Emergency Medicine News
Coronary Artery Calcium Scoring in the Emergency Department: Identifying Which Patients With Chest Pain Can Be Safely Discharged Home
Coronary artery calcium scoring (CACS) is a simple and readily available test for identifying coronary artery disease. Our objective is to evaluate whether a CACS of zero will identify chest pain patients who can be safely discharged home, without need for further cardiac testing. This was a prospective observational cohort study conducted at an urban tertiary care hospital of stable patients presenting to the emergency department (ED) with chest pain of uncertain cardiac cause. Patients with a normal initial troponin level, nonischemic ECG, and no history of coronary artery disease had stress myocardial perfusion imaging (SPECT) and CACS within 24 hours of ED admission. A majority of patients (61% in our sample) evaluated for chest pain of uncertain cardiac cause have a CACS of 0, which predicts both a normal SPECT result and an excellent short-term outcome. Our results suggest that patients with a CACS of 0 can be discharged home, without further cardiac testing.
Delirium in the Emergency Department: An Independent Predictor of Death Within 6 Months
Delirium's adverse effect on long-term mortality in older hospitalized patients is well documented, whereas its effect in older emergency department (ED) patients remains unclear. Similarly, the consequences of delirium on nursing home patients treated in the ED are also unknown. As a result, we seek to determine whether delirium in the ED is independently associated with 6-month mortality in older patients and whether this relationship is modified by nursing home status. Overall it was found that delirium in older ED patients is an independent predictor of increased 6-month mortality, and this relationship appears to be present regardless of nursing home status.
Triaging Pulmonary Embolism Risk Factors Can Rule Out Need for CT Angiography
In patients without selected thromboembolic risk factors, pulmonary embolism (PE) is extremely unlikely and investigation with CT angiography likely unnecessary. In a retrospective study that examined seven major risk factors in patients who underwent CT angiography for suspected PE, Mamlouk and colleagues found that a positive CT angiogram was extremely unlikely—0.95%—for patients with none of the risk factors. The results suggest that unless there is an unusual mitigating circumstance, CT angiography is likely unnecessary in these patients, and triaging risk factors can reduce costs and radiation exposure, the researchers concluded.
Retropharyngeal and parapharyngeal abscess in children—Epidemiology, clinical features and treatment
This article sought to describe the clinical presentation, diagnosis, management and complications of children with retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs). And was found that Children with RPA most commonly present with restricted neck movements, fever and cervical lymphadenopathy, and rarely with respiratory distress or stridor. Many patients with RPA and PPA can be treated successfully without surgery. CT scans are helpful in diagnosing and assessing the extent of the infection, but they are not always accurate.
Highly sensitive TnT assays improve pulmonary embolism risk stratification
Highly sensitive troponin T (hsTnT) assays improve the risk stratification of patients with acute pulmonary embolism (PE) by ruling out an adverse early outcome, German researchers report. The researchers report that 100 (64%) patients had hsTnT levels at or above the cut-off value of 14 pg/ml. By comparison, 52 (33.3%) patients had elevated cTnT levels above the cut-off value of 0.03 ng/ml when using the conventional assay. Baseline hsTnT was significantly higher in patients with an adverse 30-day outcome (death, or a need for catecholamines, endotracheal intubation, or cardiopulmonary resuscitation), at 71.7 pg/ml, compared with 26.4 pg/ml among those that had an uncomplicated course.
Trends and Characteristics of US Emergency Department Visits, 1997-2007
The potential effects of increasing numbers of uninsured and underinsured persons on US emergency. This article sought to describe the changes in ED visits that occurred from 1997 through 2007 in the adult and pediatric US populations by sociodemographic group, designation of safety-net ED, and trends in ambulatory care–sensitive conditions. It was found that between 1997 and 2007, ED visit rates increased from 352.8 to 390.5 per 1000 persons and the increase in total annual ED visits was almost double of what would be expected from population growth. Adults with Medicaid accounted for most of the increase in ED visits; the visit rate increased from 693.9 to 947.2 visits per 1000 enrollees between 1999 and 2007. These findings indicate that ED visit rates have increased from 1997 to 2007 and that EDs are increasingly serving as the safety net for medically underserved patients, particularly adults with Medicaid.
Just One Drop: The Significance of a Single Hypotensive Blood Pressure Reading During Trauma Resuscitations
Single, isolated hypotensive blood pressure (BP) measurements frequently are ignored or considered "erroneous." Although their clinical significance remains unknown,this article hypothesized that single, isolated hypotensive BP readings during trauma resuscitations signify the presence of severe injuries that often warrant immediate intervention. Cutpoint analysis determined that a single SBP reading <105 mm Hg best predicted the need for immediate therapeutic intervention. Although 38.1% patients with isolated SBP <105 mm Hg measurements underwent immediate therapeutic operative or endovascular procedures, only 10.4% (p < 0.001) with isolated SBP >=105 mm Hg required these procedures. Patients were 12.4 times more likely to undergo immediate therapeutic intervention than those with a single SBP >=105 mm Hg thus concluding that a single, isolated hypotensive BP measurements during trauma resuscitations should not be ignored or dismissed. Instead, our results suggest that a single SBP reading <105 mm Hg is associated with severe injuries that often require immediate operative or endovascular treatment and surgical intensive care unit admission.
IUD works for emergency birth control: study
A copper intrauterine device was 100 percent effective at emergency contraception in a study of almost 2000 Chinese women who had the device implanted up to 5 days after unprotected sex.
Prognostic Value of Lead V1 ST Elevation During Acute Inferior Myocardial Infarction
Lead V1 directly faces the right ventricle and may exhibit ST elevation during an acute inferior myocardial infarction when the right ventricle is also involved. Leads V1 and V3 indirectly face the posterolateral left ventricle, and ST depression ("mirror-image" ST elevation) in V1 through V3 may reflect concomitant posterolateral infarction. The prognostic significance of V1 ST elevation during an acute inferior myocardial infarction may therefore be dependent on V3 ST changes. This article found that V1 ST elevation at baseline, analyzed as a continuous variable, was associated with higher mortality. Unadjusted, each 0.5-mm-step increase in ST level above the isoelectric level was associated with 25% increase in 30-day mortality; this was true whether V3 ST depression was present or not. The odds ratio for mortality was 1.21 (95% confidence interval, 1.07 to 1.37) after adjustment for inferolateral ST elevation and clinical factors and 1.24 (95% confidence interval, 1.09 to 1.40) if also adjusted for V3 ST level. In contrast, lead V1 ST depression was not associated with mortality after adjustment for V3 ST level.
44-55-66-PM, a Mnemonic That Improves Retention of the Ottawa Ankle and Foot Rules: A Randomized Controlled Trial
Studies have suggested that poor knowledge of the Ottawa Ankle Rules (OAR) limits its clinical impact. This study evaluated the ability of a mnemonic to improve knowledge of the OAR. This was a single-blind randomized controlled trial performed among residents and medical students doing a pediatric emergency medicine rotation. At baseline, all participants were tested for their baseline knowledge of the OAR. 44: Is to remember that an X-ray is required if the patients is unable to walk 4 steps at the moment of the Accident AND during the physical examination 55: Is to remember that an X-ray of the foot is required if the patient has pain at the basis of the 5Th metatarsal of at the 5caphoid 66-PM: Is to remember that an X-ray of the ankle is required if the patient has pain in the Posterior of the lateral or medial malleolar. The use of the mnemonic 44-55-66-PM was associated with a better long-term knowledge of the OAR among medical students and residents. The improvement in knowledge of the OAR among the control group highlights the importance of using controlled trials for studies evaluating knowledge transfer.
Gestational sac volume in missed abortion and anembryonic pregnancy compared to normal pregnancy
This article compared gestational sac (GS) volume (GSV) between normal pregnancies and missed abortions and anembryonic pregnancies and to determine at what gestational age differences in GS volume become evident.
GSV was significantly larger in normal pregnancies than in missed or anembryonic abortion: 27.51 ± 25.25 cm3 and 8.04 ± 10.54 cm3, respectively (p < 0.001). When stratified by weeks, statistically significant differences were found beginning at 7 weeks, while GSV measurements were not significantly different between the normal and abnormal pregnancies from 6 to 6+6 weeks.
Inappropriate Prehospital Ventilation in Severe Traumatic Brain Injury Increases In-Hospital Mortality
In the setting of acute brainstem herniation in traumatic brain injury (TBI), the use of hyperventilation to reduce intracranial pressure may be life-saving. However, undue use of hyperventilation is thought to increase the incidence of secondary brain injury through direct reduction of cerebral blood flow. This retrospective review determined the effect of prehospital hyperventilation on in-hospital mortality following severe TBI. Patients with normocarbia on presenting arterial blood gas testing had in-hospital mortality of 15%, significantly improved over patients presenting with hypocarbia (in-hospital mortality 77%) or hypercarbia (in-hospital mortality 61%). Although there are many reports of the negative impact of prophylactic hyperventilation following severe TBI, this modality is frequently utilized in the prehospital setting. These results suggest that abnormal Pco2 on presentation after severe head trauma is correlated with increased in-hospital mortality and the advocatation of normoventilation in the prehospital setting.
Comparing the efficacy and safety of two regimens of sequential systemic corticosteroids in the treatment of acute exacerbation of bronchial asthma
Corticosteroids are commonly used in the management of acute asthma. However, studies comparing various steroids in the management of acute asthma are lacking.This article compared the efficacy and safety of two treatment regimens - intravenous (IV) methylprednisolone (MP) followed by oral MP and IV hydrocortisone (HC) followed by oral prednisolone in acute bronchial asthma patients. This study found that in acute asthma patients, IV MP followed by oral MP is a more efficacious and safer treatment regimen than IV HC followed by oral prednisolone.
Therapeutic Efficacy of Icatibant in Angioedema Induced by Angiotensin-Converting Enzyme Inhibitors: A Case Series
The pathophysiology of angiotensin-converting enzyme inhibitor (ACEi)–induced angioedema most likely resembles that of hereditary angioedema, ie, it is mainly mediated by bradykinin-induced activation of vascular bradykinin B2 receptors. THis article hypothesized that the bradykinin B2 receptor antagonist icatibant might be an effective therapy for ACEi-induced angioedema.Overall, first symptom improvement after icatibant injection occurred at a mean time of 50.6 minutes (standard deviation [SD] 21 minutes) and complete relief of symptoms at 4.4 hours (SD 0.8 hours). No patient received tracheal intubation, other drug treatment, tracheotomy, or a second icatibant injection. Although sample size limits the external validity of our results, the substantial decrease of time to complete symptom relief suggests that this new treatment is likely effective as a pharmacotherapeutic approach to treat ACEi-induced angioedema.
Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?
Using Poiseuille's law and standardized gauge sizes, an 18-gauge (g) intravenous catheter (IV) should be 2.5 times faster than a 20-g IV, but this is not borne out by observation, in vitro testing, and manufacturer's data. This article sought to determine if the infusion rate of a single 18-g IV was equivalent to the infusion rate of two 20-g IVs.
The mean infusion rate for a single 18-g 500-mL IV administration was 35.6 mL/min (95% confidence interval [CI], 30.3-40.8), with manufacturer's rating being 105 mL/min. The mean infusion rate for two 20-g IVs was 41.3 mL/min (95% CI, 36.1-46.4), with manufacturer's rating being 120 mL/min. The rate of infusion via two 20-g IVs were statistically significantly faster than the single 18-g IV, with a mean difference in flow rate of 5.7 mL/min.
Circadian, day-of-week, and age patterns of the occurrence of acute coronary syndrome
Previous in-hospital studies suggest that there are significant circadian rhythms associated with the incidence of acute coronary syndromes (ACSs). No study to date has examined the presentation of ACS in the prehospital setting. This article sought to examine circadian, day-of-week, and age patterns of occurrence ACS. It was found that the presentation of ACS has significant circadian rhythm characterized by 2 peaks within 24 hours, the morning peak is 0800 to 1000, and the late evening peak is 2200 to 2400 and no significant weekly rhythm observed in the present study.
Femoral-Based Central Venous Oxygen Saturation Is Not a Reliable Substitute for Subclavian/Internal Jugular-Based Central Venous Oxygen Saturation
Central venous oxygen saturation (Scvo2) has been used as a surrogate marker for mixed venous oxygen saturation (Svo2). Femoral venous oxygen saturation (Sfvo2) is sometimes used as a substitute for Scvo2. The purpose of this study is to test the hypothesis that these values can be used interchangeably in a population of patients who are critically ill. This study revealed a significant difference between paired samples of Scvo2 and Sfvo2. More than 50% of Scvo2 and Sfvo2 values diverged by > 5%. Sfvo2 is not always a reliable substitute for Scvo2 and should not routinely be used in protocols to help guide resuscitation.
Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65years old
The objective of the study was to investigate the outcomes of patients with traumatic brain injury (TBI) who had Glasgow Coma Scale (GCS) scores of 3 or 4, and were aged 66 years or older. The Factors having significant effect on outcomes were ISS, TRISS and AIS head. Closed or partially closed basal cisterns and/or midline shift > 15mm were associated with unfavorable outcome. SAH was associated with favorable outcome. Patients with GCS 3 or 4 and older than 65 years have a poor, but not hopeless prognosis. Confirmed factors of poor prognosis for this group of patients are closed basal cisterns and midline shift >15 mm on the first CT. Factors possibly related to favorable outcomes were female gender, lower trauma severity, open or partially open basal cisterns and no midline shift on first CT scan.
Treating Headache Recurrence After Emergency Department Discharge: A Randomized Controlled Trial of Naproxen Versus Sumatriptan
Multiple parenteral medications are used to treat migraine and other acute primary headaches in the emergency department (ED). Regardless of specific headache diagnosis, no medication eliminates the frequent recurrence of primary headache after ED discharge. It is uncertain which medication primary headache patients should be given on discharge from an ED. The aim of this study is to compare the efficacy of oral sumatriptan with naproxen for treatment of post-ED recurrent primary headache. In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patient's previous experience with the medication.
Tranexamic Acid Reduces Mortality in Trauma Patients
Tranexamic acid may be an effective option for reducing bleeding and mortality among trauma patients, without increasing the risk of serious complications such as myocardial infarction, stroke, or pulmonary embolism, according to a study published online June 15 in The Lancet.
Clinical Findings Distinguishing Hemorrhagic Stroke From Ischemic Stroke
The 2 fundamental subtypes of stroke are hemorrhagic stroke and ischemic stroke. Although neuroimaging is required to distinguish these subtypes, the diagnostic accuracy of bedside findings has not been systematically reviewed. This article out of this weeks JAMA sought to determine the accuracy of clinical examination in distinguishing hemorrhagic stroke from ischemic stroke. Several findings significantly increase the probability of hemorrhagic stroke: coma, neck stiffness, seizures accompanying the neurologic deficit, diastolic blood pressure greater than 110 mm Hg, vomiting, and headache. While other findings decrease the probability of hemorrhage such as cervical bruit and prior transient ischemic attack. In patients with acute stroke, certain findings accurately increase or decrease the probability of intracranial hemorrhage, but no finding or combination of findings is definitively diagnostic in all patients, and diagnostic certainty requires neuroimaging.
