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Background: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice.Objective: To compare the effectiveness and safety of 3 guideline implementation strategies.Design: Cluster-randomized, controlled trial.Setting: 32 emergency departments in Pennsylvania and Connecticut.Patients: 3219 patients with a clinical and radiographic diagnosis of pneumonia.Interventions: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12).Measurements: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients.Results: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P = 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P < 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P < 0.001). No statistically significant differences in safety outcomes were observed across interventions.Limitations: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial.Conclusions: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients. [ABSTRACT FROM AUTHOR]

Rationale: An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment.Objectives: To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes.Methods: We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our prediction rule using logistic regression with 30-day mortality as the primary outcome, and patient demographic and clinical data routinely available at presentation as potential predictor variables. We externally validated the rule in 221 inpatients with pulmonary embolism from Switzerland and France.Measurements: We compared mortality and nonfatal adverse medical outcomes across the derivation and two validation samples.Main Results: The prediction rule is based on 11 simple patient characteristics that were independently associated with mortality and stratifies patients with pulmonary embolism into five severity classes, with 30-day mortality rates of 0-1.6% in class I, 1.7-3.5% in class II, 3.2-7.1% in class III, 4.0-11.4% in class IV, and 10.0-24.5% in class V across the derivation and validation samples. Inpatient death and nonfatal complications were Conclusions: Our rule accurately classifies patients with pulmonary embolism into classes of increasing risk of mortality and other adverse medical outcomes. Further validation of the rule is important before its implementation as a decision aid to guide the initial management of patients with pulmonary embolism. [ABSTRACT FROM AUTHOR]

Background: Black patients hospitalized for heart failure have better reported short-term survival than white patients for unknown reasons. We sought to determine if initial severity of illness differed between black and white emergency department (ED) patients hospitalized for heart failure., Methods: We analyzed 1,408 black and 7,260 white randomly selected patients in one state hospitalized from an ED during 2003 and 2004 and with a discharge diagnosis of heart failure. We used three validated clinical prediction rules to estimate severity of illness on admission., Results: Black patients were younger than white patients (65.8 +/- 14.8 vs 77.4 +/- 11.5 years, P < .01) and were assigned to lower risk classes by all 3 prediction rules more frequently than white patients (P < .01). The odds ratio (95% CI) for classification of black versus white patients into the lowest risk class within the three rules ranged from 1.16 (1.00-1.33) to 4.30 (3.75-4.94). After adjusting for hospital clustering, the odds ratio (95% CI) for black versus white patient hospital death and complications was 0.75 (0.60-0.95) and, for 30-day death, was 0.34 (0.27-0.48)., Conclusions: Black ED patients hospitalized with heart failure are younger, less severely ill on admission and less likely to experience short-term fatal and nonfatal outcomes than white patients. Our findings suggest a varying opportunity between black and white patients when considering alternative initial treatment strategies and sites of care.

Study Objective: Validate a clinical prediction rule prognostic of short-term fatal and inpatient nonfatal outcomes for heart failure patients admitted through the emergency department., Methods: We retrospectively studied a random cohort of 8,384 adult patients admitted to Pennsylvania hospitals in 2003 and 2004 with a diagnosis of heart failure as defined by primary discharge diagnosis codes. We reported the proportions of inpatient death, serious medical complications before discharge, and 30-day death in the patients identified as low risk by the prediction rule., Results: The prediction rule classified 1,609 (19.2%) of the patients as low risk. Within this subgroup, there were 12 (0.7%; 95% confidence interval [CI] 0.3% to 1.2%) inpatient deaths, 28 (1.7%; 95% CI 1.1% to 2.4%) patients survived to hospital discharge after a serious complication, and 47 (2.9%; 95% CI 2.1% to 3.7%) patients died within 30 days of the index hospitalization., Conclusion: This prediction rule identifies a group of admitted heart failure patients at low risk of inpatient mortal and nonmortal complications. Our validation findings suggest the rule could assist physicians in making site-of-care decisions for this patient population and aid in analyzing presenting illness burden in study populations.

Study Objective: We examine the performance of 4 clinical prediction rules prognostic of short-term fatal and hospital-based nonfatal outcomes in heart failure patients., Methods: We used a retrospective cohort of 33,533 adult patients admitted to Pennsylvania hospitals in 1999 with a diagnosis of heart failure. We stratified patients into risk categories defined by each clinical prediction rule. We assessed prognostic accuracy according to sensitivity and specificity and compared discriminatory power according to area under the receiver operating characteristic (ROC) curves. The outcomes were inpatient death, 30-day mortality, and death or serious medical complications before hospital discharge., Results: The 4 rules each created risk groups of various proportions and frequencies of outcomes. The proportion of patients assigned to the lowest risk group ranged from 13.3% to 73.0%. The rates of inpatient death or complications in the lowest risk group ranged from 6.7% to 9.2%, and 30-day death rates varied from 1.7% to 6.0%. Patients categorized at the highest risk of death or complication demonstrated similar variability. The area under the ROC curve for inpatient death and complications differed only slightly among rules (0.58 to 0.62). The area under the ROC curve for fatal outcomes tended to be higher and differed among rules (0.59 to 0.74), Conclusion: Current acute heart failure prediction rules offer varying ability to predict short-term death or serious outcomes. Although each creates a risk gradient, differences in risk-group proportions and outcome frequencies should drive rule selection or use in clinical practice.

Background: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting., Objective: To identify the factors associated with the hospitalization of low-risk patients with pneumonia., Methods: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments., Results: Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III., Conclusions: Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.

Background: A simple prognostic model could help identify patients with pulmonary embolism who are at low risk of death and are candidates for outpatient treatment., Methods: We randomly allocated 15,531 retrospectively identified inpatients who had a discharge diagnosis of pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our rule to predict 30-day mortality using classification tree analysis and patient data routinely available at initial examination as potential predictor variables. We used data from a European prospective study to externally validate the rule among 221 inpatients with pulmonary embolism. We determined mortality and nonfatal adverse medical outcomes across derivation and validation samples., Results: Our final model consisted of 10 patient factors (age > or = 70 years; history of cancer, heart failure, chronic lung disease, chronic renal disease, and cerebrovascular disease; and clinical variables of pulse rate > or = 110 beats/min, systolic blood pressure < 100 mm Hg, altered mental status, and arterial oxygen saturation < 90%). Patients with none of these factors were defined as low risk. The 30-day mortality rates for low-risk patients were 0.6%, 1.5%, and 0% in the derivation, internal validation, and external validation samples, respectively. The rates of nonfatal adverse medical outcomes were less than 1% among low-risk patients across all study samples., Conclusions: This simple prediction rule accurately identifies patients with pulmonary embolism who are at low risk of short-term mortality and other adverse medical outcomes. Prospective validation of this rule is important before its implementation as a decision aid for outpatient treatment.

Purpose: We assessed the performance of 3 validated prognostic rules in predicting 30-day mortality in community-acquired pneumonia: the 20 variable Pneumonia Severity Index and the easier to calculate CURB (confusion, urea nitrogen, respiratory rate, blood pressure) and CURB-65 severity scores., Subjects and Methods: We prospectively followed 3181 patients with community-acquired pneumonia from 32 hospital emergency departments (January-December 2001) and assessed mortality 30 days after initial presentation. Patients were stratified into Pneumonia Severity Index risk classes (I-V) and CURB (0-4) and CURB-65 (0-5) risk strata. We compared the discriminatory power (area under the receiver operating characteristic curve) of these rules to predict mortality and their accuracy based on sensitivity, specificity, predictive values, and likelihood ratios., Results: The Pneumonia Severity Index (risk classes I-III) classified a greater proportion of patients as low risk (68% [2152/3181]) than either a CURB score <1 (51% [1635/3181]) or a CURB-65 score <2 (61% [1952/3181]). Low-risk patients identified based on the Pneumonia Severity Index had a slightly lower mortality (1.4% [31/2152]) than patients classified as low-risk based on the CURB (1.7% [28/1635]) or the CURB-65 (1.7% [33/1952]). The area under the receiver operating characteristic curve was higher for the Pneumonia Severity Index (0.81) than for either the CURB (0.73) or CURB-65 (0.76) scores (P <0.001, for each pairwise comparison). At comparable cut-points, the Pneumonia Severity Index had a higher sensitivity and a somewhat higher negative predictive value for mortality than either CURB score., Conclusions: The more complex Pneumonia Severity Index has a higher discriminatory power for short-term mortality, defines a greater proportion of patients at low risk, and is slightly more accurate in identifying patients at low risk than either CURB score.

Objective: To assess the agreement between prospectively and retrospectively determined variables comprising the Pneumonia Severity Index (PSI), assignment to PSI risk class, and designation as low risk, based on these two methods of data collection., Study Design and Setting: We analyzed data from a randomized trial of patients with community-acquired pneumonia managed in 32 hospital emergency departments (EDs). For all enrolled patients, the 20 PSI variables were collected prospectively by ED providers and retrospectively by medical record abstractors. We examined the agreement for each of the 20 PSI variables, assignment to the five PSI risk classes, and classification of patients as low (classes I-III) vs. high (classes IV and V) risk. Agreement was measured using total percent agreement and the kappa statistic., Results: Among the 3,220 enrolled patients, percent agreement was >90% for 18 of the 20 variables comprising the PSI, with most unweighted kappa's being >0.6. Agreement was substantial for assignment to PSI risk class (percent agreement: 92.7%; weighted kappa: 0.79) and for classification as low vs. high risk (percent agreement: 88.5%; unweighted kappa: 0.74)., Conclusion: There was substantial agreement between retrospective and prospective assignment to PSI risk class, classification as low vs. high risk, and the determination of most individual variables that constitute the PSI.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care. We designed an ED-based quality improvement trial focused on the initial care of patients with community-acquired pneumonia. We used the Pneumonia Severity Index and level of arterial oxygenation to identify patients at low risk for 30-day mortality and to guide admission decisionmaking. We assessed the performance of recommended "best practices," consisting of assessment of arterial oxygenation, the collection of blood cultures for inpatients, and the timely initiation of appropriate empiric antibiotic therapy for inpatients and outpatients. We conducted a 32-site, cluster-randomized trial in Pennsylvania and Connecticut, comparing the effectiveness and safety of 3 guideline implementation strategies of increasing intensity. The multifaceted implementation plans were carried out in conjunction with each state's quality improvement organization. This article describes the background, objectives, and methodology of this trial to translate evidence-based knowledge on the quality and efficiency of care for community-acquired pneumonia into clinical practice.

Objective: Previous experiments in the authors' swine lab have shown that cardiopulmonary resuscitation (CPR) using two-thumb chest compression with a thoracic squeeze (TT) produces higher blood and perfusion pressures when compared with the American Heart Association (AHA)-recommended two-finger (TF) technique. Previous studies were of short duration (1-2 minutes). The hypothesis was that TT would be superior to TF during prolonged CPR in an infant model., Methods: This was a prospective, randomized crossover experiment in a laboratory setting. Twenty-one AHA-certified rescuers performed basic CPR for two 10-minute periods, one with TT and the other with TF. Trials were separated by 2-14 days, and the order was randomly assigned. The experimental circuit consisted of a modified manikin with a fixed-volume arterial system attached to a neonatal monitor via an arterial pressure transducer. The arterial circuit was composed of a 50-mL bag of normal saline solution (air removed) attached to the manikin chest plate and connected to the transducer with a 20-gauge intravenous catheter and tubing. Rescuers were blinded to the arterial pressure tracing. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded in mm Hg, and pulse pressures (PPs) were calculated. Data were analyzed with two-way repeated-measures analysis of variance. Sphericity assumed modeling, with Greenhouse-Geisser and Huynh-Feldt adjustments, was applied., Results: Marginal means for TT SBP (68.9), DBP (17.6), MAP (35.3), and PP (51.4) were higher than for TF SBP (44.8), DBP (12.5), MAP (23.3), and PP (32.2). All four pressures were significantly different between the two techniques (p< or =0.001)., Conclusion: In this infant CPR model, TT chest compression produced higher MAP, SBP, DBP, and PP when compared with TF chest compression during a clinically relevant duration of prolonged CPR.

Study Objectives: To examine the psychometric and cardiac effects of pseudoephedrine at 1 and 3 atmospheres (atm) of pressure (0 and 66 feet of sea water, respectively), and to make recommendations about the agent's safety in the diving environment., Design: Double-blind, placebo-controlled, crossover study., Setting: Monoplace hyperbaric chamber of a university hospital., Subjects: Thirty active divers (mean age 38 yrs)., Intervention: A bank of seven tests was used to assess cognitive function during four different simulated dive combinations: placebo-1 atm, placebo3 atm, pseudoephedrine-1 atm, and pseudoephedrine-3 atm., Measurements and Main Results: Heart rate and cardiac rhythm were recorded during all dives. Repeated-measures analysis of variance was used to analyze the effects of pseudoephedrine, depth, and drug-depth interaction. No significant, independent effects of pseudoephedrine were seen on any of the seven psychometric test scores (p>0.05), although the drug tended to increase anxiety scores (p=0.092). Depth resulted in a significant increase in anxiety scores (p=0.021) and a significant decrease in verbal fluency test scores (p=0.041); it had no significant effects on the other five psychometric tests (p>0.05). Pseudoephedrine caused a significant increase (p=0.036) in mean heart rate, and depth caused a significant decrease (p=0.013). Neither pseudoephedrine nor depth affected cardiac rhythm., Conclusion: Pseudoephedrine does not cause significant alterations in psychometric performance at 3 atm of pressure that might increase the risk of diving. Depth causes significant adverse effects on anxiety levels and semantic memory at 3 atm. Pseudoephedrine and depth have significant but opposite effects on heart rate; although, these effects are unlikely to be clinically significant during diving. It is unlikely that pseudoephedrine adds significant risk to the diver.

Study Objectives: To examine the psychometric and cardiac effects of dimenhydrinate at 1 and 3 atmospheres (atm) of pressure (0 and 66 feet of sea water, respectively), and to make recommendations about the drug's safety in the diving environment., Design: Double-blind, placebo-controlled, crossover study, Setting: Monoplace hyperbaric chamber of a university hospital., Subjects: Thirty active divers (mean age 38 yrs)., Interventions: A bank of seven tests was used to assess cognitive function during four different dive combinations: placebo-1 atm, placebo-3 atm, dimenhydrinate-1 atm, and dimenhydrinate-3 atm., Measurements and Main Results: Heart rate and cardiac rhythm were recorded during all dives. Repeated-measures multivariate analysis of variance was used to analyze the effects of dimenhydrinate, depth, and drug-depth interaction. Dimenhydrinate resulted in a significant decrease in scores of mental flexibility (trail-making, part B, p<0.05) but had no effect on scores in the six other psychometric tests (p>0.05). It had no effect on mean heart rate (p>0.05), although frequent unifocal ventricular ectopic beats occurred in two subjects after ingestion of the drug. Depth resulted in a significant decrease in verbal memory test scores (p=0.001) and mean heart rate (p<0.001)., Conclusion: Dimenhydrinate adversely affects mental flexibility. This effect, when added to the adverse effect of depth on memory, may contribute to the dangers of diving.

Study Objective: This study aimed to establish whether the outpatient management of patients presenting with an asthma exacerbation to the emergency department (ED) was in compliance with the 1992 guidelines of the "International Consensus Report on the Diagnosis and Management of Asthma.", Design: Prospective, observational study using a researcher-administered questionnaire., Setting: University tertiary referral ED., Patients: Convenience sample of asthmatics (aged 18 to 54 years) presenting for asthma treatment between July 1, 1997, and June 30, 1998., Results: Eighty-five asthmatic patients were enrolled. Of these, 34 patients (40%) smoked, 53 patients (62%) were undertreated with medication when compared to the consensus guidelines, and 74 patients (87%) had no written "plan of action." During an asthma attack, 9 patients (11%) did not use a bronchodilator as first-line action and 76 patients (89%) did not commence or increase the use of an inhaled steroid. Forty-nine patients (58%) did not know that bronchospasm occurred in asthma, and 53 patients (62%) did not know that bronchial swelling occurred. Twenty-six patients (31%) thought short-acting bronchodilator drugs were asthma preventers. Sixty-two patients (73%) could not adequately define peak expiratory flow (PF), 41 patients (48%) did not own a PF meter, and only 8 patients (9%) determined their PF daily. Fifty-three patients (62%) were reviewed by a physician once a year or less, and 18 patients (21%) noted family and friends as their only source of asthma education., Conclusions: The outpatient management of most asthma patients presenting to the ED did not comply with the consensus guidelines, and asthma knowledge was poor.

Over the last 20 years, more than 15 medical practice guidelines and clinical prediction rules have emerged to assist physicians in assessing the prognosis of adult patients with community-acquired pneumonia (CAP) and selecting an appropriately matched initial site of care. Most of these guidelines and rules suffer from major methodological flaws. One, the Pneumonia Patient Outcomes Research Team (PORT) clinical prediction rule, has satisfied rigorous methodological standards for the derivation and validation of high-quality prediction rules. This rule was incorporated into the Infectious Disease Society of America medical practice guideline for the management of adults with CAP. Strengths of the rule include its derivation and validation in over 50,000 inpatients and outpatients; stratification of all immunocompetent adult patients into one of five risk strata for short-term mortality and other unambiguous adverse medical outcomes; initial site of care recommendations for all patients, particularly those at low risk; and reliance on predictor variables readily available to clinicians at the time of initial patient presentation. A recent small-scale intervention trial demonstrates that the pneumonia PORT rule can reduce admissions for adult patients with CAP without compromising patient outcomes.

Objective: To determine the feasibility of police officers providing defibrillation with automated external defibrillators (AEDs) and to assess the effectiveness of this strategy in reducing time to defibrillation of victims of out-of-hospital sudden cardiac arrest., Methods: This was a prospective, interventional cohort study with historical controls conducted in 7 suburban communities in which police usually arrived at the scene of medical emergencies before EMS personnel. All adult patients who suffered cardiac arrest before EMS arrival and on whom EMS personnel attempted resuscitation were enrolled. Police officers who were trained to use and equipped with AEDs during the intervention phase were dispatched simultaneously with EMS to medical emergencies. Police were instructed to use the AED immediately on determination of pulselessness. Outcome measures were the difference between control and intervention phases in interval from the time the call was received at dispatch to the time of first defibrillation and in rate of survival to hospital discharge for patients initially in ventricular fibrillation., Results: EMS personnel attempted 183 resuscitations in the control phase and 283 during the intervention; of these, 80 (44%) and 127 (45%), respectively, involved patients with initial ventricular fibrillation rhythms. Mean time to defibrillation decreased from 11.8+/-4.7 minutes in the control phase to 8.7+/-3.7 minutes in the intervention phase (P<.0001). Survival to hospital discharge of patients in ventricular fibrillation did not differ between phases (6% control versus 14% intervention, P=.1). When police arrived before EMS personnel, shock administered by police compared with shock administered by EMS was associated with improved survival (26% [12/46] versus 3% [1/29], P=.01). Logistic regression analysis revealed AED use was an independent predictor of survival to hospital discharge., Conclusion: In 7 suburban communities, police use of AEDs decreased time to defibrillation and was an independent predictor of survival to hospital discharge.

Objective: Portable transport ventilators (TV) and demand valves (DV) may be effective and easy-to-use alternatives to bag-valve (BV) for prehospital ventilation of adults. The purpose of the study was to determine whether such devices maintain arterial blood gases and airway pressures similar to those for BV in a pediatric swine model., Method: This study was a prospective, randomized, crossover design using immature swine (9.6 +/- 0.9 kg) to model ventilation in small children. Anesthetized, intubated, paralyzed, and cannulated animals were ventilated initially on standard mechanical hospital ventilation (HV). They were then assigned in random order to 10-minute intervals of ventilation using BV, TV, low-frequency jet ventilation (JV), and DV. Data were analyzed using repeated-measures ANOVA and Tukey multiple comparisons (alpha = 0.05)., Results: The PaO2 exceeded 90 mm Hg for all animal/ventilation combinations. Blood PaCO2 was lower for BV and DV than it was for TV, JV, or HV. In contrast, blood pH was higher for BV and DV than it was for TV, JV, or HV. Peak airway pressure was higher for BV than it was for HV, TV, or JV; it was lower for JV than it was for HV, TV, or BV., Conclusion: This animal model suggests that automated TV and JV may provide more effective ventilation of children than do manual BV or DV devices. Although promising, these findings require application in children under prehospital emergent conditions.

Objective: To determine the effect of an inhaled 50% nitrous oxide/50% oxygen mixture on measures of observed anxiety in children during laceration repair., Methods: A prospective, randomized, placebo-controlled, double-blind comparison of an inhaled 50% nitrous oxide/50% oxygen mixture (treatment group) with 100% oxygen (control group) during repair of lacerations was performed. The study population was a convenience sample of children aged 2-7 years in an urban pediatric ED. The primary outcome variable was the change in scores before and during laceration repair with a 10-point modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) assessment. The secondary outcome variable was a 4-point anxiety scale measured before and during the procedure., Results: Thirty patients were entered into the study. Seventeen children inhaled the 50% nitrous oxide/oxygen mixture and 13 inhaled 100% oxygen during laceration repair. There was no statistically significant difference in initial CHEOPS and anxiety scores between the 2 groups (p = 0.687 and 0.809, respectively). The median CHEOPS scores in the treatment group decreased by 5 points, while those of the control patients increased by 3 (p < 0.001). The median anxiety scores in the treatment population decreased by 1 point, with an increase of 1 for the control patients (p < 0.001)., Conclusion: Administration of a 50% nitrous oxide/50% oxygen mixture to children during their laceration repair resulted in a significant decrease in measures of anxiety when compared with inhalation of 100% oxygen.

Study Objective: We sought to assess the involvement of law enforcement agencies in out-of-hospital emergency medical care and their attitudes toward expanded roles in emergency medical services (EMS) systems., Methods: We mailed a 20-question survey to 800 police chiefs and sheriffs randomly selected from a list of all law enforcement agencies in the United States. The questions focused on the characteristics of each law enforcement agency, its current level of involvement in providing out-of-hospital emergency medical care, and the characteristics of its associated community and local EMS system. The survey concluded with four statements to assess officer attitudes toward an expanded role in EMS-related activities. We used the chi 2 or Fisher exact test to analyze differences in proportions. The alpha-error rate was set at .05., Results: Seventeen surveys were returned as undeliverable. Of the remaining 783 surveys, we received 602 responses (77%). Five hundred forty-nine (70.1%) of the respondents were the primary law enforcement agencies in their communities; they make up the final sample. The median number of officers per agency was 12 (range, 1 to 2,623), and the median population served was 6,936 (range, 150 to 1,500,000). Responses indicated that 442 (80.7%) agencies responded to one or more specific types of medical emergencies and 263 (50.3%) provided some level of patient care. Law enforcement officers frequently arrived at the scene of medical emergencies before EMS personnel (81.5%), with a roll-time interval of less than 8 minutes (87.2%). Only 14 agencies (2.6%) used automatic external defibrillators. Fifty-three percent agreed with the statement that EMS-related activities would interfere with their law enforcement duties. However, more than 60% of respondents agreed that law enforcement agencies should be involved in providing emergency medical services for life-threatening emergencies, that their officers would be willing to undertake extra medical training and that EMS-related activities would improve their public images., Conclusion: Many law enforcement agencies are involved to some extent in providing out-of-hospital emergency medical care, and most of the agencies we surveyed would support additional medical training and new or expanded roles for themselves in EMS systems.

Background: There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation., Methods: From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate of > or = 30 or a temperature of > or = 40 degrees C), and abnormal laboratory findings (such as a pH <7.35, a blood urea nitrogen concentration > or = 30 mg per deciliter [11 mmol per liter] or a sodium concentration <130 mmol per liter) at presentation., Results: There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P=0.22), from 0.6 to 0.7 percent for class II (P=0.67), and from 0.9 to 2.8 percent for class III (P=0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients., Conclusions: The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia.

Study Objective: To determine whether family members accept field termination of unsuccessful out-of-hospital cardiac arrest resuscitation., Methods: We carried out a prospective cohort study, using a structured interview, in an urban, municipal, advanced life support emergency medical services (EMS) system. The interview subjects were family members present at the scene in a consecutive series of unsuccessful out-of-hospital resuscitation attempts., Results: During the 4-month study period, 140 out-of-hospital cardiac arrests occurred. Follow-up with a family member was performed in 42 of the 53 cardiac arrests that met the inclusion criteria (79%). When resuscitation was terminated in the field (n = 25), 24 family members (96%) reported satisfaction with the decision. When resuscitation was terminated in the emergency department (n = 17), 14 family members (82%) reported satisfaction with the decision to transport the victim to the hospital. However, responses indicated that 13 of the family members (76%) might have accepted termination of resuscitation in the home. In all cases, relatives reported satisfaction with the paramedics' care and with the manner in which they were informed of the victims' deaths., Conclusion: Family members accept termination of unsuccessful out-of-hospital cardiac arrest resuscitation in the field.

An unstable pelvic ring fracture represents a severe injury and is associated with high morbidity and mortality. Little data are available assessing the long-term functional limitations, including disability, in a patient with an unstable pelvic ring fracture. The purpose of this study was to describe the impairment and functional outcome (disability) for patients with unstable pelvic ring fractures managed with open reduction and internal fixation (ORIF). Disability was measured at a minimum of 1 year postinjury using the Sickness Impact Profile (SIP), a measure of the health-related quality of life as perceived by the patient. Of the 230 consecutive patients with a pelvic ring fracture, 54 had unstable fractures requiring ORIF; 48 patients were available at a 1 year follow-up. The follow-up roentgenograms confirmed an osseous union and an anatomic alignment of the pelvis. Thirty-seven (77%) of the patients had mild disability (total SIP < 10); 11 (23%) of the patients had moderate disability (SIP > 10) at 1 year. Of the patients who were employed preinjury, 76% were employed 1 year postinjury; 62% had returned to full time work and 14% had returned with job modification. Of the 7 patients who had been in school, 6 had returned full time and 1 student returned part time. Mean SIP scores for subcategories were: physical health = 6.8 +/- 9.4, psychosocial health = 7.4 +/- 12.7, work = 17.6 +/- 25.5, home management = 8.3 +/- 13.0, ambulation = 10.7 +/- 13.7, and mobility = 5.3 +/- 13.0. Despite the magnitude of the bony injuries, the majority of patients with unstable pelvic ring fractures managed with ORIF had mild disability 1 year postinjury; the majority of the patients had returned to work.

Study Objective: Although some studies demonstrate otherwise, we hypothesized that metaanalysis would demonstrate a reduction in the relative risk of mortality when basic life support (BLS) providers can defibrillate out-of-hospital cardiac arrest patients., Design: Metaanalysis of studies meeting the following criteria: single-tier or two-tier emergency medical service (EMS) system, survival to hospital discharge for patients in ventricular fibrillation, and manual and/or automatic external defibrillators. The alpha error rate was .05., Results: Seven trials qualified for metaanalysis. Across all trials, the risk of mortality for BLS care with defibrillation versus that without was .915 (P = .0003). Separate subset analyses of single-tier and two-tier EMS systems demonstrated similar results., Conclusion: BLS defibrillation can reduce the relative risk of death for out-of-hospital cardiac arrest victims in ventricular fibrillation. Weaknesses in individual study designs and regional clustering limit the strength of this metaanalysis and conclusion.

Objective: To determine the effect of a hypertonic saline and dextran (HSD) solution on blood pressure and QS duration during severe cyclic antidepressant (CA) toxicity in swine., Methods: Ten domestic swine weighing 20-24 kg were anesthetized and placed on mechanical ventilation. Nortriptyline solution was infused intravenously to achieve hypotension (systolic blood pressure equal to 50% of baseline) and a QRS duration of 120 msec. After reaching toxicity, the animals received in a randomized fashion either 10 mL/kg of a 7.5% saline/6% dextran solution or an equal volume of 0.9% saline as a rapid intravenous bolus. The animals were observed for one hour or until they died. Blood pressure and ECG were recorded continuously. Arterial pH was maintained in the physiologic range by controlled ventilation., Results: Mean systolic blood pressure 10 minutes after treatment was 45 +/- 8 torr in the normal- saline group compared with 115 +/- 12 torr in the HSD group (p < 0.05). Mean QRS duration 10 minutes after treatment was 180 +/- 8 msec in the normal-saline group; it was 88 +/- 13 msec in the HSD group (p < 0.05). All normal-saline--group animals died within 20 minutes, and four of the five animals in the HSD group survived to 60 minutes (p < 0.05). The mean peak sodium concentration was 157 mmol/dL (mEq/dL) in the HSD group, and this was transient., Conclusion: In this swine model of severe CA toxicity, a solution of 7.5% saline/6% dextran significantly reversed hypotension and QRS prolongation. HSD also improved survival to 60 minutes.

Several management strategies for radiographic evaluation of head-injury patients have been developed, most are based on retrospective analysis. The study attempted to prospectively evaluate the previously published Masters' criteria defining low-, medium-, and high-yield patients. A community hospital emergency department with a low prevalence of serious head injury was studied, and 1,000 consecutive patients 2 years of age presenting with historical or physical evidence of blunt head trauma were asked to participate; 967 consented. The patients were categorized by staff emergency physicians as low-, moderate-, and high-yield for intracranial injury on the basis of their initial history and physical examination. These categories guided imaging decisions in accordance with the guidelines of Masters. The patients were evaluated 6 weeks later by multiple questionnaire and/or telephone calls to determine whether or not undiagnosed head injuries had been missed. The 967 patients initially evaluated were classified according to their risk of intracranial injury as follows: 886 at low risk, 78 at moderate risk and 3 at high risk. Complete follow-up data were available for 895 of these patients (93%). Of the 895, 71 patients (7.9%) did report receiving follow-up medical care for their head injury; none had evidence of missed intracranial injury requiring intervention. Therefore, it can be inferred with a 95% confidence interval that 0.4% or less of patients who were diagnosed as not having intracranial injuries requiring intervention may actually have such injuries. The application of Masters' management strategy in low-risk populations permits clinicians to safely reduce the number of radiographs ordered for patients with head injury.

Study Objective: To test the hypothesis that two-thumb chest compression generates higher arterial and coronary perfusion pressures than the current American Heart Association-approved two-finger method., Design: Randomized, crossover experimental trial., Setting and Participants: Animal laboratory experiment with seven swine of either sex weighing 9.4 kg (SD, 0.8 kg), representing infants less than 1 year old., Interventions: Animals were sedated with IM ketamine/xylazine, intubated with a 6.0 Hi-Lo endotracheal tube, anesthetized with alpha-chloralose, and paralyzed with pancuronium. ECG was monitored continuously. Left femoral arterial and Swan-Ganz catheters were placed. Cardiac arrest was induced with an IV bolus of KCl and verified by ECG and pressure tracings. Five American Heart Association-certified basic rescuers were randomly assigned to perform external chest compressions for one minute by either the currently recommended two-finger method or the two-thumb and thorax-squeeze method. After all five completed their first trial, rescuers crossed over to the other method for a second minute of compressions. Ventilation was performed with a bag-valve device, and no drugs were given during CPR. After three complete cycles, the fourth through sixth cycles of compressions were recorded. Every compression was analyzed for arterial systolic, diastolic, mean, and coronary perfusion pressures. One thousand fifty compressions were analyzed with repeated-measures analysis of variance and Scheffé multiple comparisons., Results: Systolic blood pressure, diastolic blood pressure, mean arterial pressure, and coronary perfusion pressure were all significantly higher (P < .001) with the two-thumb thoracic squeeze technique: systolic blood pressure, 59.4 versus 41.6 mm Hg; diastolic blood pressure, 21.8 versus 18.5 mm Hg; mean arterial pressure, 34.2 versus 26.1 mm Hg; and coronary perfusion pressure, 15.1 versus 12.2 mm Hg., Conclusion: The two-thumb method of chest compression generates significantly higher arterial and coronary perfusion pressures than the two-finger method in this infant model of cardiac arrest.

Research demonstrates a positive and graded relationship between handweighted exercise energy costs, the distance through which handweights are swung and the weight used. The energy costs of handweighted exercise when swinging 0.45 to 1.36kg handweights have been shown to be 3 to 155% greater than costs of unweighted exercise at any pace. The upper limit of such increases is unknown. Moreover, the use of handweighted arm swings can convert walking, benchstepping or running from leg dominated endurance training modalities to exercises that simultaneously challenge muscles of both the upper and lower body. The use of handweights may induce a pressor response characterised by elevated heart rate and blood pressure responses at a given exercise intensity. However, such elevations have not been consistently reproduced and when they occurred, were on average small and of little physiological concern. Individual blood pressure responses may vary more widely between handweighted and unweighted walking, with some exhibiting higher and others lower blood pressures when using handweights. Taken together, research suggests that the prescription of handweighted exercise is safe for most individuals. However, it should be prescribed using precautions similar to those used when implementing new exercise regimens, particularly among those with cardiovascular complications. Potential strength and endurance training adaptations to handweighted exercise that incorporates large arm and leg range of motion movement patterns have yet to be determined.

Cross-modal exercise prescription at absolute and relative oxygen uptake using perceived exertion. Med. Sci. Sports Exerc., Vol. 22, No. 5, pp. 653-659, 1990. The validity of cross-modal prescription of exercise intensity based on rated perceived exertion (RPE) was determined for eight men (26 +/- SE 1.9 yr) at absolute and relative VO2. Exercise modes were treadmill (TM), cycle ergometer (C), and bench stepping while pumping 0.91 kg handweights (HB). Relative (Rel) constant load sessions were performed for each mode at 70% of mode-specific VO2 peak. Absolute (Absol) constant load sessions were performed for C and HB at the VO2 equivalent to 70% of TM VO2 peak. The five 12 min sessions were presented on separate days in random order. RPE-Overall during TM-Rel (11.1) was a) lower (P less than 0.05) than C-Absol (12.6) and HB-Absol (12.5) and b) the same as C-Rel (11.3) and HB-Rel (10.7). RPE-Legs during TM-Rel was a) lower (P less than 0.05) than C-Absol and HB-Absol and b) the same as C-Rel and HB-Rel. RPE-Chest a) did not differ between TM-Rel and C-Absol or HB-Absol and b) was lower (P less than 0.05) for C-Rel and HB-Rel than TM-Rel. RPE-Arms was higher (P less than 0.05) for C-Absol, HB-Absol, and HB-Rel than TM-Rel but did not differ between TM-Rel and C-Rel. Oxygen uptake, heart rate, and ventilation during TM-Rel were a) the same as C-Absol and HB-Absol and b) higher (P less than 0.05) than C-Rel and HB-Rel. Perceptually based cross-modal prescription of exercise intensity using a psychophysical estimation method is valid provided that the physiological reference is the relative, not the absolute, VO2.

This study evaluated the aerobic metabolic requirements of simulated cross-country skiing. Five male subjects exercised on a cross-country skiing machine at 12 different arm and leg resistances and movement frequencies. Oxygen consumption (VO2) ranged from 21.6 to 44.4 ml kg(-1) min(-1). The VO2 increased significantly (p less than 0.05) as the frequency of limb movement was increased. These data suggest that simulated cross-country skiing places a significant demand on the aerobic metabolic system and as such is a viable alternative to conventional cardiovascular exercise modalities.

Rhythmic pumping of light hand-held weights while walking or running has become a popular approach to total body aerobic exercise. The use of handweights (HW) in conjunction with walking and running significantly increases the energy requirement of a given locomotor speed and adds variety to the choice of modes when prescribing exercise regimens (Auble, Schwartz, & Robertson, 1987; Francis & Hoobler, 1986; Graves, Pollock, Montain, Jackson, & O'Keefe, 1987). Handweighted exercise can also be conveniently and accurately prescribed for use with other exercise modalities such as bench stepping (Goss, et al., 1987). Stepping up and down on a bench at varying frequencies while pumping handweights is a low-impact, space efficient form of total body aerobic exercise. However, little is known about the energy cost of this unique exercise modality. Such information is important if handweighted exercise is to be used in conjunction with bench stepping when prescribing both therapeutic and recreational training regimens. The purpose of this investigation, therefore, was to evaluate the energy cost associated with combined bench stepping and rhythmic pumping of light handheld weights.

In brief: This study compared the aerobic metabolic requirements of normal walking (without handweights and with normal arm motions) with requirements of walking while pumping 1-,2-, or 3-lb handweights through Various ranges of motion. Nine male subjects Walked with and without handweights at speeds of 1.12 to 1.79 m· sec(-1). Adding hand-Weighted arm movements significantly increased the oxygen consumption (V O2) of normal walking by 2.1 to 25.5 ml· kg(-1)· min(-1). The V O2 for handweighted walking ranged from 17 to 43 ml· kg(-1)· min(-1), or 113% to 255% of normal walking requirements at any given speed. These results indicate that walking while moving handweights through large ranges of motion provides a combined upper and lower body aerobic stimulus that is sufficient for endurance training for persons with poor to excellent levels of aerobic fitness.