Læknablaðið : fylgirit - 15.06.2002, Blaðsíða 27

POSTERS / ICELAND 2002: EMERGENCY MEDICINE BETWEEN CONTINENTS
analgesia between fentanyl and morphine in a consecutive cohort
of trauma patients who were not intubated before hospital. Evalua-
tion of pain was performed with a numeric rating scale (NRS)
ranging from 0 (no pain) to 10 (maximum pain). The endpoint was
the NRS on arrival at hospital, failure being defined as a NRS > 3.
Methods: We analyzed computerized medical records from 743
trauma adult patients (> 16 y.) at a level one trauma center between
1997 and 2001, with a first NRS on site > 3, who were not intubated
and who received either intravenous (iv) fentanyl or iv morphine
for analgesia. Exclusion criteria were no NRS on site or on arrival
and administration of fentanyl and morphine together or with
another analgesic drug (paracetamol, tramadol). The age, gender,
Glasgow coma scale (GCS) on site and on arrival, systolic blood
pressure (SBP) on site and on arrival, injury severity score (ISS),
mechanism of injury (blunt/non-blunt), on-scene time and prehos-
pital time (on-scene and transport time) were compared.
Rank-sum, Fisher and Chi-square tests have been used in the
comparative analysis; p < 0.05 was considered statistically signifi-
cant.
Results: There were 696 patients in the fentanyl group and 47 in the
morphine group. The demographic and clinical characteristics for
the two groups were similar except for the age, which was younger
in the fentanyl group (42.5 y. vs. 51.0 y., p=0.003).
Although the NRS on site was not different between the two
groups (7.3 vs. 7.5, p=0.52), the NRS at hospital was lower in the
fentanyl group (3.3 vs. 3.9, p=0.02). In addition, more patients in the
fentanyl group arrived al hospital with a NRS < 3 (60.2% vs. 40.4%,
p=0.01). The mean equidose of fentanyl (130.0 mg) was twice that
of morphine (6.6 mg). There was no difference in SBP on site and
on arrival between the two groups. Similarly there was no diffe-
rence in the intubation rate on arrival, 6 in the fentanyl group and 2
in the morphine group. 17.1% of the patients in the fentanyl group
and 12.8% in the morphine group received either ketamine, drope-
ridol or benzodiazepines (p=0.57). No patient received naloxone.
Conclusion: In this study, analgesia was more effective with fenta-
nyl than with morphine in adult trauma patients, without change in
the GCS or the SBP and without an increased risk of respiratory
failure. This study suggests, thus, that fentanyl is the first line
analgesic drug in the prehospital setting. Moreover, fentanyl has a
faster onset time and a shorter duration of action than morphine so
that it is more comfortable to use in small incremental doses
titrated to pain in a possibly unstable trauma patient.
P 32 - Airway/Respiratory Emergencies
Acute laryngeal trauma from coining in an iatrogenically over-
anticoagulated patient
Villanueva TMC
Medical College of Philadelphia - Hahnemann Universiy Hospitals and St.
Christopher's Children's Hospital of Philadelphia. United States
Objective: To present a case of a patient with blunt trauma from an
alternative medicine practice which resulted in a laryngeal fracture
and hematoma secondary to being iatrogenically over-anticoagu-
lated after being prescribed clarithromycin while taking warfarin.
A 65 yo female with a five-day history of a sore throat presented
to the Emergency Department with complaints of increasing throat
pain, neck swelling and difficulty swallowing. The patient, who had
a scheduled appointment with her primary doctor for routine labs,
was prescribed clarithromycin for the flu. Over the next 2 days, the
patient developed a subjective fever, non-productive cough and
dysphagia. The patient denied trismus, difficulty swallowing liquids,
drooling, difficulty breathing or change in her voice. The pain was
constant, non-radiating, and gradual in onset and located in the
back of her throat. On the fourth day of symptoms, the patient went
to her alternative doctor who performed coining around her neck.
She had no relief and noticed increasing pain and dysphagia. Her
past medical history was positive for non-insulin dependent dia-
betes mellitus, atrial fibrillation, mitral valve prolapse, congestive
heart failure, coronary artery disease and hypertension. Her medi-
cations were glipizide, digoxin, warfarin, potassium, furosemide,
metoprolol and clarithromycin. Physical exam revealed an awake,
alert female sitting upright on a stretcher, breathing with her mouth
open and head tilted back. Vitals signs were rectal temperature of
100.8, heart rate of 136, respiratory rate of 22, and blood pressure of
153/88. She had no sclera icterus, conjunctiva and oral mucosa were
pink and her mucous membranes were dry without lesions. There
was no maxillary or mandibular swelling and no facial erythema.
Patient was edentulous. There was posterior pharyngeal erythema
without any trismus, soft palate elevation or fullness or tonsillar
exudates or mass. Her uvula was midline and tongue was normal.
The trachea was midline. She had posterior cervical lymphadeno-
pathy and swelling over her left lateral neck. No subcutaneous air.
Thyroid was normal. There was JVD. Her lungs had bibasilar rales.
Her heart was irregularly irregular with a systolic ejection murmur.
Her skin revealed ecchymosis over her anterior neck, superior to
the clavicles and sternal notch. Her laboratory studies revealed
hypokalemia, pre-renal hypovolemia, a sub-therapeutic digoxin
level and coagulation studies with an INR 11.4, PT 36.1 and PTT
100.0. Her soft tissue lateral x-ray of the neck revealed nonspecific
soft tissue density in the region of the pyriform sinuses. Nasopha-
ryngeal laryngoscopy was performed in the ED revealing a laryn-
geal hematoma over the left vocal fold. CT of the neck confirmed
the diagnosis and documented a fracture of the larynx. The patient
was admitted to the CCU with ENT consulted and her coagulo-
pathy reversed.
Condusion: With an estimated 7000 deaths per year from medica-
tion errors, emergency physicians must be aware of the common
drug interactions and their life threatening complications so we can
educate our patients and avoid adverse drug reactions. External
laryngeal trauma presents to the Emergency Center 1 in 300,000
visits, with blunt trauma being the most common etiology. In order
to do no harm, emergency physicians must be aware of the various
forms of alternative medicine treatments to protect our patients.
P 33 - Neurologic Emergencies
Optimal positioning for lumbar puncture: lateral decubitus or
sitting?
O'Brien JF
Orlando Regional Healthcare, United States
Objective: Lumbar puncture (LP) is a frequent diagnostic proce-
dure in emergency medicine. In review of the medical literature we
found no prospective study comparing success rate of lumbar
puncture based on patient position. This prospective randomized
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