ADVANCES IN THERAPY

Reperfusion of the infarct-related artery in the very first hour (golden hour) of acute myocardial infarction (AMI) significantly reduces mortality rates. Several factors may delay the initiation of reperfusion therapy (ie, thrombolytic therapy or primary percutaneous transluminal coronary angioplasty [PCTA]), most of which are related to patients. A total of 520 patients with suspected AMI were evaluated in the emergency department of Dokuz Eylul University Hospital between March 1996 and October 1999. After inclusion criteria were applied, the study consisted of 178 patients with a history of AMI. Analyzed data that affected patients' arrival to the hospital were obtained from responses to a questionnaire. The Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, 111), version 11.0, was used for all statistical analyses. The mean symptom onset-hospital arrival time was 188 +/- 325 min for the entire study group. The median delay was 110 min (similar to 2 h). Only 39 (22%) patients arrived to the hospital within the first hour. The mean time needed for late responders (n=109, 74%) (hospital arrival later than 1 h after symptom onset) to arrive was 245 363 min. According to the results of this study, many patients with AMI who may be eligible for reperfusion therapy miss the golden hour because of late hospital arrival. Some groups of patients (ie, elderly, women, those with diabetes) were especially late in arriving. To reduce such delays, training programs may be advised to focus on these groups of patients. Arrival times to the hospital during AMI can be greatly improved by efficient public education programs targeted to these groups

Adverse events associated with aggressive treatment of increased blood pressure

Patients with severely increased blood pressure often present to the emergency department. Rapid lowering of blood pressure can precipitate or worsen end organ damage. We report two cases that developed cerebrovascular and cardiovascular adverse events associated with aggressive treatment of increased blood pressure by the use of sublingual nifedipine capsule. The first patient had developed ischaemic stroke; the second patient actually had acute left ventricular failure causing deteriorated, and required positive inotropic treatment for persistent hypotension. These cases emphasise that the pseudoemergency may rapidly progress into a real emergency when blood pressure is rapidly and aggressively reduced

Acute coronary ischemia following centipede envenomation: Case report and review of the literature

This is the first known case report of electrocardiographic (ECG) changes suggestive of coronary vasospasm following a centipede envenomation. A 60-year-old man presented to the emergency department (ED) 1 hour after being stung by a 12-cm centipede. He complained of right great toe pain that did not radiate to his leg. The patient had no known ischemic heart disease. He did not describe any exertional symptoms but admitted experiencing weakness. During the ED course, concurrent with obtaining peripheral intravenous access, the patient experienced diaphoresis, dizziness, hypotension, and bradycardia. His ECG showed new ST-T wave changes, which suggested an acute ischemic process. The patient's blood pressure was 89/60 mm Hg, his pulse rate was 47 beats/min, and his respiration rate was 28 breaths/min. In the following hours, ECG findings returned to baseline. His blood pressure improved gradually with fluid resuscitation after approximately 5 hours. Cardiac markers returned to normal in the 13th hour after the event, and the patient underwent exercise stress testing, which was negative. The patient was discharged with cardiology follow-up. Adult patients with centipede envenomation should be closely monitored in anticipation of possible myocardial ischemia due to vasospasm, hypotension, and myocardial toxic effects of the venom. A child receiving the same amount of venom would be potentially at greater risk

Prilocaine Versus Plain or Buffered Lidocaine for Local Anesthesia in Laceration Repair: Randomized Double-Blind Comparison

Aim. To compare the effectiveness of 2% prilocaine plain solution, 1% lidocaine hydrochloride, and 1% buffered lidocaine in local anesthesia and pain reduction during injection in laceration repair. Methods. A double-blind randomized prospective comparison study included 183 consecutive eligible adult patients with simple lacerations, admitted to the emergency department between January 2001 and June 2002. Each of the three groups of patients received different local anesthetic before laceration suturing (1% lidocaine, 2% prilocaine, or buffered 1% lidocaine). The patients were asked to assess the pain intensity on a 0-100 numerical rating scale at the site of needle entry into the skin (P1), immediately after the completion of injection (P2), and after the first puncture of the suturing needle (P3). The differences among the three patient groups were tested with one-way analysis of variance and chi-square test. Results. The three groups of 61 patients each (one patient declined from prilocaine group) did not significantly differ in mean P1 scores (29.1 +/- 20.9 in the prilocaine, 32.2 +/- 22.9 in the lidocaine, and 33.2 +/- 21.7 in the buffered lidocaine group; p = 0.56). Mean P2 scores were highest in the prilocaine group (24.0 +/- 16.0), followed by lidocaine (20.9 +/- 14.9) and buffered lidocaine (16.1 +/- 11.3) groups (p = 0.007). Mean P3 score was significantly lower in the lidocaine group (13.4 +/- 11.3) then in the prilocaine (18.4 +/- 13.1) and buffered lidocaine (20.4 +/- 16.2) groups (p = 0.014). The number of patients who required additional anesthetic administration in each group was not significantly different (p = 0.09). Conclusion. Injection of 1% lidocaine was associated with lower pain ratings on suturing needle puncture than with 2% prilocaine or buffered 1% lidocaine.Wo

A case report of an unusual sternal fracture

Most sternal fractures are transverse, and a lateral chest radiograph is diagnostic. We report a case of vertical sternal fracture that was not seen on plain radiographs but was revealed using computed tomography (CT). Thoracic CT with coronal reformatted images can also demonstrate sternal fracture lines, supernumerary synchondrosis, and costosternal joint abnormalities

A model of standardized training in basic life support skills of emergency medicine residents

This intervention study was designed to determine the current level of basic life support knowledge and skills of residents in a university-based emergency medicine residency program, and to investigate the potential benefit derived by these residents from a standardized theoretical and practical training session. All residents underwent tests before and after the training session. The residents were asked to perform basic life support on a recording cardiopulmonary resuscitation mannequin. Assessments were made using a 10-item checklist, with the highest score being 17. Each step performed by the resident was scored by an emergency physician for accuracy and effectiveness. Twenty-eight residents participated in the study. According to the modified Berden scale, the pretest and posttest scores were 11.2 +/- 2.9 and 15.6 +/- 1.0, respectively, and the mean difference was 4.36 +/- 2.9 (t test, P <.001). Only 11 residents (39.3%) were rated as "good" or "very good" in the pretest, whereas the corresponding figure in the posttest was 27 (96.4%) (P <.001). Skills, such as checking the airway patency (P <.001), checking breathing (P <.001), appropriate compression rate (P <.003), and delivering 2 effective breaths (P <.001), improved significantly. Depth of chest compression (P <.023) was improved significantly only in residents with fewer than 2 years of experience. The training process should comprise standardized courses to facilitate acquisition of the desired skills

Are cervical spine X-rays mandatory in all blunt trauma patients?

Traumatic cervical spine injuries can result in severe disability or death unless promptly diagnosed and treated. Advanced trauma life support guidelines recommend that three-view cervical spine X-rays should be obtained routinely in all blunt trauma patients. In this retrospective study, we evaluated whether cervical spine X-rays are indeed necessary in all such patients. The study comprised those patients who were conscious, fully orientated, co-operative and nonintoxicated. Among the 303 blunt trauma patients seen at our emergency department between January and December 1993, a total of 267 patients had well-written charts and met our inclusion criteria. Thirteen (5% patients who complained of neck pain or had neck tenderness on initial examination were found to harbour cervical spine injuries. Of those patients sustaining cervical spine injuries, examination of three (23% disclosed abnormal neurological findings. On the other hand, none of the patients without neck pain and tenderness were found to have cervical spine injury. We conclude that pain and/or tenderness in the neck area are valid criteria with regard to the timely diagnosis of cervical spine injuries, and that routine cervical spine X-rays may be unnecessary for those blunt trauma patients who are conscious, fully orientated, co-operative, non-intoxicated, exhibit no neurological deficits and who do not have neck pain or tenderness. Omitting cervical X-rays speeds up patient evaluation, protects the department staff from unnecessary exposure to ionizing radiation and mitigates treatment costs, while maintaining the quality of the healthcare provided. © 1995 Chapman & Hal

Seeing the invisible: painless aortic dissection in the emergency setting

Acute dissection of the aorta can be one of the most dramatic cardiovascular emergencies. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterised as ripping or tearing in nature. However, a timely diagnosis can be elusive in the event of an atypical presentation. In this report, the authors present two patients with painless aortic dissection who were misdiagnosed during their initial evaluation in the emergency department

working in the emergency departments in Turkey

BACKGROUND: Violence and burnout are frequently seen among medical doctors; however, the relation is not clear. This study aimed to assess the violence and its possible effects on burnout in physicians working in emergency units