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Summary The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post‐1984 literature there are no published reports of aspiration‐associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus‐derived algorithm in which each patient is first risk‐stratified during their pre‐sedation assessment, using evidence‐based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

OBJECTIVES We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California. METHODS We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact. RESULTS We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control. CONCLUSIONS In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care.

Many hospitals, and medical and dental clinics and offices, routinely monitor their procedural-sedation practices—tracking adverse events, outcomes, and efficacy in order to optimize the sedation delivery and practice. Currently, there exist substantial differences between settings in the content, collection, definition, and interpretation of such sedation outcomes, with resulting widespread reporting variation. With the objective of reducing such disparities, the International Committee for the Advancement of Procedural Sedation has herein developed a multidisciplinary, consensus-based, standardized tool intended to be applicable for all types of sedation providers in all locations worldwide. This tool is amenable for inclusion in either a paper or an electronic medical record. An additional, parallel research tool is presented to promote consistency and standardized data collection for procedural-sedation investigations.

Background Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation. Methods We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events. Results Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy. Conclusions This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.

In the late 1980s, undertreated pain became a focus of many clinicians, investigators, and industry. We coined a term, oligoanalgesia, to embolden earlier, titrated opioids and other analgesic use. Regulators mandated pain assessments and actions as a part of health care facility credentialing, and the prescribing of opioids increased yearly from 1990 to 2010. We now sit amid another opioid epidemic with death and disability. Many know of the patterns of use and abuse near the turn of the 20th century when opium was a new agent; this triggered opioid regulations and control, notably, the US Harrison Narcotics Tax Act of 1914 criminalizing nonmedical use. Despite regulation of opioids, swings upward in medical and nonmedical use exist in recent modern times. For example, a 1959 Readers Digest article noted a current opioid addiction crisis, reminding us that the cycles reappear often, with varying frequency, responses, and consequences. The current opioid upswing is rooted in prescribed and illicit use, the latter including heroin (or other “street” opioids) and diversion of another’s or factitious gain of a prescribed opioid. The widespread increase in opioid use correlates with increased overdose deaths and deaths in all segments, including more affluent and suburban or rural groups, not just in an inner-city or isolated population. Although the peak of the current wave crested in approximately 2010, we retain a large group with this affliction. This triggered calls for regulation and control in many facets of opioid deployment, including emergency care, despite few data suggesting a clear link between emergency department (ED) opioid use and later harm. Some seek governmental ED dose restrictions, and others call for “an opioid-free ED.” The goal of these calls to action is good: to avoid opioid harm, notably, death. At the

Annals of Emergency Medicine - In Press.Proof corrected by the author Available online since dimanche 21 decembre 2014

Procedural sedation is an integral part of emergency medicine (EM) practice in the USA, Canada, Australia and New Zealand. These countries have produced a large, robust literature supporting the safe and efficacious use of ketamine, propofol and other ED sedation agents for managing procedural pain and anxiety.1–3 In the UK and Ireland, EM and paediatric EM practitioners are striving to similarly establish procedural sedation as a fundamental part of their practice. McCoy et al describe, through a structured interview session with a group of EM consultants, the current issues impacting procedural sedation in the UK and the barriers to its adoption. Many of these same challenges and impediments were encountered in North America and Australia/New Zealand, and the lessons learned may be applicable and helpful in the UK and Ireland.4 As veterans of these challenges, here is our perspective. The capability of paediatric emergency physicians to administer timely procedural sedation directly benefits patients and their families by providing a safe, effective and efficient outpatient way of managing procedural pain and anxiety. Emergency physicians from North America, Australia and New Zealand reading the McCoy et al report will be surprised by the acceptance of hospitalisation as standard practice for management of simple forearm fractures in children, especially in the UK where EM is an established specialty. Such an approach transforms a brief ED procedure and a 30–90 min recovery into an overnight bed, an admitting paediatrician, a theatre room and an anaesthetist. Instead of promptly returning to the comforts of home, …

Intrinsic paralysis can be the manifestation of a variety of pathologic entities (stroke, cerebral palsy, Charcot-Marie-Tooth, muscular dystrophy, leprosy, trauma, cervical disease, and compressive and metabolic neuropathies). Patients present with a spectrum of clinical findings dependent on the cause and severity of the disease. The 3 main problems caused by intrinsic weakness of the fingers are clawing with loss of synchronistic finger flexion, inability to abduct/adduct the digits, and weakness of grip. Clawing is defined as hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints. This article describes the clinical evaluation and surgical treatment options for claw hand.

It is time to abandon the Glasgow Coma Scale (GCS). As discussed below, this ubiquitous neurologic scoring system is confusing, unreliable, and unnecessarily complex, and its manner of common clinical use is statistically unsound. Teasdale and Jennett devised the GCS in 1974 not for acute care, but rather for the “repeated bedside assessment” in a neurosurgical unit to detect “changing states” of consciousness and to measure the “duration of coma.” They never intended for its elements to be assigned numeric scores or for its 3 subscales to be merged or totaled. Yet, despite their objections both such dubious modifications subsequently proved irresistible to the medical community. The quantitative GCS subsequently has become the undisputed universal criterion standard for mental status assessment and is thus a fundamental part of the culture of emergency medicine, out-of-hospital care, trauma surgery, and neurosurgery. This scale is a core component of prominent trauma and life support courses, and in most of the developed world out-of-hospital care providers routinely assess the GCS for each patient with trauma or altered mental status. The original GCS article has been cited almost 6,000 times. This editorial outlines the potent limitations of the GCS and why it should now be considered obsolete within acute care medicine. This scale might be useful, however, for detecting subtle neurologic changes over time in an ICU (as originally envisaged). Curiously, though, it has never been validated for this separate role.

INTRODUCTION Procedural sedation refers to the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate unpleasant procedures while preserving cardiorespiratory function. Procedural sedation and analgesia is a core competency in emergency medicine and a daily part of emergency department (ED) practice. As noted by the United States Centers for Medicare & Medicaid Services (CMS): “The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality.” The CMS guidelines also state that “. . . emergency medicine–trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general).” Emergency medicine residency and pediatric emergency medicine fellowship core curricula include all of the requisite procedural sedation skills, eg, advanced airway management, resuscitation, critical care, monitoring, sedation pharmacology, pain management. Emergency physicians have a wellestablished track record of safe sedation and are important research and thought leaders in this multidisciplinary field. The American College of Emergency Physicians (ACEP) is an authoritative body that has established guidelines for the use of sedation, analgesia, and anesthesia by emergency physicians. CMS guidelines support the use of the ACEP guideline: “A hospital could use multiple guidelines, for example, ACEP for sedation in the ED and American Society of Anesthesiologists (ASA) for anesthesia/sedation in surgical services, etc.” ACEP convened this task force in 2011 to provide this update to guide hospital policy for the administration of analgesia, sedation, and anesthesia by emergency physicians.

We wished to compare the acuity of adults vs. children using a representative sample drawn from a geographically isolated region. We retrospectively analyzed Emergency Department (ED) patient logs, billing records, and trauma data from two hospitals serving a geographically isolated region (Santa Barbara, California), and compared the following measures of acuity by age, triage category, rates of admission, billing levels of service, procedures (ED intubation, cardiopulmonary resuscitation, and invasive line placement), and trauma team activations. We analyzed 88,864 patients treated at the two EDs over an 18-month period, of whom 15,589 (17.5%) were children (18 years of age). Adults were 1.93 times more likely than children to receive the highest triage category (95% confidence interval [CI] 1.65-2.27), 3.47 times more likely to be admitted (95% CI 3.26-3.70), 2.92 times more likely to receive critical care or extended examination billing (95% CI 2.78-3.06), 2.63 times more likely to be intubated (95% CI 1.78-3.88), 4.59 times more likely to receive cardiopulmonary resuscitation (95% CI 1.67-12.57), and 4.39 times more likely to receive invasive line placement (95% CI 1.93-10.01). No age-based differences were noted in the rates of highest-level trauma team activation or admission directly to the operating room. ED children have overall lower acuity than ED adults-by many measures, several-fold less. These findings may have important implications for ongoing skills retention and proficiency in critical care for practitioners whose ED practice is restricted to representative samples of children.

Rodent and monkey research has shown that ketamine can induce accelerated programmed nerve cell death (apoptosis) when administered in high doses, for prolonged periods, or both. Concern about similar neurotoxicity with human therapeutic use has prompted ongoing investigations by the Food and Drug Administration and National Institutes of Health. If the results of these inquiries are unfavorable to ketamine, such action could ultimately lead to restricted availability of this drug or even its discontinuation from the market. This article discusses the limitations of the published animal research, the challenges in extrapolating such data to humans, the need for further animal and human investigations, and the potential adverse effect on current clinical practice that might result, should the use of ketamine be restricted or the drug removed from the market.

Propofol is rapidly becoming one of the most popular procedural sedation and analgesia agents in emergency medicine. However, in many hospitals emergency physicians lack access to this potent sedative. This article details the evidence and politics underlying this area of controversy, the nature and authority of hospital-wide sedation policies, and discussion of the most common criticisms of emergency department use of propofol.

Emergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. The advisory is not intended to assert a legal standard of practice or absolute requirement. It is expected that emergency physicians will at times appropriately deviate from it according to individualized judgment and unique clinical circumstances.

[Green SM, Rothrock SG. Is pediatric trauma really a surgical disease? Ann Emerg Med. May 2002;39:537-540.]

The assessment of pre-procedure fasting and control of sedation depth are prominent elements of widely disseminated procedural sedation guidelines and of the Joint Commission on Accreditation of Healthcare Organizations' standards. Both exist primarily to minimize the risk of pulmonary aspiration of gastric contents. This paper critically examines the literature on pre-procedure fasting and controlling sedation depth in association with pulmonary aspiration, and interprets this evidence in the context of modern emergency medicine practice. The article reviews the pathophysiology of aspiration and changing concepts regarding aspiration risk over the last decade. After reviewing studies on aspiration risk during general anesthesia, the paper reviews the risk of aspiration during labor and delivery as a more appropriate comparison group for aspiration risk during emergency department procedural sedation and analgesia (ED PSA). It is noted that aspiration during ED PSA has not been reported in the medical literature and that aspiration during general anesthesia and labor and delivery is uncommon. The literature provides no compelling evidence to support specific fasting periods for either liquids or solids prior to PSA, and existing guidelines for elective patients are of necessity arbitrary and based upon consensus opinion. The article discusses the implications in the areas of training and preparedness, monitoring, and research for the emergency physician practicing PSA.

ion measure quality? a prospective comparison of standardized patients with the medical record. Am J Med.

Clinical decision rules are increasingly prominent in medicine, particularly in emergency care. The quality, use, and impact of current published decision rules widely vary, requiring clinicians to be critical consumers. We present an approach to assist in the appraisal of clinical decision rules and in judging when to use such rules.

Study objective : We sought to characterize the clinical manifestations, outcome, and etiology of inadvertent ketamine overdose in the emergency department. Methods : We investigated cases of inadvertent ketamine overdose in children seen in the ED solicited through electronic mail subscription lists or reported to the Institute for Safe Medication Practices. The clinical manifestations, outcome, and reported cause for each case are described. Results : We identified 9 cases of inadvertent ketamine overdose in children treated in the ED. Patients received either 5 (n=3), 10(n=5), or 100 (n=1) times the intended dose, either by the intramuscular (n=5) or intravenous (n=4) route. All 9 experienced prolonged sedation (3 to 24 hours). Four experienced brief respiratory depression shortly after administration, and assisted ventilation was performed in 2. Two children without respiratory difficulty or hypoxemia were intubated by their physicians as a precaution. In 5 children, the dosing error was not discovered until late in the sedation, often when the child was not waking at the expected time. No adverse outcomes were noted, and all children were normal neurologically on discharge and longer-term follow-up if available. Conclusion : No adverse outcomes were noted in 9 healthy children treated in the ED who inadvertently received 5 to 100 times the intended dose of ketamine. Toxicity manifested as prolonged sedation in all 9 and brief respiratory depression in 4. The margin of safety in ketamine overdose may be wide, although less common and more serious outcomes cannot be excluded by this small, self-reported sample.

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

Injuries to the finger extensor apparatus are very common and may produce chronic deformity and loss of function. Diagnosis is contingent on an understanding of the complex anatomy of this region as well as the ability to perform a careful physical examination. Immobilization is usually the most effective treatment of acute problems. Surgery is often necessary for chronic conditions, but the results are much less predictably corrective.

Objective: To determine the test performance of leukocytosis for identifying acute myocardial infarction (AMI) in patients with nondiagnostic ECGs, admitted to rule out AMI. Methods: A retrospective, comparative test performance study was conducted using patients admitted to a university teaching hospital to rule out AMI. Clinical and laboratory information was reviewed and hospital laboratory ranges were used to define threshold elevations: total creatine kinase (CK), 275 U/L; CK-MB, 7.5 μg/L; white blood cell (WBC) count, 11.5 × 109/L; and absolute neutrophil count (ANC), 8.0 × 109. Sensitivity, specificity, and predictive values of the total CK, CK-MB, WBC count, and ANC were calculated, and receiver operating characteristic (ROC) curves constructed. Test performances of marker combinations also were determined. Results: The initial WBC count was significantly higher for the subjects who had AMI (11.1 vs 8.8 × 109/L, p < 0.001). For the 688 subjects who had nondiagnostic ECGs, sensitivities for the initial total CK, CK-MB, WBC, and ANC were 39%, 73%, 35%, and 36%, respectively, while the corresponding specificities were 94%, 93%, 85%, and 86%. Logistic regression analysis confirmed leukocytosis as an independent predictor of AMI (adjusted odds ratio 4.08, 95% CI 1.73–9.63). While CK-MB alone was 73% sensitive for AMI, the decision rule of either an elevated CK-MB or an elevated WBC count increased this sensitivity to 88% (corresponding specificity 79%). Similarly, while CK-MB alone was 93% specific for AMI, the combination of an elevated CK-MB and an elevated WBC count increased this specificity to 99% (corresponding sensitivity 20%). Conclusions: Leukocytosis is significantly associated with AMI, and is a weak but independent laboratory predictor of this condition. In this preliminary study of admitted patients suspected of AMI, the combination of the WBC and the CK-MB may have, additional diagnostic value over an isolated CK-MB result. Neither parameter in isolation was satisfactorily sensitive for AMI. Prognostic assessment of the role of the WBC count in clinical decision making should address its complementary role to that of other clinical and ancillary test parameters.

Emergency physicians (EPs) are increasingly participating in international medicine in regions that are chronically medically underserved. In August 1994, a ten-member emergency medicine team from the Loma Linda University School of Medicine staffed a 70-bed bush hospital in the primitive highlands of Papua New Guinea, providing both outpatient and inpatient medical care. Typhoid fever, malaria, polio, and numerous other infectious diseases were encountered. Rampant local tribal warfare resulted in regular penetrating injuries from arrows, spears, and machetes. The expedition was judged highly successful, in that 1) substantial medical service was provided to tribespeople accustomed to minimal care, 2) education was provided to local health care providers, and 3) team participants became adept at managing medical conditions uncommon in industrialized societies, and gained valuable ethical and utilitarian perspectives regarding health care delivery in underserved areas. In this article the objectives, organization, and experiences of the team members are described. This information may encourage other EPs to participate in medical expeditions to the developing world, and to provide general principles to assist in their organization and implementation.

This video depicts the clinical presentation of patients with a foreign body in the external auditory canal or the nasal passage and describes the most effective techniques for smooth and safe retrieval.

Are triage respiratory rates inaccurate? Absolutely. In this month’s Annals, Bianchi et al compared standard nurserecorded triage respiratory rates with those measured by a research assistant during 60 seconds and those obtained by a commercial respiratory rate sensor (BioHarness; Zephyr Technology, Corp, Annapolis, MD). Tachypnea ( 20 breaths/ min) was missed 77% of the time. This statistic is alarming because emergency physicians fundamentally rely on triage vital signs to help assess their patients. With tachypnea being missed three fourths of the time, we must be receiving false reassurance for substantial numbers of patients. Tachypnea is an integral diagnostic element of systemic inflammatory response syndrome and a key component of pneumonia scores (eg, Pneumonia Severity Index, CURB 65); accordingly, erroneous triage respiratory rates should result in misclassifications of patients. Is there any evidence this is really a problem? During your last shift, how many patients were harmed because their triage respiratory rate was inaccurate? Bianchi et al concluded that the solution is to change how respiratory rate is measured, perhaps by using the BioHarness device routinely at triage. This would be a time-consuming and expensive change for every emergency department (ED). But perhaps it must be done for the sake of accuracy. Let’s critically examine what we already know about respiratory rates, examine the implications of these new data, and then try to make sense of this conundrum. Taking vital signs is a standard prelude to every ED visit and essentially all health care encounters. There is little dispute that respiratory rate is the least objective vital sign. Bianchi et al demonstrated that routine triage assessments do not agree with measurements taken during a full minute (as recommended by the World Health Organization). Previous ED studies reported similar results. Indeed, the interrater reliability of measuring respiratory rates during a full minute is also poor, although this criterion standard has not been questioned. It is widely assumed that triage nurses often estimate respiratory rates rather than formally counting respirations for 15 seconds and multiplying by 4. Recorded values such as 14 or 18 breaths/min, which are indivisible by 4, support this contention. Bianchi et al reported that triage nurses most commonly record rates of 16 to 18 breaths/min, which seems consistent with anecdotal observations elsewhere. d

An unusual case of acute appendicitis induced by a metal drill bit that was ingested by a 27-year-old man 3 years before presentation is reported. This foreign body lodged in the patient's appendix and developed a fecalith coating. When this fecalith coating enlarged enough to obstruct the appendiceal lumen, the patient presented with classic acute appendicitis. Foreign body-induced appendicitis is reviewed.

In this issue of Annals, we present seemingly contrasting information about the search to identify individuals with acute pulmonary embolism. Our goal is to make sense of this discordance and offer a pragmatic and patient-centered approach. The systematic review and meta-analysis of the pulmonary embolism rule-out criteria (PERC) by Singh et al assesses almost 14,000 patients from the 11 best-quality studies performed in 6 countries. The authors observed that the frequency of missed pulmonary embolism in patients meeting all 8 PERC criteria was 0.3%. This 1 in 300 result is as close to ideal as is possible in medicine, allowing us to identify patients for whom D-dimer testing and imaging can be avoided altogether. Because some individuals have previously advocated D-dimer testing for low-risk pulmonary embolism patients, this is an important advance. Adding D-dimer testing can almost never help detect a pulmonary embolism in PERC-negative patients, it increases care time and resource use absent a benefit, and it may add harm. Experts estimate that 1 radiation-induced cancer will result from every 2,000 computed tomography (CT) pulmonary angiograms, with half of such cancers ultimately fatal. Similarly, 1 contrast-induced renal failure will occur for every 200 such studies, with half of such events ultimately fatal. Simply put, pulmonary embolism testing in PERC-negative patients will almost always lead to more harm than benefit. Also in this issue, Hennessey et al reported a case of a 42year-old woman presenting to an emergency department (ED) with chest pain, with apparently very low pulmonary embolism risk, whether applying the Wells score, revised Geneva criteria, PERC, or unstructured clinical judgment. An inadvertently ordered D-dimer result was abnormal, and the subsequent CT pulmonary angiography revealed a saddle embolus; the “needle in the haystack” was found. So how do we resolve this paradox? Is PERC effective or isn’t it? Can we avoid extensive testing seeking pulmonary embolism in low-risk patients? This case p

Objective. It is frequently taught that lumbar puncture is a mandatory procedure in many or all children who have fever and a seizure, because the convulsion may represent the sole manifestation of bacterial meningitis. We attempted to determine the incidence of this occult manifestation of meningitis. Design. Retrospective case series. Setting and patients. 503 consecutive cases of meningitis in children aged 2 months to 15 years seen at two referral hospitals during a 20-year period. Main outcome measures. Signs and symptoms of meningitis in patients having associated seizures. Results. Meningitis was associated with seizures in 115 cases (23%), and 105 of these children were either obtunded or comatose at their first visit with a physician after the seizure. The remaining 10 had relatively normal levels of consciousness and either were believed to have viral meningitis (2) or possessed straightforward indications for lumbar puncture: nuchal rigidity (6), prolonged focal seizure (1), or multiple seizures and a petechial rash (1). No cases of occult bacterial meningitis were found. Conclusion. In our review of 503 consecutive children with meningitis, none were noted to have bacterial meningitis manifesting solely as a simple seizure. We suspect that this previously described entity is either extremely rare or nonexistent. Commonly taught decision rules requiring lumbar puncture in children with fever and a seizure appear to be unnecessarily restrictive.

This prospective observational study was designed to assess the incidence and severity of middle ear barotrauma associated with repetitive recreational scuba diving. Eleven healthy adult experienced scuba divers were observed performing repetitive daily scuba diving over a 15 day period. Otoscopy and tympanometry were performed on days 0, 3, 7, 11 and 15. Participants averaged 41 dives during the study period. Mild otalgia occurred at some point in 23% of ears and subsequently resolved in all but one despite continued diving. Eight-two per cent of ears demonstrated otoscopic evidence of middle ear barotrauma by day 3, and all exhibited barotrauma by day 11. Tympanic membrane perforation, hemotympanum, or evidence of inner ear barotrauma did not occur. Tympanometry revealed a significant decrease in middle ear pressures but no evidence of middle ear effusions. Gross measurements of otologic acuity and conduction remained normal. No complications or sequelae were noted at three month follow-up. Otoscopic evidence of middle ear barotrauma and tympanometric evidence of eustachian tube dysfunction developed rapidly in a group of experienced scuba divers performing repetitive recreational diving. Symptoms were minimal and infrequent. No serious otologic dysfunction was noted despite continued repetitive diving, and it is possible that middle ear barotrauma at the degrees observed represents a more benign disorder than has been previously assumed.

Study objective: To prospectively evaluate previously described high-yield clinical criteria for obtaining plain abdominal radiographs in the emergency evaluation of children. Design: Prospective, observational study. Setting: Emergency departments of a university medical center and an affiliated county hospital. Participants: Three hundred fifty-four children 15 years old or younger who underwent plain abdominal radiography during a one-year period. Methods and measurements: Physicians ordering plain abdominal radiographs completed data forms that included historical and physical examination information before viewing films. At a later date, records of all patients were reviewed for radiologist interpretation and final diagnosis. The data were analyzed to determine the sensitivity, specificity, and predictive values of previously described high-yield criteria (from a retrospective series) in detecting radiographs that were diagnostic or suggestive of "major" abdominal disease. Main results: Sixty-one patients (17%) had major diseases potentially requiring procedural intervention (eg, appendicitis, ingested foreign bodies, and intussusception), whereas 296 patients (83%) had minor diseases not requiring procedural intervention (eg, gastroenteritis and nonabdominal diagnoses). The presence of any of the following features—prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, abdominal distention, or peritoneal signs—was 93% sensitive and 40% specific in detecting diagnostic or suggestive radiographs in patients with major disease. Positive and negative predictive values were 11% and 99%, respectively. If only these criteria had been used to obtain radiographs, 38% of films would have been omitted (at an estimated savings of $20,000) with only two suggestive radiographs missed. Conclusion: Our results suggest that restricting abdominal radiographs to patients with at least one of these five high-yield clinical features will detect most diagnostic and suggestive radiographs in children with major abdominal diseases.

Study objective: To evaluate the efficacy of routine early administration of IV magnesium to patients with acute asthma. Design: Prospective, randomized clinical trial. Setting: Urban teaching hospital emergency department. Type of participants: One hundred twenty consecutive patients aged 18 to 65 years with acute asthma unresponsive to a single albuterol treatment. Interventions: All patients received oxygen, 125 mg IV methylprednisolone, and hourly albuterol inhalation therapy. The study group also received 2 g IV magnesium sulfate infused over 20 minutes. Measurements and main results: Demographic and clinical characteristics were similar in both groups. Hospitalization was necessary in 13 of 58 patients who received magnesium (22%; 95% confidence intervals [CI], 13% to 32%) and 11 of 62 control patients (17%; 95% CI, 10% to 26%; P = .523). Duration of ED treatment in discharged patients was 224 ± 75 minutes in the magnesium group (95% CI, 208 to 240 minutes) and 228 ± 90 minutes in the control group (95% CI, 209 to 247 minutes, P = .832). In addition, changes in peak expiratory flow were not statistically different. Conclusion: Routine early administration of IV magnesium in acute asthma does not alter treatment outcome.

The clinical features of children treated with oral antibiotics before the diagnosis of bacterial meningitis differ from those who receive no antibiotics.Retrospective case series.University medical center.Two hundred fifty-eight children 24 months old or younger with bacterial meningitis hospitalized during a 12-year period. Eighty-three children were treated with oral antibiotics before the diagnosis of meningitis, and 175 children were not.None.The emergency department chart and hospital records were reviewed for presenting demographic, historical, physical examination, and laboratory features. Clinical features of pretreated and untreated patients were compared.Pretreated children demonstrated less frequent temperature of 38.3 C or higher, altered mental status and a longer duration of symptoms before diagnosis, with more frequent vomiting; ear, nose, and throat infections; and physician visits in the week before detection of meningitis (P less than .05 for all comparisons). There was no difference in incidence of upper respiratory symptoms, seizures, nuchal rigidity, Kernig's and Brudzinski's signs, focal neurologic signs, mortality, and length of hospitalization between groups.Clinical features of children who have taken antibiotics before the detection of meningitis differ significantly from those who have not undergone antibiotic therapy. Physicians should be aware of these differences when evaluating young children on antibiotics for the possibility of meningitis.

Madelung’s deformity is a rare condition of the wrist characterized by a shortened distal radius with volar–ulnar curvature and a dorsally prominent distal ulna. It occurs predominantly in adolescent females who present with pain, decreased wrist mobility, and deformity. Although its aetiology remains unclear, its treatment is becoming more refined. Several different surgical techniques have recently been described in the literature. This review addresses Madelung’s deformity and suggests an algorithm for management based on current literature and the authors' own clinical experience.

A retrospective review was performed to determine the utility of plain abdominal radiographs in evaluating children presenting to the emergency department. Clinical features, radiographic interpretation, and final diagnoses of 431 patients seen over one year were recorded. One hundred three (24%) patients had major diseases (ventriculoperitoneal shunt malfunction, foreign body ingestion, appendicitis, intussusception, bowel obstruction, necrotizing enterocolitis, toxic megacolon, blunt abdominal trauma, pyloric stenosis, and Hirschsprung's disease), while the remaining 328 (76%) had minor diseases. Radiographs were categorized as diagnostic, suggestive, normal, incidental, or misleading, with respect to the patient's final diagnosis. No single clinical feature was able to detect all diagnostic radiographs in patients with major diseases. Limiting radiographs to patients with prior abdominal surgery, suspected foreign body ingestion, abnormal bowel sounds, abdominal distention, or peritoneal signs identified all patients with radiographs diagnostic of a major disease while eliminating 48% of studies ordered. Our results suggest that restricting abdominal roentgenograms to patients with at least one of these features will detect most diagnostic radiographs in children with acute abdominal diseases.

Throughout the past quarter century, there have been slow but dramatic changes in the nature and practice of trauma surgery, and this field increasingly faces potent economic, logistic, political, and workforce challenges. Patients and emergency physicians have much to lose by this budding crisis in our partner discipline. This article reviews the specific issues confronting trauma surgery, their historical context, and the potential directions available to this discipline. Implications of these issues for emergency physicians and for trauma care overall are discussed.

Objective:To determine if 3 objective criteria – pulse oximetry, respiratory syncytial virus (RSV) testing, and age – could be used to predict which children hospitalized with bronchiolitis will have brief (Methods:This was a retrospective medical record review of medically uncomplicated children 3 to 24 months of age with emergency department and hospital discharge diagnoses consistent with bronchiolitis who were admitted to a general pediatric ward in our university-based, tertiary care hospital between Jan. 1, 1992, and Nov. 12, 2002. Multiple logistic regression was used to assess the predictor variables.Results:Our study consisted of 225 patients (45% female) with a median age of 7 months (interquartile range [IQR], 4–11 mo; range, 3–22 mo). Median pulse oximetry value was 94% (IQR 91%–96%; range 76%–100%), and 71% of the patients tested positive for RSV. Thirty children (13%) had brief hospitalizations Conclusions:Pulse oximetry, RSV testing and age do not predict which children will have brief hospitalizations and are appropriate candidates for admission to short-stay observation units.

Background:The 15-point Glasgow Coma Scale (GCS) frequently is used in the initial evaluation of traumatic brain injury (TBI) in out-of-hospital settings. We hypothesized that the GCS might be unnecessarily complex for out-of-hospital use. Objectives: To assess whether a simpler scoring system might demonstrate similar accuracy in the prediction of TBI outcomes. Methods: We performed a retrospective analysis of a trauma registry consisting of patients evaluated at our Level 1 trauma center from 1990 to 2002. The ability of out-of-hospital GCS scores to predict four clinically relevant TBI outcomes (emergency intubation, neurosurgical intervention, brain injury, and mortality) by using areas under receiver operating characteristic curves (AUROCs) was calculated. The same analyses for five simplified scales were performed, and compared with the predictive accuracies of the total GCS score. Results: In this evaluation of 7,233 trauma patients over a 12-year period of time, the AUROCs for the total GCS score were 0.83 (95% confidence interval [CI] = 0.81 to 0.84) for emergency intubation, 0.86 (95% CI = 0.85 to 0.88) for neurosurgical intervention, 0.83 (95% CI = 0.82 to 0.84) for brain injury, and 0.89 (95% CI = 0.88 to 0.90) for mortality. The five simplified scales approached the performance of the total GCS score for all clinical outcomes. Conclusions: In the evaluation of injured patients, five simplified neurological scales approached the performance of the total GCS score for the prediction of four clinically relevant TBI outcomes.

Study objective The Glasgow Coma Scale (GCS) score is widely used in the initial evaluation of patients with traumatic brain injury. This 15-point score, however, has been criticized as unnecessarily complex. Recently, a 3-point Simplified Motor Score (defined as obeys commands=2; localizes pain=1; withdrawals to pain or worse=0) was developed from the motor component of the GCS and was found to have a similar test performance for predicting outcomes after traumatic brain injury when compared with the GCS score as the criterion standard. The purpose of this study was to validate the Simplified Motor Score in a large heterogeneous trauma population. Methods This was a secondary analysis of a prospectively maintained trauma registry with consecutive trauma patients who presented to a Level I trauma center from 1995 through 2004. Test performance of the GCS and the Simplified Motor Score relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, clinically significant brain injury, neurosurgical intervention, and mortality) was evaluated with areas under the receiver operating characteristic curves (AUCs). Results Of 21,170 patients included in the analysis, 18% underwent emergency intubation, 14% had clinically significant brain injuries, 7% underwent neurosurgical intervention, and 5% died. The AUCs for the GCS and its components ranged from 0.76 to 0.92 across the 4 outcome measures. The AUCs for the Simplified Motor Score ranged from 0.71 to 0.89, and the relative differences from the GCS AUCs ranged from 3% to 7%, with a median difference of 5%. Conclusion In this external validation study, the 3-point Simplified Motor Score demonstrated similar test performance when compared with the 15-point GCS score and its components for the prediction of 4 clinically important traumatic brain injury outcomes.