American Journal of Emergency Medicine - Articles in Press

Can retinal changes predict coronary artery disease in elderly hypertensive patients presenting with angina? - Corrected Proof

2010-03-10

Abstract: Background: The prevalence of coronary artery disease (CAD) has been increasing in India, and so is the population of elderly patients with hypertension. In the predominantly resource-poor setting prevailing in India, this study is an effort to analyze the accuracy of retinal changes in predicting CAD among a cohort of elderly patients with hypertension presenting to the emergency department with angina.Methods: A total of 72 elderly patients with hypertension older than 65 years presenting to the emergency department with acute angina were studied. Optic fundi were assessed for retinopathy after pupillary dilatation, which were photographed. All patients underwent coronary angiogram, and the presence or absence of CAD was determined.Results: Mean ± SD age of the participants was 72.95 ± 6.51 years, and there were 39 men (54.2%) and 33 women (45.8%). Prevalence of CAD and retinopathy was 40.8% and 30.6%, respectively. Coronary artery disease showed a strong association with retinopathy (P < .0001). Male sex (P = .035), microalbuminuria (P = .025), and increased high-sensitivity C-reactive protein (P = .001) were identified as risk factors for CAD. Tests of accuracy for retinopathy as a predictor of CAD showed a likelihood ratio of a positive test and likelihood ratio of a negative test of 3.92 and 0.52, respectively. Area under the receiver operating characteristics curve was 70.6%.Conclusion: Prevalence of CAD (40.8%) and retinopathy (30.6%) was quite high in our cohort of elderly patients with hypertension. Retinal changes of any grade have a moderate accuracy in predicting CAD and, hence, may be used as an early screening tool in a resource poor setting.

Transbuccal fentanyl for rapid relief of orthopedic pain in the ED - Corrected Proof

2010-03-10

Abstract: Objectives: This study's objectives were to assess administration of a rapidly dissolving transbuccal fentanyl tablet to patients in emergency department (ED) with orthopedic extremity pain. The main end point was time required to achieve a 2-point drop on a 0 to 10 pain scale.Methods: In this double-blind trial, subjects received either transbuccal fentanyl, 100 μg, and a swallowed placebo, or a swallowed oxycodone/acetaminophen, 5/325-mg pill, and a nonanalgesic transbuccal comparator. Pain assessment occurred every 5 minutes for an hour, and vital signs were monitored for 2 hours.Results: Transbuccal fentanyl was associated with faster pain relief onset (median, 10 vs 35 minutes; P < .0001). Secondary end points (pain relief magnitude, rescue medication rate, subject preference for medication on future visit) favored transbuccal fentanyl. No vital sign abnormalities or significant side effects occurred in the ED or on 100% next-day follow-up.Conclusions: Transbuccal fentanyl shows promise for continued investigation as a means to safely provide rapid and effective pain relief for ED patients.

Emergency medical services' use of poison control centers for unintentional drug ingestions - Corrected Proof

Scott A. Bier, Douglas J. Borys — 2010-03-10

Abstract: Introduction: Every year, emergency medical services (EMS) providers respond to thousands of calls for toxic ingestions. Many systems have begun using poison control centers (PCCs) when unsure of disposition. We sought to determine the type of exposures EMS personnel were using the PCCs for and treatments suggested. Secondary end points included transport rate after consulting the PCC and amount of money saved by avoiding unnecessary transports.Methods: This study was a qualitative retrospective chart review. Encounters between 2004 and 2006 originating in Austin, TX, were queried and limited to accidental ingestion calls placed by prehospital personnel. Data from charts were then analyzed.Results: A total of 386 charts met inclusion criteria for this study. Household chemicals were the most frequently encountered agents. The most common recommendation was to observe patients at home for the development of concerning symptoms. In only 6% of cases did the PCC recommend administration of medication. Also of interest was the fact that only 63 patients were transported (16%).Conclusions: It is unreasonable to expect prehospital providers to know what to do for every toxic exposure. This study suggests that the use of PCCs by EMS systems can be beneficial to patient care. For the time period of this study, EMS crews who contacted the PCC saved the City of Austin more than $205,000 in unnecessary ambulance transport costs. When emergency department expenses are factored in and other regions of the country are included, the savings would likely be much greater. This modality is an important resource for providers in a potentially uncertain realm.

Does sex influence the allocation of life support level by dispatchers in acute chest pain? - Corrected Proof

Martin Gellerstedt, Angela Bång, Emma Andréasson, Anna Johansson, Johan Herlitz — 2010-03-10

Abstract: Aim: The aim of this study was to evaluate (a) the differences between men and women in symptom profile, allocated life support level (LSL), and presence of acute myocardial infarction (AMI), life-threatening condition (LTC), or death and (b) whether a computer-based decision support system could improve the allocation of LSL.Patients: All patients in Göteborg, Sweden, who called the dispatch center because of chest pain during 3 months (n = 503) were included in this study.Methods: Age, sex, and symptom profile were background variables. Based on these, we studied allocation of LSL by the dispatchers and its relationship to AMI, LTC, and death. All evaluations were made from a sex perspective. Finally, we studied the potential benefit of using a statistical model for allocating LSL.Results: The advanced life support level (ALSL) was used equally frequently for men and women. There was no difference in age or symptom profile between men and women in relation to allocation. However, the allocation of ALSL was predictive of AMI and LTC only in men. The sensitivity was far lower for women than for men. When a statistical model was used for allocation, the ALSL was predictive for both men and women. Using a separate model for men and women respectively, sensitivity increased, especially for women, and specificity was kept at the same level.Conclusion: This exploratory study indicates that women would benefit most from the allocation of LSL using a statistical model and computer-based decision support among patients who call for an ambulance because of acute chest pain. This needs further evaluation.

Diagnosing pediatric appendicitis: usefulness of laboratory markers - Corrected Proof

Karen Y. Kwan, Alan L. Nager — 2010-03-10

Abstract: Objective: This study aimed to evaluate the utility of C-reactive protein (CRP), procalcitonin (PCT), d-lactate, and white blood cell (WBC) count as an aid to distinguish appendicitis from other diagnoses.Methods: This prospective, observational study was conducted at an urban tertiary academic pediatric emergency department (ED). Subjects aged 1 to 18 years presenting with abdominal pain suspicious for acute appendicitis were enrolled. Data included history, physical examination, laboratory data (complete blood count, CRP, d-lactate, PCT [semiquantitative]), laboratory results, x-rays, surgical consultation notes, histopathology, and admission data. Stepwise logistic regression analysis was performed to identify independent risk factors.Results: Two hundred nine subjects (59% male, 41% female) were enrolled over 6 months. One hundred fifteen subjects were histologically diagnosed with appendicitis; 94 subjects did not have appendicitis and were used as controls. Mean values of WBC, CRP, PCT, and absolute neutrophil count in subjects with definitive appendicitis were significantly higher than in subjects with no definitive appendicitis. d-Lactate levels were noncorrelative. Significant independent risk factors identified for definitive appendicitis included WBC count more than 12 cells × 1000/mm3 (adjusted odds ratio [AOR], 6.54), CRP level greater than 3 mg/dL (AOR, 3.44), presence of hopping pain (AOR, 2.69), and presence of pain with walking (AOR, 2.56). Odds ratio for definitive appendicitis and its 95% confidence interval was found to be 7.75 for subjects with both WBC more than 12 cells × 1000/mm3 and CRP greater than 3 mg/dL.Conclusions: C-reactive protein with WBC is useful in distinguishing appendicitis from other diagnoses in pediatric subjects presenting to the ED. White blood cell count greater than >12 cells × 1000/mm3 and CRP greater than 3 mg/dL increases the likelihood of appendicitis. d-Lactate is not a useful laboratory adjunct.

Radiation exposure in emergency physicians working in an urban ED: a prospective cohort study - Corrected Proof

Brent E. Gottesman, Amy Gutman, Christopher J. Lindsell, Hollynn Larrabee — 2010-03-10

Abstract: Objective: The National Council on Radiation Protection (NCRP) limits health care–associated occupational exposures to radiation to 5000 mrem/y. Previous studies suggested that emergency physicians were not exposed over this limit. Their relevance to contemporary practice is unknown. We hypothesized that emergency physicians are currently exposed to radiation levels above the NCRP limits.Methods: This prospective cohort study was conducted at an urban, academic, level I trauma center emergency department (ED). Thermoluminescent dosimeter radiation badges were placed on the torso and ring finger of all physicians staffing the ED during May 2008. Thermoluminescent dosimeter badges were affixed to 8 portable phones that are carried by physicians in the ED 24 hours a day. At the end of the study period, exposure dose for each subject was estimated.Results: Seventy-five physicians enrolled in the study; 41 residents worked a median of 94 hours and 34 attendings worked a median of 54 hours. Compliance for physician badge wearing was 99%, ring wearing was 98%, and phone wearing was 100%. Two subjects had detectable levels of radiation on their torso thermoluminescent dosimeters of 4 and 1 mrem, respectively. One phone badge had a detectable level of 1 mrem. The annual extrapolated exposure for the subject with the highest radiation level would have been 50 mrem, below the 5000 mrem exposure limit for health care workers.Conclusion: Emergency physicians working in an urban, academic, level I trauma center ED do not appear to be at risk of exceeding the NCRP dose limits for ionizing radiation exposure to their torso or extremities.

The role of risk factors in delayed diagnosis of pulmonary embolism - Corrected Proof

2010-03-10

Abstract: Background: Despite diagnostic advances, delays in the diagnosis of pulmonary embolism (PE) are common.Objective: In this study, we aimed to investigate the relationship between delays in the diagnosis of PE and underlying risk factors for PE.Methods: We retrospectively evaluated the records of 408 patients with acute PE. Patients were divided into 2 groups, surgical or medical, based on risk factors leading to the embolism. Analysis involved demographic characteristics of the patients, dates of symptom onset, first medical evaluation, and confirmatory diagnostic tests. Diagnostic delay was described as diagnosis of PE more than 1 week after symptom onset.Results: The mean time to diagnosis for all patients was 6.95 ± 8.5 days (median, 3 days; range, 0-45 days). Of the total number of patients, 29.6% had presented within the first 24 hours and 72.3% within the first week. The mean time to diagnosis was 4.4 ± 7.6 days (median, 2 days; range, 0-45 days) in the surgical group and 8.0 ± 8.6 days (median, 4 days; range, 0-45 days) in the medical group (P = .000). The mean time to diagnosis in the medical group was approximately 4 times greater than that of the surgical group on univariate analysis. Early or delayed diagnosis had no significant impact on mortality in either group.Conclusion: Delay in the diagnosis of PE is an important issue, particularly in medical patients. We suggest that a public health and educational initiative is needed to improve efficiency in PE diagnosis.

Inappropriate dispatcher decision for emergency medical service users with acute myocardial infarction - Corrected Proof

2010-03-10

Abstract: Objectives: Current guidelines recommend utilization of prehospital emergency medical services (EMSs) by patients with ST-elevation myocardial infarction (STEMI). The aims of this study were to estimate the percentage of inappropriate initial dispatcher decisions and determine their impact on delays in reperfusion therapy for EMS users with STEMI.Methods: As part of a prospective regional registry of patients with STEMI, we analyzed the original data for 245 patients who called a university hospital-affiliated EMS call center in France. The primary study outcome was time to reperfusion therapy calculated from the documented date and time of the first patient call.Results: The initial EMS dispatcher's decision was appropriate (ie, dispatching a mobile intensive care unit staffed by an emergency or critical care physician) for 171 (70%) patients and inappropriate for 74 (30%) patients. Inappropriate decisions included referring the patient to a family physician (n = 59), providing medical advice (n = 9), and dispatching an ambulance (n = 6). Inappropriate initial decisions resulted in increased median time to reperfusion for 140 patients receiving fibrinolysis (95 vs 53 minutes; P < .001) and 91 patients undergoing primary percutaneous coronary intervention (170 vs 107 minutes; P < .001). In-hospital mortality was not different between the 2 study groups (6.8% vs 9.9%; P = .42).Conclusion: The initial dispatcher's decision is inappropriate for 30% of EMS users with STEMI and results in substantial delays in time to reperfusion therapy. Accuracy of telephone triage should be improved for patients who activate EMSs in response to symptoms suggestive of acute coronary syndrome.

Nosocomial and community-acquired infection rates of patients treated by prehospital advanced life support compared with other admitted patients - Corrected Proof

Scott M. Alter, Mark A. Merlin — 2010-03-10

Abstract: Objectives: Nosocomial infections are a large burden to both patients and health care organizations, causing hospitals to take measures in an attempt to reduce microorganism transmission. Patients treated by emergency medical services are one population that has not been studied regarding infection rates. This study examines admitted patients treated by advanced life support (ALS) and their likelihood of having community-acquired and nosocomial infections.Methods: A retrospective cohort study was conducted of 154 318 admitted patients between 2003 and 2007. Subjects identified as having either community-acquired or nosocomial infections were grouped based on infection type and ALS treatment. The proportion of infected patients among total hospital admissions in each of these groups was calculated and compared using odds ratios (ORs).Results: A total of 5418 patients had at least 1 infection while admitted (3653 nosocomial, 1765 community). The probability of an ALS patient getting a nosocomial infection was 3.20% versus 2.28% for non-ALS patients (OR, 1.42; 95% confidence interval [CI], 1.28-1.57). There was no significant difference in community-acquired infections between ALS and non–ALS-treated groups (1.22% vs 1.14%; OR, 1.08; 95% CI, 0.92-1.26).Conclusions: Despite having similar rates of community-acquired infections, patients admitted after ALS treatment had significantly greater risk for nosocomial infections. Because causality is not established, it remains unknown whether paramedic interventions contributed to the increased rate. Quite possibly, these patients are more susceptible to virulent organisms; however, prospective research is needed to identify causal relationships. Thus, treatment by ALS can be used as an identifier of patients at an increased risk of acquiring nosocomial infections.

Higher incidence of major complications after splenic embolization for blunt splenic injuries in elderly patients - Corrected Proof

2010-03-10

Abstract: Background: Nonoperative management (NOM) of blunt splenic injuries has been widely accepted, and the application of splenic artery embolization (SAE) has become an effective adjunct to NOM. However, complications do occur after SAE. In this study, we assess the factors leading to the major complications associated with SAE.Materials and Methods: Focusing on the major complications after SAE, we retrospectively studied patients who received SAE and were admitted to 2 major referral trauma centers under the same established algorithm for management of blunt splenic injuries. The demographics, angiographic findings, and factors for major complications after SAE were examined. Major complications were considered to be direct adverse effects arising from SAE that were potentially fatal or were capable of causing disability.Results: There were a total of 261 patients with blunt splenic injuries in this study. Of the 261 patients, 53 underwent SAE, 11 (21%) of whom were noted to have 12 major complications: 8 cases of postprocedural bleeding, 2 cases of total infarction, 1 case of splenic abscess, and 1 case of splenic atrophy. Patients older than 65 years were more susceptible to major complications after SAE.Conclusion: Splenic artery embolization is considered an effective adjunct to NOM in patients with blunt splenic injuries. However, risks of major complications do exist, and being elderly is, in part, associated with a higher major complication incidence.

Anticoagulant-induced intramural intestinal hemorrhage - Corrected Proof

2010-03-10

Abstract: Background: Long-term use of warfarin can provide benefits in the treatment of many diseases, but adverse bleeding events are unpreventable because of a narrow therapeutic range.Objective: The aim of this retrospective chart review with data abstraction was to investigate the clinical presentations of intestinal intramural hemorrhage in emergency department (ED) patients.Methods: We reviewed the cases of 17 patients with acute abdominal pain in our ED. Medical records including demographic data and results of abdominal computed tomography were retrospectively reviewed and analyzed.Results: The mean ± SD age of the reviewed patients was 77.7 ± 8.5 years (range, 60-93 years). The mean ± SD duration from onset of symptoms to ED visit was 2.5 ± 1.3 days (range, 1-5 days). All patients had abdominal pain, and 64.7% had nausea/vomiting. A total of 64.7% of patients had peritoneal signs. The jejunum was most commonly involved (88.2% of all cases). The maximal mean ± SD wall thickening of the bowel was 14.1 ± 4.4 mm (range, 7.4-26.7 mm), and the estimated mean ± SD length was 35.6 ± 24.4 cm (range, 9-105 cm). The mean ± SD prothrombin time and activated partial thromboplastin time were prolonged to 86.5 ± 26.9 and 116.2 ± 43.1 seconds, respectively. All patients received medical treatment and survived. At the last follow-up (mean, 27.4 months), none of the patients had recurrence of intestinal intramural hemorrhage or intestinal obstruction.Conclusion: Prolonged prothrombin time and drug history can indicate the possibility of intramural intestinal hemorrhage, and abdominal computed tomography may help to exclude surgical diseases and prevent unnecessary surgery.

Bradyarrhythmia caused by ginseng in a patient with chronic kidney disease - Corrected Proof

Wen-I Liao, Yen-Yue Lin, Shi-Jye Chu, Ching-Wang Hsu, Shih-Hung Tsai — 2010-03-10

One of the most popularly used Chinese herbal medicines (CHMs) is ginseng, which is a highly valued herb in the Far East and has gained popularity in the West during the last decades. Ginseng has been reported to have pharmacological effects, including modulation of immune response and anticancer, antiaging, anti-amnestic, cardiovascular protective, and wound-healing effects. It is known that ingestion of ginseng can cause false-positive reading in certain digoxin immunoassays; however, bradyarrhythmia-caused by ginseng-associated digitalis glycoside–like effect has not been reported before. We propose that Asian ginseng could exhibit cardiac glycoside-like cardiovascular effects in susceptible patients. Here, we present a patient who had chronic renal insufficiency who developed atrial fibrillation (AF) with slow ventricular rate after taking Asian ginseng for 1 week.

Acute myocardial infarction due to coronary vasospasm in a heart transplant recipient - Corrected Proof

Jonathan R. Dalzell, Colette E. Jackson, Mark C. Petrie, Kerry J. Hogg — 2010-03-10

Coronary vasospasm in the transplanted heart is a rare phenomenon. We report an unusual case of coronary vasospasm–induced myocardial infarction (MI) in a transplant recipient. The pathophysiology of this rare and potentially catastrophic phenomenon is also discussed.

Electric shock and Brugada syndrome - Corrected Proof

János Tomcsányi, Béla Bózsik, Arabadzisz Hrisula — 2010-03-10

We present a case of a 33-year-old woman with a history of feinting episodes attributed to vagal stimulation who sustained an electric shock when touching a 220-V garden switch. Electrocadiogram (ECG) at the scene was normal. On admission, the ECG showed saddleback ST-segment elevation in leads V1 and V2. Both the creatine kinase and troponin levels were normal on admission and 6 hours later. Because the ECG changes were suggestive for Brugada syndrome, the sodium-channel blocker propafenone was administered, which elicited the typical coved-type ST-segment elevation. Electrophysiologic stimulation resulted in a spontaneously terminating polymorphic ventricular tachycardia with a loss of consciousness. An implantable cardioverter defibrillator (ICD) was implanted. The suspicion of Brugada syndrome should be raised in patients with a history of what may seem to be vasovagal syncope and a normal resting ECG, and sodium-channel blockers can be used to reveal the coved-type ST-segment elevation typical of Brugada syndrome.

Outcomes associated with small changes in normal-range cardiac markers - Corrected Proof

2010-03-10

Abstract: Introduction: Troponin concentrations rising above an institutional cutpoint are used to define acute myocardial necrosis, yet it is uncertain what outcomes are associated with fluctuations in troponin that do not exceed this level. We evaluate the association between troponin fluctuations below an institutional upper limit of normal and acute coronary syndrome (ACS).Materials and methods: This was a post hoc analysis of the Internet tracking registry of ACS (i*trACS), which describes patients presenting to emergency departments (EDs) with suspected ACS across the spectrum of risk. Patients were included in this registry if they were at least 18 years old and had suspected ACS at the time of their ED visit. Inclusions in this analysis required that patients had at least 1 cardiac marker (creatine kinase-MB [CK-MB], troponin T, or troponin I) drawn twice within 6 hours of presentation, with both measures being below the institution's upper limit of normal. A marker change was defined as either an increase or decrease that exceeded 15% of the institutional upper limit of normal. Acute coronary syndrome was defined as a positive stress test, documented myocardial infarction, coronary revascularization, or death within 30 days of their ED admission.Results: Of 17 713 patient visits, 2162 met inclusion and exclusion criteria. There were 1872 patient visits with 2 troponin results and 1312 with 2 CK-MB results. Patient visits with increasing troponin had increased odds of ACS compared with those with stable troponin levels (odds ratio, 3.6; 95% confidence interval, 1.4-9.2). Changing CK-MB and decreasing troponin were not associated with increased odds of ACS.Conclusions: Small increases in troponin concentration below the upper limit of normal are associated with increased odds of ACS.

Spontaneous coronary artery dissection in a postpartum woman presenting with chest pain - Corrected Proof

2010-03-10

Pregnancy-associated spontaneous coronary artery dissection is a rare but potentially lethal condition presenting as acute coronary syndrome. Forty percent of patients die suddenly or within a few hours of symptom onset. Survivors of the acute phase who subsequently receive proper diagnosis and treatment usually have good prognosis. Proposed etiologies include altered endocrine status, hemodynamic stress, eosinophilic inflammatory infiltrate, and disruption of vasa vasorum. Definitive diagnosis is made by coronary angiography. Treatment has not been well defined. Strategies include medical management, stenting, and coronary artery bypass grafting. We report a case of a 32-year-old woman, less than a week postpartum, who developed spontaneous multivessel coronary dissection involving left anterior descending artery and the right coronary artery, leading to severe systolic dysfunction. She underwent surgical revascularization resulting in recovery of the left ventricular function.

Intraocular mass causing acute angle-closure glaucoma - Corrected Proof

Kaira King, David C. Pigott, Andrew R. Edwards — 2010-03-10

Acute angle-closure glaucoma is a clinical phenomenon with potentially devastating consequences, including permanent blindness, if not promptly diagnosed and treated. We describe an unusual case of acute angle-closure glaucoma, leading to the detection of a uveal melanoma, a potentially life-threatening cause of glaucoma. Bedside ultrasonography of the eye was used to assist in the diagnosis, providing rapidly available diagnostic information about the size and extent of the tumor. Because acute angle-closure glaucoma may occur due to multiple etiologies, this case highlights the importance of uncovering occult causes of increased intraocular pressure.

The early presence of pneumatosis in traumatic colonic perforation: a sequential computed tomography demonstration - Corrected Proof

Yu-Tso Liao, Tzu-Hsin Lin, Wen-Je Ko — 2010-03-10

Blunt abdominal trauma is a common but potentially lethal injury at the emergency department. Traumatic colonic perforation occurs rarely among blunt abdominal injury. The appropriate surgical intervention depends on early detection and diagnosis. The diagnosis of traumatic colonic perforation might be difficult especially while confronting a stable patient with equivocal peritoneal sign. Recently, the wide use of the computed tomography (CT) increased the diagnostic accuracy of traumatic colonic perforation. However, the timing to arrange CT depends on clinical condition and personal experiences; and the optimal time does not meet consensus. In this case, we report a traumatic patient with a negative colonic finding who presented with colonic pneumatosis at a sequential CT 2 hours later. Traumatic colonic perforation was diagnosed; and consequently, explorative laparotomy was performed. The case reminds us that a significant CT finding could appear soon after a previously negative one.

What proportion of patients with chest pain are potentially suitable for computed tomography coronary angiography? - Corrected Proof

Sulieman Hamid, Fiona Bainbridge, Anne-Maree Kelly, Debra Kerr — 2010-02-26

Abstract: Objectives: Serial electrocardiographic and biomarker data are used to rule out acute coronary syndrome (ACS) in emergency department (ED) patients with chest pain. These do not identify coronary artery disease (CAD). Functional tests are often used but have limitations. Multislice computed tomography coronary angiography (MSCT-CA) is evolving rapidly, raising the possibility of fast, accurate, and relatively noninvasive anatomical testing for CAD. We aimed to quantify the proportion of ED rule-out ACS patients suitable for MSCT-CA.Methods: This retrospective cohort study (by explicit record review) included adult patients who underwent a rule-out ACS process in ED-associated short-stay units. Data collected included demographics, electrocardiographic and biomarker data, contraindications/factors likely to make MSCT-CA unsuccessful or difficult to interpret including irregular heart rhythm, high pulse rate (with rate control contraindicated), renal or thyroid disease, contrast allergy, metformin use, pregnancy, and already confirmed CAD. Outcome of interest was the proportion of patients suitable for MSCT-CA. Data analysis is by descriptive statistics.Results: Four hundred sixty patients were studied (63% male; median age, 63 years). Forty-nine percent (224/460; 95% confidence interval, 44%-53%) were suitable for MSCT-CA. One hundred eighty-one (39%) already had known CAD. Reasons for unsuitability of the remainder were metformin use 18 (6%), irregular heart rhythm 15 (5%), renal dysfunction 12 (4%), high pulse rate with contraindications to rate control 8 (3%), thyroid disease 7 (3%), and contrast allergy 2 (0.7%).Conclusion: Approximately half of ED patients with chest pain who have underwent ACS rule-out were potentially suitable for MSCT-CA to identify CAD. The best use of MSCT-CA in the investigation of patients with chest pain requires further clarification.

Are scoop stretchers suitable for use on spine-injured patients? - Corrected Proof

Gianluca Del Rossi, Glenn R. Rechtine, Bryan P. Conrad, MaryBeth Horodyski — 2010-02-26

Abstract: Introduction: In the prehospital setting, spine-injured patients must be transferred to a spine board to immobilize the spine. This can be accomplished using both manual techniques and mechanical devices.Objectives: The study aimed to evaluate the effectiveness of the scoop stretcher to limit cervical spine motion as compared to 2 commonly used manual transfer techniques.Methods: Three-dimensional angular motion generated across the C5-C6 spinal segment during execution of 2 manual transfer techniques and the application of a scoop stretcher was recorded first on cadavers with intact spines and then repeated after C5-C6 destabilization. A 3-dimensional electromagnetic tracking device was used to measure the maximum angular and linear motion produced during all test sessions.Results: Although not statistically significant, the execution of the log roll maneuver created more motion in all directions than either the lift-and-slide technique or with scoop stretcher application. The scoop stretcher and lift-and-slide techniques were able to restrict motion to a comparable degree.Conclusion: The effectiveness of the scoop stretcher to limit spinal motion in the destabilized spine is comparable or better than manual techniques currently being used by primary responders.

The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain - Corrected Proof

2010-02-26

Abstract: Objectives: We sought to determine whether risk tolerance as measured by scales (malpractice fear scale [MFS], risk-taking scale [RTS], and stress from uncertainty scale [SUS]) is associated with decisions to admit or use computed tomography (CT) coronary angiogram and decisions to order cardiac markers in emergency department (ED) patients with chest pain. We also studied if the opening of an ED-based observation unit affected the relationship between risk scales and admission decisions.Methods: Data from a prospective study of ED patients 30 years or older with chest pain were used. Risk scales were administered to ED attending physicians who initially evaluated them. Physicians were divided into quartiles for each separate risk scale. Fisher's exact test and logistic regression were used for statistical analysis.Results: A total of 2872 patients were evaluated by 31 physicians. The most risk-averse quartile of RTS was associated with higher admission rates (78% vs 68%) and greater use of cardiac markers (83% vs 78%) vs the least risk-averse quartile. This was not true for MFS or SUS. Similar associations were observed in low-risk patients (Thrombolysis in Myocardial Infarction risk score of 0 or 1). The observation unit was not associated with a higher admission rate and did not modify the relationship between risk scales and admission rates.Conclusion: The RTS was associated with the decision to admit or use computed tomography coronary angiogram, as well as the use of cardiac markers, whereas the MFS and SUS were not. The observation unit did not affect admission rates and nor did it affect how physician's risk tolerance affects admission decisions.

Bioterrorism: what might be walking into the ED? - Corrected Proof

Thomas E. Goffman — 2010-02-26

Bioterrorism is a big word thrown about like a brickbat by politicians. As a start, we should all know of the most feared agents, which are a subset of the category A list from the 72 select agents compiled by the Centers for Disease Control and Prevention (CDC). It would appear that even emergency department (ED) personnel would be worth reintegrating this knowledge . To save time and space, the author will simply describe those biologics most feared by Homeland Security such as smallpox, plague, Ebola, and anthrax.

Clinical predictors for testicular torsion as seen in the pediatric ED - Corrected Proof

Tali Beni-Israel, Michael Goldman, Shmual Bar Chaim, Eran Kozer — 2010-02-26

Abstract: Objective: The aim of the study was to identify clinical findings associated with increased likelihood of testicular torsion (TT) in children.Design: This study used a retrospective case series of children with acute scrotum presenting to a pediatric emergency department (ED).Results: Five hundred twenty-three ED visits were analyzed. Mean patient age was 10 years 9 months. Seventeen (3.25%) patients had TT. Pain duration of less than 24 hours (odds ratio [OR], 6.66; 95% confidence interval [CI], 1.54-33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-30.1), abnormal cremasteric reflex (OR, 27.77; 95% CI, 7.5-100), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), and high position of the testis (OR, 58.8; 95% CI, 19.2-166.6) were associated with increased likelihood of torsion.Conclusions: Testicular torsion is uncommon among pediatric patients presenting to the ED with acute scrotum. Pain duration of less than 24 hours, nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex are associated with higher likelihood of torsion.

Early anion gap metabolic acidosis in acetaminophen overdose - Corrected Proof

Joe G. Zein, David J. Wallace, Gary Kinasewitz, Nagib Toubia, Christine Kakoulas — 2010-02-26

Abstract: Purpose: The study aimed to determine the incidence and clinical significance of early high (>15 mEq/L) anion gap metabolic acidosis in acetaminophen (APAP) overdose.Methods: A retrospective review of a cohort of 74 patients presenting within 24 hours of APAP overdose was conducted.Results: Early high anion gap metabolic acidosis was present in 41% of patients on admission and persisted for 1.5 ± 0.1 days. The anion gap was associated with an elevated lactate level (4.5 ± 1 mmol/L) (r2 = 0.66, P < .05), which persisted for 1 day. The lactate level increased in proportion to the APAP concentration (r2 = 0.75, P < .05). Patients with increased anion gap had a higher incidence of confusion (48% vs 3%; P < .001) and lethargy (39% vs 6%; P = .003). Early high anion gap metabolic acidosis was found in the absence of shock or liver failure. All patients were treated with N-acetylcysteine and, despite the early high anion gap metabolic acidosis, none developed hepatic failure or hypoglycemia.Conclusion: Early high anion gap metabolic acidosis in patients with APAP overdose is self-limited and does not predict clinical or laboratory outcomes. Persistent or late metabolic acidosis in the absence of liver failure is not likely due to APAP and should prompt a search for other causes of metabolic acidosis. Finally, APAP overdose should be considered in patients presenting to the emergency department with altered mental status, as this is a treatable condition when detected early.

Catastrophic complications of intravenous promethazine - Corrected Proof

Richard Paula, Brad Peckler, Mai Nguyen, David Orban, Tara Butler — 2010-02-26

Promethazine is a commonly used drug in emergency departments to treat headaches and nausea. It is generally considered safe, but after thoroughly reviewing the literature, multiple instances of tissue toxicity were documented. We describe a cluster of 3 cases of promethazine-related tissue toxicity in our community. Two patients experienced extensive complications related to local necrosis, one leading to gangrene requiring amputation, and the other developing chronic pain and hypersensitivity, with a permanent decrease range of motion. Intravenous use of promethazine should be avoided when possible.

Spontaneous spinal epidural hematoma presenting as flank pain and constipation - Corrected Proof

Joseph B. Miller, Gurujot Khalsa, Taher Vohra — 2010-02-26

We report a case of a spontaneous spinal epidural hematoma presenting as constipation and flank pain in a patient on warfarin. The patient initially complained of these symptoms and was evaluated for renal colic or an aortic aneurysm. On the patient's second emergency department visit, he developed progressive paralysis and never regained neurological function. An adynamic ileus causing constipation may have been an early neurological finding in the patient's presentation. This case report illustrates a critical diagnosis to consider in the evaluation of an anticoagulated patient with flank or back pain.

Reversible posterior leukoencephalopathy syndrome after rituximab - Corrected Proof

Joseph A. Zito, Christopher C. Lee, Scott Johnson, Adam Singer, Jeffrey Vacirca — 2010-02-26

We present a case of a 25-year-old woman with posterior leukoencephalopathy syndrome presenting with acute bilateral visual loss and headache to our emergency department. The patient had a history of pure red blood cell dysplasia as a consequence of chronic hepatitis C and recently started rituximab after failing hepatitis C virus therapy, steroids, and intravenous IgG.

Monday preference in onset of takotsubo cardiomyopathy - Corrected Proof

2010-02-26

Abstract: Objective: Acute cardiovascular events show definite temporal patterns of occurrence. Takotsubo cardiomyopathy (TTC) has been recently shown to exhibit a seasonal (summer) and circadian (morning) temporal distribution. The aim of this study, based on the database of a multicenter Italian network, was to investigate the possible existence of a weekly pattern of onset of TTC.Methods: The study included all cases of TTC admitted to the coronary care unit of 8 referral cardiac centers in Italy (five in Southern Italy and three in Northern Italy, respectively), belonging to the Takotsubo Italian Network (January 2002-December 2008). Day of admission was categorized into seven 1-day intervals according by week, and chronobiological analysis was performed by partial Fourier series.Results: The database included 112 patients with TTC (92.9% females). The weekly distribution identified the highest number of cases on Monday and the lowest on Saturday. Chronobiologic analysis yielded a rhythmic pattern with a significant peak on Monday (P = .036).Conclusions: This study confirms a Monday preference for TTC occurrence on Monday, similar to that reported for acute myocardial infarction. Stress of starting weekly day life activities, could play a triggering role.

Impact of addition of propofol to ED formulary - Corrected Proof

Gary Senula, Alfred Sacchetti, Sandra Moore, Teena Cortese — 2010-02-26

Abstract: Study Objectives: Access to propofol remains a challenge for many emergency physicians. This report examines changes in patient care after the introduction of propofol to an emergency department formulary.Methods: The Procedural Sedation in the Community Emergency Department registry is a prospective multicentered database of community emergency physician–directed procedural sedation cases. Medication selection and patient outcome were compared at a single Procedural Sedation in the Community Emergency Department registry study site before and after credentialing of emergency physicians for the use of propofol. Analysis was done through analysis of variance and χ2 test.Results: Over a 36-month period, 573 patients were entered into the registry from the single study site, 255 before and 318 after propofol introduction. The percentage of propofol use increased from 26% of procedural sedation cases in the first 3 months of availability to 69% in the final 3 months analyzed. Before propofol use, 46% of cases were completed with a single agent compared with after propofol use, in which 66% were completed with a single agent (P < .001). Complications decreased from 9% of patients before propofol use to 3% of patients after propofol use (P < .05), whereas sedation failures decreased from 5.1% to 4.1% (P < .02).Conclusion: Granted access to propofol, emergency physicians will preferentially use this medication over prior procedural sedation agents with fewer procedural sedation complications and greater procedural success.

The role of the heart-type fatty acid binding protein in the early diagnosis of acute coronary syndrome and its comparison with troponin I and creatine kinase-MB isoform - Corrected Proof

2010-02-26

Abstract: Objectives: The aim of this study was to research the effectiveness of the heart-type fatty acid binding protein (H-FABP) in the early diagnosis of acute coronary syndrome (ACS) in patients admitted to emergency service (ES) within 6 hours of onset of chest pain.Equipment and Method: A total of 83 patients admitted with chest pain to our ES were included in this study. The patients were divided into 2 groups: those with a diagnosed ACS and those diagnosed with non–cardiac-related chest pain. Patients were also were divided into 2 groups according to the time of admission: those admitted within 0 to 3 hours and 3 to 6 hours of onset of chest pain. Peripheral venous blood samples were obtained from all patients for H-FABP, troponin I, and creatine kinase-MB (CK-MB) serum concentration measurements.Results: Of a total of 83 patients, 21.6% (n = 18) were in the control group and 78.3% (n = 65) were in the ACS group. The average H-FABP value for the patients in the control group was 0.86 ± 0.54 ng/mL. When the ACS and control groups were compared in means of cardiac markers for CK-MB (P = .000) and H-FABP (P = .000), there was a statistically significant difference, whereas no difference was observed for troponin I (P = .013). In the ACS group, H-FABP sensitivity for diagnosis was found to be 98% and specificity was 71%; CK-MB sensitivity was 86% and specificity was 52%; and troponin I sensitivity was 77% and specificity was 20%.Conclusions: For patients admitted with chest pain to ES, H-FABP was found to be more sensitive and specific than troponin I and CK-MB in the early diagnosis of ACS.

Ultrasound-guided pigtail catheters for drainage of various pleural diseases - Corrected Proof

2010-02-26

Abstract: Objective: Little is known about the efficacy and safety of ultrasound-guided pigtail catheters for the management of various pleural diseases in the emergency department, ward, and intensive care unit.Methods: We conducted a retrospective study in a university hospital during a 1-year interval.Results: A total of 276 patients (178 men and 98 women) underwent 332 pigtail catheters (the drain size ranged from 10F to 16F) under ultrasound guidance. The mean ± SEM patient age was 59 ± 18 years, and mean duration of drainage was 6.1 ± 2 days. A total of 64 drains (19.2%) were inserted for pneumothoraces; 98 drains (29.5%), for malignant effusions; 119 drains (35.8%), for parapneumonic effusions/empyemas; and 38 drains (11.4%), for massive transudate pleural effusions. The overall success rate was 72.9%. The success rate was highest when the drain was used to treat massive transudate effusions (81.6%) and malignant pleural effusions (75.5%), followed by parapneumonic effusions/empyemas (72.2%), hemothoraces (66.6%), and pneumothoraces (64.0%). Only 10 (3.0%) drains had complications due to the procedure, including infection (n = 4, 1.2%), dislodgment (n = 4, 1.2%), wound bleeding at the pigtail catheter puncture area complicated with hemothoraces (n = 1, 0.3%), and lung puncture (n = 1, 0.3%). There was no significant difference in success rate when different catheter sizes were used to treat pleural diseases.Conclusions: Ultrasound-guided pigtail catheters provide a safe and effective method of draining various pleural diseases. We strongly suggest that ultrasound-guided pigtail catheters be considered as the initial draining method for a variety of pleural diseases.

Spectrum of corrosive esophageal injury after intentional paraquat ingestion - Corrected Proof

2010-02-26

Abstract: Introduction: This is an observational study that examines the clinical features, the degrees of esophageal injury, physiological markers, and clinical outcomes after paraquat ingestion and seeks to determine what association, if any, may exist between these findings.Methods: The study included 16 of 1410 paraquat subjects who underwent endoscopies at Chang Gung Memorial Hospital between 1980 and 2007.Results: Corrosive esophageal injuries were classified as grade 1 in 8, 2a in 5, and 2b in 3 patients. No patients had grade 0, 3a, or 3b esophageal injuries. After paraquat ingestion, systemic toxicity occurred, with rapid development of hypoxia, hepatitis, and renal failure in many cases. Hypoxia occurred in 1 (12.5%), 5 (100%), and 3 (100%) patients with grades 1, 2a, and 2b esophageal injury, respectively. There were more hypoxic patients with grades 2a and 2b than those with grade 1 esophageal injury (P < .05). The nadir Pao2 was lower in patients with grades 2a and 2b than those with grade 1 esophageal injury (P < .05). However, there were no significant differences in terms of acute hepatitis, peak serum alanine aminotransferase, acute renal failure, and peak serum creatinine between the 3 groups (P > .05). Kaplan-Meier analysis did not find any difference in survival between the groups (P > .05).Conclusion: Paraquat, a mild caustic agent, produces only grades 1, 2a, and 2b esophageal injury. Our findings showed a potential relationship between the degree of hypoxia, mortality, and degree of esophageal injury, although such a low number of study subjects limits the conclusions that can be made by this study.

Cardiac ultrasound helps for differentiating the causes of acute dyspnea with available B-type natriuretic peptide tests - Corrected Proof

2010-02-26

Abstract: Introduction: The aim of this study was to evaluate the role of cardiac ultrasound in diagnosing acute heart failure (AHF) in patients with acute dyspnea with available plasma B-type natriuretic peptide (BNP) level.Methods: Patients with acute dyspnea presenting to the emergency department (ED) of a tertiary medical center were prospectively enrolled. The enrolled 84 patients received both BNP tests and cardiac ultrasound studies and were classified into AHF and non–heart failure groups.Results: Plasma BNP levels were higher in the AHF group (1236 ± 1123 vs 354 ± 410 pg/mL; P < .001). The AHF group had larger left ventricular end-diastolic dimension (LVEDD; 32 ± 7 vs 27 ± 4 mm/m2; P < .001) and worse left ventricular ejection fraction (52% ± 18% vs 64% ± 15%; P = .003). Multiple logistic regression analysis showed that both BNP levels more than 100 pg/mL and LVEDD were independent predictors for AHF. In patients with plasma BNP levels within gray zone of 100 to 500 pg/mL, LVEDD was larger in the AHF group than that in the non–heart failure group (29 ± 4 vs 26 ± 4 mm/m2; P = .044).Conclusion: Both LVEDD by cardiac ultrasound and BNP levels can help emergency physicians independently diagnose AHF in the ED. In patients with plasma BNP levels within 100 to 500 pg/mL, cardiac ultrasound can help differentiate heart failure or not.

Assessing the prevalence of modifiable risk factors in older patients visiting an ED due to a fall using the CAREFALL Triage Instrument - Corrected Proof

2010-02-26

Abstract: Objective: Falls in older people are a common presenting complaint. Knowledge of modifiable risk factors may lead to a more tailored approach to prevent recurrent falls and/or fractures. We investigated prevalence of 8 modifiable risk factors for recurrent falling and/or a serious consequence of the fall among older patients visiting the emergency department after a fall with the Combined Amsterdam and Rotterdam Evaluation of Falls Triage Instrument (CTI), a self-administrated questionnaire that consists of questions concerning demographics, possible cause(s) of the fall, and questions relating to (modifiable) risk factors for falling.Methods: After treatment for their injuries, 1077 consecutive patients 65 years or older visiting the accident and emergency department due to a fall were evaluated by the CTI. The following were assessed: impaired vision, mobility disorder, fear of falling, mood disorder, high risk of osteoporosis, orthostatic hypotension, incontinence, and polypharmacy.Results: The percentage of respondents who returned the questionnaire was 59.3%. The mean (SD) age was 78.5 (7.5) years, and 57.8% experienced a fall with serious consequences. There were 60.9% of patients with a recurrent fall versus 51% with a first fall who experienced with a serious consequence (P = .025). Age and risk factors mobility disorder (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3), high risk of osteoporosis (OR, 2.0; 95% CI, 1.2-3.2), incontinence (OR, 1.7; 95% CI, 1.0-2.7), fear of falling (OR, 2.2; 95% CI, 1.3-3.7), and orthostatic hypotension (OR, 2.4; 95% CI, 1.4-4.2) were independently associated with a recurrent fall. Age and high risk of osteoporosis were the only risk factors predicting a serious consequence of a fall (OR, 4.6; 95% CI, 2.9-7.2).Conclusions: Age and 5 modifiable risk factors assessed with the CTI were independently associated with a recurrent fall. Only high risk of osteoporosis was associated with a serious consequence.

Spontaneous intramural duodenal hematoma—a rare cause of upper gastrointestinal obstruction - Corrected Proof

S. Simi, T.M. Anoop, K.C. George — 2010-02-24

Intramural duodenal hematoma is a rare cause of proximal gastrointestinal tract obstruction. We report an unusual case of duodenal obstruction caused by spontaneous intramural duodenal hematoma secondary to coagulopathy after hepatic encephalopathy. Patient was treated symptomatically with nil orally, intravenous fluids, nasal gastric tube, vitamin K, frozen fresh plasma. Patient recovered completely 48 hours after medical treatment. Intramural hematoma of the gastrointestinal tract is an uncommon occurrence1 . Most cases are secondary to abdominal trauma. Nontraumatic intramural duodenal hematoma are rather rare. Only few cases of intramural duodenal hematoma have been reported as a cause for duodenal obstruction .

Derivation and reliability of an instrument to estimate medical benefit of emergency treatment - Corrected Proof

Jason S. Haukoos, Mallory D. Witt, Roger J. Lewis — 2010-02-08

Abstract: Objectives: For many patients, it is difficult to define the benefit derived from a visit to the emergency department (ED). No criterion standard exists that defines benefit from emergency treatment compared to routine outpatient care, and our limited ability to estimate benefit from emergency treatment has significant implications for emergency care-related health services research. The objectives of this study were to develop a decision algorithm to be used in estimating benefit of emergency treatment (EBET) and to assess its reliability when applied to patients making unscheduled ED visits.Methods: The EBET instrument defines benefit as a 3-level outcome, namely, significant, possible, or unlikely, and its content validity was assessed through expert review. The instrument was independently applied by multiple investigators to 3 different ED patient cohorts. A consensus-based process was used to determine the final EBET for each patient visit. Weighted κs and their 95% confidence intervals were calculated to assess the reliability of the EBET Instrument applied individually, and the Spearman-Brown formula was used to assess the overall reliability of the EBET instrument when applied using multiple raters and a standardized consensus process.Results: A total of 875 visits (300 from a general ED population, 300 from a homeless ED population, and 275 from an HIV-infected ED population) were scored using the EBET instrument. The consensus process included independently scoring groups ranging from approximately 50 to 100 patient visits, determining the level of agreement, discussing the discordant results among the investigators, and assigning a final EBET category to each visit. This process was repeated sequentially until all visits within each cohort were scored. The overall weighted κs ranged from 0.66 to 0.76, and the Spearman-Brown correlation ranged from 0.83 to 0.87.Conclusions: The EBET instrument demonstrated good to excellent reliability when applied independently by raters to both unselected and selected ED patients. Its reliability, however, was excellent to outstanding when multiple raters applied it using a consensus process. The EBET instrument may serve as a useful tool for defining benefit from emergency treatment.

Triage pain scales cannot predict analgesia provision to pediatric patients with long-bone fracture - Corrected Proof

Yi-Ming Weng, Yu-Che Chang, Yu-Jr Lin — 2010-02-08

Abstract: Purpose: This study evaluated the effects of pain assessment at triage on analgesia provision to pediatric patients with closed long-bone fractures in the emergency department (ED).Methods: This was a retrospective cohort study conducted at a university-affiliated teaching hospital. Children who presented to the ED of a teaching hospital with the main diagnosis of a closed fracture of the extremities in 2007 constituted the study cohort. We reviewed the charts and collected the following variables regarding the subjects' ED visits: patient demographics, pain scale reassessment, category of fracture, associated injuries, time from triage to the first administration pain medication, and the route and type of analgesic. The data were divided on the basis of triage in accordance with pain assessment or other triage modifiers.Results: In our study, 211 (54.7%) patients enrolled received analgesia. Oral acetaminophen was the most commonly prescribed medication (131 patients, 62.1%), whereas opioids were used in only 24 (11.4%) patients. The average time taken to deliver analgesia to children arriving in our ED was 70 minutes. The logistic regression analysis indicated that enrolled patients triaged based on the pain assessed at triage was not associated with the subsequent provision of analgesia. Analgesia provision was not associated with patients with moderate or severe pain assessed at triage as compared to patients with mild pain.Conclusion: The pain management of pediatric patients with closed long-bone fractures in the ED was inadequate and delayed. Moreover, the pain assessment at triage did not predict analgesia provision to these patients.

Initial serum glucose level and white blood cell predict ventricular arrhythmia after first acute myocardial infarction - Corrected Proof

Jiann-Hwa Chen, Chiu-Liang Tseng, Shin-Han Tsai, Wen-Ta Chiu — 2010-02-08

Abstract: Objective: The aims of this study are to analyze the factors that predispose the occurrence of ventricular arrhythmia (VA) in young patients with a first acute myocardial infarction (AMI) in the emergency department (ED) and to establish predictive implications.Methods: This is a 10-year retrospective cohort study. Patients who were older than 18 years and younger than 45 years with a first attack of AMI were recruited from the ED of 3 university teaching hospitals from January 1, 1998, to December 31, 2007.Results: Five hundred young patients (472 men and 28 women) who met the inclusion criteria were enrolled. Within these patients, the incidence of life-threatening VA with first attack of AMI was 8% (n = 40). They were categorized into 2 groups: VA attack (n = 40) and non-VA attack (n = 460). In univariable analyses, acute anterolateral ST-segment elevation myocardial infarction (65% vs 47.8%; P = .04), elevate white blood cell (WBC) count (16.4 ± 3.4 vs 11.5 ± 3.1 × 103/mm3; P < .01), and initial serum glucose level (202.6 ± 90.9 vs 151.9 ± 64.7 mg/dL; P < .01) were significantly increased in the VA group. Multiple logistic regression model identified WBC count and initial serum glucose level as the significant independent variables in the prediction of VA attack for young patients with first attack of AMI. The receiver operating characteristic area for WBC count and serum glucose level in predicting the risk of VA occurring after AMI was 0.869 and 0.756, respectively.Conclusion: Initial serum glucose level and WBC may be used as valuable predictors for VA attack in young patients with first AMI.

Platelet aspirin resistance in ED patients with suspected acute coronary syndrome - Corrected Proof

Jonathan Glauser, Charles L. Emerman, Deepak L. Bhatt, W. Frank Peacock — 2010-02-08

Abstract: Background: Platelet aspirin resistance is reported to be as high as 45%. The prevalence of emergency department (ED) platelet aspirin resistance in suspected acute coronary syndrome (ACS) is not described. Our purpose was to determine the prevalence of platelet aspirin resistance.Methods: We determined platelet aspirin resistance in a convenience sample of ED suspected ACS patients. Eligible patients had longer than 10 minutes of chest pain or an ischemic equivalent. Two hours after receiving 325 mg of aspirin, blood was assessed for platelet function (Accumetrics, San Diego, CA). Definitions are as follows: aspirin resistance, at least 550 aspirin reaction units; positive troponin T, greater than 0.1 ng/mL; significant coronary lesion, at least 70% stenosis. The composite end point was prospectively defined as a 30-day revisit, positive cardiac catheterization, or hospital length of stay (LOS) longer than 3 days.Results: Of 200 patients, 50.5% were male, 50.0% were black, troponin T was positive in 7.5%, cardiac catheterization was done in 10.5%, and 33.3% had a significant stenosis. Final diagnoses were noncardiac in 83.4%, stable angina in 8.0%, and unstable angina in 8.5%. Overall, 6.5% were resistant to aspirin; and high-risk patients trended to more aspirin resistance than non–high-risk patients (23.1% [3] vs 9.1% [17]; P value 95% confidence interval [CI], −0.0929 to 0.373). One-month follow-up found ED revisits in 12.5% of aspirin-resistant vs 4.9% of non–aspirin-resistant patients (95% CI, −0.114 to 0.182) and rehospitalization in 12.5% of resistant patients vs 4.3% of nonresistant patients (P value 95% CI, −0.108 to 0.187). Although LOS was similar at index admission, if rehospitalized, LOS was 6.5 for aspirin-resistant patients vs 3.2 days in nonresistant patients (P < .0001).Conclusion: This first report of platelet aspirin resistance in patients presenting to the ED with suggested ACS finds that it is present in 6.5% of patients.

Efficacy of tramadol vs meperidine in vasoocclusive sickle cell crisis - Corrected Proof

Belkan Uzun, Zeynep Kekec, Emel Gurkan — 2010-02-08

Abstract: Despite progress in management, patients with sickle cell disease who are experiencing acute painful episode are often incompletely treated. We compared meperidine and tramadol with respect to their effects on the hemodynamics and pain relief in patients with sickle cell disease who were admitted to the emergency department with painful crisis. A total of 68 patients with sickle cell disease were randomly assigned to receive either tramadol 1.5 mg/kg (n = 34) or meperidine 1 mg/kg (n = 34). Hemodynamic parameters were recorded at regular intervals after analgesic infusions. Pain intensity and relief were documented by visual analog and pain relief scale, respectively. Sedation level was defined according to Ramsay sedation scale. Both meperidine and tramadol administration resulted in a significant reduction in systolic and diastolic blood pressure after 2 hours (P < .05). Efficacy in pain relief between the analgesics was more rapid and better in the meperidine group, although the degree of relief were significantly improved compared to baseline levels in both groups (P < .05). Sedation was more commonly seen in the meperidine arm. None of the patients had experienced neurotoxicity. In summary, both agents had proven safe and effective for emergent use in patients with sickle cell disease. Avoiding meperidine injections as recommended with previous guidelines needs to be carefully reconsidered especially when low doses are mentioned.

Risk of venous thromboembolism in patients with borderline quantitative D-dimer levels - Corrected Proof

Taku Taira, Breena R. Taira, Matt Carmen, Jasmine Chohan, Adam J. Singer — 2010-02-08

Abstract: Objective: The lower threshold for D-dimer in evaluating patients with low clinical risk of venous thromboembolism (VTE) ranges from 200 to 500 ng/mL. We compared the rates of VTE in patients based on D-dimer values. We hypothesized that the rate of VTE in low-risk patients with D-dimer levels less than 500 would be less than 1%.Methods: Study Design: This was a retrospective chart review: Setting: The study was performed in a academic, suburban emergency department (ED). Subjects: Emergency department patients with suspected VTE and D-dimer obtained were included in the study. D-dimer assay: The D-dimer assay is a quantitative instrumentation latex suspension of plasma specimens. Outcomes: Presence of VTE within 30 days of ED visit. Data Analysis: Assuming a 0% event rate in patients with D-dimer levels between 200 and 500 ng/mL, a sample of 450 patients would result in a 95% confidence interval upper limit of 0.6%.Results: There were 1270 ED patients with suspected VTE in which D-dimer levels were performed between October 2005 and October 2006. Patient mean age was 47.8 ± 19.3 years; 63.2% were female, 78.2% were white. Of all D-dimer levels, 497 (39.1%) were less than 200 ng/mL, 479 (37.7%) were between 200 and 500 μg/mL, and 294 (23.1%) were greater than 500 ng/mL. There were no VTE events diagnosed in any of the patients with D-dimer levels less than 200 ng/mL. Four patients with D-dimer levels between 200 and 500 μg/mL had a pulmonary embolism on computed tomography angiography. Of these 4 patients, 3 had moderate clinical risk based on Well's criteria and one had a false-positive computed tomography. There were no cases of VTE in the remaining 475 patients (0%; 95% confidence interval 0%-0.6%).Conclusion: The rate of confirmed VTE in low-risk patients with D-dimer levels between 200 and 500 ng/mL is very low. Low-risk patients with suspected VTE with D-dimer levels less than 500 ng/mL might not require additional testing.

Radiopacity of ingested transdermal medicinal patches: a simulated human model - Corrected Proof

Adam K. Rowden, Christopher P. Holstege, Marcia L. Buck, David L. Eldridge — 2010-02-08

Numerous transdermal medicinal patches are currently available on the pharmaceutical market. Patients who ingest transdermal medicinal patches, either accidentally or intentionally, typically present to emergency departments (EDs) . Such cases are not benign and may develop adverse outcomes . For example, over a 2-year period, a network of 15 regional poison centers received 453 reports of intentional fentanyl patch abuse. One hundred fifty-seven of those cases involved the actual ingestion of the patch . Ingestion of other types of transdermal medicinal patches have also been reported with some cases resulting in delayed and prolonged adverse clinical outcomes .

Survival in out-of-hospital cardiac arrest before and after use of advanced postresuscitation care: A survey focusing on incidence, patient characteristics, survival, and estimated cerebral function after postresuscitation care - Corrected Proof

2010-02-08

Abstract: Background: Knowledge of the epidemiology of postresuscitation care is insufficient. We describe the epidemiology of postresuscitation care in a community from a 26-year perspective, focusing on incidence, patient characteristics, survival, and estimated cerebral function in relation to intensified postresuscitation care and initial arrhythmia.Methods: The study included patients with out-of-hospital cardiac arrest (OHCA) who were brought alive to a hospital ward in Göteborg, Sweden, between 1980 and 2006. Two periods (1980-2002 and 2003-2006) were compared.Results: In all, 1603 patients were included. For age, sex, and history, no significant differences between the 2 periods were seen. There was a significant multiple increase in bystander cardiopulmonary resuscitation, the use of coronary angiography, coronary revascularization, and therapeutic hypothermia. The number of patients found in ventricular fibrillation (VF) decreased (P = .011).For all patients, 1-year survival did not change significantly (27% vs 32%; P = .14). Among patients found in VF, an increase in 1-year survival was found (37% vs 57%; P < .0001), whereas no significant change was seen in nonshockable rhythm (10% vs 7%; P = .38). Survivors to discharge displaying low cerebral function (ie, cerebral performance categories score ≥3) decreased from 28% to 6% (P = .0006) among all patients.Conclusion: After the introduction of a more intensified postresuscitation care, there was no overall improvement in survival but signs of an improved cerebral function among survivors. There was a marked increase in survival among patients found in a shockable rhythm but not among those found in a nonshockable rhythm.

Ultrasound guidance for central venous catheter placement: results from the Central Line Emergency Access Registry Database - Corrected Proof

2010-02-08

Abstract: Background: Ultrasound guidance of central venous catheter (CVC) insertion improves success rates and reduces complications and is recommended by several professional and regulatory organizations.Methods: This is a prospective observational study using data extracted from the Central Line Emergency Access Registry database, a multicenter online registry of CVC insertions from medical centers throughout the United States. We compared success rates with ultrasound and with the anatomic-landmark technique.Results: A total of 1250 CVC placement attempts by emergency medicine residents during the study period were selected from the Central Line Emergency Access Registry database. Because a few attempts (n = 28) were made to place lines in either the left or right supraclavicular locations, data on these attempts were eliminated from the analysis. A total of 1222 CVC attempts from 5 institutions were analyzed. Successful placement on the first attempt occurred in 1161 (86%) cases and varied according to anatomic location. Ultrasound guidance was used in 478 (41%) of the initial attempts. The remainder of placements were presumably placed using the anatomic-landmark technique based on visible surface and palpatory subcutaneous structures. Overall successful placement rate did not vary according to the use of ultrasound guidance, nor did it vary at different anatomic sites. However, ultrasound was found to be significant for reducing the total number of punctures per attempt (P < .02, t = 2.30).Conclusions: Our study did not observe improved success with the use of ultrasound for CVC cannulation on the first attempt, but we did observe a reduced number of total punctures per attempt.

Physiologic effects of prolonged conducted electrical weapon discharge in ethanol-intoxicated adults - Corrected Proof

Ronald Moscati, Jeffrey D. Ho, Donald M. Dawes, James R. Miner — 2010-02-08

Abstract: Objectives: This study examines the physiologic effects of prolonged conducted electrical weapon (CEW) exposure on alcohol-intoxicated adult subjects.Methods: Adult volunteers were recruited at a TASER International training conference. All subjects ingested mixed drinks until clinical intoxication or until a minimum breath alcohol level of 0.08 mg/dL was achieved. Blood samples for venous pH, Pco2, bicarbonate, and lactate were measured in all subjects at baseline, immediately after alcohol ingestion, immediately after exposure to a 15-second TASER X26 discharge (Taser International Inc, Scottsdale, AZ), and 24 hours post-alcohol ingestion. Laboratory values were compared at sampling times using repeated-measure analysis of variance. A focused analysis comparing time points within groups was then performed using paired t tests.Results: Twenty-two subjects were enrolled into the study. There was a decrease in pH and bicarbonate and an increase in lactate after alcohol ingestion. There was a further increase in lactate and drop in pH after CEW exposure. No subject experienced a significant adverse event. All values had returned to baseline levels at 24 hours except lactate, which demonstrated a small but clinically insignificant increase.Conclusions: Prolonged continuous CEW exposure in the setting of acute alcohol intoxication has no clinically significant effect on subjects in terms of markers of metabolic acidosis. The acidosis seen is consistent with what occurs with ethanol intoxication or moderate exertion.

Topical antacid therapy for capsaicin-induced dermal pain: a poison center telephone-directed study - Corrected Proof

2010-02-08

Abstract: Purpose: The study aimed to assess the effects of topical antacids for treatment of capsaicin-induced dermal pain after exposure to capsaicin containing hot peppers, personal protection sprays, or topical creams.Procedures: Participants of the study were California Poison Control System (CPCS) hotline callers 12 years or older with dermal pain from exposure to capsaicin-containing products or plants. Participants were instructed to apply a topical antacid and assessed for perceived pain (using a 0-10 scale) pre- and posttreatment. A positive response was defined as a sustained reduction of pain 33% or more within 30 minutes or achieving a pain score of 0 to 1.Main findings: Of 93 eligible patients, 64 applied antacids and had outcome data available. Patients contacted the CPCS a median of 1 hour postexposure with a median initial pain score of 7.5/10. Thirty-six (56%) were exposed to unrefined (natural) peppers and 28 (44%) to refined capsaicin (eg, capsaicin-containing cream). Before calling the CPCS, 57 (89%) attempted at least one treatment. Forty-five (70%) reported positive response to antacid treatment as a 33% reduction in pain in 30 minutes (n = 17), a reduction in pain to a score of 0 to 1 (n = 3), or both (n = 25). A 33% reduction in pain within 30 minutes was associated with exposure to refined capsaicin (odds ratio, 3.37; 95% confidence interval, 0.98-11.66). Concomitant refined capsaicin exposure and early treatment (<1 hour of symptoms) was associated with even greater odds of response (odds ratio, 5.4; 95% confidence interval, 1.4-21.2).Conclusion: Topical application of antacids for capsaicin-induced pain is effective, particularly in early treatment of exposure to refined capsaicin.

Accurate prediction of the needle depth required for successful lumbar puncture - Corrected Proof

Sze Yee Chong, Lee Ai Chong, Hany Ariffin — 2010-02-08

Abstract: Introduction: The aim of this study is to formulate an accurate estimate of the spinal needle depth for a successful lumbar puncture in pediatric patients.Methods: This is a prospective study of pediatric oncology patients who had lumbar punctures in the course of their treatment. The distance from skin entry point to the tip of the spinal needle was measured after lumbar punctures were performed. The relationship between the depth of needle insertion with weight, height, body surface area, body mass index, intervertebral space used, ethnicity, and sex of patient were studied. Predictive statistical models were used for the formulation of the ideal lumbar puncture needle depth.Results: Two hundred seventy-nine patients who had nontraumatic lumbar punctures were studied. The patient characteristics were as follows: age, 0.5 to 15 years; weight, 7 to 63 kg; and height, 70 to 162 cm. Analysis using multiple regression tests with stepwise approach showed a strong relationship between the lumbar puncture needle depth and weight/height ratio. By using a predictive regression model, ideal depth of needle insertion (cm) = 10 [weight(kg)/height(cm)] + 1, with a regression coefficient r = 0.77.Conclusion: This formula is accurate and practical with less complex calculations. However, further validation in a prospective study will be needed.

Effectiveness of mouth-to-mouth ventilation after video self-instruction training in laypersons - Corrected Proof

2010-02-08

Abstract: Background: Mouth-to-mouth ventilation is a skill taught in cardiopulmonary resuscitation (CPR) training for laypersons. However, its effectiveness is questioned. Our aim was to determine the effectiveness of mouth-to-mouth ventilation training using a self-instruction CPR training video for laypersons.Methods: Video-self-instruction CPR training was conducted with CPR Anytime (American Heart Association [AHA] & Laerdal Corporation) for laypersons who had not received CPR training during the recent 5 years. Immediately before, immediately after, and 8 weeks after the CPR training, an AHA basic life support instructor carried out a skill performance test using a standardized checklist. Also, 8 weeks after the training, a skill test concerning chest compression and mouth-to-mouth ventilation was conducted using a trained reporter.Results: Cardiopulmonary resuscitation training of 84 laypersons was conducted. The mean performance score (from 0 to 2) for mouth-to-mouth ventilation was 0.24 right before the training, 1.58 right after the training, and 0.95 eight weeks after the training. The mean performance scores for chest compression were 0.13, 1.79, and 1.40, right before, right after, and 8 weeks after the CPR training, respectively. The rates of successful mouth-to-mouth ventilation and compression were 11.9%, and 39.1%, respectively.Conclusions: The effectiveness and short-term retention rate of mouth-to-mouth ventilation after video self-instruction CPR training in laypersons was significantly lower than for chest compressions.

Probability of survival, early critical care process, and resource use in trauma patients - Corrected Proof

2010-02-08

Abstract: Background: Trauma Injury Severity Score is a frequently used prediction model for mortality. However, few studies have assessed the probability of survival (Ps) and early resource use after trauma. We studied the impact of Ps on early critical care or costs to test its applicability to efficient trauma care.Methods: The relationship between Ps in 8207 trauma patients and patients' demographics, organ injured, comorbidities, use of critical care, and total charges during the initial 48 hours was analyzed using multiple regression analyses.Results: Significant differences were observed among study variables across different Ps. A large variability in total charges was observed and explained by critical care, which Ps was significantly associated with.Conclusions: Trauma Injury Severity Score offers a tool for estimating resource use and might improve monitoring of early trauma care quality. Measuring the combined effect of Trauma Injury Severity Score and injured organs would refine the methodology for evaluating the trauma care system.

Verification of airway management during cardiac arrest: a manikin-based observational study - Corrected Proof

2010-02-08

Abstract: Introduction: The study aimed to clarify the difficulties concerning insertion of advanced airway devices during cardiac arrest.Method: In an observational study using manikins, we examined the airway management techniques of 19 teams at the Osaka Senri medical rally. For ex-post verification, we recorded chest compression and ventilation using the Resusci® Anne Advanced Skill Trainer (Laerdal, Norway) and recorded actions of the teams using a video camera.Results: Only a small proportion of teams did not adopt advanced airway management (4 teams, 21.1%). Thirteen teams selected tracheal intubation. None showed chest compression interruptions during intubation manipulation, and the median duration of chest compression interruption during confirmation of postintubation was 6.4 seconds. The median duration of ventilation interruption during intubation was 45.5 seconds. When teams were evaluated for the duration of direct laryngoscopy, that is, so-called duration of intubation, the median duration was 19 seconds, which constituted a large underestimate compared with the duration of ventilation interruption. This represents an underestimation of about 27 seconds. We considered the issues to be identified for shortening the duration of ventilation interruption.Conclusion: From this study, it is clear that the strategy of Guideline 2005 that was designed to minimize chest compression interruption has permeated deeply. The recommendation that the duration of intubation manipulation should not exceed 30 seconds has had various interpretations, but it is important to focus on the duration of ventilation interruption.