American Journal of Emergency Medicine

Masthead

2012-02-01

Diagnostic accuracy of heart-type fatty acid–binding protein for the early diagnosis of acute myocardial infarction

2011-01-05

Abstract: Objective: The aim of this study was to evaluate the diagnostic efficacy of multiple tests—heart-type fatty acid–binding protein (H-FABP), cardiac troponin I (cTnI), creatine kinase-MB, and myoglobin—for the early detection of acute myocardial infarction among patients who present to the emergency department with chest pain.Methods: A total of 1128 patients provided a total of 2924 venous blood samples. Patients with chest pain were nonselected and treated according to hospital guidelines. Additional cardiac biomarkers were assayed simultaneously at serial time points using the Cardiac Array (Randox Laboratories Ltd, Crumlin, United Kingdom).Results: Heart-type fatty acid–binding protein had the greatest sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours (85.3%) after chest pain onset. The combination of cTnI measurement with H-FABP increased sensitivity to 71.4% at 3 to 6 hours and 88.2% at 3 to 6 hours. Receiver operating characteristic curves demonstrated that H-FABP had the greatest diagnostic ability with area under the curve at 0 to 3 hours of 0.841 and 3 to 6 hours of 0.894. The specificity was also high for the combination of H-FABP with cTnI at these time points. Heart-type fatty acid–binding protein had the highest negative predictive values of all the individual markers: 0 to 3 hours (93%) and 3 to 6 hours (97%). Again, the combined measurement of cTnI with H-FABP increased the negative predictive values to 94% at 0 to 3 hours, 98% at 3 to 6 hours, and 99% at 6 to 12 hours.Conclusion: Testing both H-FABP and cTnI using the Cardiac Array proved to be both a reliable diagnostic tool for the early diagnosis of myocardial infarction/acute coronary syndrome and also a valuable rule-out test for patients presenting at 3 to 6 hours after chest pain onset.

Should we fear “flu fear” itself? Effects of H1N1 influenza fear on ED use

William M. McDonnell, Douglas S. Nelson, Jeff E. Schunk — 2011-01-05

Abstract: Background: Surges in patient volumes compromise emergency departments' (EDs') ability to deliver care, as shown by the recent H1N1 influenza (flu) epidemic. Media reports are important in informing the public about health threats, but the effects of media-induced anxiety on ED volumes are unclear.Objective: The aim of this study is to examine the effect of widespread public concern about flu on ED use.Methods: We reviewed ED data from an integrated health system operating 18 hospital EDs. We compared ED visits during three 1-week periods: (a) a period of heightened public concern regarding flu before the disease was present (“Fear Week”), (b) a subsequent period of active disease (“Flu Week”), and (c) a week before widespread concern (“Control Week”). Fear Week was identified from an analysis of statewide Google electronic searches for “swine flu” and from media announcements about flu. Flu Week was identified from statewide epidemiological data.Results: Data were reviewed from 22 608 visits during the study periods. Fear Week (n = 7712) and Flu Week (n = 7687) were compared to Control Week (n = 7209). Fear Week showed a 7.0% increase in visits (95% confidence interval, 6-8). Pediatric visits increased by 19.7%, whereas adult visits increased by 1%. Flu Week showed an increase over Control Week of 6.6% (95% confidence interval, 6-7). Pediatric visits increased by 10.6%, whereas adult visits increased by 4.8%.Conclusion: At a time of heightened public concern regarding flu but little disease prevalence, EDs experienced substantial increases in patient volumes. These increases were significant and comparable to the increases experienced during the subsequent epidemic of actual disease.

Cancer diagnosis and outcomes in Michigan EDs vs other settings

Veronica Sikka, Joseph P. Ornato — 2011-01-19

Abstract: Objective: This study determined the proportion of incident colorectal and lung cancers with a diagnosis associated with an emergency department (ED) visit. The characteristics of these patients and the correlation between diagnosis near an ED visit and stage at diagnosis were also examined.Methods: A population-based sample of all Michigan cancer cases diagnosed in all EDs and other health care settings was used to extract a sample of patients >65 years old, diagnosed with colorectal and lung cancers between January 1, 1996, and June 30, 2000 (n = 20 311). Logistic regressions were used for the statistical analysis.Results: Patients with a colorectal cancer diagnosis associated with an ED visit were more likely insured by Medicaid before diagnosis (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.17-1.60), had an inpatient admission before diagnosis (OR, 1.29; 95% CI, 1.06-1.56), had 3 or more comorbidities (OR, 4.11; 95% CI, 3.53-4.79), were more likely to be female (OR, 1.18; 95% CI, 1.07-1.31), and were more likely to be aged 85 years and older (OR, 1.89; 95% CI, 1.57-2.27). Patients who had at least one primary care physician (PCP) visit before diagnosis were less likely to have a diagnosis associated with an ED visit (OR, 0.68; 95% CI, 0.61-0.76). Patients diagnosed with lung cancer in association with an ED visit were also more likely to have an inpatient admission before diagnosis (OR, 1.21; 95% CI, 1.02-1.43), a higher comorbidity burden (OR, 12.44; 95% CI, 10.18-15.20), be female (OR, 1.13; 95% CI, 1.02-1.25), African-American (OR, 1.42; 95% CI, 1.21-1.66), and older (80 years and older) (ages 80-84 years: OR, 1.33; 95% CI, 1.13-1.57; age 85 years and older: OR, 1.52; 95% CI, 1.25-1.85). Patients with an ED visit near a colorectal cancer (OR, 1.28; 95% CI, 1.15-1.42) or lung cancer diagnosis (OR, 1.65; 95% CI, 1.44-1.88) were more likely to be diagnosed at a later stage compared with patients diagnosed in other settings.Conclusions: An examination of patients' patterns of care leading to a cancer diagnosis in association with an ED visit lends insight to conditions precipitating a more immediate diagnosis and their associated outcomes.

ED visits for drug-related poisoning in the United States, 2007

Yuxi Xiang, Weiyan Zhao, Huiyun Xiang, Gary A. Smith — 2011-03-03

Abstract: Background: Fatal drug-related poisoning has been well described. However, death data only show the tip of the iceberg of drug-related poisoning as a public health problem. Using the 2007 Nationwide Emergency Department Sample, this study described the characteristics of emergency department visits for drug-related poisoning in the United States.Methods: Any ED visit that had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 960-979 was defined as a drug-related poisoning case. Intentionality of poisoning was determined by E-codes. Weighted estimates of ED visits were calculated by patient and hospital characteristics, intentionality of poisoning, and selected drug classes. Population rates by sex, age, urban/rural classification, median household income in patient's zip code, and hospital region were calculated.Results: An estimated 699 123 (95% confidence interval, 666 529-731 717) ED visits for drug-related poisoning occurred in 2007. Children 0 to 5 years old had the highest rate for unintentional poisoning (male, 237 per 100 000; female, 218 per 100 000). The rate of drug-related poisoning in rural areas (684 per 100 000) was 3 times higher than the rates in other areas. Psychotropic agents and analgesics were responsible for 43.7% of all drug-related poisoning. Women 18 to 20 years old had the highest ED visit rate for suicidal poisoning (245 per 100 000). The estimated ED charges were $1 394 051 262, and 41.1% were paid by Medicaid and Medicare.Conclusion: Antidepressants and analgesics were responsible for nearly 44% of ED visits for drug-related poisoning in the United States. Interventions and future research should target prescription opioids, rural areas, children 0 to 5 years old for unintentional drug-related poisoning, and female ages 12 to 24 years for suicidal drug-related poisoning.

Practice patterns and management strategies for purulent skin and soft-tissue infections in an urban academic ED

2011-01-31

Abstract: Background: Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is the most common cause of purulent skin and soft-tissue infections (SSTIs) in the Unites States. Little is known regarding health care provider management strategies for abscesses in the emergency department (ED). Understanding variability in practice patterns could be an important step in implementing evidence-based guidelines.Objectives: The objectives of this study are to describe practice patterns for purulent SSTI in a single, urban, academic ED, including antibiotic selection and incision and drainage (I & D) technique, and to compare these practices with current evidence.Methods: Prospective data were collected on a convenience sample of adults presenting to our urban, academic ED (annual volume, 65 000 per year) between June 2009 and May 2010. Characteristics of patients and their providers were collected as well as specific management strategies including use of irrigation, packing, and antibiotics.Results: One hundred forty-five patients were enrolled. Most SSTIs were single (80.4% abscesses), most commonly on the extremities (29.8%). Both I & D and antibiotics were used 79.9% of the time, with the largest predictor for the addition of antibiotics being erythema more than 2 cm (odds ratio, 4.52; 95% confidence interval, 1.39-14.7); I & D technique varied by provider-type and experience. Providers suspected MRSA in 75% of cases, despite only 48% demonstrating MRSA on culture. Many patients received antimicrobials after I & D, even in those with 2 cm or less abscesses (57.5%).Conclusions: Practice patterns vary significantly, especially antibiotic overuse, at least in this urban academic ED. Further study should be undertaken to evaluate factors that influence management strategies for SSTI.

Impact of trauma activation on the ED length of stay for nontraumatic patients

Rajiv Arya, Frank Dossantos, Pamela Ohman-Strickland, Mark A. Merlin — 2011-02-07

Abstract: Introduction: Trauma activation prioritizes hospital resources for the assessment and treatment of trauma patient over all patients in the emergency department (ED). We hypothesized that length of stay (LOS) is longer for nontrauma patients during a trauma activation.Methods: A retrospective, case-control chart review was conducted in a level I trauma center. Cases consist of patients who present 1 hour before and after the presentation of the trauma activation. Controls were patients presenting to the ED during the same period exactly 1 week before and after the cases. Confounding variables measured included sex, age, arrivals, and census for the 3 areas.Results: Two hundred ninety-four trauma events occurred from January 1 until September 30, 2009. A significant difference was found between LOS of patients seen during a trauma activation with an average increase of 10.7 minutes in LOS (P =.0082; 95% confidence interval [CI], 2.8-18.7). This difference is attributable to the middle acuity area of the ED, in which the average increase in LOS was 20.3 minutes (P = .0004; 95% CI, 9.1-31.5). Significant LOS difference was not found when a trauma activation had an LOS of less than 60 minutes (P = .30; 95% CI, −7.1-61.7 for trauma LOS <60 minutes vs P = .02; 95% CI, 1.6-18.0 for trauma LOS ≥60 minutes).Conclusion: This retrospective case-control chart review identified an increase in ED LOS for patient presenting during trauma activations. Resource prioritization should be accounted for during times when these critical patients enter the ED.

A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED

2011-01-31

Abstract: Purposes: Bedside lung ultrasound (LUS) is useful in detecting radio-occult pleural-pulmonary lesions. The aim of our study is to compare the value of LUS with other conventional routine diagnostic tools in the emergency department (ED) evaluation of patients with pleuritic pain and silent chest radiography (CXR).Methods: Ninety patients consecutively admitted to the ED with pleuritic pain and normal CXR were retrospectively (n = 49) and prospectively (n = 41) studied. All patients were blindly examined by LUS and submitted to clinical examination and blood samples. The ability of blood tests and symptoms to predict any radio-occult pleural-pulmonary condition confirmed by conclusive image techniques and follow-up was evaluated and compared with LUS.Results: In 57 cases, the final diagnosis was chest wall pain. The other 33 patients were diagnosed with a pleural-pulmonary condition (22 pneumonia, 2 pleuritis, 7 pulmonary embolism, 1 lung cancer, 1 pneumothorax). Lung ultrasound showed a sensitivity of 96.97% (95% confidence interval [CI], 84.68%-99.46%) and a specificity of 96.49% (95% CI, 88.08%-99.03%) in predicting radio-occult pleural-pulmonary lesions and significantly higher area under the curve (AUC) of receiver operating characteristic analysis (AUC, 0.967; 95% CI, 0.929-1.00) than d-dimer (AUC, 0.815; 95% CI, 0.720-0.911) and white blood cell count (AUC, 0.778; 95% CI, 0.678-0.858). None of the other routine tests considered or a combination between them better predicted the final diagnosis.Conclusions: Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.

Computed tomography angiography in patients with suspected pulmonary embolism—too often considered?

2011-01-31

Abstract: Background: Pulmonary embolism (PE) is a major cause of morbidity and mortality associated with surgery and medical illnesses. In recent years, pulmonary computed tomography angiography (CTA) has become the diagnostic method of choice. However, it remains unclear when to perform CTA and how often a decision based on clinical judgment results in positive or negative findings.Methods: In a retrospective study, 261 patients admitted for suspected PE were evaluated with pulmonary CTA. Decisions to order CTA were based on clinical judgment and optionally quantitative d-dimer assays. Clinical, radiologic, and laboratory data were revisited and compared in patients with and without proven PE.Results: The patients' mean age was 63 ± 1 years; almost 30% of all participants had at least a moderately reduced renal function. Pulmonary CTA demonstrated PE in only 14.9%; both age and sex distribution was comparable in the PE and non-PE group. Proximal deep vein thrombosis or pathologic chest x-rays were significantly more likely in patients with PE (P < .001 and P < .05), whereas echocardiography results were comparable. d-dimer values were noticeably higher in the PE group (P < .001); however, C-reactive protein and troponin T levels were not helpful.Conclusions: Pulmonary CTA confirmed PE in only a minority of patients and may be overused. Clinical judgment in conjunction with d-dimer evaluation was of limited help to predict positive results but surprisingly comparable with previous results using pretest probability scoring systems. Using present and previous data, a simplified enhanced algorithm is proposed to reduce use of CTA.

Factors associated with self-reported pain scores among ED patients

Catherine A. Marco, Jacqueline Nagel, Ellen Klink, David Baehren — 2011-03-02

Abstract: Introduction: Pain is a common presenting complaint among emergency department (ED) patients. The verbal numeric pain scale is commonly used in the ED to assess self-reported pain. This study was undertaken to describe and compare pain scores in a variety of painful conditions and identify factors associated with self-reported pain scores.Methods: The study was a prospective, observational, descriptive survey study conducted at an urban university hospital ED. Eligible participants included consenting adults 18 years and older, with an acute painful condition, who spoke English, and were not in severe distress. Through a structured interview, collected data included pain score; diagnosis; medical history; previous painful experiences; and demographic information including age, insurance status, and highest level of education completed.Results: Among 268 eligible participants, 263 (98%) consented and completed the study protocol. Seventy-one percent of participants were 50 years old or younger; 55%, women; and 68%, white. Fifty-four percent had private insurance, and 81%, high school education or higher. The most common chief complaints were soft tissue injury (33%), abdominal pain (18%), and chest pain (13%). The median self-reported pain score was 7/10 (mean, 6.7; interquartile range, 6-9; range, 0-10). The most common previous painful experiences were childbirth (21%), major trauma (18%), and surgery (14%). Participants cited reasons for self-reported pain scores, including current feeling of pain (62%), comparison to previous pain (31%), and comparison to hypothetical pain (12%). The number of previous ED visits was positively correlated with current pain score (Spearman correlation R = 0.28; P < .001). The chief complaints associated with the highest pain scores included dental pain (mean pain score, 8.5) and back pain (mean pain score, 7.6). Chief complaints associated with the lowest pain scores included chest pain (mean pain score, 5.2) and other medical conditions (mean pain score, 5.3). Factors associated with higher pain scores included younger age (P < .001, Kruskal-Wallis), Medicaid insurance (P = .02), and lower educational status (P = .01). There was not a statistically significant association between current pain score and sex, race, previous painful experiences, or number of hospital admissions.Conclusion: Emergency department patients with acute painful conditions report a wide range of self-reported pain scores. Participants rated pain based on current feeling of pain or comparison to previous or hypothetical pain. Chief complaints with highest pain scores included dental pain and back pain. Factors associated with higher pain scores included younger age, Medicaid insurance, lower educational status, and higher number of previous ED visits.

Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period

Michael Blaivas, Richard Pawl — 2011-01-31

Abstract: Objective: The study aims to define extent of lawsuits filed against emergency physicians (EPs) over point-of-care emergency ultrasound (US) during the last 20 years.Methods: We performed a nationwide search of the WESTLAW legal database for filed lawsuits involving EPs and US. WESTLAW covers all state and federal lawsuits dating back to 1939. Using an electronic search feature, all states were searched using emergency and US as key words. The database automatically accounts for different variants on US such as sonography. An attorney who is also boarded in and practices emergency medicine, as well as an emergency US expert, reviewed returned cases. Descriptive statistics were used to evaluate the data.Results: Using the search criteria and excluding obvious radiology suits, 659 cases were returned and reviewed. There were no cases of EPs being sued for performance or interpretation of point-of-care US. There was one case alleging EP failure to perform point-of-care US and diagnose an ectopic before it ruptured. This case was won by the defense. There were no cases against EPs for common causes of radiology and obstetric litigation including sexual assault during endovaginal US. Cases of missed testicular torsion on US were frequent in the emergency setting but none linked EP US.Conclusions: Only one case filed against EPs over the last 2 decades was identified, it was over failure to perform US. Most frequent litigations against radiologists and obstetricians are unlikely to be duplicated in the emergency department, and future litigations may also come from EP failure to perform point-of-care US.

Early embolization without external fixation in pelvic trauma

2011-01-31

Abstract: Purposes: In this retrospective study, we reviewed our protocol consisting of early embolization without acute external fixation in patients with pelvic fracture.Patients and Methods: Eighty-eight patients with pelvic fracture were identified by reviewing the records of the Fukui Prefectural Hospital from April 2005 through September 2009. We managed the patients with a treatment protocol consisting of hemodynamic resuscitation and early pelvic embolization. Patients with hemodynamic instability without nonpelvic hemorrhage or extravasation of contrast in the pelvis by computed tomography (CT) were indicated to angiography and embolization. External fixation of the pelvic ring was not used in our protocol.Results: Of the 88 patients with pelvic fractures, 43 underwent angiography. Twenty-eight patients (65%) were hemodynamically unstable. Twenty-five patients (58%) had major ligamentous disruption. Computed tomography detected extravasation in 21 patients (48%). Of the 43 patients who underwent angiography, 29 (67%) were positive. The average time from hospital arrival to angiography was 76.3 ± 34.5 minutes. The packed red blood cell requirement in the initial 24 hours was 8.4 ± 8.2 U, required in the embolization group. There was no complication-related embolization. Repeat angiography was not required in all patients. The mortality rate of patients requiring angiography was 11%.Conclusions: Early pelvic embolization without external fixation may be useful for the initial treatment for patients with hemodynamic instability without nonpelvic hemorrhage or with extravasation of contrast in the pelvis by CT.

Factors associated with failure to follow-up at a medical clinic after an ED visit

2011-11-14

Abstract: Background: Although emergency department (ED) discharge is often based on the presumption of continued care, the reported compliance rate with follow-up appointments is low.Study Objectives: The objectives of this study are to identify factors associated with missed follow-up appointments from the ED and to assess the ability of clinicians to predict which patients will follow-up.Methods: Patients without insurance or an outpatient primary care provider (PCP) were given a follow-up clinic appointment before discharge. Information identifying potential follow-up barriers was collected, and the physician's perception of the likelihood of follow-up was recorded. Patients who missed their appointment were contacted via telephone and were offered a questionnaire and a rescheduled clinic appointment.Results: A total of 125 patients with no PCP were enrolled. Sixty (48%; 95% confidence interval, 39-57) kept their scheduled appointment. Sex, distance from clinic, availability of transportation, or time since last nonemergent physician visit was associated with attendance to the follow-up visit. Clinicians were unable to predict which patients would follow-up. Contact by telephone was made in 48 (74%) of patients who failed to follow-up. Of the 14 patients willing to reschedule, none returned for follow-up.Conclusion: Among ED patients who lack a PCP and are given a clinic appointment from the ED, less than half keep the appointment. Moreover, clinicians are unable to predict which patients will follow up. This study highlights the difficulty in maintaining continuity of care in populations who are self-pay or have Medicaid and lack regular providers. This may have implications on discharge planning from the ED.

Operation care: a pilot case management intervention for frequent emergency medical system users

Michael L. Rinke, Elisabeth Dietrich, Traci Kodeck, Kathleen Westcoat — 2011-01-27

Abstract: Objectives: This study aims to determine if a prehospital case management intervention reduces transport and nontransport emergency medical system (EMS) responses to frequent EMS users.Methods: The 25 most frequent EMS users in a major metropolitan area were identified, and 10 were enrolled in the intervention. These patients received linkage to psychosocial and medical resources through weekly case management visits for 5 to 12 weeks between May and August 2008. Main outcome measures were the number of transport and nontransport EMS responses to patients during the intervention as compared with predicted EMS responses based on each patient's previous year's EMS use. Transport data were available for all patients, but nontransport data were unavailable for 1 patient who was homeless and 6 patients living in apartment buildings. Secondary outcome measures included cost savings to the entire health care system and the Baltimore City Fire Department.Results: Transport responses decreased 32% over the 76 predicted transport responses during the intervention, and nontransport responses decreased 79% over the 24 predicted nontransport responses during the intervention. Including the dedicated case manager's salary, this represented a cost savings to the entire health care system and to the Baltimore City Fire Department of $14 461 and $6311, respectively, over 12 weeks.Conclusions: Prehospital case management may reduce EMS use in high-frequency EMS users and create significant cost savings to municipalities and the health care system. Additional large-scale studies are needed to validate these findings.

Can mainstream end-tidal carbon dioxide measurement accurately predict the arterial carbon dioxide level of patients with acute dyspnea in ED

2011-01-31

Abstract: Objective: This study was designed to determine whether the mainstream end-tidal carbon dioxide (ETCO2) measurement can accurately predict the partial arterial carbon dioxide (Paco2) level of patients presented to emergency department (ED) with acute dyspnea.Methods: This prospective, observational study was conducted at a university hospital ED, which serves more than 110 000 patients annually. Nonintubated adult patients presented with acute dyspnea who required arterial blood gas analysis were recruited in the study for a 6-month period between January and July 2010. Patients were asked to breathe through an airway adapter attached to the mainstream capnometer. Arterial blood gas samples were obtained simultaneously.Results: We included 162 patients during the study period. The mean ETCO2 level was 39.47 ± 10.84 mm Hg (minimum, 19 mm Hg; maximum, 82 mm Hg), and mean Paco2 level was 38.95 ± 12.27 mm Hg (minimum, 16 mm Hg; maximum, 94 mm Hg). There was a positive, strong, statistically significant correlation between ETCO2 and Paco2 (r = 0.911, P < .001). The Bland-Altman plot shows the mean bias ± SD between ETCO2 and Paco2 as 0.5 ± 5 mm Hg (95% confidence interval, −1.3165-0.2680) and the limits of agreement as −10.5 and +9.5 mm Hg. Eighty percent (n = 129) of the ETCO2 measurements were between the range of ±5 mm Hg.Conclusion: Mainstream ETCO2 measurement accurately predicts the arterial Paco2 of patients presented to ED with acute dyspnea. Further studies comparing mainstream and sidestream methods in these patients are required.

Application of the Sequential Organ Failure Assessment (SOFA) score in patients with advanced cancer who present to the ED

Jong Seok Lee, Oh Young Kwon, Han Sung Choi, Hoon Pyo Hong, Young Gwan Ko — 2011-02-28

Abstract: Background: There is limited literature describing clinical predictors for critically ill patients with cancer who present to the emergency department (ED).Purpose: The aim of this study was to investigate the usefulness of the Sequential Organ Failure Assessment (SOFA) score at the time of ED presentation for predicting short-term mortality in patients with advanced cancer.Methods: This was a prospective observational study of 108 consecutive patients with advanced cancer who presented to the ED. The outcome was defined as death within 14 days after admission.Results: The median survival time of the study subjects was 26.5 days (interquartile range, 9.0-78.0 days), and 31 patients (28.7%) died within 14 days after admission. In univariate analysis, SOFA score (≥4), previous chemotherapy, and altered mental status were predictive of 14-day mortality. Of those variables, only SOFA score was an independent predictor in multivariate analysis.Conclusions: The use of the SOFA score is an acceptable method for risk stratification and prognosis of patients with advanced cancer in the ED. This score can help clinicians to predict 14-day mortality and plan appropriate treatment for critically ill patients with cancer who present to the ED.

Head multidetector computed tomography: emergency medicine physicians overestimate the pretest probability and legal risk of significant findings

Jerry Ray Baskerville, John Herrick — 2011-03-16

Abstract: Objectives: This study focuses on clinically assigned prospective estimated pretest probability and pretest perception of legal risk as independent variables in the ordering of multidetector computed tomographic (MDCT) head scans. Our primary aim is to measure the association between pretest probability of a significant finding and pretest perception of legal risk. Secondarily, we measure the percentage of MDCT scans that physicians would not order if there was no legal risk.Methods: This study is a prospective, cross-sectional, descriptive analysis of patients 18 years and older for whom emergency medicine physicians ordered a head MDCT.Results: We collected a sample of 138 patients subjected to head MDCT scans. The prevalence of a significant finding in our population was 6%, yet the pretest probability expectation of a significant finding was 33%. The legal risk presumed was even more dramatic at 54%. These data support the hypothesis that physicians presume the legal risk to be significantly higher than the risk of a significant finding. A total of 21% or 15% patients (95% confidence interval, ±5.9%) would not have been subjected to MDCT if there was no legal risk.Conclusions: Physicians overestimated the probability that the computed tomographic scan would yield a significant result and indicated an even greater perceived medicolegal risk if the scan was not obtained. Physician test-ordering behavior is complex, and our study queries pertinent aspects of MDCT testing. The magnification of legal risk vs the pretest probability of a significant finding is demonstrated. Physicians significantly overestimated pretest probability of a significant finding on head MDCT scans and presumed legal risk.

How the newly introduced compression, airway, and breathing sequence affects the training in pediatric cardiopulmonary resuscitation

Riccardo Lubrano, Gianni Messi, Marco Elli, Training Center PBLS SIMEUP — 2011-10-26

We read, with interest, the article by Pozner et al stressing the importance of teaching high-quality chest compressions in cardiopulmonary resuscitation. Teaching and long-time retention of resuscitation skills are influenced by the methodology applied. After the recent publication by ILCOR of “The Universal Algorithm 2010” recommending the adoption of the compression, airway, and breathing (CAB) sequence, AHA introduced new guidelines for pediatric basic life support (PBLS) . It is of interest to evaluate if the changes affect the learning process and on the retention of knowledge.

Ultrasound-guided catheter-over-needle internal jugular vein catheterization

Michael D. Zwank — 2011-10-28

I describe here a novel technique of inserting a 2.5-inch catheter into the internal jugular vein with ultrasound guidance using sterile technique but no barrier precautions. Patients often present to the emergency department (ED) and have difficult veins for inserting an intravenous (IV) catheter. Most commonly, this is because of previous IV drug use, morbid obesity, or previous medical illness. The options in this setting usually depend on the acuity of the patient and experience of the providers. They include ultrasound-guided peripheral vein catheter, intraosseous catheter, and central vein catheter . Based on my experience, each of these options has significant limitations. Insertion of a peripheral catheter with ultrasound guidance is technically challenging and is time consuming even in the best of hands. Intraosseous catheters are common enough in the ED setting, but inpatient nurses and physicians are unfamiliar and uncomfortable with this access. Central vein catheters are time intensive, are uncomfortable, and carry many other well-known risks.

Association between acute urinary retention and Guillain-Barré syndrome

Wisit Cheungpasitporn, Madiha Alvi, Venkatrao Medarametla — 2011-10-28

We thank Wu et al for their excellent case study on Guillain-Barré syndrome (GBS). The authors presented a case of GBS with acute urinary retention from autonomic dysfunction. Dysautonomia, including urinary retention, tachycardia, and orthostatic hypotension, can occur in 70% of patients with this syndrome . However, acute urine retention in GBS can be associated with other mechanisms such as Escherichia coli infection.

Incidence of tricyclic antidepressant-like complications after cyclobenzaprine overdose

Vikhyat S. Bebarta, Joseph Maddry, Doug J. Borys, David L. Morgan — 2011-11-21

We thank the authors for their comments of our study. We agree that an ideal study of acute cyclobenzaprine toxicity would be prospective with blood levels, review of electrocardiograms by 2 reviewers, and prospective collection of data from hospital records. Because this type of study is both expensive and it is difficult to find centers with sufficient cases, it is rarely performed. In lieu of this ideal study, we used a retrospective data set to evaluate a large volume of short-term cases as reported to several poison centers, a source of cases used to develop clinical guidelines .

Incidence of tricyclic antidepressant-like complications after cyclobenzaprine overdose

Ari Greenwald, Colleen M. Birmingham, Robert S. Hoffman — 2011-12-28

Bebarta et al commendably set out to determine whether patients who overdose on cyclobenzaprine are at risk for developing Tricyclic antidepressant (TCA)-like effects (ie, a widened QRS or ventricular dysrhythmia). This topic is of interest as clear evidence that cyclobenzaprine does not cause cardiotoxic effects could save the health care system considerably with regard to bed use. Unfortunately, this retrospective study fails to definitively answer this question. Moreover, misinterpretation of their findings as proof that cyclobenzaprine overdose does not cause TCA-like cardiotoxicity might place patients at risk. In addition to highlighting some of the study's flaws, we set out here to respectfully outline the methodology required to answer this important question in the future.

A “summertime differential diagnosis“ of elevated cardiac troponin

Friedrich C. Prischl — 2011-11-21

In patients with chest pain, heart failure (HF), syncope, cardiac arrhythmias, and other, measurement of cardiac troponin (cTn) eases early recognition of high-risk patients. Recently, a high-sensitive troponin assay has shown to improve diagnosis of myocardial infarction or to identify patients at high risk of recurrent infarction and death . However, not infrequently, slightly elevated cTn is seen but without immediate clinical relevance. Elevated cTn is not exclusively specific for myocardial disease.

Too good to be true? Our experience with the Cunningham method of dislocated shoulder reduction

Ryan Walsh, Hillary Harper, Owen McGrane, Christopher Kang — 2011-11-21

Anterior glenohumeral dislocations are the most common major joint dislocation encountered in the emergency department . Over time, multiple methods for reduction have been described and evaluated, with varying rates of success and complication, such as Hill-Sachs fractures or Bankart lesions . A method of reduction, first described by Dr Neil Cunningham in 2003, was recently published, resulting in a resurgence of this technique that asserts to provide painless, effective shoulder reduction . We present a case series of 3 anterior glenohumeral shoulder reductions using the “Cunningham technique” and our observations of the benefits and difficulties encountered that may be of interest to the emergency medicine community.

Cardiovascular emergencies related to the Xynthia Storm

Eve Trebouet, Sophie Prieur, Jérôme Dimet, Damien Lipp, Laurent Orion — 2011-11-21

An association between stress and coronary events has been documented in many studies . Natural disasters are a major source of stress, and numerous studies have established that major earthquakes are followed by an increase in cardiovascular events.

Diagnosis of spontaneous urinary bladder rupture in the ED

2011-12-28

Urinary bladder (UB) rupture is an uncommon but serious event, mainly caused by trauma . Nontraumatic rupture of UB is called spontaneous UB rupture. Sporadic case reports have been found in the emergency medicine literature . The actual incidence of spontaneous UB rupture among the emergency department (ED) visits is still unknown. The clinical features of this condition are vague. Only small proportion of patients could be diagnosed preoperative after the initial onset of this disease . A definite diagnosis is generally made only after surgical exploration . The purposes of this study were to investigate the incidence of spontaneous UB rupture among the ED census and to assess how spontaneous UB rupture presents.

Takotsubo-pericarditis association

Hesham R. Omar — 2011-12-28

I have read the interesting article by Jimmy and Foo in a recent issue of the journal and congratulate them for their observation. The article clearly exemplified that Takotsubo cardiomyopathy (TC) can present with electrocardiographic (ECG) features of pericarditis. In the presented ECG, the widespread concave upwards ST-segment elevation and PR-segment depression (except in aVR and V1) and the absence of reciprocal ST-segment depression is a clear ECG evidence of acute pericarditis. TC with ECG criteria of acute pericarditis is known in the literature and has been previously reported. demonstrates all previously published cases taking into account the sequence of events, outcome, and possible explanations provided by the authors for this association. Regarding the sequence of both pathologies, it is clear from the table that in the first 3 cases, TC seemed to be the primary pathology, whereas in the second 3 cases pericarditis seemed to be the primary pathology, which preceded the onset of TC.

Acute kidney injury from bilateral ureteral calcium stones in the setting of primary hyperparathyroidism

Wisit Cheungpasitporn, Promporn Suksaranjit, Sirisak Chanprasert — 2011-11-21

We thank Stone et al for their article on “Bilateral obstructing renal stones: an uncommon cause of acute renal failure.” This was an interesting case presentation in American Journal of Emergency Medicine. The authors presented a case of recurrent calcium stones with bilateral ureteral obstruction. We found an interesting point that should be raised in this case. Approximately 5% of patients with renal stones have concurrent hyperparathyroidism . In addition, most stones in patients with hyperparathyroidism are composed of calcium oxalate . Serum calcium, phosphate, calcitriol, and parathyroid hormone level are helpful tests to make the diagnosis of this condition. Primary hyperparathyroidism should be considered in patients presenting with recurrent renal stones especially calcium stones and a high-normal or elevated serum calcium level.

Pathophysiology of vomiting-induced hypokalemia and diagnostic approach

Wisit Cheungpasitporn, Promporn Suksaranjit, Sirisak Chanprasert — 2011-12-14

We thank Mayr et al for their article on “Hypokalemic paralysis in a professional bodybuilder.” The authors presented an excellent case presentation on hypokalemic paralysis. The authors also discussed on common causes of renal and extrarenal potassium losses. Although vomiting can cause fluid loss directly from gastrointestinal tract, potassium depletion in this setting is primarily due to increased urinary losses from the fact that concentration of potassium in gastric secretions is only 5 to 10 mEq/L. Loss of gastric acid induces metabolic alkalosis and high plasma bicarbonate level. Water and sodium bicarbonate are transported to the distal potassium secretory site. In addition, hypovolemia from vomiting induces increase in aldosterone release. These 2 effects increase renal potassium loss in the urine and cause hypokalemia. Laboratory testings for defining causes of hypokalemia should include urine potassium, acid-base status, urine chloride, and blood pressure evaluation .

Regarding “unresponsive ventricular tachycardia associated with aluminum phosphide poisoning”

Hossein Sanaei-Zadeh — 2011-12-28

I read with interest the case presented by Dr Jadhav et al published in your journal. They presented a patient with aluminum phosphide (ALP) poisoning who developed ventricular tachychardia (VT) unresponsive to treatment with intravenous magnesium sulfate (MgSO4), amiodarone therapy, and electrocardioversion. They concluded that, in previously reported cases of successful conversion of VT associated with ALP poisoning, all patients were hypomagnesemic, whereas serum magnesium levels were normal throughout their patient's hospital course. Interestingly, as they themselves mentioned, it has been shown that intravenous lidocaine converted 2 patients with VT associated with ALP poisoning to sinus rhythm , but it is not clear why they have not tried lidocaine as well as amiodarone when the patients developed hemodynamically stable monomorphic sustained VT. As you know, it has been suggested that lidocaine should continue to be used as first-line drug therapy for stable ventricular tachycardia , in particular when ongoing myocardial ischemia is present .

Emergency physician diagnosis of pediatric infective endocarditis by point-of-care echocardiography

Alfred B. Cheng, Deborah A. Levine, James W. Tsung, Colin K.L. Phoon — 2011-01-27

Infective endocarditis is an uncommon infection in children and may rarely present to the emergency department. The clinical diagnosis of infective endocarditis in children can be challenging, especially in children without a history of underlying cardiac disease. Misdiagnosis or delayed diagnosis may lead to substantial morbidity and mortality. The modified Duke criteria for diagnosing infective endocarditis include echocardiographic findings as major criteria, vegetations on valves or supporting structures, periannular abscess, or new valvular regurgitation. Use of focused point-of-care echocardiography is growing in acute care settings such as emergency departments and can assist in the immediate diagnosis of endocarditis. Focused point-of-care echocardiography is noninvasive, is painless, and can be performed at bedside. Diagnosing infective endocarditis in a pediatric patient by focused point-of-care echocardiography has not been previously reported. We report a case of infective endocarditis in a 16-year-old girl diagnosed by focused point-of-care echocardiography in the emergency department.

Herbal syncope: ginger-provoked bradycardia

Enes Elvin Gul, Halil I. Erdogan, Murat Erer, Mehmet Kayrak — 2011-02-04

Herbal therapies are widely used in Turkey. Especially, ginger is mostly recommended to patients with symptoms of flu by their relatives. A 59-year-old woman was admitted to the emergency department (ED) because of sudden loss of consciousness. She was recommended ginger for the relief of flu symptoms. As a result of diagnostic and laboratory evaluation, the probable cause of syncope was ginger usage. This case demonstrated that sometimes herbal therapies are harmful and clinicians must be reminded of this effect.

A 61-year-old man with cough and abnormal chest x-ray

Nancy Lutwak, Curt Dill — 2011-01-31

We present a case of a 61-year-old male smoker presenting with complaints of nonproductive cough and flulike symptoms. The chest x-ray revealed an enlarged mediastinal silhouette and no evidence of pneumonia. A computerized axial tomography scan was done, which demonstrated a very large thoracic aortic aneurysm with evidence of a hyperattenuating crescent sign, indicative of impending rupture. The patient denied chest and abdominal pain. He went to the operating room and had repair of the aneurysm.

Therapeutic hypothermia after profound accidental hypothermia and cardiac arrest

2011-02-04

A 58-year-old man presented to the emergency department (ED) pulseless and with severe hypothermia. The patient received standard Advanced Cardiac Life Support (ACLS) measures and mechanical cardiopulmonary resuscitation for 57 minutes before regaining a pulse. In addition to other traditional passive and active measures, the patient was gradually rewarmed (∼1°C per hour) with an endovascular catheter in the ED with therapeutic hypothermia at 33°C maintained for 12 hours during his intensive care unit (ICU) stay. He was then rewarmed to normothermia over 15 hours and ultimately discharged at his neurologic baseline 11 days later. This case study explores the 3 issues that make this instance of cardiac arrest caused by severe hypothermia treated with an endovascular catheter unique: (1) graduated rewarming at ∼1°C per hour, (2) combined treatment with therapeutic hypothermia, and (3) return to baseline neurologic status at discharge.

Bystander cardiopulmonary resuscitation–induced splenic laceration and hepatosplenic hematoma

Matthew Salzman, Jason Friedman — 2011-02-04

Splenic laceration is an uncommon complication of cardiopulmonary resuscitation (CPR). We report a case of bystander CPR-induced splenic laceration with hepatosplenic hematoma complicating management of a patient with cardiovascular collapse because of acute myocardial infarction.

Extrapyramidal symptom masquerading as subarachnoid hemorrhage

Ken-Hing Tan, Shih-Yu Ko, Hee-King Su, Hon-Ping Ma — 2011-01-24

A subarachnoid hemorrhage without typical presentation often poses a great challenge to an emergency physician. A 36-year-old man presented to our emergency department with symptoms mimicking extrapyramidal symptoms but was ultimately found to have a ruptured intracranial aneurysm. Emergency craniotomy and aneurysm clipping were performed. Interestingly, involuntary movements of his face, mouth, and limbs diminished soon after the operation. The patient fully regained his verbal function and completely restored his muscle power. A full neurologic examination is emphasized for timely diagnosis to prevent catastrophic deterioration, especially in patients with verbal dysfunction or with a psychiatric disorder.

Severe dengue with massive pleural effusion requiring urgent intercostal chest tube drainage: a case report

2011-02-28

Dengue is one of the most common mosquito-borne infection affecting more than 50 million people worldwide annually. Most common causes for dengue-associated mortality are shock, bleeding, and respiratory failure.

The use of bedside ultrasonography in the evaluation of a neck mass

Cindy Chavez, Eitan Dickman, Lawrence Haines — 2011-02-07

A 53-year-old man presented to the emergency department (ED) with neck swelling, shortness of breath, and a change in the sound of his voice. Physical examination revealed an afebrile man speaking in 2- to 3-word sentences with a firm, nontender, nonerythematous mass on the right side of his neck. A bedside ultrasound demonstrated a homogenous mass with internal vascular flow. This constellation of findings was felt to be most consistent with a malignancy. Nasopharyngoscopy confirmed a near obstructing supraglottic mass, and the patient underwent an emergent tracheostomy. A lesion in the head and neck region can cause airway compromise, and, if the patient displays any evidence of respiratory decompensation, rapid evaluation is essential. Bedside ultrasonography facilitates assessment of space occupying lesions in the neck without removing the patient from a monitored setting, making it an optimal tool for the unstable patient who presents to the emergency department.

Spontaneous rupture of ureter: an unusual cause of acute abdominal pain

Didem Ay, Esin Yencilek, Mustafa Ferudun Celikmen, Meltem Akkas, Baki Ekci — 2011-02-28

Spontaneous rupture of the ureteropelvic junction is a rare entity with diagnostic problems. Here, we reported a case who presented with severe acute abdominal pain mimicking many abdominal problems. Physical examination and laboratory tests did not reveal any specific diagnosis, and an abdominal computed tomographic scan was performed. It showed 4-mm calculus in proximal ureter, grade 2 hydronephrosis, and perinephric fluid collection. The patient undergone to systoscopic procedure, her calculus was removed, and a double-J catheter was placed. The next day, she was discharged without any complication.

Acute kidney injury associated with tumor lysis syndrome: a paradigm shift

2011-02-07

Tumor lysis syndrome (TLS) causes acute kidney injury (AKI) by various pathophysiologies. Herein, we report on a case of recurrent AKI in TLS induced by 2 different mechanisms and highlight the increasing magnitude of acute phosphate nephropathy after wide use of rasburicase.

Editorial Board

2012-02-01

Info for Authors

2012-02-01

American Journal of Emergency Medicine

Masthead

Diagnostic accuracy of heart-type fatty acid–binding protein for the early diagnosis of acute myocardial infarction

Should we fear “flu fear” itself? Effects of H1N1 influenza fear on ED use

Cancer diagnosis and outcomes in Michigan EDs vs other settings

ED visits for drug-related poisoning in the United States, 2007

Practice patterns and management strategies for purulent skin and soft-tissue infections in an urban academic ED

Impact of trauma activation on the ED length of stay for nontraumatic patients

A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED

Computed tomography angiography in patients with suspected pulmonary embolism—too often considered?

Factors associated with self-reported pain scores among ED patients

Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period

Early embolization without external fixation in pelvic trauma

Factors associated with failure to follow-up at a medical clinic after an ED visit

Operation care: a pilot case management intervention for frequent emergency medical system users

Can mainstream end-tidal carbon dioxide measurement accurately predict the arterial carbon dioxide level of patients with acute dyspnea in ED

Application of the Sequential Organ Failure Assessment (SOFA) score in patients with advanced cancer who present to the ED

Head multidetector computed tomography: emergency medicine physicians overestimate the pretest probability and legal risk of significant findings

How the newly introduced compression, airway, and breathing sequence affects the training in pediatric cardiopulmonary resuscitation

Ultrasound-guided catheter-over-needle internal jugular vein catheterization

Association between acute urinary retention and Guillain-Barré syndrome

Incidence of tricyclic antidepressant-like complications after cyclobenzaprine overdose

Incidence of tricyclic antidepressant-like complications after cyclobenzaprine overdose

A “summertime differential diagnosis“ of elevated cardiac troponin

Too good to be true? Our experience with the Cunningham method of dislocated shoulder reduction

Cardiovascular emergencies related to the Xynthia Storm

Diagnosis of spontaneous urinary bladder rupture in the ED

Takotsubo-pericarditis association

Acute kidney injury from bilateral ureteral calcium stones in the setting of primary hyperparathyroidism

Pathophysiology of vomiting-induced hypokalemia and diagnostic approach

Regarding “unresponsive ventricular tachycardia associated with aluminum phosphide poisoning”

Emergency physician diagnosis of pediatric infective endocarditis by point-of-care echocardiography

Herbal syncope: ginger-provoked bradycardia

A 61-year-old man with cough and abnormal chest x-ray

Therapeutic hypothermia after profound accidental hypothermia and cardiac arrest

Bystander cardiopulmonary resuscitation–induced splenic laceration and hepatosplenic hematoma

Extrapyramidal symptom masquerading as subarachnoid hemorrhage

Severe dengue with massive pleural effusion requiring urgent intercostal chest tube drainage: a case report

The use of bedside ultrasonography in the evaluation of a neck mass

Spontaneous rupture of ureter: an unusual cause of acute abdominal pain

Acute kidney injury associated with tumor lysis syndrome: a paradigm shift

Editorial Board

Table of Contents

Info for Authors