374 The Journal of Emergency Medicine

of this size suggests that a clinical trial comparing the treatment of these injuries with and without antibiotic prophylaxis is neither indicated or feasible.

accommodate diagnosis and support efficient interchange between the clinician and the radiologist, yet be easy to learn and use without disruption of clinical services. A multidisciplinary approach was taken to meet these objectives with EPs included as members of the design team.

24 OUTPATIKNTBURNMANAGEMENT-LESSISBKITER Ross, J, Brison. R, Pickering, R, Queens University, Kingston Gntario, Canada

The management of outpatient bums remains a controversial topic despite numerous studies advocating different antibiotics and dressings. Patients tend to be over- treated resulting in unnecessary cost and patient inconvenience. We studied a dressing without antibiotics and fewer dressing changes to see if there was a difference in infection rate or healing time compared to the common practice of topical antibiotics and daily rechecks. 54 consecutive patients were involved in a prospective observational study at the acute care hospitals in Kingston June 15 to October 30, 1989. All patients were followed at a biweekly ‘burn clinic’ by one Emergency Medicine Resident. The standard dressing was petroleum gauze (Adaptic. Johnson & Johnson), saline moist plus dry gauze, kling and elastic gauze where applicable. First rechecks were 24 days after the burn. subsequent visits every 4-7 days until no dressing was mquhed. Most burns occured in the 15-40 age group, on the limbs, superficial or deep partial thickness. less than 5% BSA, and required 24 rechecks. Gnly one infection occured in a deep partial thickness tar burn to both forearms. Healing time was similar to previous studies.

After a briefing session the trial took place and analogue and digital images were compared. An observer-assistant mcorded how EPs used the system and were available to assist the EP. After the trial six EPs participated in an extensive debriefmg interview, the results of which are presented.

R 4 - RESPIRATORY EMERGENCIES

26 IMPACT OF THERAPY ON ACUTE BRONCHIAL ASTHMA Anantharaman. V, Accident & Emergency Department, Singapore General Hospital, Singapore

We conclude that topical antibiotics are expensive and unnecessary as are frequentrechecks/dressing changes.

Drug armamentaria and routes of drug administration in acute bronchial asthma are expanding. There are yet no uniform criteria for a decision on the optimum drug therapy for this condition. We have previously mported that improvement in the Patient’s Subjective Assessment Scale (PSAS - a parameter that employs a scale of 10 to 0 in decreasing order as an index of severity of acute asthma) is more predictive of patient outcome and disposal after therapy of acute asthma, than improvements in other parameters of Bronchial Asthma Assessment, viz pulse rate (PR), respiratory rate (RR) and peak expiratory flow rate (PEFR). We attempted to come to a decision on which of three commonly used regimes (outlined below) was best for an acute asthmatic episode, using these parameters.

25 ATBIALOFIBIS-ANEXPERIMENT ALMULTIMEDIA WORKSTATION LINKING THE DEPARTMENT OF EMERGENCY MEDICINE AND RADIOLOGICAL SCIENCES Ahuja, J, Coristine, M, McKnight, D, Beilby, W, Department of Emergency Medicine, Ottawa Civic Hospital, and Department of Psychology, Carleton University, Ottawa, Ontario. Canada

We thus examined the impact of therapy on PSAS versus the other parameters in 73 consecutive patients, aged between 15 and 40 years evaluated at the Accident & Emergency Department by a single observer. Patients were assigned to one of three therapeutic regimes, viz subcutaneous adrenaline lmg (Gp A), nebulired salbutamol 10 mg (Gp B), and intravenous aminophylline 250 mg (Gp C). All parameters were evaluated pre-treatment and at 20 minutes post-treatment. The improvement with therapy was compared amongst the three treatmentregimens.

A trial of an experimental version of a multimedia medical communication system called IRIS (The Integrated Radiological Information System) operated between the Department of Emergency Medicine and the Department of Radiological Sciences at the Ottawa Civic Hospital for seven weeks during April and May 1989. IRIS is being developed to enhance communication between clinicians and radiology consultants to improve diagnosis and mporting.

Though all groups were comparable for severity of asthma as assessed by PEPR, PR and RR pm-treatment, patients in Gp BhadalowerPSASm easurement (6.8 in Gp B vs. 7.9 in Gps A and C [P = 0.00281).

IRIS supports the capture and distribution of digitized x-ray images and voice reports in the form of “electronic” patient folders which can be accessed at physician workstations throughout the hospital. It also supports on-line consultation between the radiologist and clinician by providing a multimedia shared space through synchmnixed workstation operation Each workstation has a high resolution image screen to display documents and x-ray images; a control screen to access patient folders; and a hands-free telephone to dictate, play back reports, and enable realtime consultation between physicians.

Post-treatment PEPR was sipificantly improved in Gps A andBoverthatofGpC(APEPR124f76inGpA,147f91in Gp B vs 70 f 62 in Gp C [P = 0.0031). In contrast the improvement in PSAS was significantly more in Gp A than Gps BandC(APSAS-5.7inGpAvs4.6inGpBand4.5inGpC. [p = 0.0361). In addition a much higher proportion of Gp A patients (23/27) achieved a PSAS c 3 than in Gps B (13/17) and c (13/27) [p = O.Ol].

The changes in PR and RR were comparable among the three groups. None of the 73 patients had adverse cardiovascular side-effects. A significantly smaller proportion of Gp A patients (4/27) required admission for further treatment of the asthmatic attack than for Gp B (6/17) and Gp C (12/27) [p = 0.0171.

From an Emergency Physician’s (EP) perspective such an Subcutaneous adrenaline appears to be more effective in involved system must have the appropriate functions to therapy of Bronchial Asthma than nebulixed salbutamol or

Abstracts

intravenous aminophylline, without an excessive risk for cardiovascular side-effects.

27 THE EFFECT OF THERAPEUTIC THEOPHYLLINE LEVELS ON THE HOSPITALIZATION OF ASTHMATIC PATIENIS Mattimore, JD, Cooper, MA, Chen, E. University of lllinois. Division of Emergency Medicine, Chicago, Illinois, USA

Asthma is a very frequent presenting complaint in the emergency department (ED.) and many asthmatics am taking theophylline, although with varying degrees of compliance. The determination of patient disposition has historically been determined by the response to full, and sometimes lengthy, emergency department therapy. This study wss undertaken to determine if a therapeutic serum theophylline level (FI’L) upon presentation to the E.D. of patients who are supposed to be on theophylline is predictive of hospital admission

A prospective study of patients age 15-55 years with a primary diagnosis of exacerbation of asthma, who were prescribed theophylline, was conducted from April 1 thru December 15. 1988. Patients with concommitant congestive heart failure. chronic obstructive puhnonaty disease, or recent toxic respiratory exposure were excluded. A structured questionnaire was completed by the examining physician and included information on the home use of inhalers or steroids, smoking history, previous intubation or intensive care unit admission, the time since the last theophylline dose, and the last E.D. visit for asthma The theophylline level, E.D. therapy, and the response to that therapy was recorded, including the peak flow on arrival, after the initial therapy, and the best peak flow. Eighty-six patients with an average age of 32 were evaluated 69% were female. 22% had a ‘lTL on arrival in the E.D. 68% of those with a TTL were admitted vs. only 31% of those with a subtherapeutic level (P < 0.006). An odds ratio analysis demonstrated that those patients with a TTL were 4.38 times more likely to require admission than those who were subtherapeutic. Improvement in peak flow of less than 100 L&run was a significant predictor of admission (P= 0.0043). odds ratio 5.89. Similarly, the peak flow after initial therapy (174 vs. 262 L/nun) predicted admission (P = 0.0001) as did the best peak flow (202 vs 310 urnin, P = .oool). This is consistent with previously published studies. There was no significant difference in admission based on arrival peak flow, temperature, sex, prior ICU admission or intubation, smoking history or past steroid use.

ln conclusion, this study supports the hypothesis that a therapeutic serum theophylline level on arrival to the emergency department is a strong predictor of the need for admission. The theophylline level, used in conjunction with other information which is available early in the emergency department course of treatment, can be used to shorten the time to the disposition decision and the time that a patient who is likely to be refractile to treatment remains in the emergency department.

28 PANCURONIUM BROMIDE IN LIFE-THREATENING ASTHMA Cluybo, RA. St. Michael’s Hospital, University of Toronto, Toronto, Ontario. Canada

Pancuronium bromide (Pavulon) is a non-depolarizing neuromuscular blocking agent. It is used extensively in Anaesthesia and Intensive Care Units. There is very little documentation in the literature of its use in the treatment of ventilated patients with status asthmaticus. ln 4 cases of life- threaten& asthma presenting to the Emergency Department at St. Michael’s Hospital, aggressive conventional bronchodilator therapy after intubation was unsuccessful which included assisted ventilation with 100% 02, continuous endotracheal salbutamol, intraveneous aminophylline and sohrmedrol. The patients continued to demonstrate high airway pressures (40-60 mm Hg). and showed no improvement in their ventilatory status. Each was given IV pancuronium and showed rapid ventilatory improvement, as measured by lowered airway pressures (20-30 mm Hg), improved pH, pCO2 and pG2, and general clinical status. The use of a non-depolarizing muscle relaxant such as pancuronium should be considered in the management of intubated patients with refractory bronchospasm.

29 SPONTANEOUS PNEUMOMEDIASTINUM - CASE REVIEW Zmwers, T, Department of Emergency Medicine, Resurection Medical Center, Chicago, lllinois, USA

23 cases of spontaneous pneumomediastinum (SP) are presented, including clinical presentations and outcomes. Because nontraumatic chest pain is uncommon in the pediatric and young adult age groups. SP should always be considered as an etiology of it. ln adults, diagnosis of SP may allow one to rule out more serious conditions which it can mimic, including pericarditis. puhuonary embolism and ischemia

The study varied from previous ones in that: (1) three physical fmdings - Hamman’s crunch, hyperresonance

over the anterior cheat, and subcutaneous emphysema of the neck - were absent in most cases;

(2) the diagnosis was often overlooked. prominent features of this group of patients which correspond well to previous studies included: (1) association with activities which increased intraalveolsr pressure; (2) prepondersnce of younger patients; (3) the benign course of the disease.

The pathophysiology and related anatomy of SP are reviewed, as well as radiographic characteristics of the condition.

30 EMERGENCY PERCUTANEOUS DILATATIONAL CRICOTHYROIDOSTOMY Ciuglio, P. Grauiero, ED, Brady, CW, St. Elizabeth Hospital, Utica, New York, USA

Fortunately, not too often, a critical situation demands au immediate airway as a life-saving measure. Frequently, a surgeon is not on the scene to do an emergency cricothyroidostomy. but EMTS and paramedics are usually present

We have devised a percutaneuous method which trained non-physicians (EMTS and parsmedics) can use with safety and speed. With one blade of a modified nasal speculum embedded