ABSTRACTS

.with a higher rate among EMTs than paramedics. In 31% of the personnel, the back injuries were recurrent . There was no correlation between job experience and injury rates. Overall, injury rates were h igher in EMTs than in paramedics, in women than in men, and i n personnel less than 30 years old. Approximately 96 injuries accounted for 48 lost work days, while low back strain accounted for 375 lost work days. Guidelines for prevention are discussed, including proper lifting techniques and not at- tempting to lift weights beyond one's capability.

.Robin Johnson, MD

prehospital care, protocols

Does paramedic-base hospital contact result in beneficiai deviations from standard prehospital protocols? Hoffman JR, Luo J, Schriger D, et al West J Med 153:283-287 Sep 1990

In some Prehospital systems, para- medics are authorized to provide care essentially 0nly under the direct su- pervision of certified base hospital physicians or certified mobile inten- sive care nurses. For many prehospi- tal chief complaints, t reatments al- most never vary and generally follow simple protocols. The authors hy- pothesized that the preh0spital man- agement of patients with these com- plaints would be easily amenable to an algorithm-directed system and by- pass the need for direct hospital com- munication. Four common prehospi- tal chief complaints (abdominal pain, syncope, seizure, and altered mental status) were selected and algorithms were abstracted from standard local protocols. A retrospective review of the written and audio records of para- medic:base hospital radio contact for all patients (659) with one of these chief complaints was performed to de te rmine whe the r t r e a t m e n t dif- fered from that suggested in the ab- stracted algorithms. Cases that in- vo lved u n a n t i c i p a t e d t r e a t m e n t s were reviewed to determine the basis

156/113

for the variation in treatment. Unan- t ic ipated therapies were adminis- tered to only 13 patients, all of whom had abnormal vital signs, diaphoresis, r e sp i ra to ry distress, or a second p rominen t symptom. It was con- cluded that protocols could replace radio contact for most patients and that the few who might benefit from radio contact could be identified eas- ily. Such selective base-station con- tact would not only decrease the t ime spent in the prehospital envi- ronment, but would dramatically di- minish the number of radio contacts, thus allowing consolidation of base stations and u l t imate ly translating into cost savings. [Edftor's note: It is interesting to note the variability be- tween those prehospita] care systems requiring m a n d a t o r y base stat ion contact and those using field man- agement with standing protocols and select base station contact. Those of us involved with the latter type of system realize that it is a safe and efficient means of delivering prehos- pital care, provided there is an ongo- ing audit of paramedic runs.]

Mark Copeland, MD

trauma, blunt chest; myocardial contusion

Suspected myocardial contusion: Triage and indications for monitoring Wisner DH, Reed WH, Riddick RS Ann Surg 212:82-86 Jul 1990

In th is r e t ro spec t ive study, all 3,010 blunt trauma admissions for a 16-month consecut ive period tO a t r auma center were reviewed. Of these pat ients , 10l were declared dead in the emergency department; 14 had autopsy evidence of myocar- dial contusion, and another 12 had other types of cardiac injury. Thir- teen patients died in the operating room, and one had evidence of myo- cardial contusion. Of the 644 pa- tients admitted to monitored beds, there were 47 deaths. None of these pa t ien ts had autopsy evidence of myocardial contusion. There were 2,252 admiss ions to unmon i to r ed beds; nine of these patients required

Annals of Emergency Medicine

transfer to the iCU, and two subse- quently died. Neither had clinical/ autopsy evidence of myocardial con- tusion. Of the 95 patients admitted with diagnosis of rule-out myocardial contusion, none developed subse- quent cardiac failure. Arrhythmias occurred in 19 patients, four of whom were considered serious enough to require treatment; three of these pa- tients had conduction abnormalities on admission ECG, and the other was s u b s e q u e n t l y d e t e r m i n e d to have a benign baseline arrhythmia. CPK-MB fractions and echocardio- grams were poor predictors of serious arrhythmias. It was concluded that patients wi th clinically significant blunt cardiac injury will manifes t signs of injury shortly after t rauma and that stable patients with no con- duction abnormalities on admission ECG can Safely be admitted to un- monitored beds.

Ilya Chern, MD

cerebrovascular accidents, cocaine

Cerebrovascular compli- cations of the use of the "crack" form of alkaloid cocaine Levine SR, Brust JCM, Futrell N, et al N Engl J Med 323:699-704 Sep 1990

A mixed prospective and retrospec- tive review of 28 patients who had strokes temporally related to the use of alkaloid cocaine (crack) was per- formed. Patients were included in the study if there was a confirmatory his- tory of smoking crack cocaine within 72 hours of their neurologic event. Pa t i en t s were excluded f rom the study if they had used cocaine hydro- chloride in the recent past or if the nature of thei r cocaine use was in doubt. Toxicology screening was per- formed on 16 of the 28 patients and was posit ive for cocaine in all 16. The mean age of the patients was 34 years (range, 23 to 49 years). Eighteen (64%) had acute neurologic symp- toms i m m e d i a t e l y or wi th in one hour of using crack, and five (18%) developed symptoms within one to

20:1 January 1991