Faculty Bibliography

OBJECTIVE: To describe the epidemiology of alcoholism in ED patients. METHODS: Over a two-month period, every adult patient brought by ambulance to the ED of a large municipal hospital was prospectively enrolled by questionnaire. Data collected included demographics, previous ED use, triage complaint-related diagnoses, hospital admission rates, and ethanol levels (if determined). The CAGE alcoholism questions were administered to all patients by trained assistants. The only exclusion criterion was the inability to communicate while in the ED. A chi-square analysis was used to compare categorical variables. RESULTS: A total of 2,658 patients were enrolled in the study; 226 were unable to respond to the CAGE questions. Five hundred eighty-eight of the remaining 2,432 patients (24%) were defined as being alcoholic by an affirmative response to at least two of the CAGE questions. All four questions were answered affirmatively by 17% of the total patients. Alcoholic patients were more likely to be male (88% vs 60%), unemployed (87% vs 71%), undomiciled (46% vs 20%), polysubstance users (52% vs 25%), and tobacco users (77% vs 41%), and to have had an ED visit in the previous six months (51% vs 35%) (p < 0.001 for all tests). Ethanol levels ranged from zero to 573 mg/dL. Whereas no positive response to a single CAGE question was predictive of a final diagnosis of alcoholism, a blood ethanol level more than 300 mg/dL predicted an affirmative response to at least two CAGE questions in 97% of cases. CONCLUSIONS: Alcoholism should be presumed to be present in a substantial number of patients who present to urban EDs by ambulance

STUDY OBJECTIVE: To develop guidelines for the stocking of antidotes at hospitals that accept emergency admissions using combined evidence-based and consensus methods. METHODS: Study participants were 12 medical care providers from disciplines that are affected by insufficient stocking of emergency antidotes (clinical pharmacology, critical care, clinical pharmacy, emergency medicine, hospital pharmacy, internal medicine, managed care pharmacy, clinical toxicology, pediatrics, poison control centers, pulmonary medicine, regulatory medicine). Selection of individuals for the study panel was based on evidence of previous antidote research or perspective regarding the purchase and use of antidotes. The literature regarding each antidote was systematically amassed using pre-1966 literature files, current MEDLINE searches, the reference lists of major medical textbooks, and citations solicited from the consensus panel. Articles relevant to 4 defined core questions were included. These articles formed the basis of an evidence-based analysis performed by the principal investigator. After literature analysis, a literature summary and proposed guidelines for antidote stocking were submitted to the panel. Consensus was formed by electronic iterative presentation of alternatives to each panel member using a modified Delphi method. All panel members participated in 5 rounds of guideline analysis of 20 antidotes. RESULTS: Of the 20 antidotes, 16 antidotes were ultimately recommended for stocking (N -acetylcysteine, atropine, Crotalid snake antivenin, calcium gluconate and chloride, cyanide antidote kit, deferoxamine, digoxin immune Fab, dimercaprol, ethanol, fomepizole, glucagon, methylene blue, naloxone, pralidoxime, physostigmine, sodium bicarbonate), 2 were not recommended for stocking (black widow antivenin, ethylenediamine tetraacetic acid), and consensus could not be reached for 2 antidotes (flumazenil, physostigmine). CONCLUSION: These guidelines provide a tool to be used in revising or creating policies and procedures with regard to the stocking of antidotes in hospitals that accept emergency patients

OBJECTIVES: To investigate the epidemiologic characteristics of potentially infectious occupational exposures to blood among emergency medicine (EM) residents. METHODS: A SAEM-sponsored multiple-choice survey was administered anonymously to all EM residents participating in the 1998 American Board of Emergency Medicine in-service examination. Survey questions included resident demographics, use of universal precautions, frequency and types of exposures to blood, and exposure reporting. Residents who experienced at least one exposure were then asked to complete an additional set of questions referring only to their latest exposure. Mean values were calculated for each variable and differences between groups were compared by chi-square analysis. RESULTS: Three thousand one hundred sixty-two surveys were distributed to the resident participants, and 2,985 surveys (94.4%) were returned. Of the participants, 56.1% reported at least one exposure to blood during their EM training. The frequency of this self-reported exposure increased with advancing EM level of training (43% EM-1, 58% EM-2, 64% EM-3, 76% EM-4, p<0.001). Of these residents, 36.6% always followed universal precautions, 54% frequently, and 9.4% sometimes, rarely, or never. Those individuals who 'always' followed universal precautions reported significantly fewer exposures than those who did not (p<0.005). The latest exposures were most commonly caused by a solid needle or sharp object (39.4%), by a hollow-bore needle (30.6%), or by eye splashes (17.2%). Of these exposures, 71.7% occurred in the ED setting, and only 46.7% of these exposures were reported to health care providers. CONCLUSION: Emergency medicine residents are frequently exposed to blood, most commonly due to puncture injuries by sharp objects. The rate of exposure reporting is low, which may compromise appropriate postexposure counseling and prophylaxis