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OBJECTIVE: To determine whether there are patterns in the incidence of emergency department (ED) visits for congestive heart failure (CHF) by month of the year, day of the week, or hour of the day. METHODS: This was a retrospective analysis of a computerized billing database of ED visits, involving seven northern New Jersey hospitals EDS: Consecutive patients seen by emergency physicians over an 11-year period (January 1, 1988--December 31, 1998) were included. Chi-square tests were used to evaluate for significant differences (p < 0.05). RESULTS: There were a total of 2,370,233 patients in the database, of whom 26,224 had a primary ED diagnosis of CHF. The chi-square test rejected uniformity for month of the year, for day of the week, and for hour of the day (p < 0.0001). Visits for CHF were increased in the winter months. Compared with the average of the other months, December was the highest (14.3% above, p < 0.0001) and August was the lowest (15.5% below, p < 0.0001). There was also a day-of-the-week variation. Compared with the average of the other days, Monday was the highest (14.5% above, p < 0.0001) and Saturday was the lowest (9.6% below, p < 0.0001). There was also an hour-of-the-day pattern, with a rapid rise after 8 AM and a downtrend after 3 PM. CONCLUSIONS: These data revealed a higher incidence of ED visits for CHF in the winter months, on Mondays, and during the hours of 8 AM to 3 PM. In comparison with previous studies, these data revealed a similar pattern by month of the year and a different pattern by hour of the day.

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INTRODUCTION: The safety and efficacy of medications stored on air medical helicopters may be adversely affected by extreme temperatures. The purpose of this study was to determine whether temperatures inside an air medical helicopter drug box were within the U.S. Pharmacopeia recommendations for controlled room temperature. This is defined as a temperature between 15 degrees and 30 degrees C (59 degrees and 86 degrees F) with a mean kinetic temperature of less than 25 degrees C (77 degrees F). An additional goal was to determine whether time/temperature indicator labels can reliably monitor mean kinetic temperatures. METHODS: Temperatures were monitored with miniature electronic temperature recorders and color-changing time/temperature indicator labels. RESULTS: The mean kinetic temperatures for the summer and winter periods were 25.1 degrees C (77.2 degrees F) and 12.7 degrees C (54.8 degrees F), respectively. In the summer, the electronic recorders logged temperatures exceeding 25 degrees C (59 degrees F) 37% of the time and more than 30 degrees C (86 degrees F) 6% of the time. In the winter, temperatures less than 15 degrees C (59 degrees F) were recorded 83% of the time. The mean kinetic temperatures obtained from the electronic recorder and the time/temperature indicator labels differed by less than 0.7 degree C (1.3 degrees F). The results show that medications on an air medical helicopter are subject to temperatures out of the recommended range and that time/temperature indicator labels can reliably monitor mean kinetic temperatures.

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STUDY OBJECTIVE: To determine whether the use of diclofenac ophthalmic solution is a safe and effective analgesic in the treatment of traumatic corneal abrasions in the emergency department. METHODS: We conducted a prospective, randomized, double-blinded, placebo-controlled clinical trial. Consenting consecutive patients with corneal abrasions who presented to a community-based ED from August through February 1998 were randomly assigned to receive either diclofenac or control vehicle drops. Pain relief was measured using a visual Numeric Pain Intensity Scale (NPIS) before and after treatment. Exclusion criteria were as follows: age younger than 18 years, pregnancy, history of glaucoma, ocular infection, recent eye surgery, other signs of ocular trauma, narcotics within 6 hours, minimal pain (NPIS score <3), and any allergy to diclofenac or nonsteroidal anti-inflammatory drugs. Patients were discharged with study drug or control vehicle solution, a topical antibiotic, oxycodone-acetaminophen as a rescue analgesic, and a pain diary. The outcome measurements were improvement in NPIS score 2 hours after treatment, use of oxycodone-acetaminophen, and occurrence of any adverse effects. RESULTS: Forty-nine patients were enrolled in the study; 25 received diclofenac and 24 received control vehicle drops. Both groups were similar in gender, age, pretreatment pain duration, NPIS score, and analgesic use. There was significantly greater improvement in the 2-hour NPIS score in the diclofenac group (3.1; 95% confidence interval [CI] 2.3 to 4) compared with the control group (1.0; 95% CI 0.1 to 2.0). The difference between the 2 groups was 2.1+/-1.3 (95% CI 0.8 to 3.4). There was a trend toward fewer patients taking rescue oxycodone-acetaminophen in the diclofenac group (20%; 95% CI 4% to 36%) versus the control group (42%; 95% CI 22% to 62%). Other than transient mild stinging, there were no complications associated with diclofenac use. CONCLUSION: Diclofenac ophthalmic solution appears to be a safe and effective analgesic in the treatment of traumatic corneal abrasions in the ED.

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OBJECTIVES: To determine whether temperatures inside drug boxes used in the out-of-hospital setting are within the U.S. Pharmacopeia recommendations for "controlled room temperature," which is defined as a temperature maintained between 15 degrees C and 30 degrees C with a mean kinetic temperature less than 25 degrees C, and to determine whether time-temperature indicator labels can reliably monitor mean kinetic temperatures. METHODS: Two methods were used to monitor temperatures: miniature electronic temperature recorders and color-changing time-temperature indicator labels. These were placed in drug storage boxes of advanced life support units over three summer months and two winter months. RESULTS: In summer, the electronic recorders logged temperatures exceeding 30 degrees C in all drug storage boxes, ranging from 3% to 29% of the total time. The mean kinetic temperatures by location for the whole period ranged from 21 degrees C to 30 degrees C. In the winter, the electronic recorders logged temperatures exceeding 30 degrees C at one location 2% of the total time. There were significant temperature excursions below 15 degrees C at all locations, ranging from 16% to 90% of the total time. At one location, there were temperature readings below 0 degrees C for 9% of the total time. The mean kinetic temperatures obtained from the electronic recorders and the indicator labels differed by less than 1 degrees C. CONCLUSIONS: This study demonstrates that out-of-hospital medications are subject to temperatures both above and below recommended storage temperatures. Time-temperature indicator labels can reliably monitor exposure to elevated temperatures.

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OBJECTIVE: To describe the epidemiology of pediatric visits to the emergency departments (EDs) of 10 general hospitals by age and gender. DESIGN: Review of ICD-9 codes from the billing database of a practice of emergency physicians. SETTING: Ten hospitals in north/central New Jersey. PATIENTS: All children <18 years treated by group physicians in EDs of study hospitals. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Diagnoses and visits. RESULTS: There were 319,430 diagnoses recorded for 241,839 children (18.9% of the 1,277,233 total visits by all ages). The number of visits was highest in the <2 and >14 years age groups, with males predominating in all age groups. The number of visits from trauma increased with age. Otitis accounted for over 3% of all ED visits in this sample, over 7000 visits. CONCLUSIONS: Children account for a significant portion of ED visits in general hospitals. EDs need to be equipped and staffed to handle this clientele.

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The most common diagnoses of elderly patients in the emergency department (ED) were compared among three age subgroups: 65 to 74, 75 to 84, and 85 and older. The computerized billing records for patient visits to 10 northern New Jersey hospital EDs for the years 1985 to 1991 were retrospectively analyzed. The most frequently occurring ICD-9-CM codes for elderly patients were compared among the three age subgroups. Elderly persons comprised 174, 146 (14% of the total) patient visits. The 176,146 patient visits were assigned 259,440 ICD-9-CM codes. The most common ICD-9-CM codes for medical diagnoses included chest pain, cardiac dysrhythmias, congestive heart failure, syncope, abdominal pain, and dyspnea. Fractures, particularly of the lower limb and upper limb; contusions; open wounds, particularly of the head, neck, and trunk; and falls were among the most common trauma diagnoses. The proportions in the three age subgroups of each diagnosis were statistically significantly different, except for cardiac arrest and contusions of the trunk and of multiple sites. The diagnoses with clinically significant higher relative risks in older age subgroups were atrial fibrillation, congestive heart failure, syncope, hypovolemia/dehydration, gastrointestinal hemorrhage, dyspnea, pneumonia, pulmonary edema, cerebrovascular accident, septicemia, urinary tract infection, fractures, and open wounds of the head, neck, trunk, particularly the scalp, and falls. Clinically significant lower relative risks were found in older age subgroups for chest pain, acute myocardial infarction, hypertension, angina, chronic airway obstruction not elsewhere classified, epistaxis, contusions of the upper limb, and open wounds of the finger.

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Spontaneous cervical epidural hematoma is a rare cause of neck pain. We present the case of a 64-year-old woman who presented to the emergency department with neck pain from a partial Brown-Sequard syndrome secondary to spontaneous cervical epidural hematoma. The prompt recognition of this entity resulted in a favorable outcome.

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A prospective case series was conducted to demonstrate the safety and efficacy of intravenous nitroglycerin (i.v. NTG) boluses in the treatment of ischemic chest pain (CP) in the emergency department (ED). Patients with CP symptomatic after sublingual nitroglycerin (SL NTG) therapy with a systolic blood pressure (SBP) greater than 95 mmHg were included. Patients were treated with i.v. NTG boluses of 0.05 mg to 0.4 mg during a 1- to 2-minute period per a protocol based on the patient's prebolus SBP. This was followed by a maintenance infusion. Additional NTG boluses were repeated every 5 minutes as needed. The end point of treatment was the resolution of chest discomfort, thrombolysis, or a SBP less than 95 mmHg. There were 16 cases of CP. All 16 patients treated, ie, 5 with acute myocardial infarction and 11 with unstable angina showed significant decrease in chest discomfort after 1 to 2 boluses. Two of five with acute myocardial infarction and 9 of 11 patients with unstable angina had complete relief of chest pain after 1 to 4 boluses. There were no episodes of hypotension (SBP < 90 mmHg) in any of the 16 cases. The judicious use of i.v. NTG boluses administered during a 1- to 2-minute period, in the ED, appears safe and efficacious in patients with CP unresponsive to SL NTG therapy.

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The objective of this study was to report the authors' experience using intravenous ketorolac (Syntex Laboratories, Palo Alto, CA) as an analgesic in the treatment of renal colic in a convenience sample at three suburban community hospital emergency departments. Twenty-five patients with renal colic were participants. Pregnant women, patients with a history of renal or hepatic impairment, bleeding diathesis, active peptic ulcer disease, or hypersensitivity to aspirin or nonsteroidal antiinflammatory drugs (NSAID) were excluded. Ketorolac 30 mg administered intravenously during a 1-minute period, and the following parameters were monitored at times 0, 5, 10, 20, 30, and 60 minutes: pain on a scale of 0 to 10, pulse rate, blood pressure, and adverse side effects. A total of 25 patients were included in our series. Initially, they had a median pain score of 9 with an interquartile range of 1. Thereafter, the median pain scores and (interquartile ranges) were 8 (three) at 5 minutes, 5 (four) at 10 minutes, 2 (four) at 20 minutes, 1 (three) at 30 minutes, and 0 (one) at 60 minutes. There were no adverse side effects observed in any patients. Therefore, it can be concluded that intravenous ketorolac is an effective analgesic agent for the control of pain in patients with renal colic.

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The authors polled emergency medicine groups in an attempt to identify whether equity was offered and the time, costs, and methods of achieving equity. Several characteristics of equity and nonequity groups were compared. A survey was distributed to 514 groups from a list identified by the American College of Emergency Physicians. Nonresponders received a second mailing. Valid responses were received from 127 groups representing 3,405 physicians. Of the respondent groups, 69 allowed full equity participation. The mean time to full partnership was 2.2 years for new physicians. Single hospital groups tended to have shorter (1.6 years) buy-in periods compared with multihospital groups (3-4 years). The most common method of buy-in was a differential in the "bonus" structure between new physicians and partners. The actual cost to attain full equity varied greatly with a range of from $0 to $500,000. Groups not owning their accounts receivable had a total mean buy-in cost of approximately $40,000 as compared with those that did own their accounts receivable, where the average buy-in cost was approximately $106,000. The proportion of equity groups that had two thirds or more physicians board-certified in emergency medicine was significantly greater than those groups without equity. The detailed structure for attaining equity varied greatly between groups. The authors conclude that many emergency physician groups allow full equity participation. The average time to full partnership is generally less than 3 years. There are many diverse schemes of entering into partnership. The cost of acquiring full equity varies greatly.

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A 46-year-old man suffered a witnessed cardiac arrest. Ventricular fibrillation persisted despite 62 minutes of basic and advanced cardiac life support measures in the field. On arrival in the emergency department, he received 4 g magnesium sulfate IV and was defibrillated successfully to normal sinus rhythm with the next countershock. The patient was discharged neurologically intact. We discuss the possible mechanisms of action and clinical use of IV magnesium sulfate in cardiac arrest.

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Reagent teststrip determination of blood glucose has been shown to be accurate for hospital and home testing and is commonly used in prehospital care despite the lack of studies in this arena. This prospective, multicenter study examines the ability of glucose reagent teststrips to detect hypoglycemia when used under field conditions compared with simultaneously drawn control samples for laboratory glucose determination. Also examined was the accuracy of the teststrips in the laboratory glucose range less than or equal to 200 mg/dL. One hundred eighty-one pairs of data were analyzed. Hypoglycemia was defined as laboratory glucose less than or equal to 60 mg/dL. The teststrips correctly identified 31 of 33 patients in this range (sensitivity = 94%), and 125 of 148 patients without hypoglycemia (specificity = 85%). The two false negative readings were 70 and 90 mg/dL. Reagent teststrips were within +/- 40 mg/dL of the laboratory value in 70% of cases. The correlation coefficient (Spearman r) between teststrip and laboratory glucose in the range less than or equal to 200 mg/dL was .80. Using teststrip readings of 90 mg/dL or less as a measure of hypoglycemia yields 100% sensitivity with a specificity of 57%. We conclude glucose reagent teststrips are a useful adjunct for use in the prehospital setting and may be valuable for the detection of hypoglycemia.

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Ambulatory patients frequently ingest liquids or smoke just before temperature measurement. The change in body temperature measurements over time following ingestion of ice water, hot water, and smoking were investigated. Twenty-two healthy, afebrile study subjects sequentially ingested temperature-controlled water and smoked a cigarette. Simultaneous oral and auditory canal temperatures were measured over 15 minutes following ingestion. Auditory canal temperatures were obtained with an infrared detection probe; we designated this process a tympanic membrane-derived (TMD) temperature. To determine the correlation between rectal and TMD temperatures, 100 patients had simultaneous measurements at both sites. Mean initial temperatures were rectal, 37.1 +/- 0.5 degrees C (mean +/- S.D.); oral, 36.4 +/- 0.4 degrees C; and TMD, 37.4 +/- 0.4 degrees C. Maximal mean oral temperature change was greatest at 1.5 minutes after hot, +0.9 +/- 0.1 degrees C, and cold, -1.2 +/- 0.2 degrees C, water. This change was statistically significant for seven minutes at the 95% confidence level (analysis of variance test with Dunnett's multiple range test for significance). There was no significant change in the TMD temperature with any ingestion. The Pearson correlation coefficient for 107 pairs of rectal and TMD temperatures, r = 0.90 (P less than .001), was excellent. It was concluded that hot and cold liquids significantly influence oral temperature measurement for seven to nine minutes following ingestion. TMD temperature is unaffected by liquid ingestion and may allow accurate measurement of body temperature. Further studies are needed to determine the accuracy of TMD temperature over a wide range of body temperature in diverse clinical settings.

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In order to enhance subtle changes not apparent in resting ECGs by conventional criteria, a computerized signal processing technique, biopotential coordinate transformation (BCT), has been developed to increase the physician's perceptibility of CAD in seemingly "normal" resting ECGs. ECGs initially read as normal then can be tested with this process to predict the presence or absence of CAD. A blinded, retrospective study of 93 Caucasian patients with normal ECGs was performed using coronary angiography as the test standard. The BCT process identified the presence or absence of CAD with an 84.3% sensitivity and 81.8% specificity in 62 men. Similarly, a 76.2% sensitivity and 80% specificity was obtained for 31 women. These results suggest that the BCT process may provide the emergency physician with a noninvasive screening test for the detection of CAD in patients with apparently normal resting ECGs. Further studies are necessary for process refinement and verification.

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