RESEARCH FORUM ABSTRACTS

Methods: This study was a retrospective chart review. All participants in the inau- gural San Diego Rock 'n' Roll Marathon (June 1998) presenting to 1 of the 12 local EDs were included in the study. Medical records were used to obtain demographic information, presenting complaints, vital signs, physical examination findings, labora- tory data, and hospital course. Marathon times were obtained from the Rock 'n' Roll Marathon Web site. Serum sodium values were plotted over rime to identify any trends during sodium correction for patients with initial serum sodium values < 130 mEq/L. The mean times to race completion for patients with initial serum sodium val- ues <125 mEq/L were compared with the mean times for a random sampling of 100 runners who completed the race. Linear regression was used to evaluate initial serum sodium versus postrace time in all patients in whom serum chemistries were obtained.

Results: A total of approximately 20,000 runners participated in the event; nearly 50% percent were female, more than for any previous marathon of this size. A total of 74 runners presented to 1 of the 12 EDs; 31 of these were transported by ambulance. Laboratory evaluation was performed in approximately 50% of these patients; nearly half of these were hyponatremic (<135 mEq/L). Nine patients presented with "severe" hyponatremia (<125 mEq/L); 8 of these were female. There was no significant difference between race times for runners with severe hyponatremia (5:24) versus a random sam- piing of runners (4:54). A statistically significant correlation between postrace time and serum sodium was observed (r=-0.73, P<.05), with later presentations predicting lower serum sodium values. Difficulty in correcting hyponatremia was observed in patients with initial serum sodium values <125 mEq/L. In several patients, a decrease in serum sodium despite normal saline therapy led to resistant seizures requiring intubarion.

Conclusion: Exercise-induced hyponatremia can result in significant morbidity, even in association with relatively common events such as marathons. The pathophysi- ology of this disease most likely involves a combination of water intoxication and hor- monal maladaptations to moderate-to-severe exercise. Females appear to be at higher risk. These results along with the existing literature have led to our recommendations, which include the rapid analysis of serum sodium and the use of hypertonic saline with severe hyponatremia.

5 5 The Effect of Trendelenburg Position on Subclavian Vein Diameter in Euvolemic and Hypovolemic Volunteers

Gibson GP. Rankins RC, Utecht T/Universib/of California-San Francisco. University Medical Center, Fresno, CA

Study objectives: We sought to compare the diameter of the subclavian vein in supine and Trendelenburg positions with both euvolemic and hypovolemic subjects. Our goal was to determine if there was a significant change in the diameter of the vein that would aid in central line placement.

Methods: Thirteen volunteers were enrolled and 10 completed the study. All vol- unteers had subclavian vein measurements made with ultrasound while in the supine and Trendelenburg position in both euvolemic and hypovolemic states. Hypovolemia was accomplished by phlebotomizing 2 units of blood from the volunteers. The films were then read by a radiologist who was blinded to the volunteer's position and vol- ume status.

Results: The average change in the diameter of the subclavian vein (Trendelenburg-flat) in euvolemia was -0.02 mm (95% confidence interval [CI], -0.28 to +0.24). In hypo- volemic subjects, the average change was +0.09 m m (95% CI, -0.39 to +0.57).

Conclusion: Trendelenburg position produces little change in the subclavian vein diameter in euvolemic and hypovolemic patients. These small changes are unlikely to be clinically significant in the placement of a subclavian central venous catheter.

56 The Sexual Assault Examination: A Comparison of Physical Findings Between an Emergency Department and Freestanding Nurse Examiner Clinic

Rossman L, Wynn B, Jones JS/Spectrum Health-Downtown Campus, MSU College of Human Medicine, Grand Rapids, MI

Study objective: To compare the documentation of genital trauma in women evalu- ated for sexual assault between an academic emergency department and a freestanding nurse examiner clinic (NEC).

Methods: This was a retrospective cohort analysis of consecutive female patients presenting after alleged sexual assault to either the ED of a university-affiliated urban hospital (n=100 patients) or to a freestanding NEC (n=100). The ED was staffed by board-certified emergency physicians and residents who identified genital trauma using gross visual examination alone. The NEC is located within 1 mile of the hospital and is staffed by registered nurses trained to perform medicolegal examinations using

colposcopy vclth digital imagang. The 2 patient groups were compared for baseline demographics, assault history, and documentation of genital trauma using a standard- ized classification system Primary outcome was the frequency and type of docu- mented genital injunes.

Results: Case files of 200 patients were reviewed; the mean age was 24.5 years (range 14 to 69 years) with 95% reporting penile-genital contact. The 2 patient groups (NEC, ED) were comparable in terms of demographics, time to examination, assault history, relationship to offender, type, and frequency of nongenital trauma. Genital injuries were documented in 71% of the patients evaluated in the N EC (mean number of genital injuries, 2.1). In companson, 20% of those patients examined in the ED had documented genital trauma (mean number of injuries, 0.3). These differences were statistically significant (;(2=50.4, P<.000I). Trauma types varied in both groups by site--tears appeared most often on the posterior fourchette and fossa, abrasions appeared on the labia, and ecchymosis was seen on the hymen.

Conclusion: These results suggest that colposcopy with digital imaging improves detection of genital trauma in female sexual assault victims and may provide valuable medical and legal information.

157 Do Oiabntic Patients Present to Emergency Departments With Infectious Complications at a Higher Rate Than Nondiabctic Patients?

Feuer H, Butterfass A, Fairweather P, Richardson L/Mount Sinai School of Medicine. New York, NY

Stud)' objective: Diabetes mellitus is a medical disorder that is recognized to impair the immune system. Diabetic patients are assumed to present to emergency depart- ments with infectious complications at a higher rate than nondiabetic patients. We tested the hypothesis that diabetic patients have a more frequent disposition diagnosis of an infectious etiology than nondiabetic patients.

Methods: A retrospective chart review was conducted for two 1-week periods dur- ing different seasons at a municipal hospital in the northeastern United States with 70,000 adult ED vasits annually. The charts of all patients who identified themselves as having diabetes mellitus were reviewed; an equal number of nondiabetic patient charts were randomly selected from the same time penods as controls. A precoded data col- lection instrument for chart review was developed; pertinent demographic and clinical information was abstracted from these ED charts. ED diagnoses were categorized as infectious or noninfectious in etiology Data were analyzed using SPSS 8.0. The Z 2 statistic was used to analyze categorical vanables; the Student's t test was used for con-

tinuous vanables. Results: A total of 2,585 adult patients presented to our ED during the two 1-week

stud)' periods. Data were obtained from 168 diabetics (6.5% of all ED visits) and 148 nondiabetic controls. The mean age of all study patients was 46.1 years of age (range 18 to 103 years) Fifty percent were male, 50% female; 14.3% were white, 17.3% African American, 51.1% Hispanic, 14% Asian, and 5.8% other. There were no statis- tically significant differences in demographic composition between our diabetic and nondiabetic study groups. In the diabetic group, 34.9% took insulin for glucose con- trol, and 3.5% had other immune-compromising illnesses (H1V or malignancy) versus 5.0% for controls (P=.58). Diabetics were found to have a significantly higher rate of cardiac comorbidiries, 15% versus 6.4% (P=.01). The diabetic group was also found to have significantly higher rates of Medicare and Medicaid coverage. There was no statis- tical difference bet;veen the 2 groups in the frequency of an infection-based diagnosis: 12.1% of diabetics versus 14.2% of nondiabetics (P=.62). More insulin-dependent dia- betics (17.0%) were diagnosed with infection than non-insulin-dependent diabetics (9.3%), although this was not statistically significant (P=. 19). The data also revealed a significantly higher admission rate among diabetic patients: 31.5% versus 181% for

nondiabetics (P<.005) Conclusion: The incidence of infectious conditions in patients visiting our ED was

not shown to significantly differ between diabetic and nondiabetic populations. Ancillary data gathered portray diabetics using the ED as a more acutely ill population with a significant coincidence of cardiac disease.

5 8 Empiric Treatment of Gonorrhea and Chlamydia in the Emergency Department

Weist DR. Spear SJ. Bartfield JM/Albany Medical College. Albany. NY

Stud)" objectives: This stud)" was conducted to determine how often women screened for Neissena ganorrhoeae (GC) and Chlamydia trachomatis (CT) in an emer- gency department setting are given proper empinc treatment.

Methods: This retrospective chart review was conducted in an urban university

OCTOBER 1999, PART 2 34:4 ANNALS OF EMERGENCY MEDICINE S 41

RESEARCH FORUM ABSTRACTS

teaching hospital ED among females 12 to 40 years of age who had GC./CT screens sent to tire hospital laboratory between January 1, 1998, and January 31, 1999. Sexual assault victims were excluded because it is our practice to empirically treat these patients. GC/CT results identified from microbiology records were recorded. Patient charts wem abstracted for age, race, diagnosis, provider, and treatment. Patients who were treated on the index visit with Centers for Disease Control and Prevention-approved regimens for GC/CT were considered empirically treated for GC/CT. The following variables were tested for their abifily to predict appropriate empiric treatment: patient age, race, pregnancy, and provider type (midlevel provider [MLP] or physician [MD]). A Z2 test was used for categorical data and t test for contin- uous data with significance defined as P<.05.

Results: One thousand ninety-three records were reviewed. The mean age was 24+6 years; 580 (53%) were African American, 420 (38%) Caucasian, 72 (7%) Hispanic, and 21 (2%) were of other ethnic backgrounds. Cervicitis or pelvic inflam matory disease was diagnosed in 216 (20%) of the patients; 182 (17%) patients were found to be pregnant. One hundred thirteen (10%) subjects had positive screens: 39 for GC only, 56 for CT only, and 18 for both GC and CT; 980 (90%) had negative screens. Of the 254 (23%) patients given empiric treatment, 54 had positive screens and 200 had negative screens. Thus 48% (54/113) subjects with positive screens were appropriately treated and 20% (200/980) with negative screens were overtreated. Provider type and pregnancy were the only factors that consistently influenced empiric treatment. MkPs were more likely than MDs to empirically treat subjects. MLPs treated 35 of the 45 subjects (78%) with positive screens compared with 19 of 68 (28%) patients seen by MDs (P<.O001). MLPs overtmated 110 of the 285 (39%) patients with negative screens compared with 89 of the 691 (13%) patients seen by MDs (P<.0001). None of the 13 pregnant patients with positive GC/CT screens were initially treated compared with 54 of 100 (54%) nonpregnant patients with positive screens (P=.00Ol). Of the 169 pregnant patients with negative screens, only 1 (0.6%) was overtreated compamd with 199 (25%) of 811 nonpregnant subjects (P<.00Ol).

Conclusion: In this retrospective study, women screened for GC/CT received empiric treatment 23% of the time. The majority of these patients had negative screens for GC/CT, and only approximately half of the patients with positive screens received empiric treatment. MLPs gave empiric treatment more often than MDs. Further prospec- tive studies are needed to determine factors that influence practitioner decisionmaking.

59 The Incidence, Treatment, and Disposition of Hemorrhagic CVA in the Emergency Department

Bunney EB, Sloan EP, Silva JC, Sharpe L J, Rosengerg MS/Resurrection Medical Center, University of Illinios, Chicago, IL

As new modafities become available for the treatment of ischemic cembrovascular accident (CVA), there is greater interest in studying patients who present with an acute hemorrhagic CVA. However, little information exists regarding the acute treat- ment and outcome of these patients.

Study objective: To describe hemorrhagic CVA patients who were initially diag- nosed and treated m the emergency department. This study was conducted in a com- prehensive urban, community hospital ED.

Methods: A retrospective chart review of 108 consecutive ED hemorrhagic CVA patients treated between January 1996 and December 1997 was performed. The mean age was 66 years, and 46% were male. Hypertension was noted in 56%, coronary artery disease in 16%, and diabetes in 8%.

Results: The incidence of hemorrhagic CVAs was 1 per 500 ED patients. The most common sites of hemorrhage were parietal (49%) and temporal (22%) lobes. The most common hemorrhage types were intraparenchymal (67%), subarachnoid (24%), ven- tricular (23%), and subdural (14%). Coma was present in 43% of patients, and intu- bation was required in 37%. Mannitol was used in 53%, decadron (52%), phenytoins (18%), and nimodipine in (7%). Surgical intervention took place in 39% of patients. The overall mortality rate was 34%. At discharge, 43% of the patients had minimal disability and 22% had severe disability. Mean hospital length of stay was 9.5_+6.8 days. Disposition to home was possible for 30% of the patients. A nursing home was required in 16%.

Conclusion: Hemorrhagic CVA patients are seen commonly in the ED. Although the mortality for hemorrhagic CVA remains high, the majority of the surviving patients were successfully discharged home with only minimal residual disability. The findings suggest that aggressive therapy, similar to the "Brain Attack" for ischemic CVA, is war- ranted for these patients. More information regarding optimal treatment strategies could be obtained through a muhicentemd prospective case series.

60 Emergency Medicine Resident Training in Mechanical Ventilation

Couvillon L, Brandhurst R, DeBlieux P/Medical Center of Louisiana at New Orleans, New Orleans, LA

Study objective: Emergency physicians confront respiratory failure and the need for the institution of mechanical ventilatory support frequently in their practice. Currently emergency medicine literature minimally addresses this topic. The goal of this study was to describe mechanical ventilation (MV) education during emergency medicine residency training.

Methods: The study design was a closed cohort survey of 126 emergency medicine programs. A 14 question survey was E-maded or faxed to emergency medicine pro- gram directors with follow-up via fax or E-marl. Programs were asked if they provided didactic instruction in the initiation of MV and by whom, the number of hours a year dedicated to the topic, and average and maximum duration of time patients are man- aged in the ED on MV.

Results: Seventy-seven (61%) of 126 programs responded. The amount of didactic instruction a year included: 53% of programs offer <2 hours and 16% offer <1 hour. Primary instructors included 37.6% ED staff only, and 22% by a combination of pul- monary, critical care, surgery, and ED staff; 28.3% of programs stated the average duration of time patients were managed on MV in their ED was >3 hours and 75% have managed patients on MV in their ED for ->3 hours this year.

Conclusion: All emergency medicine programs receive some form of MV instruc- tion during their residency training, although more than half receive less than 2 hours per year. With the frequency of instituting MV in the ED and the prolonged times patients are managed in the ED on MV, the authors feel additional educational inter- ventions are warranted.

61 Perceptions of Medical Providers Regarding Their Care of HIV- Positive Patients in the Emergency Department Setting

Alcindor F, Stoller M/Albert Einstein College of Medicine, Emergency Medicine Residency Program at Beth Israel Medical Center, New York, NY

Study objective: To identify any significant differences in the perceptions of emer- gency department providers and H1V-positive patients relating to the care delivered in the emergency department setting.

Methods: A 42-item survey was mailed to 172 emergency medicine residents, 357 attending physicians, and 290 emergency medical services (EMS) staff in the New York City area to assess their perceptions about the care provided to HlV-positive patients. There was a 45% response rate. The results were compared with the responses from a previous matching 42-item survey of 301 HlV-positive ED patients. Data were analyzed by the t test and Fisher's exact test.

Results: The majority of providers felt that they allocated adequate time to take a proper history (97%), considered non-HlV causes of complaints (96%), thought that the patients had confidence in them and the ED staff (96%), perceived themselves as being compassionate and nonjudgmental in their care (99%), and paid more attention to chief complaints because of the patients' HIV status (97%). Most of the HIV group shared these perceptions; however, a significant proportion felt ignored (35%), reported being touched only with gloves (31%), and perceived their providers as judg- mental (37%). Forty percent of providers believed that the HlV-positive patients com- plied with ED recommendations, whereas their HlV-positive patients reported a compliance rate of 85%. Both providers and patients concurred that there was inade- quate aftercare follow-up after the ED visit.

Conclusion: There were significant differences in the perceptions of ED providers and HIV-positive patients pertaining to the care delivered in the ED Although the majority of both groups have the same perception about the compassion and compe- tence of the ED provider, a significant proportion of the HIV group felt that they did not receive competent, compassionate care. They felt dehumanized by their experience.

162 Differences in Patient Age and Antibiotic Type in the Inappropriate Use of Antibiotics in the ED

Stone S, Cairns CB, Gonzalez R, Lowenstein SR/University of Colorado Health Sciences Center, Denver, CO

Antibiotic resistance has become a major health threat. Several recent studies have demonstrated a direct association between recent antibiotic use and drug resistance. We recently reported on the inappropriate use of antibiotics in adult emergency department patients.

S 42 ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER 1999, PART 2