker dislodgment(1). Complications
occurred in 20% (CI 11%,30%) of the TVP inserted by
Cardiologists. Multiple attempts(4), failure to capture(2),
line infection(3), arrhythmia(1), myocardial perforation(1),
bleeding complications(2), and dislodgment(4) were in-
cluded in this cohort. Complications were observed in 38%
(CI 8%,69%) of the cases that were not directly supervised by
an attending. There was no statistical difference in errors
between the specialties and no complication resulted in
death or prolonged disability. Conclusions: Physicians
trained in Emergency Medicine perform TVP insertions in
the acute care setting with a proficiency equal to their
counterparts in Cardiology.
400 Pro-inflammatory Effects of Hypercholesterolemia
and Anti-inflammatory Effects of a Peroxisome
Proliferator-activated Receptor-gamma (PPAR)
Agonist Hui-Rong Liu, Ling Tao, Erhe Gao, Theodore
A Christopher, Bernard L Lopez, Tian-Li Yue, Xin L Ma;
Thomas Jefferson University: Philadelphia, PA, Albert
Einstein Medical Center: Philadelphia, PA, GlaxoSmithKline
Pharmaceuticals: King of Prussia, PA
Objective: Hypercholesterolemia (HC) is the major risk
factor for coronary artery disease (CAD). Leukocyte myelo-
peroxidase (L-MPO) content may be a novel inflammatory
marker in CAD and has implications for risk assessment.
Peroxisome proliferator-activated receptors (PPARs) acti-
vation has been reported to attenuate the formation of
atherosclerosis-induced inflammation with unclear mechan-
isms. Our aims were 1) to determine whether HC may
cause L-MPO increase and 2) if so, to determine if rosi-
glitazone (ROSI), a novel PPARg agonist, may have anti-
inflammatory effects. Method: Male New Zealand rabbits
were fed with normal diet (control, C), high cholesterol
diet (HC, 1% for 8 weeks) or HC with ROSI (4mg/kg/day
for the last 5 weeks). L-MPO and heart tissue MPO
(H-MPO) was quantified and expressed in IU/g protein.
Expression of VCAM-1 and ICAM-1 in the heart tissue was
determined by immunohistochemistry. Data were analyzed
with ANOVA. Results: HC caused significant increase in
both L-MPO (1.43 6 0.37 vs. 0.11 6 0.02 in C, P \ 0.01)
and H-MPO (0.10 6 0.01 vs. 0.05 6 0.01 in C, P \ 0.01).
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Treatment with ROSI markedly reduced L-MPO (0.19 6
0.02, P \ 0.01 vs. HC) and H-MPO (0.07 6 0.013, P \ 0.01
vs. HC). To further explore the anti-inflammatory effects of
ROSI, rabbit were subjected to 1 h of myocardial ischemia
(MI) and 4 h of reperfusion (R), and the expression of
VCAM-1 and ICAM-1 in coronary venues was determined.
MI/R cause upregulation of VCAM-1 and ICAM-1, which
were inhibited by treatment with ROSI (23.2 6 2.5% vs.
46.1 6 3.1% for VCAM-1 and 24.6 6 1.6% vs. 38.1 6 3.1%
for ICAM-1 in HC, P \ 0.01). Conclusion: HC may not
only contribute to atherosclerosis by promoting lipid depo-
sition, but also by enhancing inflammatory response. PPAR
agonist not only inhibited the inflammatory response
associated with HC, but also inhibited the untypical in-
flammatory response associated with MI/R. This anti-inflam-
matory property of PPAR agonist may be a major mechanism
for their newly discovered anti-atherosclerotic effects.
401 Impaired Adaptative Responses to Catecholamine
Stress in Aging Heart Gregory Tokarsky, Dian-Yuan
Li, Jian-Zhong Sun, Bernard L Lopez, Theodore A Christopher,
Erhe Gao, Xin L Ma; Thomas Jefferson University: Philadelphia,
PA, Albert Einstein Medical Center: Philadelphia, PA
Objective: Older patients experience greater cardiac dys-
function in the peri- and post-operative state with unknown
mechanisms. Since insufficient myocardial blood supply is
common in aged patients and blood catecholamine level is
increased in the peri-operative state, we hypothesize that
the cardiac adaptative responses to catecholamine stress
may be impaired in aged hearts subjected to low coronary
flow. Method: Hearts from male young (6 month) and aged
(24 month) rats were placed on a Langendorff perfusion
system. Moderate myocardial ischemia (MI) was induced
by reduction of coronary perfusion rate to 50% of control.
Coronary infusion of isoproterenol (Iso, 1 mM for 30 min)
was initiated 30 min after MI. Left ventricular systolic
pressure (LVSP), diastolic pressure (LVDP) and generated
pressure (LVGP ¼ LVSP-LVDP) were derived from com-
puter algorithms. Data (M 6 SD) analyzed with ANOVA.
Results: LVGP and þdp/dtmax were slightly (P [ 0.05) and

dp/dtmax was significantly (P \ 0.05) lower in aged heart
than young heart before MI. MI resulted in a comparable
degree (P [ 0.05) of cardiac dysfunction (20–30% reduction
in all 3 parameters) in both young and aged hearts. In young
hearts, infusion of Iso caused a partial recovery of cardiac
function (LVGP: from 79 6 21 before Iso to 91 6 36 mmHg;
þdp/dtmax: from 1530 6 451 to 1886 6 900 mmHg/s;

dp/dtmax: from
935 6 227 to
1739 6 951 mmHg/s).
In striking contrast, Iso to aged hearts not only failed to
improve MI-induced cardiac depression but worsened the
cardiac function (LVGP: from 74 6 13 to 34 6 17 mmHg;
þdp/dtmax from 1493 6 694 to 652 6 408 mmHg/s;
dp/
dtmax from 747 6 140 to 462 6 228 mmHg/s, P \ 0.01
between young and aged groups). Conclusion: The adapta-
tive response to Iso challenge is severely impaired in aged
hearts subjected to MI and may be major mechanism re-
sponsible for increased cardiac dysfunction in the peri- and
post-operative state. Further study to determine the
mechanisms responsible for age-related impairment of
catecholamine stress are under way.
559
402 Cardioprotective Effects of PPARg Agonist
Rosiglitazone on Hypercholesterolemic
Rabbits Cedric Lefebvre, Hui-Rong Liu, Ling Tao, Theodore A
Christopher, Bernard L Lopez, Tian-Li Yue, Xin L Ma; Thomas
Jefferson University: Philadelphia, PA, GlaxoSmithKline
Pharmaceutical Company: King Of Prussia, PA
Objective: Hypercholesterolemia (HC) is an important risk
factor for ischemic heart disease. The aim of the present
study was to determine the effect of rosiglitazone (ROSI),
a novel peroxisome proliferator-activated receptor-gamma
(PPAR) agonist that has been shown to retard the formation
of atherosclerosis, on myocardial ischemia/reperfusion (MI/
R) injury in HC rabbits. Methods: Male New Zealand HC
rabbits (8 weeks of 1% cholesterol diet) treated with vehicle
(n ¼ 13) or ROSI (n ¼ 13) were subjected to 1 hour of MI
(LAD occlusion) and 4 hours of R. Left ventricular end-
diastolic pressure (LVEDP), positive and negative maximal
values of the first derivative of LVP (þdP/dt max,
dP/dt
max) and cardiac contractile index (CI) were derived by
computer algorithms. Cardiac cellular injury was assessed
by measurement of plasma creatine kinase (CK). Data was
analyzed with unpaired t test. Results: MI/R in HC rabbits
resulted in LVEDP elevation, dp/dtmax and CI decreasing,
and plasma CK increasing. ROSI treatment reduced LVEDP
(162.8 6 13.2% vs. 230.9 6 26.9% of pre-MI control values at
the end of R, P \ 0.01), increased þdP/dtmax (72.0 6 2.9%
vs. 60.0 6 6.7% of pre-MI control values, P \ 0.01) and
dP/
dtmax values (61.8 6 3.6% vs. 49.2 6 5.7% of pre-MI control
values, P \ 0.01), and enhanced CI (74.3 6 3.4% vs. 65.1 6 6.0
of pre-MI control values, P \ 0.01). Moreover, cardiomyocyte
cellular injury was also diminished in the drug-treated
group as evidenced by reduced levels of CK (13.85 6 0.538
U/g protein vs. 21.42 6 1.28 U/g protein at the end of R, P \
0.01). Conclusion: PPARgamma agonist ROSI significantly
reduced MI/R injury and improved cardiac function in HC
rabbits. Given the fact that HC is the major risk factor for
ischemic heart disease, our results suggest that treatment
with PPAR agonists may not only attenuate the formation of
atherosclerosis as previously reported, but also protect heart
from subsequent ischemic injury.
403 A Rapid ELISA D-dimer Is Sensitive and Has an
Extremely High Negative Predictive Value for Acute
Pulmonary Embolism in High-risk Emergency
Department Patients Christopher Kabrhel, Andrew T
McAfee, Samuel Z Goldhaber; Brigham and Women’s
Hospital and Massachusetts General Hospital, Harvard
Affiliated Emergency Medicine Residency: Boston, MA
Introduction: We sought to determine the sensitivity of
a rapid ELISA d-dimer in the ED evaluation of pulmonary
embolism (PE) in patients at high risk for PE. The rapid
ELISA d-dimer (VIDAS, BioMerieux) has a high sensitivity
and NPV for PE in populations of undifferentiated out-
patients. However, its performance in a group of high-risk
ED patients has not been studied. This study used two
methods to prospectively define high-risk patients: the
Canadian PE Score (CEPS) developed by Wells et.al.; and
the physician’s subjective pre-test assessment of PE as the
most likely diagnosis. Methods: ED physicians were asked
to complete the CEPS each time they initiated a work-up for
560 2003 SAEM ANNUAL MEETING ABSTRACTS

PE, including ordering a d-dimer. Two high-risk groups
were defined: (a) patients with CEPS [ 4, (b) patients in
whom clinicians thought PE was the most likely diagnosis.
PE was defined by a positive pulmonary angiogram,
positive CT scan, high-probability V/Q scan, or diagnosis
of PE on 3-month follow-up. D-dimer results were com-
pared to the diagnosis of PE. Results: 140 patients with
CEPS [ 4 were identified. Of these, 23 (16%) were diag-
nosed with PE and 41 (29%) had a negative d-dimer
(\500ng/ml). For 134 patients, the clinician thought the
most likely diagnosis was PE prior to knowing the d-dimer
result. Of these, 22 (16%) were diagnosed with PE and 47
(35%) had a negative d-dimer (\500ng/ml). No patient
diagnosed with PE had a negative d-dimer in either group.
For patients with CEPS [ 4, sensitivity was 100%, specificity
was 35.0%, 95%CI [26.3%–43.6%], PPV was 23.2%, 95%CI
[14.7%–31.3%], and the NPV was 100%. For patients whose
most likely pre-test diagnosis was PE, sensitivity was 100%,
specificity was 42.0%, 95%CI [32.9%–51.1%], PPV was
25.3%, 95%CI [16.2%–34.4%], and the NPV was 100%. Con-
clusions: The rapid ELISA d-dimer is a highly sensitive test
in ED patients at high risk for PE. A normal d-dimer helps
rule out high-risk patients suspected of PE.
404 ST Elevation in Anterior Acute Myocardial
Infarction Differs with Different Methods of
Measurement Stephen W Smith; Hennepin County
Medical Center: Minneapolis, MN
Background: The literature seldom specifies the location or
method of measurement (MoM) of ST elevation (STE) for
determining eligibility (EL) for reperfusion therapy. Hy-
pothesis: Different MoMs of STE result in significantly
different results. Methods: Retrospective review of diag-
nostic ECGs of consecutive patients (pts) presenting to our
ED with anterior acute MI (aAMI) who had emergent
primary percutaneous coronary intervention, left anterior
descending artery occlusion, and no bundle branch block.
STE was measured relative to the PR segment, to the nearest
0.5mm, at the J-point (JP) and at 60 milliseconds (ms) after
the JP in leads V1–V6. Data was analyzed by descriptive
statistics and Chi square. EL at 1mm and 2mm STE in 2
consecutive anterior leads (STEin2CAL) was evaluated. ST
scores (sum of STE in leads V1–V6) were compared.
Results: 37 records were available. See Table 1. ST scores
were significantly different as measured (M) at the JP vs. 60ms
after the JP (p \ .05). Criteria of 1 mm STEin2CAL was met in
32 of 37 (87%) ECGs when M at the JP and 36 of 37 (97%) when
M at 60ms after the JP and (p ¼ .09). Criteria of 2 mm
STEin2CAL was met in 23 of 37 (62%) ECGs when M at the JP
and 31 of 37 (84%) when M at 60ms after the JP (p \ .04).
ST score was $6 in 25 of 37 pts when M at the JP, and in
32 of 37 pts when M at 60ms after the JP (p ¼ .05). Conclu-
sion: STE measurements produce different results depend-
ing on the MoM. Future clinical trials should specify the
MoM.
405 Effect of Neural Network Feedback to Emergency
Physicians on Admission Rate for Chest Pain
Patients Judd E Hollander, Frank D Sites, Frances S Shofer,
Sanjay Shewakramani, Keara Sease, Dina M Sparano, Bradford
Glavan, William G Baxt; University of Pennsylvania:
Philadelphia, PA
Objective: Neural networks (NN) can risk stratify ED
patients (pts) with potential ACS and AMI. It has been
postulated that the high specificity may facilitate EP’s
discharging pts to home. This has not previously been
tested. We hypothesized that ‘‘real time’’ NN feedback
would decrease the ED admission rate for chest pain (CP)
pts. Study design: Before-after trial. Methods: Consecutive
ED CP pts were identified by trained research assistants
during the study periods (before NN, 7/99–3/02; after NN,
9/02–12/02). Data included 40 variables (demographics,
medical/cardiac history, ECG, CK-MB and cTnI) used in
two NNs: AMI and ACS. Data was obtained by the treating
physician, NN output calculated by research assistants
(after marker results received-approx 1 hr) and provided
to attending physician while patient was in the ED. Upon
hospital discharge, attending received feedback including
NN output, their initial clinical impression, cardiac test
results, and final diagnosis. The main outcome was the
admission rate prior to vs after the implementation of the
NNs. Standard summary statistics and 95% CI’s were used
for analysis. Results: Pre-implementation, 4492 pts were
enrolled; Post implementation, 432 pts were enrolled. They
were similar with respect to mean age (52.3 v 51.3 yrs);
%male (41 v 45%); race (AA 70 v 69%). The pre- group had
a higher frequency of AMI (7.1 v 4.6%) and ACS (19.2 v
10.4%). Implementation of the NN did not decrease the
hospital admission rate (before: 62.7%, [95% CI: 61.3–64.1%]
v after: 66.6%, [95% CI: 62.2–71.0%]. Additionally the ICU
admission rates were not different (11.4%, [95% CI: 10.5–
12.3%] v 9.3%, [95% CI: 6.6–12.0%]. Physician query found
that NN was used in only 2 cases (\1%). Conclusions: The
use of real time neural network feedback did not influence
the admission decision for ED chest pain pts. Most likely,
this occurred because NN output was delayed until the
return of cardiac markers ([1 hour) and the disposition
decision was already made.

TABLE 1. Mean STE in mm (695% CI)

STE at STE 60 ms STE STE 406 Common Variants in CYP11B2 and AGTR1 Could
Leads JP after JP range–JP range–60 Account for Excess Hypertension in African
Americans Sean O Henderson, Philip Bretsky; Keck
V2 2.6 (0.57) 3.8 (0.65)
1 to 7.5 0–9
V3 2.8 (0.68) 4.4 (0.84)
2 to 6.5 0.5–9.5 School of Medicine of the University of Southern
V4 2.1 (0.58) 3.2 (0.77)
1 to 7.5 0–9.5 California: Los Angeles, CA
ST Score 9.7 (2.14) 14.9 (2.69)
6 to 26 2–36 Background: The risk of developing hypertension (HTN)
ST Sum V2–V4: 7.4 (1.64) 11.3 (1.99)
4 to 20 1.5–26
and the risk of hypertensive mortality is higher among
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
African Americans (AA) than among Caucasian and
Latino populations. Access and socioeconomic reasons
have been cited for this excess morbidity and mortality,
yet there remains an unexplained increased risk even
when these other factors are controlled for. The genes
coding for aldosterone synthase (CYP11B2) and for the
Angiotensin II Receptor gene (AGTR1) have been impli-
cated in the development of hypertension in Caucasian
and Asian populations. Objective: To explore the role of
these genetic polymorphisms within the Renin-Angioten-
sin-Aldosterone system in an attempt to explain part of
this excess hypertension. Methods: We genotyped African
Americans and Latinos within a large multiethnic cohort
in an attempt to evaluate the possible contribution of two
polymorphisms (CYP11B2 C/T and AGTR1 C/T) to the
presence of HTN. Calculations of the Population Attribut-
able Risk (PAR) associated with the putative alleles
(CYP11B2 T and AGTR1 T). Results: The PAR for HTN
(the risk associated with the presence of the polymor-
phism in the general population) associated with CYP11B2
in AA males, less than 65 years of age was 37.4% and for
AGTR1 68.2%. For Latino males, the PAR for HTN
associated with these same polymorphisms was dramat-
ically lower (0% for CYP11B2 and 2.3% for AGTR1).
Similar findings are seen in AA females (27.7% for
CYP11B2 and 52.3% for AGTR1) and Latina females (0%
for CYP11B2 and 23% for AGTR1). If this could be
confirmed, AGTR1 accounts for 68% of HTN in AA and
between the two polymorphisms, the majority of hyper-
tensive excess may be explained. Conclusion: Acknowl-
edging that these polymorphisms act in the presence of
environmental stimuli, there is still major genotypic
discrimination between the two groups. AA and Latinos
have a similarly large difference in the presence and
consequences of HTN disease suggesting a causal re-
lationship.
407 Incomplete Reporting of Important Information in
Cardiac Risk Stratification Studies Bradford J
Glavan, Sanjay Shewakramani, Judd E Hollander;
University of Pennsylvania: Philadelphia, PA
Objective: A multi-disciplinary panel of experts is de-
veloping standardized reporting criteria for risk stratifica-
tion studies of ED patients with potential ACS. We assessed
the need for such criteria by reviewing published studies to
determine whether these core criteria are currently being
reported. Methods: Studies published in 2000–2001 in major
EM journals (Annals, Acad EM, Am JEM, JEM); cardiology
journals (Circ, JACC, AJC, Am Heart J), NEJM or JAMA that
evaluated cardiac troponin I for risk stratification of ED
chest pain patients were identified by a systematic MED-
LINE review. 2 raters independently analyzed each study
with a structured tool. Mention of 52 core criteria in 8 major
reporting areas were abstracted from the articles. When the
2 raters disagreed, discrepancies were resolved by con-
sensus. Data are presented as frequencies with 95% CI’s.
Results: 22 articles met all inclusion criteria. The 2 reviewers
had a median of 7.5 initial discrepancies per article (IQR,
6–10) but achieved consensus on all. The % of articles
reporting the core criteria in each topic area are below.
561
median % (IQR)
# of core criteria of articles reporting
Topic area in this topic area each core criteria
Enrollment criteria 3 41% (23–100%)
Demographics 3 100% (32–100%)
ECG Criteria 9 27% (5%–41%)
Risk Factors 10 32% (7–50%)
Chief complaint 4 18% (9–23%)
Cardiac markers 7 87% (27–96%)
Patient course 6 30% (22–41%)
Outcome definitions 10 32% (12–43%)
Conclusions: Many items considered core criteria by the
expert committee writing standardized reporting guidelines
for risk stratification studies of potential ACS patients were
not often reported in major subspecialty and general med-
icine journals. There appears to be a need for standardized
reporting guidelines, since important information is not
currently being reported.
408 Emergency Physician Echocardiography Decreases
Time to Diagnosis of Pericardial Effusions Paul R
Sierzenski, Stephen J Leech, Jason Gukhool, Michael Blaivas,
Robert E O’Connor; Christiana Care Health System: Newark,
DE, Medical College of Georgia: Augusta, GA
Introduction: Pericardial effusions (P-EFF) can result in life
threatening complications. Early identification of P-EFF can
result in early intervention and may limit complications.
Objectives: To evaluate if emergency physician performed
echocardiography (EP-ECHO) to diagnose pericardial effu-
sions decreases the time to diagnosis, time to intervention or
hospital length of stay when compared to historical controls.
Methods: After IRB approval, an explicit chart review using
a standardized data collection form was performed. Patients
with an EP-ECHO diagnosed P-EFF from 7/2000–11/2002
were eligible for the study group (SG). Data was obtained
from our ED ultrasound (US) log. The control group (CG)
included a random selection of patients with pericardial
effusion, pericardiocentesis or pericardial window as listed
in the discharge or hospital ICD-9 code. Patients who were
not initially evaluated in the ED were excluded. Time to
diagnosis was calculated from either real time videotapes
of the ED-ECHO or from time documentation in the pa-
tient chart. Group averages, and 95% confidence intervals
(95%CI: X,Y) were calculated. Setting: Tertiary care hospital
system with 130,000 ED visits/year and a large emergency
residency program. Results: 39 patients were identified for
inclusion (SG ¼ 23; CG ¼ 15). Mean patient age for SG was
55.1 (95%CI: 47.3,62.8) and 70.3 (95%CI: 63.6,77) for CG. The
mean time to ED diagnosis of a P-EFF was 114.3 minutes
(95%CI: 72.2,156.4) in the SG, and 1029.3 minutes (95%CI:
525.6,1533) in the CG. Mean hospital length of stay (LOS) for
the SG and CG were 5.1 days (95%CI: 3.3,6.9) and 10.9 days
(95%CI: 7.2,14.7). 10 patients (25%) required surgical in-
tervention, 4 were emergent. Conclusion: EP-ECHO signif-
icantly decreases the time to diagnosis of P-EFF in ED
patients. Patients with an EP-ECHO identified P-EFF were
noted to have hospital LOS nearly half that of the control
group. This study adds support for emergency physicians to
perform bedside echocardiography.
562
409 Comparison of Oral, Tympanic and Rectal
Thermometry in the Adult Emergency
Department Barbara J Barnett, Stacy M Nunberg,
Richard Powell, Patricia Nichols, Vladimir Fridman, Robert
A Silverman; Long Island Jewish Medical Center:
New Hyde Park, NY
Objective: To determine the agreement between oral,
tympanic and rectal temperature measurements in Emer-
gency Department(ED) patients. Methods: A convenience
sample of adult patients presenting to an academic ED was
prospectively studied. Oral, rectal (IVAC Temp-plus II Model
2080A) and bilateral tympanic (Genius First) temperatures
were obtained within 30 minutes of the patient’s ED arrival.
The tympanic thermometer was set at the rectal equivalent
mode. Calibration of instruments was confirmed prior to the
start and at the end of the study. Agreement was assessed
using the method of Bland and Altman (1986, Lancet).
Results: 457 patients were recruited. Mean (sd) temper-
atures(8F) were as follows: oral 98.3(1.3), rectal 99.4(1.3), left
tympanic(TM) 99.6(1.4), right TM 99.6(1.4). Using the limits of
agreement, notable differences between the modalities in-
cluding left and right ears were found (table). For example,
oral temperatures may be 2.98F below or 0.88F above the rectal
temperature. Using a rectal temperature of 100.48F or more to
define fever, the sensitivities and specificities were as follows:
oral 33%, 99%; right ear 74%, 85%; left ear 79%, 86%; maxi-
mum TM 82%, 81%. Conclusion: Substantial variability exists
between oral, tympanic and rectal temperature measure-
ments in adult ED patients. Given the importance of assessing
body temperature, the medical community should consider
standardizing temperature measurements for patients in
Emergency Departments.
MEAN LIMITS OF
DIFFERENCE AGREEMENT
(md) (md 6 2sd)
oral–rectal (8F)
1.08
2.91,0.75
left TM–rectal (8F) 0.29
1.54,2.11
max TM
rectal (8F) 0.52
1.14,2.17
right
left TM (8F)
0.05
1.30,1.40
410 Adequacy and Utility of Acute Flexion Extension
X-rays after Minor Blunt Trauma Pia Myers,
Dee Dee G Mimran, William P Bozeman; University of
Florida: Jacksonville, FL
Background: Rigid cervical collars are known to be detri-
mental in patients with cervical strain injuries, but are
frequently utilized after blunt trauma due to concerns of
occult unstable ligamentous injuries. Dynamic flexion/
extension (F/E) x-rays can exclude unstable ligamentous
injuries, but may be delayed for days or weeks due to concern
that acute muscle spasm may limit cervical motion and
preclude adequate F/E imaging. However, data to support
this concern are lacking. Objectives: We sought to determine
if Emergency Department patients with neck pain after
minor blunt trauma have adequate cervical motion to allow
exclusion of ligamentous injury during their ED visit on
the day of injury. Methods: Adult patients with neck pain
after minor blunt trauma and normal cervical spine x-rays
were enrolled in a prospective study. A bedside physician
2003 SAEM ANNUAL MEETING ABSTRACTS
assessment of neck mobility was performed; those with
clinically adequate cervical motion received F/E x-rays.
Adequacy was determined by angular motion of at least 30
degrees flexion and extension; abnormalities were defined as
subluxation greater than 2mm or angulation more than 16
degrees between adjacent cervical bodies. Results: A total
of 43 patients were enrolled. Of these, 2 had clinically
inadequate cervical motion and were excluded. Remaining
patients received F/E x-rays. 81% percent (33/41) of these
x-rays showed adequate cervical motion (95% CI 66% to
90%). One ligamentous injury was identified. Conclusions:
In the majority of adult patients with neck pain after minor
blunt trauma, F/E films can be obtained immediately with
adequate motion to reliably exclude unstable ligamentous
injury. This safely allows treatment of their cervical strain
injuries without the cost, discomfort, and disability associ-
ated with rigid cervical collars.
411 Racial Disparity among Patients Receiving
Computed Head Tomography for Diagnosis of Blunt
Head Injury Stephen Wall, Evelyn Ha, Michael Habicht,
Haneefa Wawda, Guy Merchant, William Mower; UCLA
Department of Emergency Medicine: Los Angeles, CA
Objectives: Prior studies suggest physicians may alter
process of care based on race alone. Given this evidence, we
sought to examine if race predicts whether a patient receives
computed head tomography for diagnosis of blunt head
injury. Methods: This was a non-concurrent cohort study
enrolling all patients presenting to an urban level I trauma
center. Patients were excluded from the study if unstable or
transferred. Study variables included race, ethnicity, use of
computed head tomography, insurance, age, sex, English
ability, initial GCS, skull fracture findings, focal neurol-
ogic deficit, vomiting, scalp hematoma, LOC, presence of
intoxication, and trauma status. Logistic regression with a
clustering correction by attending physician was used to
calculate the odds ratios for the predictors. Hosmer-Leme-
show testing was used to evaluate the model’s goodness of fit.
Results: The study enrolled 634 patients. Computed head
tomography was used in minority patients 15% (95CI 6.5,
22.6) less often than non-Hispanic whites, but the prevalence
of significant intracranial injury was 1/5 lower among
minority patients. The prevalence of significant intracranial
injury among minority patients was 0.57% compared to 2.86%
for non-Hispanic whites. (95CI for the difference 0.33, 4.2.)
After adjusting for the other predictors, the odds of a minority
patient obtaining computed head tomography was 0.56 (95CI
0.30, 1.03) times the odds of a non-Hispanic white person
receiving computed head tomography. After adjustment, race
was not a significant predictor in the model. Conclusions:
Minority patients may receive less computed head tomogra-
phy following blunt head injury, but this may be in part due to
less significant injuries found in the minority population.
412 Availability of Technology to Image and
Risk-stratify Patients with Pulmonary Embolism
in Academic Emergency Departments Jeffrey A Kline,
Alan E Jones; Carolinas Medical Center: Charlotte, NC
Objective: This survey addresses the availability of services
to evaluate for suspected PE and to risk-stratify PE after
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
diagnosis in the ED of academic medical centers in the US.
Methods: A random sample of 30 academic EDs was
chosen, and a questionnaire was emailed to two attending
emergency medicine physicians with [1 year experience at
each center (N ¼ 60 total). The multiple-choice question-
naire asked three questions, summarized as follows: Q1. The
primary imaging modality used: CT angiography (CTA), VQ
scanning, or CTA with indirect CT venography (CTV); Q2.
The availability of methods to risk stratify a normotensive
patient within 2 hours of PE diagnosis: echocardiography,
vital signs, pulse oximetry, 12-lead ECG, and troponin I or T;
Q3. Number of cases of PE diagnosed per year by the re-
spondent. Proportions and percent agreement calculated.
Results: Response rate was 100% (N ¼ 60). Q1. Primary
method of imaging: CTA without CTV, N ¼ 32 (53%); VQ
scanning, N ¼ 17 (28%); CTA with CTV, N ¼ 11 (18%). Q2.
Availability of echocardiography within 2 hours: During
convenient times only (defined as daytime hours 8a–5p), N
¼ 33 (55%); Occasionally (defined as \30% of all times), N ¼
24 (40%); Always (24h/7d), N ¼ 3 (5%); Availability of all
four of vital signs, pulse oximetry, ECG, and troponin I or T
within 2 hours: Always, N ¼ 55 (92%); Not always, N ¼ 5
(8%). Interobserver agreement was [80% for all Q1 and Q2
answers. Q3. Number of PE cases diagnosed per year: Six to
ten N ¼ 30 (50%); Three to five N ¼ 18 (30%); Greater than
ten N ¼ 11 (18%); Two or less N ¼ 1 (2%). Conclusions: In
a random sample of academic EDs, the majority employ
CTA without CTV and indicate inadequate availability of
echocardiography to risk-stratify normotensive patients
with PE. Most physicians surveyed diagnosed more than
five cases of PE per year. These data indicate the need for
better education regarding the advantages of CTV and the
need for more widely available clinical criteria to risk-
stratify ED patients with PE.
413 Can Venous Blood Gas Replace Arterial Blood Gas
in Emergency Patients? Nicolas Simon, Cedric
Ramaut, Renaud Getti, Nassim Abderrahim; Hôpital
Intercommunal de Poissy: Poissy, Yvelines, France
Objectives: Venous blood gas (VBG) measurements are less
aggressive than arterial blood gas (ABG) and values are
correlated except for PO2. The use of VBG for clinical
decision making has not been assessed in emergency
departement patients. Methods: All adult patients in whom
ABG were ordered were prospectively included. Clinical
context was defined as suspected acid-base disturbances,
respiratory failure or suspected pulmonary embolism. ABG
and VBG were drawn and processed in immediate ran-
domized succession. ABG were transmitted to a referent
physician for security. VBG results were available to the
Physician in charge for diagnosis, treatment and disposition
with all other clinical and lab data ordered in the usual way.
Decisions were collected on a data sheet. The ABG were
secondarily disclosed to the physician in charge. Modifica-
tions in diagnosis treatment or disposition were assessed as
principal judgement criteria. All patients gave informed
consent. The estimated number of patients to include was
150. Results: The study included 209 patients out of 275
with ABG. Median age 76 y (q1:56–q3:85). ABG and VBG
values of pH, pCO2 and CO2T were well correlated (r2 ¼
0,89; 0,79; 0,85 respectively). Clinical decision was modified
563
22 times i.e. 10,5% (CI95 : 6,7–15,5). Types of modification
are reported in table I.
TABLE I. Decision modification with ABG after VBG
Additional
Modification: Diagnosis Investigations Treatment Disposition
Number 6 4 10 2
Percent 2,9 1,9 4,8 1
CI95 1,1–6, 10,5–4,8 2,3–8,6 0,1–3
Hypoxia was the most frequently modified diagnosis on
ABG. Oxygen was added 7 times out of 9 and 2 patients
were admitted to ICU. Six times hypoxemia was initially
apparent on EtcO2. Conclusions: Less aggressive VBG can
replace ABG in most occurences. Correlation values have to
be determined in every institution.
414 The Effect of the Reverse Trendelenburg Position
on the Cross-sectional Area of the Femoral
Vein Michael B Stone, Dan D Price, Brad S Anderson;
Alameda County Medical Center, Highland Campus:
Oakland, CA
Objectives: Emergency physicians often obtain central
venous access via the femoral vein in critically ill patients
or patients with difficult peripheral access due to chronic
intravenous drug use. Previous studies using two-dimen-
sional ultrasonography have demonstrated that the Trende-
lenburg position increases the cross-sectional area of the
internal jugular vein. This study is designed to determine the
effects of the Reverse Trendelenburg position on femoral
vein dimensions. Methods: Design: Prospective, nonrando-
mized observational study. Setting: Subjects were enrolled at
an urban Level I Trauma Center and an affiliated School of
Medicine. Subjects: Informed consent was obtained from 52
adult subjects with no history of deep venous thrombosis or
vascular surgery in the lower limbs over a 2 month period.
Interventions: Using two-dimensional ultrasound with
a 7.5MHz linear transducer, femoral vein cross-sectional
areas on the right and left sides were measured with subjects
supine and in approximately 15 degrees Reverse Trendelen-
burg. Results: Data was analyzed using a two-tailed
Student’s t test. The mean cross-sectional area of the femoral
vein with subjects supine was 0.85 cm2 (SD 6 0.41 cm2) and
with subjects in Reverse Trendelenburg was 1.22 cm2 (SD 6
0.51 cm2.) The cross-sectional area of the femoral vein
increased significantly (p \ 0.001) with the Reverse
Trendelenburg position [55.2% 6 9.1% (95%CI)]. There were
no statistically significant differences between right and
left femoral vein dimensions (p ¼ 0.90.) Conclusions: A
significant increase in femoral vein cross-sectional area is
achieved with the Reverse Trendelenburg position. This
maneuver may increase the rate of successful femoral vein
catheterization.
415 Physician Certainty in the Diagnosis of Abdominal
Pain John Tobias Nagurney, Swati Sane, David FM
Brown, Yuchiao Chang, Justin B Justin, Andrew C Wang;
Partners Health Care: Boston, MA, University of Michigan
Medical School: Ann Arbor, MI, Princeton University:
Princeton NJ
564
Background: Little is known about how ED providers make
decisions about patients presenting with nontraumatic
abdominal pain (NTAP). Objective: We attempted to
confirm the hypothesis that the level of certainty (LOC)
that physicians assigned to their most likely diagnosis
would increase based on a diagnostic ED evaluation, to
measure that change, and to determine which characteristics
of patient, provider, and evaluation predicted these pretest
(pre) and posttest(post) LOCs. Methods: We conducted
a pilot single-center, prospective observational study. The
setting was a level one 70,000-visit university ED. We
enrolled all eligible adults who presented to our ED with
NTAP or flank pain. Based on interviews pre- and post, we
measured provider LOCs on a three-point scale before and
after ED evaluation, and any changes. We also measured the
values of twelve potential predictors of those LOCs and
performed ordinal logistic regression to determine which of
these predictors were significant (sig). Our IRB approved
this study. Results: Respondents to our questionnaire
included 40 physicians within three specialties. We enrolled
128 patients and had 124 evaluable subjects (39% male) with
a mean age of 44 years; 27% were admitted. There was a sig
change in the distribution in the LOCs from pre to post (p \
0.001). Overall, providers became more certain of their most
likely diagnosis after ED evaluation in 41% of patients and
became less certain in seven percent. In univariate testing,
pain location and patient age appeared to predict pre LOC.
Only pain location remained sig in the ordinal logistic
regression. (p ¼ 0.026). The only sig predictor for both post
LOC and change in LOC appeared to be the pre LOC (p \
0.001). Conclusion: Among ED patients who present with
NTAP or flank pain to one academic center, the post LOC is
sig higher than the pre LOC, and decreases in the LOC are
uncommon. Pain location is a predictor of pre LOC, while
the pre LOC predicts the post level.
416 OneStep ABAcard p30 Test for the Identification of
Semen in Sexual Assault Victims Eduardo G
Marvez-Valls, Debbie Travis, Tom Savadore, Micelle Haydel;
Louisiana State University: New Orleans, LA
Objectives: Our objective was to compare the frequency of
positive tests for semen after sexual assault, before and after
the implementation of the OneStep ABAcard as part of our
SANE (Sexual Assault Nurse Examiner) Program. Unlike
the acid phosphatase test, which relies on enzymatic
activity, the OneStep ABAcard p30 Test (Abacus Diagnos-
tics, Inc.) is an antibody immunoassay test that detects p30,
a glycoprotein produced by the prostate which is present
in human semen, even if the assailant is sterile or has
undergone vasectomy, and is present in seminal fluid at
dilutions of up to one part per million. Methods: This was
an observational, prospective, consecutive study conducted
in an urban, inner-city emergency department which serves
as the referral center for all local sexual assault victims.
From March 1998 to March 2000, emergency medicine
residents collected specimens and the acid phosphatase
presumptive test was used in the detection of semen. From
April 2000 to April 2002, SANE practicioners obtained the
forensic data and the OneStep ABAcard was used to detect
semen. Tests were performed and data was obtained from
the New Orleans Coroner’s Forensic Laboratory. Results:
During the two years prior to the implementation of the
2003 SAEM ANNUAL MEETING ABSTRACTS
OneStep ABAcard p30 test, 724 patients were evaluated for
sexual assault. Using the acid phosphatase presumptive
test, 127 patients (17.5%, central confidence interval 62.8%)
had a positive test for semen. In the two years after the
inception of OneStep ABAcard, 359 patients were evaluated,
and 160 patients (44.6%, central confidence interval of
65.1%) had a positive test for semen. The 27.1% absolute
difference between these two groups was statistically sig-
nificant on chi square analysis (p \ .001). Conclusions: The
implementation of the OneStep ABAcard p30 Test for the
forensic identification of semen performed by SANE
practitioners, resulted in a statistically significant improve-
ment in detecting semen from sexual assault victims.
417 Interpretation of Plain Radiographs by Pediatric
Emergency Physicians: Do We Need Routine Review
by a Radiologist? Serge Gouin, Thanh-Van Trieu, Sylvie
Bergeron, Hema Patel, Ronald Guérin; Ste-Justine Hospital:
Montreal, Quebec, Canada, The Montreal Children’s Hospital:
Montreal, Quebec, Canada
Objectives: To evaluate the accuracy of diagnostic inter-
pretation of plain radiographs by Pediatric Emergency
Physicians (PEPs) and pediatric radiologists. To determine
the effect of incorrect radiologic interpretation by PEPs on
patient management. Methods: Series of all consecutive
patients (0–18 years) who underwent plain radiological
studies while they presented to an Emergency Depart-
ment (ED) of a pediatric university-affiliated centre during
September 2001, were reviewed. The radiographic inter-
pretation of the PEP, documented at the time of the ED
visit, was compared to the pediatric radiologist’s report,
documented within 72 hours of the ED visit. Data were
obtained via the ED Hospital Information System, the
Radiological Information System and the medical records.
The criterion validity (sensitivity, specificity, NPV, PPV,
accuracy) (range) of the PEPs’ radiographic interpretations
were measured. Results: Data were available from 1644 of
the 1651 sets of plain radiographs ordered by PEPs during
the study period: chest (42%), abdomen (19%), extremities
(24%), sinus (4%), skull (3%), clavicle (3%), spine (2%),
pelvis (2%) and others (1%). The prevalence of positive
radiological studies as per the radiologists was 32.2%
(529/1644). Overall the PEP’s accuracy was 98.1% (1613/
1644) (94.6–100%), sensitivity 96.4% (33.3–100%), specific-
ity 98.9% (98.5–100%), NPV 98.3% (88.9–100%) and PPV
97.7% (90.6–100%). The proportion of false negatives (FN)
was 1.2% (19/1644) and of false positives was 0.7% (12/
1644). Of the 19 FN, 1 required immediate follow-up, 2
required follow-up in 1–2 days, 2 required follow-up in
several days, 13 had a missed abnormality but no change
in therapy was required and 1 had a questionable diag-
nosis. Conclusions: Plain radiograph interpretations by PEPs
were extremely accurate. Infrequently, a severe diagnosis
(1/1644) was missed by the PEPs. The routine review by
a radiologist must be further evaluated. A selective approach
may be more cost-efficient.
418 Chest CT Angiography (CTA) to Rule-out Pulmonary
Embolism (PE) Frequently Reveals Clinically
Significant Ancillary Findings: A Multi-Center Study of
1025 Emergency Department Patients Peter B Richman,
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
D Mark Courtney, Jeremy Friese, Jessica Matthews, Adam Field,
Roland Petri, Jeffrey A Kline; Mayo Clinic Hospital: Scottsdale,
AZ, Northwestern University Medical School: Chicago, IL,
Carolinas Medical Center: Charlotte, NC
Introduction: CT chest angiography (CTA) has become the
diagnostic imaging modality of choice in many EDs to
evaluate patients with symptoms suspicious for PE.
Objective: To evaluate the pre-study hypothesis that CTA
reveals clinically significant, non-PE related ancillary find-
ings for ED patients with symptoms suggesting PE.
Methods: Study design—multi-center, retrospective case
series; Setting—academic EDs (2 urban þ 1 suburban);
Population—ED patients with symptoms suggesting PE
who underwent CTA to rule out PE during a 1-year period;
Study protocol—CTA ordered at the discretion of the
treating physician at point of care; patients identified by
query of final board-certified radiologist CT readings
reviewed by two independent study physicians at each site
who categorized the non-PE findings into one of four
categories according to acuity: A ¼ Requiring specific and
immediate intervention, B ¼ Requiring specific action on
follow-up, C ¼ Requiring no action, D ¼ Indeterminate
findings. Interobserver agreement measured by weighted
agreement and weighted kappa. Results: A total of 1025
patients with CTA were included (sum of N ¼ 222, 363, and
440 from 3 sites), the prevalence of a filling defect diagnostic
for PE on CTA was 9.4% (95% CI 7.7 to 11.4%). For cate-
gorization of non-PE findings, the weighted agreement was
87%, 94% and 86% with weighted kappas of 0.66, 0.86 and
0.71. The mean prevalence (range between sites) of ancillary
findings categorized the same by two observers: A 7% (3%
to 11%), B 10% (9% to 12%), C 17% (9% to 23%), D 4% (0% to
9%), no ancillary finding 47% (37% to 53%). The most
common category A findings included: infiltrate or consol-
idation suggesting pneumonia (81%), aortic aneurysm or
dissection (7%), and mass suggesting undiagnosed malig-
nancy (7%). Conclusions: In ED patients with suspected PE,
the CT angiogram frequently provides evidence of an
important diagnosis other than PE. Pulmonary infiltrate
suggesting pneumonia was the most common non-PE
finding.
419 One-year Survival among Patients Hospitalized
with COPD Exacerbation Sunghye Kim, Carlos
A Camargo Jr; Massachusetts General Hospital: Boston, MA
Objective: To describe the natural history of chronic
obstructive pulmonary disease (COPD) among patients
(pts) who are hospitalized for COPD exacerbation, and to
determine risk factors for mortality in this high-risk group.
Methods: Retrospective cohort study of pts with COPD
exacerbation. Administrative data were queried for all
hospitalizations (1/1/00–9/30/01) with a primary ICD-9
code of 491, 492, and 496 among pts age 55þ. Demographic
factors, details of index hospitalization (e.g., length-of-stay),
and other ICD-9 codes (e.g., congestive heart failure) were
abstracted. Survival was ascertained using medical records
and searches of social security databases. Multivariate
logistic regression yielded odds ratios (OR) and 95%
confidence intervals (CI). Results: During the study period,
there were 426 index hospitalizations and 147 repeat
565
admissions. One-year follow-up data were available in
337 (79%) of the 426 pts. Mortality rates after the index
hospitalization were 12% at 3 months, 16% at 6 months
and 27% (95%CI 23–32) at 12 months. Pts age 70þ had
higher one-year mortality than those age 55–69 (34% vs 18%,
p ¼ 0.001), and men had higher mortality than women (34%
vs 23%, p ¼ 0.03). Other univariate predictors of mortality
were congestive heart failure and longer hospital length-of-
stay during the index hospitalization. Among survivors, re-
admission or emergency department visit for COPD
exacerbation occurred in 12% at 3 months, 18% at 6 months,
and 22% (95%CI 18–27) at 12 months. In a multivariate
model (including congestive heart failure), older age (OR
2.2, 95%CI 1.3–3.7), male sex (OR 1.6, 95%CI 1.0–2.7), and
hospital length-of-stay (OR 1.03, 95%CI 1.01–1.06) were
independent predictors of one-year mortality. Conclusion:
One-year mortality among pts hospitalized for COPD
exacerbation was 27%, and was related to both demographic
factors and severity of index hospitalization. These results
will be used to plan future trials on new COPD treatment
regimens at ED discharge.
420 Systematic Review: What to Do When There
Is No Fully Published Evidence: The Case of
Levalbuterol Barnet Eskin, Ann-Jeannette Geib;
Morristown Memorial Hospital: Morristown, NJ
Background: Levalbuterol has been proposed as a preferred
bronchodilator for the treatment of asthmatic ED patients.
We wished to review the evidence for this. Objectives: To
perform a search of the literature and systematically review
the evidence that levalbuterol (LEV) compared to racemic
albuterol (RAC) benefits asthmatics in the ED. Methods:
Medline from 1966 through November 2002 and the
Cochrane Controlled Trials Register were searched for the
term ‘‘levalbuterol.’’ A list of relevant publications was
obtained from Sepracor, the producer of LEV, and additional
publications were sought using the internet Google search
engine. Authors of published papers were asked about
knowledge of additional trials. Inclusion criteria for studies
were: patients with acute exacerbation of asthma, reports of
patient-important outcomes (hospital admission, length of
stay, adverse reactions) and randomized controlled trial
(RCT) design of high quality using the criteria of Jadad,
comparing LEV with RAC. Where details were missing,
attempts were made to contact the authors. Results of
relevant trials were summarized. Results: None of the 20
papers met inclusion criteria, because they reported only
spirometry or other non-patient-important outcome data, as
was true of 7 of the 17 abstracts found. Of the remaining
abstracts, 3 were retrospective, 3 were not acute, and 2 did
not report an RCT design. Of the latter, one showed no
difference in admission rates, whereas the second showed
a 53% absolute risk reduction (ARR) (95% confidence
interval (95%CI) 46%, 60%). One additional abstract, an
small RCT without blinding, showed a small but non-
significant ARR in admission rates. The final abstract, an
RCT of 556 children, scored high on the Jadad criteria. ARR
in admission rates was 8% (95%CI, 0.2%, 17%). Conclu-
sions: Use of LEV in the ED has a small benefit over RAC.
Abstracts may contain sufficient information to make
566
clinical decisions when no fully published reports are
available.
421 Capnometry as a Continuous Measure of
Bronchospasm Severity: A Pilot Study Howard A
Smithline, Geoffrey M Scriver, Fidela SJ Blank, Jennifer
Michalack, Richard Goulding, Emily J Wilcox; Baystate Medical
Center: Springfield, MA
Objectives: The slope of the plateau phase (dp/dt) of the
expiratory capnogram varies with bronchospasm severity.
Prior attempts to measure the dp/dt of capnograms sam-
pled by a modified nasal cannula were unsuccessful. This
was a pilot study of a computer-based technique of mea-
suring dp/dt. Methods: A prospective observational study
of a convenience sample of ED patients with an asthma
exacerbation from 6/02 to 7/02. A nasal cannula was
placed for continuous capnography via a HP M1015A/6A
sidestream module wired to a computer running a semi-
automated data acquisition & analysis program. Every 10
minutes we recorded: capnograms for 3 breaths, 3 peak
expiratory flow rates (PEFR), and a dyspnea visual analog
score (VAS). The dp/dt is the slope between ‘‘Q’’ and the
peak of the capnogram. ‘‘Q’’ is the point on the capno-
gram corresponding to the lowest value of its 2nd deri-
vative plot. Precision was assessed by the coefficient of
variation (CV). Overall association between dp/dt and
both PEFR and VAS was assessed by repeated measures
regression models. A standardized treatment protocol was
used. N ¼ 20 was chosen a priori. Results: Baseline data,
median(IQR): age 35 yrs (32 to 42); height 65 inches (62 to
68), weight 179 lbs (161 to 205), smoking pack yrs 1 (0 to
17), initial PEFR 165 L/m (144–208), initial VAS 68 mm
(49–84); 67% female, and 79% Caucasian. Four patients
were admitted. The CV was 10% for dp/dt and 16% for
PEFR. The median(IQR) percent change between the first
and last measurement sets were:
33% (
18 to
49%),
35% (6 to 94%), and
89% (
56 to
96%) for dp/dt,
PEFR, and VAS respectively. The overall associations be-
tween dp/dt and both PEFR and VAS were: R2 ¼ 0.04
(p ¼ 0.05) and R2 ¼ 0.00 (p ¼ 0.78). Conclusions: A data
acquisition & analysis program can adequately calculate
the dp/dt of a capnogram sampled by a nasal cannula.
The clinical utility of this continuous measure of bronchos-
pasm severity has not been studied.
422 Serum Levels of Human Surfactant Protein-A in
Patients with Pulmonary Embolism Scott Stoughton,
Cindy Parker, Sarah Heringer, Marco Coppola, Charles
McCuskey; Scott and White: Temple, TX
Objectives: Human surfactant protein-A (Sp-A) is a lung
specific protein and serum levels of Sp-A are elevated in
some diseases with acute lung injury including ARDS and
pulmonary edema. Our hypothesis was that serum Sp-A
levels would be elevated in patients with pulmonary
embolism. Methods: A retrospective case control observa-
tional study in a rural tertiary care hospital. Between August
2001 and May 2002 a convenience sample of patients 18 years
or older with CT or angiographically proven pulmonary
embolism in the ED or inpatient setting was studied. Serum
2003 SAEM ANNUAL MEETING ABSTRACTS
was obtained within six hours of diagnosis and frozen.
Serum from concurrent unmatched controls was also
obtained. Pts. with PEs were excluded if they were unable
or unwilling to give consent, were pregnant or had
concurrent lung disease. Controls were excluded for self
reported pregnancy or chronic lung disease. Serum Sp-A
levels were determined by ELISA by an investigator blinded
to clinical information. Mean Sp-A levels were compared
with a t-test and logistic regression was performed. Based on
values reported for other diseases, to have an 80% power to
detect similar elevations in Sp-A a sample of 7 patients was
needed in each group. A larger sample was obtained to allow
a ROC to be generated. Results: 19 patients with PE were
enrolled along with 36 controls. Median time from symptom
onset to Sp-A measurement was 26.5 hrs (Range 4–264 hrs.)
Mean Sp-A levels were 29.4 ng/ml in pts with PE and 32.5
ng/ml in the controls. (p ¼ ns). Logistic regression showed
no relationship between Sp-A and PE OR ¼ 1 (p ¼ ns). There
was no point on the ROC where sensitivity and specificity
appeared useful. Conclusions: Serum levels of Sp-A are not
elevated in patients with PE. Our sampling included patients
with a large variance in time from symptom onset and it is
possible that there is a window of time that the Sp-A is
elevated but it does not appear to be clinically useful.
423 End Tidal CO2 Determination to Predict PaCO2 in
Emergency Department Asthmatics Michael Lahn,
EJ Gallagher, Polly Bijur, Steve Abrams; Albert Einstein
College of Medicine: Bronx, NY
Background: Arterial blood gas (ABG) determination of
arterial PCO2 (PaCO2) is a painful but commonly used test
to identify hypoventilation in Emergency Department (ED)
asthmatic patients. Previous studies have suggested, but not
confirmed, that End-Tidal CO2 (ETCO2) determination may
accurately estimate PaCO2 in patients with respiratory
complaints. Objectives: To test the hypothesis that ETCO2
accurately predicts PaCO2 in ED patients treated for an
asthma exacerbation. Methods: Prospective, observational
cohort study of adult ED patients treated for an asthma
exacerbation, undergoing an ABG as part of their evalua-
tion. A simultaneous ETCO2 determination was obtained
while blood was visibly pulsing in the ABG tubing. The
ETCO2 level was measured in mm Hg using a Tidal Wave
hand-held capnograph (Novametrix Medical Systems, Inc.
Wallingford, CT 06492). A predetermined difference of
greater than 5mm Hg was chosen a priori to represent the
minimal clinically important difference between the two
CO2 measurements. Results: Thirty patients completed the
study. The difference between the means of the ETCO2
levels and PaCO2 levels was 0.7 mm Hg (95%CI:
0.6, 2.1)
with a median of 0 mm Hg. The intraclass correlation
coefficient was 0.94 (95%CI: 0.88, 0.97). Ninety seven percent
of the ETCO2 levels were within the predetermined 5mm
Hg difference. Conclusions: Non-invasive ETCO2 levels
appear to accurately predict PaCO2 measured by ABG in ED
patients with asthma exacerbations.
424 Continuous and Non-invasive Pulsus Paradoxus
Monitoring James R Rayner, Dale W Steele, Sergei
Ziad, Ammar Shaikhouni, Gregory D Jay; Brown University
School of Medicine: Providence, RI
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
Background: Measuring pulsus paradoxus (PP) is a corner-
stone in assessing asthma severity as recommended by
NHLBI guidelines. Measurement of PP is not ergonomically
feasible as pointed out by earlier investigations. Objective:
Does automated PP measurement (PPa) predict true PP
(PPt) determined post hoc from a non-invasive continuous
blood pressure measurement (NIBP)? Methods: PP was
induced in a healthy volunteer by inspiring through a fixed
inspiratory resistance connected to a Rudolph valve while
blood pressure was measured by NIBP (Colin Medical
Instruments). Different degrees of PP were induced corre-
sponding to different degrees of negative inspiratory
pressure:
5,
10,
15,
20 mmHg. A PPa virtual instrument
(VI) was programmed in Lab View (National Instruments)
performing periodic amplitude analysis over 20 respirations
which measured the inspiratory decrease in systolic blood
pressure (SBP) as compared to expiratory SBP. This VI did
not require a respiratory strain gauge. PPt was determined
post hoc by performing the same calculation manually
aided with a respiratory strain gauge identifying points of
maximal inspiration. 95% CI’s for PPa and PPt were cal-
culated and a linear regression model was constructed of
PPa in predicting PPt. Results:
PPa PPt
IPAP Mean S.D. 95% CI Mean S.D. 95% CI
(mmHg)
Baseline 4.88 .781 3.35–6.41 6.1 3.63
1.02–13.22

5 7.12 .621 5.90–8.34 8.52 2.87 2.89–14.16

10 9.56 .821 7.95–11.17 10.57 1.66 7.31–13.83

15 13.62 1.44 10.79–16.45 14.12 3.74 6.77–21.46

20 19.51 1.50 16.56–22.46 20.85 2.42 16.09–25.61
Correlation between PPa and PPt was r ¼ .998. The
regression model was defined by PPa ¼ 1.06PPt–1.16
mmHg. Conclusion: Automated PP measurement from
NIBP data is possible and would serve as an important
adjunct in assessing asthma severity. PP is a non-effort
dependent metric of work of breathing and therefore
asthma severity.
425 Predictors of Short Hospital Length-of-stay among
Patients Admitted with Acute Asthma: A
Multicenter Study Richard T Griffey, Jennifer A Emond,
Carlos A Camargo Jr; Brigham and Women’s Hospital: Boston,
MA, Massachusetts General Hospital: Boston, MA
Background: Asthma treatment in ED observation (EDOBS)
units appears to improve patient (pt) satisfaction and
resource utilization; such treatment is approved for re-
imbursement by the Centers for Medicare and Medicaid
Services. While many institutions use criteria for EDOBS vs.
inpatient admission, based on severity of illness and other
factors, the evidence base for this decision is limited.
Objective: The aim of our study was to identify factors
associated with hospital length-of-stay (LOS) of \ 24 hours
among adults hospitalized with acute asthma. Such factors
would provide the beginnings of an evidence-based
567
approach to the EDOBS decision. Methods: Retrospective,
national study of a random sample of inpatients, ages 18–54,
admitted for acute asthma during 1/99–5/00 to one of 30 US
hospitals. Data were collected on pts’ demographic char-
acteristics, medical history, ED and inpatient course, and
discharge care. Analysis was limited to information easily
obtainable by an emergency physician. We constructed
a multivariate logistic regression model of patient factors
associated with a LOS of \24 hours vs. [24 hours. Model
building used univariate-significant predictors and back-
ward elimination, with a p-value of 0.05. All odds ratios are
reported with 95% CI. Results: Independent predictors of
LOS \ 24 hours were: black race 1.7 (1.1–2.7); history of
allergies 2.1 (1.3–3.6) or COPD 0.2 (0.1–0.6); use during first
24 hours of admission of anticholinergics 2.0 (1.3–3.2),
inhaled long-acting beta-agonists 0.3 (0.1–0.7), and inhaled
corticosteroids 0.6 (0.4–0.99); [9 nebulized beta-agonist
treatments in the ED 3.6 (1.3–9.4); and final peak flow in
ED of [230 L/min 2.0 (1.2–3.2). Conclusion: Several clinical
variables were found to have significant associations with
hospital LOS. A prospective study is being developed to
validate these findings. Application of a decision rule using
similar criteria might assist in the disposition of acute
asthma pts from the ED to EDOBS vs. inpatient admission.
426 Circadian Differences among Emergency
Department Patients with Chronic Obstructive
Pulmonary Disease Exacerbation Barry E Brenner, Rita K
Cydulka, Brian H Rowe, Carlos A Camargo Jr; University of
Arkansas for Medical Sciences: Little Rock, AR, MetroHealth
Medical Center: Cleveland, OH, University of Alberta: Edmonton,
Alberta, Canada, Massachusetts General Hospital: Boston, MA
Objective: Airway diameter varies daily and is smallest in
the early morning hours. We hypothesized that this might
affect ED presentations of chronic obstructive pulmonary
disease (COPD) exacerbation. To examine this hypothesis,
we compared ED visits for COPD presenting during the
night (12:00 midnight to 7:59 AM) versus other times of the
day. Methods: Prospective cohort study at 29 EDs, as part of
the Multicenter Airway Research Collaboration. Each site
maintained a registry of consecutive COPD patients (pts),
ages 55þ, of whom 68% underwent a structured interview
in the ED; 88% of enrolled pts were contacted by telephone 2
weeks later. Data analysis used chi2. Results: Of 582 COPD
pts, 15% (95% CI, 13–19) presented during the night. Pts
with asthma/COPD versus COPD only were equally likely to
present at night (18% vs 14%; p ¼ 0.23). Compared to pts
presenting at other times, nocturnal pts were less likely to
have private insurance (27% vs 17%; p ¼ 0.03) and a primary
care provider (92% vs 82%; p ¼ 0.03), but did not differ by
other sociodemographic factors. They were more likely to
have a history of corticosteroid use (68% vs 80%; p ¼ 0.03), but
did not differ by other markers of chronic disease severity.
Although the two groups did not differ by presentation and
exacerbation severity, pts presenting at night were more likely
to have symptoms for \24 hours before presenting to the ED
(28% vs 43%; p ¼ 0.004). Nocturnal pts did not differ from
pts presenting during the day according to b-agonist and
anticholinergic treatments in the 1st hour, and were equally
likely to receive antibiotics and steroids (all p[0.15). The two
groups also were equally likely to be admitted (65% vs 66%; p
568
¼ 0.81), and to experience a relapse event at 48 hours (2% vs
7%; p ¼ 0.10) or at 2 weeks (17% vs 19%; p ¼ 0.82). Conclusion:
Among ED patients presenting to the ED with COPD
exacerbation, circadian phenomena appear to minimally
affect ED presentation, treatment and clinical course.
427 Multicenter Study of Emergency Department Visits
for Pneumonia Brian H Rowe, Jessica L Hohrmann,
Jennifer A Emond, Ian Colman, Carlos A Camargo Jr, for the
MARC/CAEP-16 Investigators; University of Alberta:
Edmonton, AB, Canada, University of Alberta Hospital:
Edmonton, AB, Canada, Massachusetts General Hospital:
Boston, MA
Objective: Current patterns of emergency department (ED)
diagnosis and treatment for pneumonia are unknown. The
objectives of this study were to define the epidemiology of ED
pneumonia visits, including pneumonia type, antibiotic
selection, and disposition. Methods: Multicenter, retrospec-
tive chart review over a consecutive 4-week period between
12/01–04/02. Using standardized protocols, 23 EDs ab-
stracted data for patients, age 18þ, with a physician-diagnosis
of pneumonia. Data collection focused on patient character-
istics, diagnostic testing, and treatment. Pneumonia severity
index (PSI) was calculated for patients where data were
complete. Proportions are presented with 95% confidence
intervals (CI). Results: A total of 1,268 charts were reviewed.
Patients had a mean age of 62 years; 51% were female (95% CI:
49–54%); and 57% were white, 20% black, 6% Hispanic, and
17% other race/ethnicity. Community acquired pneumonia
(75%) was more common than institutional (11%) and as-
piration (2%) pneumonia; 12% of pneumonia cases were
unclassified. Admissions were common (61%), even for low
PSI scores (Table). Overall, median length-of-stay was 5.3
hours in the ED and 10 days for those hospitalized. Most
(74%) patients received antibiotics during their ED stay.
Although antibiotic selection varied by PSI group, many ED
patients were given a quinolone.
Admitted In ED: overall(% of row) –
PSI n (%) n (% of row) ceph, macrolide, quinolone
I 92(9%) 11(12%) 50(54%) – 8(9%) 25(27%) 19(21%)
II 268(25%) 172(64%) 206(77%) – 66(24%) 66(24%) 94(35%)
III 222(21%) 161(73%) 172(77%) – 47(21%) 37(17%) 96(43%)
IV 323(30%) 267(83%) 266(82%) – 92(28%) 72(22%) 129(40%)
V 156(15%) 133(85%) 133(85%) – 41(26%) 13(8%) 83(53%)
Conclusions: ED patients with pneumonia are a heteroge-
neous population. Antibiotic selection and ED disposition
vary by PSI score, and appear suboptimal.
428 Decreased Use of Acute Care Hospitalization in
Older Patients with Pneumonia: 1995–2001 Louis G
Graff, Thomas P Mehan, Jonathan Fine, Shih-Yieh Ho, Kathy
Tuzzo; New Britain General Hospital: New Britain, CT,
Qualidigm: Middletown, CT, Norwalk Hospital: Norwalk, CT
Objective: Determine trends in care of pneumonia, one of
three common, serious conditions that CMS and Joint
2003 SAEM ANNUAL MEETING ABSTRACTS
Commission examine in measuring hospital quality. Meth-
ods: Retrospective analysis of hospitalized at Connecticut
acute care hospitals (n ¼ 31) during five time periods [4/95–
3/96 (n ¼ 1909), 1/97–6/97 (n ¼ 1526), 7/98–12/98 (n ¼
1749), 7/00–12/00 (n ¼ 1419), 1/01–12/01 (n ¼ 2035)]
excluding if initial diagnosis other than pneumonia, neg-
ative chest x-ray, \65 years old, immunosuppressed, prior
admission within 10 days. Quality improvement efforts
occurred in collaboration with Connecticut Quality Im-
provement Organization (Qualidigm) and Thoracic Society:
feedback performance data, dissemination model pneumo-
nia critical pathway, sharing pathway implementation
experience, and in 2001 at selected hospitals (n ¼ 12)
quality improvement plan, educational conference, emer-
gency department clinical path, nurse case management.
Demographic, clinical, process of care, outcome measures
were examined. Severity of illness (PSI) was calculated.
Results: Quality improved as evidenced by improved pro-
cesses of care [oxygen assessment (94.9% (95% CI .93,.95)
to 99.4% (.98,1.00)), blood cultures before antibiotic (60.2%
(.57,.62) to 83.9% (.81,.85)), mean time in hours to admin-
istration of antibiotic (4.1 to 3.0), administered antibiotic
within 8 hours of arrival (83.0% (.81,.85) to 90.3% (.89,.91)),
in hospital length of stay in days (7.0 to 5.0)], and improved
outcome [in hospital mortality (11.3% (.10,.12) to 6.6% (95%
CI .06,.08)), 30 day mortality (17.3% (.15,.19) to 12.4%
(.11,.13))]. Severity of illness increased (% low risk decreased
from 26.7% to 23.0%), % hospitalized released to skill
nursing facilities increased (31.4% to 37.7%), 30 day readmit
rate increased (13.0% to 16.5%). Conclusions: Over time
there was reduced hospitalization of low risk pneumonia
patients and increased discharge of hospitalized patients to
skilled nursing facilities yet improved quality of patient care
and outcomes.
429 Interest in Smoking Cessation among Emergency
Department Patients: A Prospective Multicenter
Study Edwin D Boudreaux, Sunghye Kim, Jessica L
Hohrmann, Sunday Clark, Carlos A Camargo Jr;
UMDNJ-Robert Wood Johnson Medical School: Camden,
NJ, Massachusetts General Hospital: Boston, MA
Objective: Routine tobacco screening and referral to out-
patient tobacco treatment programs are an essential part of
preventive medicine. Little is known about whether ED
patients (pts) are interested in smoking cessation. We
conducted a multicenter study to examine smoking preva-
lence, quit attempts in the past year, and interest in
outpatient referral among ED pts. Methods: For two 24-
hour periods, we interviewed pts age $18 years presenting
to 4 Boston EDs. Exclusion criteria included severe illness
and emotional disturbance (n ¼ 224). Data analysis used
Chi2 and t-test. Results: Of 754 eligible pts, 530 (70%) were
interviewed. 26% of pts were current smokers, 31% former
smokers, and 43% never smokers. 72% of current smokers
had tried to quit in the past year, and 33% wanted an out-
patient referral. Current smokers were younger than non-
smokers (41 vs. 50 years; p \ 0.001), and less likely to have
a high school education (34% vs. 54%; p \ 0.001), primary
care provider (73% vs. 84%; p ¼ 0.005) and private insurance
(34% vs. 49%; p ¼ 0.001); they did not differ by sex or race/
ethnicity. Private insurance was less common among pts
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
who attempted to quit smoking in the past year (compared to
those who did not), and among those who were interested in
referral to a smoking cessation program (compared to those
who were not), with both p \ 0.05. Pts interested in referral
were less likely to have completed high school (p \ 0.05).
The quit and referral groups did not differ by other
sociodemographic characteristics. Rates of smoking, quit
attempts, and interest in referral did not differ by site (all p [
0.1). Conclusion: Our findings extend those of prior single-
center studies on smokers in the ED. Because many
Americans use the ED as a source of regular healthcare, the
public health implications are substantial. These results
reinforce the potential benefit of routine tobacco screening in
the ED and indicate that many smokers are interested in
quitting and desire assistance in their efforts.
430 Risk Stratification of Adult Pneumonia in a Tertiary
Emergency Center in Japan Masaru Suzuki, Kenji
Kobayashi; Saiseikai Utsunomiya Hospital: Utsunomiya,
Tochigi, Japan
Objective: Patients with pneumonia can be stratified
according to their mortality risk using the pneumonia PORT
clinical prediction rule. The objective of this study was to
determine whether the prediction rule is applicable to
stratifying the mortality risk of patients presenting to
a tertiary emergency center in Japan. Methods: Ninety-
seven consecutive patients with pneumonia, who presented
to the emergency room and were admitted to our hospital,
were identified, retrospectively. The patients were classified
into two groups, a moderate risk (risk classes III and IV of
the prediction rule) and a high-risk group (risk class V of the
prediction rule). Employing complete 30 day follow-up
information, mortality rates were compared between the
two groups. Results: Of the 97 patients, 50 (51.5%) were
classified into the moderate risk group, while the high-risk
group consisted of 37 patients (38.1%). Mortality data were
analyzed using actuarial life table methods. Cumulative
mortality rates at 30 days were 18.9% for the high-risk group
and 4.0% for the moderate risk group (P ¼ 0.02). Using Cox
proportional hazards analysis, the standardized value of
the coefficient associated with high risk was significant for
mortality (relative risk ¼ 5.15, 95% confidence interval 1.07
to 24.82). Conclusion: The pneumonia PORT clinical pre-
diction rule allowed moderate and high 30 day mortality
risks to be distinguished in a tertiary emergency center in
Japan. The prediction rule is promising and potentially
helpful for emergency physicians in Japan.
431 The Use of Risk Factor Assessment to Screen for
Spinal Epidural Abcess in Emergency Department
Patients with Spine Pain Ailinh Tran, Daniel P Davis,
Ruth M Wold, Raj Patel, Theodore C Chan, Gary M Vilke;
University of California, San Diego: San Diego, CA
Objectives: The classic diagnostic triad for spinal epidural
abscess (SEA) includes fever, spine pain, and neurologic
deficits; however, once these deficits are present, the prog-
nosis for full recovery is limited. This retrospective, case-
control analysis explores the use of risk factor assessment
569
in the early detection of SEA. Methods: A registry of SEA
patients was used for the study cohort, with controls hand
matched 2:1 based on age and gender from a database of ED
patients with spine pain. Chi-square and descriptive
statistics were used to compare the ‘‘classic triad’’ to risk
factor assessment as screening tools for SEA. A priori risk
factors included: IVDA, chronic hepatitis/cirrhosis, immu-
nocompromised, recent spinal procedure, diabetes, indwell-
ing catheter, chronic renal failure, or distant infection site.
Results: SEA patients comprised 0.4% of ED patients with
spine pain. A total of 63 ED patients with SEA were hand-
matched to 126 controls. There were no differences with
regard to age (47.7 vs. 47.7 yrs, 95%CI for diff –3.3 to 3.3, p [
0.999) or gender (58.7% vs. 58.7% male; OR 1.0, 95%CI 0.54–
1.84, p [ 0.999). More SEA patients had the ‘‘classic triad’’
(7.9% vs. 0.8%, OR 10.8, 95%CI 1.23–94.3, p ¼ 0.008) and had
identified ‘‘risk factors’’ (98.4% vs. 21.4%; OR 227, 95% CI
30.1–1715, p \ 0.0001). Test characteristics were:
Sens Spec PPV NPV LRþ LR

Classic triad 7.9% 99.2% 83.3% 68.3% 10 0.93
Risk factors 98.4% 78.6% 69.7% 99.0% 4.6 0.02
Based on these data, approximately 50 patients without SEA
would be identified as having a risk factor for every SEA
patient. Conclusions: Risk factor assessment offers better
sensitivity and NPV without significant loss of specificity
for detecting SEA in ED patients with spine pain; however,
many patients without SEA would screen positive due to the
low prevalence of SEA in the cohort of ED patients with
spine pain.
432 Clinical Predictors of Influenza A Diane Rimple,
Kim Kresovich, Sumner Williams, Cameron Crandall,
Stephen Young, Judith C Brillman; University of New Mexico:
Albuquerque, NM
Objective: Identify a symptom complex to help clinicians
predict which patients have Influenza A. Methods: Design
and Setting: A cross-sectional study of all patients presenting
to an urban teaching hospital Emergency Department with
‘‘flu-like’’ syndrome based on their completion of a symptom
checklist. Participants: Nurses enrolled subjects approxi-
mately 12 hours a day from December 2001 to March 2002.
A convenience sample of subjects had nasopharyngeal
and throat swabs for viral cultures. Inclusion criteria: adult
patients with fever, cough, sore throat, eye or ear pain,
muscle pain, headache, nasal congestion, malaise or fatigue,
chills or sweats. Exclusion criteria: age less than 18 years,
inability to provide informed consent. Observations: sensi-
tivity (SEN), specificity (SPC), negative predictive power
(NPV), positive predictive power (PPV), odds ratios (OR)
and 95% confidence intervals (CI) were calculated for
associations with Influenza A. Results: 330 patients were
cultured. One sample was lost, for a total of 329. 23% patients
tested positive for Influenza A. Of the nine symptoms on the
checklist, only one symptom was associated with Influenza
A (OR [ 2, CI not including 1). Cough had a SEN of 97%,
SPC of 13.4%, PPV of 25 %, and NPV of 94%, OR 5.7 (CI: 1.34–
24.5). Malaise/fatigue approached association with a SEN of
570
92%, SPC of 16%, PPV of 25% and NPV of 87%, OR 2 (CI: 0.9–
5.4). Combining cough and malaise/fatigue had SEN of 89%
and SPC of 26%, PPV of 27% and NPV of 89%, OR 3 (CI: 1.3–
6.4). Conclusions: We did not identify a symptom complex
to diagnose Influenza A reliably. All symptoms were prev-
alent in subjects with and without Influenza A. Subjects with-
out cough do not have Influenza A with a NPV of 94%,
however, using cough as a trigger to culture decreases
testing by only 11%.
433 The Effect of a Financial Incentive on Outpatient
HIV Testing Referrals from the Emergency
Department Jason S Haukoos, Mallory D Witt, Roger J
Lewis; Harbor-UCLA Medical Center: Torrance, CA
Objectives: Many patients who seek care in the ED have
unidentified HIV infection. Most EDs utilize outpatient
referrals for HIV counseling and testing (HIV-CT) to identify
these patients. In a previous evaluation of our HIV-CTreferral
process, we found only ;10% completed HIV-CT after
a referral. The purpose of this study was to evaluate the
effect of a financial incentive on the proportion of referred ED
patients who completed outpatient HIV-CT. Methods: This
study was performed at an urban county teaching hospital
primarily serving a medically indigent, minority population.
ED patients identified by treating physicians as being at risk
for HIV infection using CDC guidelines were referred for
outpatient HIV-CT at our institution within one week. A con-
trol period with no incentive was followed by an intervention
period in which $25 was offered to those patients who
completed HIV-CT. ORs for the completion of HIV-CT
between control and intervention groups were calculated
with 95% CIs. Results: 226 HIV referrals were made from our
ED. Of these, 127 (56%) referrals occurred during the control
period, and 99 (44%) occurred during the intervention period.
Of the 226 patients referred, 135 (64%) were male, 96 (46%)
were Hispanic, 60 (28%) were African-American, 34 (16%)
were Caucasian, 10 (5%) were Asian, and 11 (5%) were of
another racial or ethnic group. The median age was 32 (IQR
25–39) years. Of the 127 patients referred for HIV-CT during
the control period, 8 (6%) completed HIV-CT, and of the 99
patients referred during the intervention period, 21 (21%)
completed HIV-CT (OR 4.0, 95% CI 1.7–9.5). Of the 29 total
patients who completed HIV-CT, 0 (0%) tested positive for
HIV. Conclusions: The use of a modest financial incentive
increased the proportion of patients who completed HIV-CT
after being referred from the ED. It is unclear whether the use
of a financial incentive will increase the proportion of patients
identified as HIV-infected, or if it will be cost-effective.
434 Streptococcus pneumoniae Culture and Resistance
in Low-risk Patients with Pneumonia Brian H
Rowe, Sam Campbell, Jessica L Hohrmann, Jennifer A Emond,
Carol H Spooner, Carlos A Camargo Jr, for the MARC-16
Investigators; University of Alberta: Edmonton, Alberta,
Canada, Queen Elizabeth Hospital II: Halifax, NS, Canada,
Massachusetts General Hospital: Boston, MA
Objective: Limited information exists on the presence and
resistance of Streptococcus pneumoniae (SP) in patients with
2003 SAEM ANNUAL MEETING ABSTRACTS
pneumonia discharged from the emergency department
(ED). This ED study examined the utility of a standardized
collection of sputum for patients with a physician-diagnosis
of pneumonia. Methods: Multicenter, prospective cohort
study in Canadian and US EDs between 12/01–10/02.
Using a standardized method for sputum sample collection,
22 EDs enrolled patients, age 18þ, discharged with com-
munity-acquired pneumonia (CAP). Patients with a pneu-
monia severity index (PSI) of [III were excluded. All
patients were treated with clarithromycin for 7 days and
followed by telephone (2 wks) and in person (4 wks) to
ascertain outcomes. Cultures were completed on ‘‘culturable
sputum’’ and SP resistance to macrolides and penicillin was
determined by local and central laboratories. Proportions
are presented with 95% confidence intervals (CI). Results: A
total of 270 patients have been enrolled in this interim
analysis, 141 (52%, 95%CI 46–58) had sputum samples that
qualified for culture and 59 (22%, 95%CI 17–27) grew an
identifiable organism. Overall, 35 (13%, 95% CI 9–18) were
positive for non-SP organisms, and 24 (9%, 95%CI 6–13)
grew SP. No penicillin and 3 macrolide resistant organisms
were identified in the SPþ cases; 4-wk cure rates were sim-
ilar in all SPþ and SP
groups. Conclusions: Out-patient
treatment of CAP is common in the ED, and empirical
treatment is recommended with macrolides. SP resistance
appeared low and patients did well in this setting, although
\25% of sputum samples grew pathogens in PSI Class I–III
patients. In these low-risk PSI groups, sputum cultures
should be reserved for surveillance purposes only.
435 Bacterial Contamination Rates of Antimicrobial
Impregnated Disposable Stethoscope Diaphragms
in an Urban Emergency Department Setting
Douglas MKleinerWilliam PBozemanUniversity
of Florida: Jacksonville, FL
Background: Bacterial contamination of stethoscopes has
been implicated in the transmission of nosocomial infec-
tions, which can contribute to hospital morbidity and
mortality. A disposable soft stethoscope diaphragm impreg-
nated with silver zeolite, designed to be discarded and
replaced weekly, is now commercially available. Objectives:
Our purpose was to evaluate the ability of this device to
reduce the bacterial contamination of stethoscopes in a
clinical setting. Methods: A prospective, double-blind, ran-
domized trial compared 40 diaphragms impregnated with
the antimicrobial agent (EXP) to 40 identically appearing
diaphragms without the antimicrobial agent (CTL). Physi-
cians and nurses in a high-volume emergency department
used the diaphragms for 1 week. After 1 week diaphragms
were collected and divided in half. One-half of each
diaphragm was cultured immediately, while the other was
cultured 24 h later. Results: Overall, 96% of the diaphragms
showed bacterial growth on initial culture; 55% had greater
than 5 colony forming units per diaphragm (CFU/d). Of
the 40 EXP diaphragms, 10 were highly contaminated
([20 CFU/d) at 0 hours, with a mean of 60.4 CFU/d. The
remaining 30 EXP diaphragms had a mean of 9.4 CFU/d at
0 h and the CTL diaphragms had 33.7 CFU/d. Upon re-
culture at 24 h, the highly-contaminated group showed
significant (p ¼ 0.0001) reduction of 87.3 % to 7.7 CFU/d.
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org 571

The remaining EXP diaphragms had a mean of 13.5 CFU/d Background: Empiric treatment of UTIs is dictated by
(p ¼ 0.0825) at 24 h, and the controls decreased to 11.8 antimicrobial susceptibility patterns of the most common
CFU/d (p ¼ 0.0059). The most commonly isolated bacterial uropathogens, most notably Escherichia coli (E coli). Al-
species was coagulase negative staphylococcus. Other though excellent data on these patterns exists for adults, the
commonly isolated bacterial species included micrococcus, susceptibility patterns in children are largely unknown.
bacillus, corynebacteria, and Staphylococcus aureus. Methicil- Objectives: We examined the E coli susceptibility patterns
lin resistant Staphylococcus aureus was isolated in two of the from urine cultures obtained as part of a national surveil-
diaphragms. Conclusions: Among stethoscopes with high lance network. Methods: Antimicrobial susceptibility pat-
bacterial contamination rates, the antimicrobial impreg- terns to commonly prescribed antibiotics were performed
nated diaphragm showed a significant reduction in bacterial on E coli isolated from patients presenting between 1999–
counts within 24 hours. 2001. Resistance rates between 5 age groups from infancy to
$50 years were separately analyzed. Results: There was
a total of 10,204 pediatric and 61,457 adult urine cultures.
The resistance rates are contained in the table below. In
436 The Effect of an Educational Intervention on the
general, there were higher resistance rates seen in the early
Contamination Rate of Physicians’
pediatric age groups. Infants or toddlers showed the highest
Stethoscopes Scott W Melanson, Courtney E Melanson,
resistance rates in 4 of the 6 antibiotics studied. This overall
Rebecca Pequeno, Christopher Stromski, James Reed;
trend was not true for ciprofloxacin and nitrofurantoin
St. Luke’s Hospital: Bethlehem, PA
where resistance increased as age increased.
Objective: To assess the impact of an educational in-
tervention on the bacterial contamination rate of physicians’
stethoscopes. Methods: The stethoscopes of 34 EM residents TABLE–Antibiotic Resistance by Age Group
and attendings were cultured before, and 3 weeks after, (Percent)
being provided with a 30-minute educational session
0–4 1–24 2–12 13–17 18–50 $50
addressing nosocomial infections and the importance of weeks months yrs yrs yrs yrs
stethoscope cleaning. The physicians were advised to clean
their stethoscope with alcohol swabs after each patient. Amox/clav 6.2 5.8 5.4 3.8 3.9 4.9
Culturing was unannounced and participants were not Ampicillin 48.9 54.1 47.6 36.4 38.0 31.7
Cefazolin 7.3 5.1 3.3 2.4 2.5 3.5
told that a repeat culturing would occur after the first.
Cipro 0.6 0.5 0.7 0.5 1.3 4.1
Participants were surveyed regarding stethoscope cleaning Nitrofur 0.0 0.3 0.4 0.5 0.4 0.9
practices before the intervention. Results: 68% of respon- TMX/SMZ 13.5 24.1 21.3 13.9 16.4 15.4
dents knew that cleaning their stethoscope was important
but only 38% had cleaned their stethoscope within the prior
week. While 97% of stethoscopes cultured before the inter-
Conclusions: Pediatric UTIs caused by E coli show similar
vention were contaminated with 8 bacterial species, post-
resistance trends to adults. Ampicillin and TMP-SMZ show
intervention contamination was seen in 56% of stethoscopes
high rates of resistance and their utility in empiric treatment
with 4 bacterial species (Table). The differences between the
of UTIs should be questioned. Resistance rates to amoxicil-
2 phases of the study were statistically significant (p \ .02).
lin/clavulanate, cefazolin, ciprofloxacin, and nitrofurantoin
remain low and should be considered for the empiric
Pre-intervention Post-intervention treatment of pediatric and adult UTIs.
Bacteria (%) (%)
Coag-neg staph 97.1 53.1
Corynebacterium spp. 41.2 9.4
Alpha-hemolytic strep. 35.3 6.3 438 A Prospective Study of North Asian Tick Typhus
Bacillus spp. 29.4 15.6 Infection in Members of a Scientific Expedition to
Acinetobacter lwoffi 5.9 0 Outer Mongolia Matthew R Lewin, David H Walker, Donald
Enterobacter 2.9 0
Bouyer, Daniel M Musher; University of California San
Staph. aureus 2.9 0
Francisco–Fresno: Fresno, CA, University of Texas Medical
Gamma strep 2.9 0
Branch: Galveston, TX, Baylor College of Medicine: Houston, TX

Conclusions: EM physicians’ stethoscopes had a very high
rate of bacterial contamination. A brief educational in-
tervention significantly decreased the contamination rate of
physicians’ stethoscopes.
437 Age Based Antimicrobial Resistance Rates of
Urinary Escherichia coli: Infants to Elderly Romolo
J Gaspari, Eric W Dickson, James Karlowski, Gary Doern;
University of Massachusetts: Worcester, MA, Univeristy of
Iowa: Iowa City, IA, The Surveillance Network Database:
Herndon, VA
Objectives: A prospective, clinical-serological study was
undertaken to describe the risk of acquiring North Asian
tick typhus (Rickettsia sibirica infection) during travel to
endemic parts of Asia. The syndrome of R. sibirica infection
is similar to other spotted fever group (SFG) rickettsial
infections where eschar, fever, headache and rash pre-
dominate in the acute phase. Methods: We asked teams of
paleontologists beginning fieldwork in Outer Mongolia 2001
& 2002 to participate. Upon return from expeditions, sub-
jects filled out questionnaires about tick exposure and pres-
ence of symptoms or signs of disease consistent with SFG
rickettsioses. Questionnaires were collected before antibody
assays were done. Sera from field scientists and adventure
572
travelers to other continents were used as additional con-
trols. All were assayed for IgM and IgG antibody against
R. sibirica, R. typhi and Ehrlichia chaffeensis after which results
were matched with questionnaires. Fluorescence at $1:32
dilution was considered positive for IgM and $1:64 for IgG.
Each subject was tested only once. Results: Of 13 scientists
completing the study, four (31%) reported clinical syn-
dromes consistent with SFG rickettsiosis, and all four had
positive serologies. Only two of four affected paleontolo-
gists noted ticks embedded in their skin prior to onset of
illness. Of 15 control subjects, two reported febrile illness
consistent with rickettsiosis, though none tested positive for
R. sibirica. Conclusions: We report the first four cases of R.
sibirica infection to be identified by prospective study. All
four had clinical syndromes and serologic studies consistent
with acute R. sibirica infection. Our study suggests a sub-
stantial risk of developing N. Asian tick typhus during
summer field work in Outer Mongolia. Physicians should
have a high-index of suspicion for arthropod borne illnesses
in persons returning from endemic areas with characteristic
syndromes—even in the absence of recognized tick bite.
439 Triage Application of Topical Anesthetic for IV
Placement in the Pediatric Emergency Department
(PED): Comparing a Prediction Model to Nurse
Judgment Marc H Gorelick, Joel A Fein; Medical
College of Wisconsin: Milwaukee, WI, Children’s Hospital
of Philadelphia: Philadelphia, PA
Objectives: To test: 1) The accuracy of a triage prediction
rule for IV placement in the PED, compared to nurse
judgment alone; 2) The feasibility of placing EMLA in triage
for ‘‘high risk’’ pts. Methods: Randomized, unblinded
experimental design. All pts. in the ED triage area of an
urban pediatric tertiary care center from 2/6/00 to 3/9/00
were eligible. Triage nurses were randomized into two
groups: Prediction score nurses (PRD) categorized pt. as
‘‘selected for IV’’ if pt. was $2 on a previously developed
prediction score, which includes high-risk chief complaints,
high risk past medical history, and referral by another
doctor. ‘‘Own judgment’’ nurses (RN JDGMT) categorized
pts. without using the prediction score. EMLA was applied
randomly to 75% of ‘‘selected for IV’’ pts. Clinicians making
IV placement decisions were blinded to triage decision, but
not to EMLA placement. Chi square was used to compare
accuracy of PRD and RN JDGMT groups. Results: We
enrolled 3790/5025 (75.4 %) of eligible pts. 14.8% in the PRD
group and 14.5% in the RN JDGMT group received IVs. RN
JDGMT was more sensitive than PRD for the IV placement
outcome (p \ 0.0001). There was no difference in eventual
IV placement between those who did and did not receive
EMLA (58.8% vs. 51.1%; diff ¼ 7.7%;95%CI:
1.4%,16.8%).
91.7% of IVs were placed $45 min and 82.7% $60 min after
triage EMLA. Ease of IV placement was ‘‘same’’ or ‘‘easier’’
than usual for 84.4% of those ‘‘selected for IV’’ pts. receiving
EMLA and 89.9% of those not (diff ¼ 5.5%,95%CI:

1.1%,12.0%). Conclusions: In our PED, triage RN judg-
ment to predict IV placement had greater sensitivity and
similar specificity compared with a prediction model. Triage
placement of EMLA in high-risk pts. was feasible, with no
change in rate or ease of IV placement.
2003 SAEM ANNUAL MEETING ABSTRACTS
PREDICTION RN JDGMT
Sens 41.6 (36.0, 47.4) 66.0 (59.8, 71.9)
Spec 93.8 (92.5, 94.8) 92.0 (90.5, 93.4)
PPV 53.1 (46.6, 59.6) 58.9 (52.9, 64.7)
NPV 90.4 (89.0, 92.5) 94.0 (92.6, 95.1)
440 Frequency Of Incomplete Abdominal Aorta
Visualization By Ultrasound When Ruling Out
Aneurysm Daniel Theodoro, Michael Blaivas; North
Shore University Hospital: Manhasset, NY, Medical
College of Georgia: Augusta, GA
Background: Literature on abdominal aortic aneurysm
(AAA) suggests that among fasted patients nearly 98% will
have the entire abdominal aorta (AA) visualized by ultra-
sound (US). However, this may not apply to critically ill and
non-fasted patients seen by emergency physicians (EPs).
Objective: To determine if EPs scanning the AA are able to
visualize the entire AA as frequently as seen in general US
literature. Methods: We performed a prospective study of all
patients receiving an US from an EP to rule out AAA over a 12
month period at an urban level I emergency department with
residency. Patients younger than 50 years of age and whose
aorta was evaluated for a reason other than AAA were
excluded. Residents and attending EPs underwent an 8-hour
introductory US course including 2.5 hours directly on AA.
Physicians evaluated the entire length of the AA with US in
short axis making standard proximal, middle and distal
measurements. AAA was defined as dilation of the AA to [3
cm. Video of each US and data sheets were evaluated by
a hospital credentialed sonologist for complete visualization
of the AA. Any portions of the AA which could not be
visualized were noted and those 1/3 of the AA or greater in
length were considered significant for potentially missing an
AAA. Statistical analysis included descriptive statistics with
95% confidence intervals (CI). Results: US of 209 patients
were completed but data sheets were incomplete for 2. In 35
(17%; CI 12 to 23%) patients a portion of the AA was not seen.
In 17 (8%; CI 5 to 13%) patients a significant portion of the AA
could not be visualized and could have potentially concealed
an AAA. In 4 patients the AA could not be seen at all; 3 due
to bowel gas and 1 due to free air. Computed tomography
was used instead. There were a total of 29 (14%; CI 10 to
19%) AAAs discovered and none were missed. Conclu-
sion: Contrary to suggestions in radiology literature signif-
icant portions of AA were not visualized on bedside US in
8% of non-fasted patients.
441 Short Axis versus Long Axis Approaches for
Teaching Ultrasound Guided Vascular Access
Larry Brannam, Eleanor Fernandez, Michael Blaivas;
Medical College of Georgia: Augusta, GA
Background: Recently ultrasound (US) guidance has been
mandated by the AHRQ for central line placement and its
use for peripheral access is also being taught to emer-
gency medicine (EM) residents. Objective: To determine
whether a short axis (SA) or long axis (LA) US guidance
approach is easier for novice US users. Methods: We
performed a prospective, randomized observational study
on EM residents at a level I trauma center. After a 30 min
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
tutorial on US guided vascular access residents were ran-
domized to one of two groups. A Jell-o and Metamucil
mixture, providing a realistic US image, was placed inside
a synthetic arm skin used for training phlebotomists that
contained a rubber vein filled with red fluid at a depth of
1.5 cm. Group one attempted SA first and then the LA.
Group two tried LA first. Any resident not wishing to
participate was excused. Time from skin break to can-
nulation, number of skin breaks and needle redirections
and difficulty on a 10-point Likert scale were recorded.
Statistical analysis included paired Student’s t-test with
95% confidence intervals (CI). Results: 17 residents were
enrolled. Mean time to vein cannulation in SA and LA
was 2.36 min (CI 1.15 to 3.58) and 5.02 min (CI 2.9 to
7.13) respectively. The 112% difference of 2.65 min (CI .24
to 5.1) was statistically significant, p ¼ 0.03. Mean number
of skin breaks for SA and LA was 5.8 (CI 1.2 to 7.2) and
7.6 (CI 1.8 to 9.7) respectively. The difference of 1.59 (CI

3.2 to 6.4) was not statistically significant, p ¼ 0.5. Mean
number of needle redirections in the SA and LA was 13.7
(CI 4.5 to 22.9) and 18.2 (CI 7.9 to 28.4) respectively. The
difference of 4.47 (CI
9.7 to 18.6) was not statistically
significant, p ¼ 0.5. Mean difficulty scores for SA and LA
were 3.99 (CI 2.4 to 5.6) and 5.86 (CI 4.3 to 7.4) re-
spectively. The difference of 1.86 (CI
.9 to 4.9) was not
significant, p ¼ 0.17. Conclusion: Novice US users obtain
vascular access much faster using a SA approach on an
inanimate model after a brief tutorial.
442 Ultrasound Image Quality in the Emergency
Department: Sonosite 180 Plus versus GE
400 Daniel Theodoro, Larry Brannam, Michael Blaivas;
North Shore University Hospital: Manhasset, NY, Medical
College of Georgia: Augusta, GA
Background: Questions have been raised about quality of
imaging provided by portable ultrasound (US) machines in
an article on missed intra-abdominal blood. Objective: To
determine if a difference exists between images from
a leading portable US machine and a more expensive larger
US machine when comparing typical views used by
emergency physicians. Methods: We performed a prospec-
tive, blinded comparison of identical images obtained on
healthy models on a Sonosite 180 plus and General Electric
(GE ) 400 US machines. Both machines were optimized by
company representatives. Images obtained included typical
abdominal and vascular applications utilizing the abdominal
and linear transducers on each machine. All images were
printed on identical high resolution printers then digitized
using bitmap format at 300 dpi resolution. Images were then
cropped, masked and placed into random order comparing
each view per model by a commercial web design company
(Loracs.com). Three credentialed emergency sonologists,
blinded to machine type, rated each image pair for resolution
(RES), detail (DET) and total image quality (IQ) as previously
defined in the literature using a 10 point Likert scale. 10 was
best for each category. Paired t-test, confidence intervals (CI)
and interobserver correlation were calculated. Results: A
total of 49 image sets were evaluated. Mean GE 400 RES, DET
and IQ scores were 6.8, 6.8 and 6.6 respectively. Correspond-
ing 180 plus means were 6.3, 6.3 and 6.0 respectively. The
difference of 0.5 (CI .13 to 1.1) for DET was not statistically
significant, p ¼ 0.06. The differences of 0.5 (CI .1 to 1.1) and
573
0.6 (CI .2 to 1.2) for RES and IQ were statistically significant
with p ¼ 0.01 and 0.01. There was good interobserver
agreement (kappa ¼ 0.71 95% CI 0.67 to 0.78). Conclusions:
Statistically significant difference was seen between GE 400
and Sonosite 180 plus in IQ and RES but not DET. Clinically
significant difference between these two US machines
appears unlikely based on this study.
443 ED Ultrasound Evaluation of the Index Flexor
Tendon: A Comparison of Water-bath Evaluation
Technique (WET) versus Direct Contact
Ultrasound Stephen J Leech, Jason Gukhool, Michael Blaivas,
Paul R Sierzenski; Medical College of Georgia: Augusta, GA,
North Shore University Hospital, Manhasset, NY, Christiana
Care Health System: Newark, DE
Objectives: Flexor tendon (FT) injuries are a common
problem in patients with hand lacerations. We sought to
compare standard direct-contact ultrasound (DC) with
a newly described water-bath evaluation technique (WET)
for the assessment of an index FT in a normal volunteer.
Methods: A volunteer served as a hand model. Emergency
residents (EMR) & attendings (ATT) without previous
tendon ultrasound (US) experience were randomized to
perform either DC or WET US of the index FT of a normal
volunteer. Subjects had prior teaching of key anatomic
landmarks for the flexor tendon identification. Subjects were
randomized to DC/WET evaluation of the index finger FT
from origin to insertion using a 38 mm (5–10MHz) linear
transducer. DC was performed with Aquasonic 100 gel as the
contact medium. With WET-US, the model’s hand was
submersed in 1.5L of H2O. Subjects were not to contact the
surface of the finger, but use the water as the contact medium
to evaluate the index FT in its entirety. Subjects could adjust
frequency, depth, & gain. Standardized evaluation forms,
using a 10-point Likert scale were completed. Subjects were
asked to rate each method for: ease of use (E), image quality
(IQ), ability to evaluate the flexor tendon (EVAL/FT), &
degree of image artifact (ART) for each method. Mean,
difference, paired t-test, 95% confidence intervals (CI) and p-
values (p) were calculated. Results: 25 subjects: 9 EM ATT, 14
EMR, 2 sonographers participated. The mean DC scores
were DC-E ¼ 8.0, DC-IQ ¼ 7.1, DC-EVAL/FT ¼ 7.3, DC-ART
¼ 4.0. Means WET ratings were WET-E ¼ 8.9, IQ ¼ 9.0, WET-
EVAL/FT ¼ 8.5, and WET-ART ¼ 2.3. The difference
between WET & DC mean scores were E ¼ 0.9 (CI:0.26–1.5,
p ¼ 0.008), IQ ¼ 1.96 (CI:1.5–2.4, p \ 0.0001), EVAL/FT ¼ 1.2
(CI:0.5–1.9, p ¼ 0.002), and ART ¼ 1.7 (CI:1.1–2.3, p \ 0.001).
Conclusion: WET was superior in ease of use, image quality,
evaluation of the index flexor tendon, & degree of image
artifact when compared to DC. Differences between WET vs.
DC are statistically significant.
444 Water-bath vs Direct Contact Ultrasound: A
Randomized, Controlled, Blinded Image
Review Stephen J Leech, Michael Blaivas, Jason Gukhool,
Daniel Theodoro, Paul R Sierzenski; Medical College of Georgia:
Augusta, GA, North Shore University Hospital: Manhasset,
NY, Christiana Care Health System: Newark, DE
Objectives: To compare image detail, resolution and overall
image quality of standard direct-contact (DC) ultrasound
574
with a newly described water-bath evaluation technique
(WET). Methods: Matched images of ultrasound of avian
tissue with imbedded wood and metallic foreign bodies were
obtained by both DC and WET using a standard 38 mm (5–
10MHz) linear transducer. Images of the index flexor tendon
were obtained using both techniques. All studies were
recorded on digital video with identical matching still images
digitally captured through Final Cut Pro (Apple, INC).
Images were cropped to blind image evaluators to which
technique was used, excluding such identifiers as depth. 9
total matched still images including one identical control set
were inserted into a Power Point presentation and reviewed
by 4 emergency physicians experienced in emergency
ultrasound. Evaluators rated each image with a 10-point
Likert scale for image detail, resolution and overall image
quality. Mean, paired t-test and p-values (p) were calculated.
Results: Mean scores for WET images in detail, resolution
and image quality were: 8.028, 8.306, and 8.056 respectively.
DC images for detail, resolution, and image quality were
7.81, 7.03, and 7.97 respectively. Resolution with WET scored
statistically better with a p value ¼ 0.027. Kappa values
showed high inter-rater reliability. Conclusion: WET is
equivalent in image detail, and quality to DC technique with
minimal improvement in image resolution.
445 Higher Diagnostic Imaging Use in tPA-treated
Stroke Patients in University Hospital Compared to
Matched Community Teaching Hospital Robert Silbergleit,
Shirley M Frederiksen, Rodney W Smith, Phillip A Scott; St.
Joseph Mercy Hospital: Ann Arbor, MI, University of Michigan:
Ann Arbor, MI
Objectives: It is difficult to evaluate inter-hospital differ-
ences in diagnostic imaging use following stroke due to
referral selection bias. tPA-treated patients are not suscep-
tible to referral bias due to treatment time limits. We tested
the null hypothesis that no difference exists in the pro-
portion of stroke patients undergoing MRI following tPA
treatment between matched teaching hospitals. Secondary
outcome measures included the proportion of patients
undergoing MRA, echocardiography, carotid ultrasound,
angiography and post-treatment CT. Methods: Retrospec-
tive cohort study of 138 consecutive intravenous tPA-treated
stroke patients at two teaching hospitals (one university, one
community-based) located five miles from each other. The
hospitals are the only tertiary centers within a 30-mile
radius and have 600 and 545 beds, respectively. Inpatient
diagnostic imaging use and demographics analyzed using
Chi-squared test, with Bonferroni’s correction, to compare
differences. Results: 58 and 80 stroke patients received tPA
at the university and community hospitals, respectively. No
inter-hospital transfers occurred. Patients were well
matched for age, race, gender, cardiac disease, stroke risk
factors and in-patient mortality. Median pre-treatment
NIHSS scores were 13 and 12, respectively. 41% [95% CI:
0.29–0.55] of patients underwent MRI at the university
compared to 11% [95% CI: 0.05–0.20] at the community-
teaching hospital (p \ 0.001). Significant differences also
identified in the use of MRA (31% vs. 9%) and transeso-
phageal echocardiography (52% vs. 15%). Conclusions: We
identified higher diagnostic imaging use in tPA-treated
stroke patients at a university hospital compared to a similar
2003 SAEM ANNUAL MEETING ABSTRACTS
sized community-teaching hospital. This could not be
explained on the basis of stroke severity, patient character-
istics or hospital transfer. This wide variation of practice has
broad implications regarding resource use and patient
exposure to risk from diagnostic procedures.
446 Noninvasive Fireground Assessment Of
Carboxyhemoglobin Levels in Firefighters Donald
S MacMillan, Carin VanGelder, Dennis Brown, Scott D Weir,
Sandy Bogucki, David C Cone; Yale University School of
Medicine: New Haven, CT
Objectives: Carboxyhemoglobin (COHb) levels can be
estimated by chemical analysis of exhaled breath. Such
noninvasive measurement would allow operational EMS
personnel to screen firefighters (FFs) and victims for carbon
monoxide (CO) toxicity on the fireground. The purpose of
this IRB-approved study was to assess the feasibility of
using a hand-held, battery-powered CO monitoring device
to screen for CO toxicity in FFs under field conditions.
Methods: Using an FDA-approved hand-held breath CO
detection device (CO Sniffer, Scott/Bacharach Instruments,
Exton PA), COHb readings were collected from FFs wearing
self-contained breathing apparatus (SCBA) and performing
interior fire attack and overhaul during live-fire training
exercises. Ambient CO levels were periodically measured in
interior areas where the FFs were working to assess the
degree of CO exposure. Data were collected by 5 EMS
physicians or PA’s who are cross-trained as FFs, qualified to
wear SCBA for interior ambient measurements. Baseline
COHb levels were obtained from all participating FF’s
during the informed consent process. COHb levels were
obtained from FFs as they exited burn buildings following
training evolutions. Data were entered into a computer
spreadsheet, and simple, descriptive statistics were ob-
tained. Results: Baseline COHb readings of 64 FF’s ranged
from 0% to 3% (mean 2%, median 1%). A total of 184 COHb
readings were collected during 5 training exercises. The
mean COHb was 2%; the median was 1%. The maximum
value with SCBA was 3%; a value of 14% was measured on
an instructor who removed his SCBA mask during a fire
attack evolution. Each reading was also compared to the
FF’s baseline: the mean and median changes were both 0%.
Ambient CO readings for fire attack ranged from 75 to 1290
ppm, and for overhaul from 0 to 130 ppm. Conclusions: The
hand-held CO monitoring device adapted for estimation of
COHb levels by exhaled breath analysis can feasibly be
deployed on the fireground to assess CO exposure in FFs.
447 Identifying Medical Errors: Developing Consensus
on Classifications and Consequences Jennifer L
Eaton, Ernesto Olmedo, Bryan J Weiner, Cherri D Hobgood;
University of North Carolina School of Medicine and Public
Health: Chapel Hill, NC
Objective: To develop consensus among clinical experts on
the classification and severity of medical errors in the
emergency department setting. Methods: A multidisciplin-
ary panel of 20 experts participated in a 3-round modified-
Delphi process to discriminate between specific classes
of medical error common to emergency medicine practice.
Panelists evaluated 19 case vignettes representing 2 classes
ACAD EMERG MED d May 2003, Vol. 10, No. 5 d www.aemj.org
of error (medication (MED) and cognitive (COG)) and vary-
ing clinical severity. Participants were asked to: (1) deter-
mine to what degree each case represented a COG error
(2) determine to what degree each case represented a
MED error (3) assign a severity score for the medical con-
sequences of the error. A 9-part Likert scale was used to
indicate level of agreement. Frequency distributions and
descriptive statistics were calculated for each item. Results:
19 panelists (95%) completed all three rounds. Panelists
reached consensus on both error classes and severity in 6 /19
(32%) cases. In only 1/19 (5%) cases did panelists agree on
error class and not severity. Class consensus was achieved in
11/19 (58%) of cases. Of these, a single error class was
identified in 8/19 (42%) of cases, and in 3/19 (16%) cases
both COG and MED error were identified. No case was
identified as a non-error. On average, when consensus was
achieved, COG cases required 1.6 rounds, MED cases
required 2.66 rounds and cases identified as both MED &
COG required 3 rounds. In 8/19 (42%) cases, error class
consensus could not be achieved. In all cases where class
consensus was not achieved the no-consensus category was
COG. There were no cases where panelists did not achieve
consensus in the MED category. In 16/19 (84%) of cases,
panelists achieved agreement on clinical severity. Conclu-
sions: There is increasing evidence that cognitive errors in
medical decision-making can be difficult to identify. This
study suggests that error classification may challenge expert
panel groups as well as individual providers.
448 National Study of ED Patients Who ‘‘Left Before
Being Seen’’ by a Physician, 1992–2000 Nan Wang,
Carlos A Camargo Jr, Emily E Spilseth; Massachusetts General
Hospital: Boston, MA
Objectives: To examine national trends in ‘‘left before
being seen’’ (LBBS), and to compare characteristics of
LBBS patients versus other ED patients. Methods: Data
were obtained from the National Hospital Ambulatory
Medical Care Survey, a probability sample of ED visits
completed annually. LBBS data are available for 1992 and
1995–2000. National estimates were obtained through use
of assigned patient visit weights. 95% CI were calculated
using the relative standard error of the estimate; data
analysis used linear and logistic regression. Results:
Approximately 8,754,000 ED visits resulted in LBBS. LBBS
visits were stable between 1992 (1.2%) and 1997 (1.1%) but
began an exponential rise in 1998; LBBS grew to 1.7% of
all ED visits by 2000 (P \ 0.001). The most common
symptoms given at triage for LBBS visits were abdominal
pain (7.5%), fever (5.4%) and chest pain (3.4%). 28% of
LBBS visits were coded as urgent/emergent at triage,
compared to 48% for other visits. The mean patient age
was 29 (95% CI 28–30) for LBBS, versus 35 (CI 35–35) for
other visits. LBBS was most common among age 20–29
(1.8%), and least common among age [60 (0.5%). LBBS
frequency did not differ between males (1.3%) and
females (1.2%), but was twice as common among blacks
(2.0%, CI 1.8–2.2%) compared to whites (1.1%, CI 1.0–
1.2%). LBBS was more common among urban hospitals
(1.4%) compared to non-urban hospitals (0.8%), and in the
South (1.6%) compared to the Midwest (0.9%). In a multi-
variate model, independent predictors of LBBS were young
age, black race, urban hospital, southern region, and visit
575
after 1998. Conclusion: The frequency of LBBS was stable
for several years, but began an exponential rise in 1998.
This rise likely reflects increased ED crowding during this
time period. The LBBS problem and its adverse con-
sequences differentially affect specific populations. These
findings are a ‘‘call to action’’ to develop and implement
solutions to address ED crowding, and to improve timely
access to emergency care.
449 Language Barriers among Patients in Boston EDs:
Use of Medical Interpreters after Passage of
Interpreter Legislation Sunghye Kim, Jessica L Hohrmann,
Carlos A Camargo Jr, Gabrielle C Hunter; Massachusetts
General Hospital: Boston, MA
Objective: Since July 2001, Massachusetts state law dictates
that ED patients (pts) with no or limited English proficiency
have the right to a medical interpreter. We conducted
a prospective multicenter study in which we assessed
language barriers during an interview in English (to assess
interpreter demand), and compared this demand with the
observed use and type of interpreter during the ED visit. We
hypothesized that hospital interpreters would provide
\50% of required assistance. Methods: For two 24-hour
periods in July 2002, we interviewed pts age $18 years
presenting to 4 Boston EDs: 2 large urban, 1 small urban,
and 1 small suburban. Exclusion criteria included severe
illness and emotional disturbance (n ¼ 224). Proportions are
reported with 95% CI. Results: Of 754 eligible pts, 530 (70%)
were interviewed. Among these 530, the interview was
conducted largely or entirely in English for most pts. Only
45 (8%, 95%CI 6–11%) pts had their interview conducted in
a language other than English. (Among pts whose interview
was conducted in English, a significant communication
barrier was detected for 9 [2%] pts.) Among those whose
interview was not conducted in English, the primary
interpreter was study staff (88%), a friend or family member
age $18 years (10%), or an MD healthcare provider (2%).
During the ED stay, we estimated that an interpreter was
needed for 50 (10%, 95%CI 7–12%) pts. The primary
interpreter for these pts’ clinical encounters was an MD
healthcare provider (34%), a friend or family member age
$18 years (22%), hospital interpreter services (16%),
younger family members (11%), other healthcare providers
(9%), and other hospital staff (8%). Conclusion: In 4 Boston
EDs, we found that 10% of pts had language barriers that
required interpreters. Only 16% of interpretation was
provided by professional medical interpreters. The impact
of language barriers on ED care is likely negative, and
merits greater emphasis in professional education and
quality improvement programs.
450 Federal Funding of Emergency Medicine
Investigators Sunghye Kim, Carlos A Camargo Jr;
Massachusetts General Hospital: Boston, MA
Objective: To create a database of EM investigators who
have served as Principal Investigator (PI) of federally
funded research, and to describe the characteristics of
identified investigators and grants. Methods: Federal
grants between 1972–2000 were identified using CRISP
(Computer-Retrieval Information on Scientific Projects),
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a system that allows searching of grants from NIH, AHRQ,
CDC, and other federal agencies. As part of the Registry
for Emergency Medicine Investigators (www.search-remi.
org), we entered 20 EM-related search terms, as well as the
names of [600 established EM investigators. To be
recognized as an ‘‘EM investigator’’, the individual had
to meet at least one of four criteria: 1) clinician working in
an ED, 2) member of a national EM-based organization, 3)
director of an EM-based residency or a fellowship pro-
gram, or 4) clinician trained in EM. Data analysis used
chi2. Results: We identified 121 EM investigators who
served as PI of a federal grant. 87% were men. 64% of
investigators had a MD degree only, while 28% had MD þ
another degree (e.g., PhD, MPH). From 1972–2000, the 121
researchers received funding from 193 federal grants.
AHRQ/AHCPR was the most frequent sponsor, account-
ing for 23% of grants. Other major sponsors were NHLBI
(19%), and the National Center for Research Resources
(13%). The most popular research areas were CPR/
resuscitation (16, 8%), ischemia/reperfusion (15, 8%),
technology/computer modeling (15, 8%), infectious disease
(12, 6%), cardiovascular medicine (12, 6%), and toxicology
(12, 6%). The initiation of grant awards to EM investigators
has increased in recent years: grant initiation before 1971 (3
grants, 2%), 1971–75 (11, 7%), 1976–80 (32, 19% [due to
eight A18 grants]), 1981–85 (15, 9%), 1986–90 (16, 9%),
1991–95 (32, 19%), and 1996–2000 (57, 34%); p for trend
\0.001. Conclusion: Federal funding of EM investigators re-
mains uncommon but recent trends are favorable. One-third
of grants over 3 decades were obtained during 1996–2000.
451 Pulmonary Gene Expression after Experimental
Pulmonary Embolism Robert M Grattan,
John Zagorski, John A Watts, Jeffrey A Kline;
Carolinas Medical Center: Charlotte, NC
2003 SAEM ANNUAL MEETING ABSTRACTS
Background: Untreated or partially treated pulmonary
embolism (PE) can cause persistent pulmonary hyperten-
sion. Hypothesized mechanisms include severity-depen-
dent production of vasoconstrictors, augmented vascular
reactivity and vascular hyperplasia in response to inflam-
matory, and mitogenic (or antiapoptotic) proteins. Objec-
tive: We used a commercial gene array to quantify and
characterize total lung gene expression after a fixed,
experimental PE in rats. Methods: PE was induced with
a previously described rat model of intrajugular infusion of
inert polystyrene microspheres. Five groups were examined:
mild PE (sPAP ¼ 36 6 5 mm Hg) at 2 h; severe PE (sPAP ¼
59 6 6 mm Hg) at 2 h and 6 h; and shams at 2 h and 6 h.
Total lung RNA was pooled from N ¼ 3 per group and
reverse transcribed to produce cDNA which was transcribed
to biotinylated cRNA. Gene expression was quantified with
Affymetrix gene chips and an Agilent GeneArray scanner,
which measures 8700 cloned genes. Results: At 2 h, mild PE
induced a significant induction ([3-fold induction vs. sham)
of 31 genes, including 13 inflammatory, 6 mitogenic and 1
vasoconstrictive. Severe PE induced 52 genes at 2 h,
including 18 inflammatory and 12 mitogenic genes with
two antinflammatory genes and one vasodilator increased;
at 6 hours of severe PE, 98 genes were increased, including
20 inflammatory, 14 mitogenic and 5 vasoconstrictor genes
with 2 vasodilators. Inflammatory genes included cytokines,
chemokines, and adhesion molecules. Mitogenic genes were
signaling kinases, protooncogenes, growth, and antiapopto-
tic factors. Vasoconstrictive genes were arachidonate oxi-
dases and endothelins. Antiinflammatory genes were HSP-
70 and SOCS-2 & 3 and vasodilators were HO-1 and iNOS.
Conclusion: Fixed PE rapidly induces proinflammatory and
mitogenic gene expression that increases with severity and
duration of vascular occlusion. Rapid diagnosis and
successful treatment of PE may reduce sequela from
inflammation and cell proliferation.