404 AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 9, Number 4 n July 1991

5. Krajewski LP, Hertzer NR: Blunt carotic artery trauma- Report of two cases and review of the literature. Ann Surg 1980;191:341-346.

6. Hilton-Jones D, Warlow CP: Non-penetrating arterial trauma and cerebral infarction in the young. Lancet 1965; 1:1435-l 436.

7. Little JM, May J, GK Vanderfield, et al: Traumatic thrombo- sis of the internal carotid artery. Lancet 1969;2:630-633.

ADMISSION DILEMMA

To the Editor:-We read with interest the recent editorial in Emer-

gency Medicine News by James R. Roberts, MD, of Philadelphia, PA.’ In this editorial, Dr Roberts describes his experiences and approach to the problem of assuming responsibility for the decision making regarding admission to the hospital.

This problem has existed for many years and has been com- pounded by the development of emergency medicine as a speciality field. There are several issues involved, including (1) in those hos- pitals with training programs, the responsibilities (and conflict of interest) of the admitting resident; (2) the responsibilities of the emergency physician; (3) the attending physician’s knowledge of his or her patients.

It should be understood that the emergency physician is ulti- mately responsible for any patient in the emergency department until such time as another attending assumes that burden of respon- sibility. The emergency physician therefore is expected to act as the patient’s advocate, and unfortunately, in response to potential med- ical/legal pressures.

Most hospitals, including ours, have attempted to remove any conflict of interest for emergency physicians by denying them the opportunity to provide any continuity of care once a decision has been made to admit the patient. It is very clear. therefore, that they are only acting in response to the two issues already noted. Resident physicians are often placed in the schizophrenic position of evalu- ating a patient and then making a decision to admit the patient to their services. All of us who have trained in the traditional manner (including some emergency physicians), can remember the “discomfort” of making a decision to admit either to our own ser- vice or a colleague’s service in the wee hours of the morning. In those cases where we had a holding area, the patient would often be held several hours to permit our colleagues to avoid a middle- of-the-night admission (occasionally to the detriment of the patient). Alternatively, we would at times determine that the patient wasn’t sick enough to be admitted and would be referred to the out-patient clinic (often referred to as the V-Tach Clinic).

It is clear then, except in unequivocal situations, that the patients’ best interests were frequently not the primary consideration when deciding whether to admit. In the setting of an institution with a “private” attending staff, patients are often well known to the at- tending physician. Here, the communications process between the emergency physician and the attending physician are critical. The attending physician must provide appropriate history to the emer- gency physician to mitigate any decisions regarding admission of that patient. Even in those cases in which the patient’s problems are clearly and well established as chronic, the emergency physician is still faced with the decision of an ill-appearing patient who is asking that physician to be his or her advocate.

We are all aware of those situations in which a patient with re- current angina, chronic lung disease, etc, dies shortly after being seen in the emergency department. either in the hospital or at home. This often occurs with little change in the patient’s chronic condi- tion. Emergency physicians are placed in the position of trying to make the appropriate decision for that patient. It is clear that unless the attending physician is willing to come in and assume responsi- bility for a patient who the emergency physician wishes to admit

(over the attending’s objection), the attending has yielded his or her primary rights.

We have all been in the position of the emergency physician at one point or another in our training, and it is quite clear that until some- one (the attending physician) is willing to assume the burden of responsibility, the emergency physician must act in what he or she perceives to be the best interest of the patient, even in the face of objections from the house staff and the attending.

As we all know, when viewed through the retrospect scope, it is easy to second guess a decision. We also know that our colleagues soon tire of “Monday-morning quarterbacks.” We hope that by taking this position, we, as Program Director in Internal Medicine and Director of Emergency Medicine, try to clarify the issues and make it patently clear to all our colleagues as lo what we consider to be appropriate behavior in emergency medicine.

MICHAEL L. FRIEDLAND, MD MICHAEL CARIUS, MD KATHLEEN HARPER, DO

St Vincent’s Medical Center

Bridgeport, CT

Reference

1. Roberts JR: About that patient you “made me admit.” Emerg Med News 1990;12:2

AN EVALUATION OF ELECTROCARDIOGRAMS BEFORE AND AFTER NITROGLYCERIN THERAPY

To the Editor:-Determining the etiology of a patient’s complaint of chest pain represents one of the more intense diagnostic dilemmas in the emergency department (ED) setting.’ Lee et al’ and Tiemey et al’ examined multiple variables to try to find if significant predic- tors of myocardial infarction could be determined. Unfortunately no one clinical parameter can allow the physician to be 100% accurate in deciding if the chest pain represents myocardial ischemia.

Physicians commonly use sublingual nitroglycerin to treat pa- tients with suspected myocardial ischemia chest pain. It is the au- thors’ experiences that a point of concern voiced by physicians is whether ischemic changes in an electrocardiogram (ECG) would be missed if the patient received sublingual nitroglycerin prior to ob- taining the initial ECG. There is no documented scientific evidence that this in fact occurs.

The purpose of this present study was to determine the effect, if any, of sublingual nitroglycerin on the ECG findings in patient’s presenting to an ED with suspected cardiac chest pain.

The present study was of cross-sectional design and conducted in the ED at Thomas Jefferson University Hospital. This institution is an urban-based and university-associated hospital. The ED has ap- proximately 42,ooO patient visits per year. The study was approved by the Institutional Review Board.

Patients presenting to the ED with complaint of chest pain sug- gestive of cardiac ischemia and treated with sublingual nitroglycerin were entered into the study. Those patients with cardiac pacemak- ers were excluded from the study due to difficulties in appreciating ST-T wave changes on sequential 12-lead EC&. All patients en- rolled in the study were evaluated by either a senior emergency resident or emergency attending.

When a patient presented to the ED with suspected cardiac chest pain, they were placed on a cardiac monitor, placed on supplemental oxygen at 2 liters by nasal cannulae, and had an intravenous line initiated. After interview by the physician, if cardiac chest pain was still considered, the patient had a 12-lead ECG performed, and then if hemodynamically stable received nitroglycerin sublingually l/150 grains. The nitroglycerin sublingual was repeated three times ap- proximately every 5 minutes if chest pain persisted. If the likelihood of cardiac ischemia persisted and the patient’s pain remained, an intravenous infusion of nitroglycerin was started. When the patient perceived an abolishment of their chest pain or had four nitroglyc- erin administered, a second 12-lead ECG was obtained.

CORRESPONDENCE 405

Pre and Post Nitroglycerine Electrocardiographic Changes

Unchanged (80%) Changed (20%)

lschemic (40%) Nonischemic (40%) Ischemic+ Ischemic+ Nonischemic-t Ischemic--+ More ischemic Less ischemic lschemic Nonischemic

2% 8% 2% 8%

FIGURE 1.

All 12-lead ECGs were evaluated by three of the authors. The authors were blinded as to whether the ECG was before or after nitroglycerin administration. ECG criteria suggesting ischemia/ infarction were based on guidelines previously published to include level of ST segment elevation and depression, T-wave peaking or flattening/inversion and pathological Q waves3 Then the ECGs were identified as which were before the nitroglycerin and which were after the nitroglycerin and if a change was observed what it was.

A data collection sheet accompanied the ED chart and ECGs on these patients. The data collection sheet recorded the amount of pain relief if any with sublingual nitroglycerin at time of the second ECG. Pain relief was recorded as complete, partial, or none. Also recorded was the number of sublingual nitroglycerin tablets that were taken.

The patient’s admission records were obtained. In-hospital car- diac evaluation and final diagnosis were recorded. This enabled the authors to correlate data collected in the ED with the in-hospital diagnosis.

A total of 50 patients with possible ischemic cardiac chest pain and receiving sublingual nitroglycerin were entered into the study. Mean age for the study sample was 57.5 2 16 years. Sixty percent of the patients were men and 40% were women. The race distribution was 56% white, 42% black, and 2% hispanic.

Seventy percent of the study sample had a discharge diagnosis related to cardiac disorders and 30% of the patients had noncardiac discharge diagnoses. Further breakdown of final diagnosis showed 34%, coronary artery disease; 8%, unstable angina; 22%, myocar- dial infarction; 2%, dysrhythmia with angina; 2%. coronary spasm secondary to cocaine abuse; 2%, cardiomyopathy; 18%, atypical chest pain; 4%, gastrointestinal disorders; 6%. musculoskeletal; 2%, other diagnosis.

Forty-nine patients took nitroglycerin at home with a mean of 1 .O 2 1.7 tablets used. In the ED 1.9 * 0.9 tablets were administered per patient. At the time of the second ECG tracing 49% of the patients had complete pain relief, 45% had partial pain relief, and 6% had no pain relief.

As described in the methodology section, patients were summa- rized based on pre- and postnitroglycerin ECG tracings and the ischemic differences or lack of differences between them (Figure 1).

Eighty percent of the patients had no change in their ECG pre- and post-nitroglycerin therapy. There were four patients (8%) in this sample who had ECGs that changed from ischemic to nonischemic after nitroglycerin therapy. None of these four patients had a myo- cardial infarction. All four had a discharge diagnosis of coronary artery disease/angina.

The ECG has become a commonly used tool in the care decision process of patients presenting with chest pain to an ED. Certain authors have demonstrated ECG findings in combination with other

historical and physical examination variables were predictive of acute myocardial infarction. is3 However, Slater et al4 and Hoffman et al5 did not find the ECG to truly play a role in the decision process to admit or discharge chest pain patients. In addition to the admit- ting decision, several authors have found the ECG to be helpful in predicting in hospital complications in acute myocardial infarction patients3.‘.s

The need to obtain an ECG in the ED evaluation of a patient with chest pain is not in question. What is in question is the need to withhold nitroglycerin therapy in a patient with suspected cardiac ischemia to obtain the ECG first. In the experiences of the authors, the concern expressed by physicians is that ischemic ECG changes maybe missed if the ECG normalizes due to an effect of the sublin- gual nitroglycerin. This in turn might alter the physician’s decision to admit the patient. The present study was designed to determine if this ECG “normalization” occurs with nitroglycerin use.

Due to the descriptive nature of this study, 50 patients were suf- ficient to approximate the types of changes if any between before and after nitroglycerin therapy ECGs.

In this sample population, 8% of the patients did have ECGs that changed from ischemic to nonischemic after sublingual nitroglyc- erin. None of these patients had an acute myocardial infarction. The final diagnosis in all four was angina/coronary artery disease.

However, 92% of the patients did not lose ischemic changes on the ECG or did not have any ischemic changes initially. Eighty percent of the patients did not have any ECG changes with sublin- gual nitroglycerin. Four percent of the patients actually had more ischemic ECGs after nitroglycerin.

Though some ECG changes were observed after nitroglycerin in 20% of this patient sample, a cause and effect with sublingual nitro- glycerin therapy cannot be demonstrated from this study. With 80% of the patients’ ECGs remaining unchanged, other undetermined factor(s) may be responsible for the 20% of ECGs which change.

The usage of sublingual nitroglycerin in patients with cardiac isch- emit pain is of therapeutic as well as perhaps diagnostic value. It appears from the above that withholding nitroglycerin therapy and pain relief to obtain an initial ECG may be unjustified.

M. ANDREW LEVITT, DO

University of California San Francisco, CA

Highland General Hospital

Oakland, CA

PATRICK J. FRICCHIONE, MD MARK E. NEPP, DO THERESE MCGURKIN, RN, MSN, CEN Thomas Jefferson University Hospital

Philadelphia, PA

406 AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 9, Number 4 m July 1991

References

1. Lee TH, Cook F, Weisberg M, et al: Acute chest pain in the emergency room. Arch Intern Med 1985;145:65-69

2. Tierney WM, Fitzgerald J, f&Henry R, et al: Physicians’ estimates of the probability of myocardial infarction in emer- gency room patients with chest pain. Med Decis Making 6:12-17, 1986

3. Brush JE, Brand DA, Acampara D: Use of initial cardio- graph to predict in-hospital complication of acute myocardial infarction. N Engl J Med 1985;312:1137-1141

4. Plotnick GD, Fisher ML: Risk Stratification: A cost effective approach to the treatment of patients with chest pain. Arch In- tern Med 1985;145:41-42

5. Slater DK, Htatky MA, Mark DB, et al: Outcome in suspected acute myocardial infarction with normal or minimally normal admission electrocardiographic findings. Am J Cardiol 1987; 60:766-770

6. Hoffman JR, lgarashi E: Influence of electrocardiographic findings on admission decision in patients with acute chest pain. Am J Med, 1985;79:699-707

7. Young MJ, McMahon Jr. LF, Stross JK: Prediction roles for patients with suspected myocardial infarction applying guide- lines in community hospitals. Arch Intern Med 1987;147:1219- 1222

8. Stark MR, Vacek JL: The initial electrocardiogram during admission for myocardial infarction. Arch Intern Med; 147:843- 846

PROSPECTIVE EVALUATION OF GASTRIC EMPTYING

To rhe E&or:-Regarding “Prospective Evaluation of Gastric Emptying in the Self-Poisoned Patient” (Am J Emerg Med 1990;8:479-483), I believe that this is an important study done on a very difficult topic.’ The ongoing debate about gastrointestinal de- contamination in overdose involves all emergency physicians and has the potential to affect the care of thousands of overdose pa- tients. We know that the American Association of Poison Control Centers has reported in excess of 100,000 cases, each treated with ipecac and activated charcoal, and more than 40,000 cases treated with gastric lavage in 1989.’

This study by Merigian et al is important because it is only one of three that has assessed true clinical outcomes in actual overdose cases.3.4 Many other studies addressing the issue of gastrointestinal decontamination have looked at markers for patient outcomes. such as recovery of gastric contents and differences in urine and serum levels. However, the bottom line in patient care is whether or not morbidity and mortality is reduced. Therefore, Merigian et al are to be congratulated for addressing patient outcomes in a large clinical trial in human poisoning.

I wish to comment on several aspects of the design of the study because I feel strongly that clinicians must be very cautious in the conclusions that they draw from the data presented. Although we have no reason to believe that inadequate randomization occurred, we would benefit from a table comparing the demographic and clin- ical characteristics of the two study groups. This would also give us important insight into the distribution of important subgroups such as age (were there any children?), time from ingestion, and types of drugs ingested.

Outcome assessment is very difftcult in such a study. 1 am con- cerned that outcomes were ascertained retrospectively from the chart and in an unblinded fashion. This raises the question of po- tential observation bias. I was pleased to see the patients identified by a precise instrument, the abbreviated mental status examination, yet was disappointed that this excellent tool was not used as an outcome assessment. I suspect that the definition of deterioration used may have been too strict to detect changes in the status of the asymptomatic patients. Furthermore, I was amazed to see that this outcome was not mentioned in the discussion of the symptomatic patients.

I must give the authors full credit for accounting for all their patients and for discussing the limitations in their sample size with regards to the lack of power for showing a difference between groups. Overdose patients are a very heterogeneous group in terms of time from ingestion as well as types and quantities of drugs in- gested. Hence, very large numbers are required to be sure that we are not missing a treatment effect in specific groups. We still have no idea whether activated charcoal is effective for patients who have taken enteric coated salicylate or acetaminophen 60 minutes previ- ously and are still asymptomatic. Likewise, I am sure that most clinicians would be uncomfortable in withholding both activated charcoal and gastric lavage in a patient who has taken large quan- tities of cyclic antidepressants a short time previously, but who is still asymptomatic.

I wonder whether the large number of intubations in the gastric lavage group were necessary and whether or not the use of succi- nylcholine had an important impact on the large number of cases of aspiration.

I agree with authors’ conclusions as worded but readers must be cautioned to observe the limirarions given by the authors on their own work: *‘. gastric emptying is unnecessary for selecred asymptomatic overdose patients and has limited clinical benefit in the routine management of symptomatic patients.” This must not be construed to mean that gastric emptying is unnecessary for all asymptomatic patients and has no clinical benefit in symptomatic patients. What needs to be determined is which “select” groups of

overdose patients might benefit from gastric emptying or gastric lavage in terms of age, time from ingestion, type of drug, and quan- tity of drug.

We know that many patients do well without activated charcoal or gastric lavage but we do not yet know which “select” subgroup of patients does benefit from these measures. This study by Merigian and associates is an excellent piece of research. I hope it will be followed by more studies that have the power and freedom from bias to answer the many remaining questions about the value of gastro- intestinal decontamination in human overdoses.

I. STIELL, MD Orrawa Civic Hospital Orrawa, ON Canada

References

1. Merigian KS, Woodard M, Hedges JR, et al: Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med 1990;8:479-483

2. Litovitz TL, Schmitz BF, Bailey KM: 1989 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1990;8:394-399

3. Kulig K, Bar-Or D, Cantrill SV, et al: Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985;14:562-567

4. Albertson TE, Derlet RW, Foulke GE, et al: Superiority of activated charcoal alone compared with ipecac and activated charcoal in the treatment of acute toxic ingestions. Ann Emerg Med 1989;18:101-104

ACUTE TRANSIENT WHEW COLfTlS AFTER ORAL METHAMPHETAMlllE IWESTlON

To the Editor:-Methamphetamine is derived by adding a methyl group onto the terminal amine of amphetamine. It is probably the most commonly abused of the amphetamine analogues that include MDMA (3,4-methylenedeoxyamphetamine, ecstasy), DOM (4- methyl-25dimethoxyamphetamine, UP), and mescaline. Reported complications from its abuse have primarily been related to neuro- logical and cardiovascular systems. Although methamphetamine has been popular since the 196Os,’ its use has been increasing in the late