Diagnostic performance of initial salivary alpha-amylase activity for acute myocardial infarction in patients with acute chest pain

Background

To rule out acute myocardial infarction (AMI) in chest pain patients constitutes a diagnostic challenge to emergency department (ED) physicians.

Study Objectives

To evaluate the diagnostic value of measuring salivary alpha-amylase (sAA) activity for detecting AMI in patients presenting to the ED with acute chest pain.

Methods

sAA activity was measured in a prospective cohort of 473 consecutive adult patients within 4 h of onset of chest pain. Comparisons were made between patients with a final diagnosis of AMI and those with non-AMI. Univariate analysis and multiple logistic regression model were used to identify independent clinical predictors of AMI.

Results

Initial sAA activity in the AMI group (n = 85; 266 ± 127.6 U/mL) was significantly higher than in the non-AMI group (n = 388; 130 ± 92.8 U/mL, p < 0.001). sAA activity levels were also significantly higher in patients with ST elevation AMI (n = 53) compared to in those with non-ST elevation AMI (n = 32) (300 ± 141.1 vs. 210 ± 74.1 U/mL, p < 0.001). The area under the receiver operating characteristic curve of sAA activity for predicting AMI in patients with acute chest pain was 0.826 (95% confidence interval [CI] 0.782–0.869), with diagnostic odds ratio 10.87 (95% CI 6.16–19.18). With a best cutoff value of 197.7 U/mL, the sAA activity revealed moderate sensitivity and specificity as an independent predictor of AMI (78.8% and 74.5%).

Conclusions

High initial sAA activity is an independent predictor of AMI in patients presenting to the ED with chest pain.     

Aspirin administration in ED patients who presented with undifferentiated chest pain: age,race, and sex effects

Study Objectives

The study aimed to determine whether aspirin therapy was differentially administered according to race, sex, or age in patients with undifferentiated chest pain who presented to an urban academic emergency department.

Methods

This was a prospective observational cohort study of patients older than 24 years who presented with chest pain between July 1999 and March 2002. Patients were grouped according to 30-day final diagnosis: acute myocardial infarction AMI, unstable angina USA, and non–acute coronary syndrome (ACS) chest pain. Data were analyzed using Fisher exact test and relative risk regression using the Gaussian estimating equation.

Results

There were 4478 patient visits, of which 4470 (99.8%) had complete information. Mean age was 52.2 ± 15.8 years. Blacks were 70.1% (n = 3135), whites 26.3% (n = 1175), and other 3.6% (n = 159). Women comprised 59.0% (n = 2639) of the patients. Aspirin therapy differed by race, sex, age, and final diagnosis. Patients who received aspirin were more likely to be white (60% vs 54%, P = .0009) or have an ACS diagnosis (82% vs 50%, P < .0001). By final diagnosis, there were no race, sex, or age differences for AMI or USA (P > .05). There were significant sex and age differences for non-ACS chest pain patients: men (53% vs 48% women, P = .0009) and older patients (>55 years, 60% vs 44% younger, P < .0001) had higher aspirin therapy due to administration to the patients with non-ACS chest pain.

Conclusion

For patients with undifferentiated chest pain, overall race, sex, and age differences were explained by higher rates of aspirin administered to older men with non-ACS chest pain.     

ECG signs of acute myocardial ischemia in the prehospital setting of a suspected acute coronary syndrome and its association with outcomes

Aims

The aims of this study were (a) to determine the prehospital prevalence of electrocardiographic (ECG) signs of acute myocardial ischemia in patients with suspected acute coronary syndrome and (b) to describe the relationships between the various ECG patterns and the diagnosis of acute myocardial infarction (AMI) and outcomes.

Methods

Prospective cohort study using data from an interventional trial in acute chest pain patients transported by the emergency medical services. These patients were classified into 3 groups: patients with ECG showing signs of acute myocardial ischemia, patients with ECG showing other abnormal changes (bundle-branch block, pacemaker rhythm, Q-wave or T-wave inversion) and patients without significant pathologic findings. All P values are age-adjusted.

Results

Among 1546 patients, 312 (20%) had ECG signs of acute myocardial ischemia. Of them, 57% had a final diagnosis of AMI versus 26% of those with other abnormal ECGs and 12% of those with ECG without significant pathologic findings (P < .0001). In all, 53% of all AMI cases involved patients without ECG signs of acute myocardial ischemia. Although ECG signs of acute myocardial ischemia predicted heart failure and ventricular tachyarrhythmias both prior to and after hospital admission, there was no significant difference in 30-day mortality between the 3 patient groups (4.3%, 3.7%, and 1.2%, respectively, P = .11).

Conclusion

Among patients with a clinical suspicion of AMI in the prehospital setting, the prevalence of ECG signs suggesting AMI was low, as was the ability to identify AMI patients using ECG findings only. We therefore need better instruments in the prehospital triage of patients with acute chest pain.     

Combined copeptin and troponin to rule out myocardial infarction in patients with chest pain and a history of coronary artery disease

Purpose

The main objective of this multicentric study was to evaluate the additional value of copeptin to conventional cardiac troponin (cTn) for a rapid ruling out of acute myocardial infarction (AMI) in patients with acute chest pain and a previous history of coronary artery disease (CAD).

Patients and Method

Patients with a previous history of CAD presenting in the emergency department with acute chest pain lasting for 6 hours or less suggestive of non–ST-segment elevation AMI and negative cTn were selected. Levels of copeptin were blindly measured at presentation. The diagnosis was adjudicated by 2 independent experts using all available data including cTn.

Results

A total of 451 patients were included (mean age, 67 ± 14; 330 [73%] men). The adjudicated final diagnosis was AMI in 36 (8%) patients, unstable angina in 131 (29%), and other diagnosis in 284 (63%). A negative cTn combined with a copeptin value lower than 10.7 pmol/L at presentation was able to rule out AMI, with a negative predictive value of 98% (95% confidence interval, 95%-99%).

Conclusion

In triage patients with acute chest pain lasting for less than 6 hours and a previous history of CAD, the combination of copeptin and cTn allows for the ruling out AMI, with a negative predictive value greater than 95%.     

Heart-type fatty acid binding protein and the diagnosis of acute coronary syndrome in the ED

Background

In combination with cardiac troponin, heart-type fatty acid binding protein (h-FABP)—a biomarker of myocardial necrosis—offers the possibility of rapidly eliminating the diagnosis of acute myocardial infarction (AMI).

Objective

The main objective of this study was to assess the incremental value of h-FABP to cardiac troponin for a rapid elimination of AMI, according to the pretest probability (PTP) of AMI.

Methods

In consecutive patients presenting to emergency departments (ED) with chest pain less than 6 hours suggestive of AMI, h-FABP levels were measured, blinded to the ED physicians, who were asked to quote the PTP of AMI. The discharge diagnosis was adjudicated by 2 independent experts, blind to the h-FABP level.

Results

Three hundred seventeen patients (mean age of 57 years) were included in whom 149 had (47%) low, 117 (37%) moderate, and 51 (16%) high PTP. The final diagnosis was AMI in 45 patients (14%), including 16 STEMIs (5%). The negative predictive value for diagnostic elimination of AMI of an h-FABP less than 3 μg/L, combined with a negative cTnI was not higher than that of cardiac troponin I (cTnI) alone (96% [95% confidence interval, 93%-98%] vs 95% [93%-98%]), regardless of the PTP). Even in the low-PTP group, we did not demonstrate a significant improvement in negative predictive value with the addition of h-FABP, compare with that of cTnI alone (100% [97%-100%] vs 99% [96%-100%]).

Conclusion

In triage of patients with chest pain, use of h-FABP does not provide useful additional information to cTnI for excluding the diagnosis of ST-elevation myocardial infarction and non–ST-elevation myocardial infarction diagnosis, whatever the PTP.     

Inequalities in the early treatment of women and men with acute chest pain?

Purpose

The aim of this study was to identify sex differences in the early chain of care for patients with chest pain.

Design

This is a retrospective study performed at 3 centers including all patients admitted to the emergency department because of chest pain, during a 3-month period in 2008, in the municipality of Göteborg. Chest pain or discomfort in the chest was the only inclusion criterion. There were no exclusion criteria.

Data Sources

Data were retrospectively collected from ambulance and medical records and electrocardiogram (ECG), echocardiography, and laboratory databases.

Main Findings

A total of 2588 visits (1248 women and 1340 men) made by 2393 patients were included.When adjusting for baseline variables, female sex was significantly associated with a prolonged delay time (defined as above median) between (a) admission to hospital and admission to a hospital ward (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.03), (b) first physical contact and first dose of aspirin (OR, 2.22; 95% CI, 1.30-3.82), and (c) admission to hospital and coronary angiography (OR, 2.50; 95% CI, 1.29-5.13).Delay time to the first ECG recording did not differ significantly between women and men.

Principal Conclusions

Among patients hospitalized due to chest pain, when adjusting for differences at baseline, female sex was associated with a prolonged delay time until admission to a hospital ward, to administration of aspirin, and to performing a coronary angiography. There was no difference in delay to the first ECG recording.     

Early Detection and Treatment of Patients with Severe Sepsis by Prehospital Personnel

Background

Severe sepsis is a condition with a high mortality rate, and the majority of patients are first seen by Emergency Medical Services (EMS) personnel.

Objective

This research sought to determine the feasibility of EMS providers recognizing a severe sepsis patient, thereby resulting in better patient outcomes if standard EMS treatments for medical shock were initiated.

Methods

We developed the Sepsis Alert Protocol that incorporates a screening tool using point-of-care venous lactate meters. If severe sepsis was identified by EMS personnel, standard medical shock therapy was initiated. A prospective cohort study was conducted for 1 year to determine if those trained EMS providers were able to identify 112 severe sepsis patients before arrival at the Emergency Department. Outcomes of the sample of severe sepsis patients were examined with a retrospective case control study.

Results

Trained EMS providers transported 67 severe sepsis patients. They identified 32 of the 67 severe sepsis patients correctly (47.8%). Overall mortality for the sample of 112 severe sepsis patients transported by EMS was 26.7%. Mortality for the sample of severe sepsis patients for whom the Sepsis Alert Protocol was initiated was 13.6% (5 of 37), crude odds ratio for survival until discharge was 3.19 (95% CI 1.14–8.88; p = 0.040).

Conclusions

This pilot study is the first to utilize EMS providers and venous lactate meters to identify patients in severe sepsis. Further research is needed to validate the Sepsis Alert Protocol and the potential associated decrease in mortality.     

Diagnostic value of ischemia-modified albumin in patients with suspected acute coronary syndrome

Introduction

Ischemia-modified albumin (IMA) has been proposed as a useful rule-out marker for the diagnosis of acute coronary syndrome (ACS) in the emergency department. This study evaluated the ability of IMA to predict the acute myocardial infarction (AMI) diagnosis in a population of chest pain patients.

Methods

The study population comprised 107 subjects (men, 62%; women, 38%) admitted with suspected ACS. None of the patients had ST-segment elevations that qualified for immediate revascularization. Ischemia-modified albumin was determined from serum with albumin cobalt binding test (Inverness Medical Innovations Inc, Stirling, UK). Furthermore, cardiac troponin T, creatinine kinase MB mass, myoglobin, and heart-type fatty acid binding protein (H-FABP) were determined on arrival, after 6 to 9 hours, and after 12 to 24 hours. All patients had at least 2 blood samples taken to exclude/verify the AMI. AMI was defined by a cardiac troponin T level greater than 0.03 μg/L.

Results

Thirty-three percent of the patients (n = 35) had a final diagnosis of AMI. The sensitivity of admission IMA for a final diagnosis of ACS was 0.86 (95% confidence interval [95% CI], 0.69-0.95). Specificity was 0.49 (95% CI, 0.36-0.60). Negative predictive value was 0.88 (95% CI, 0.72-0.95). The optimal cutoff threshold derived from the receiver operating characteristics (ROC) curve (ROC analysis) was determined as 91 U/mL. The area under the ROC curve was 0.73. Ischemia-modified albumin did not, at any time, provide superior sensitivity or specificity compared with other biomarkers.We do not find the data supportive of IMA as a standard marker in the emergency department.     

Application of the Sequential Organ Failure Assessment score for predicting mortality in patients with acute myocardial infarction

Background

Thrombolysis in Myocardial Infarction (TIMI) score and Global Registry of Acute Coronary Events (GRACE) score have been validated as predictors of death in patients with acute myocardial infarction (AMI). This study was undertaken to determine whether the Sequential Organ Failure Assessment (SOFA) score had good accuracy for predicting mortality in AMI patients, and to compare the discriminatory performance of the 3 risk scores (RSs).

Methods

This was a retrospective study. We calculated the TIMI RS, GRACE RS, and SOFA score for 726 consecutive AMI patients. The study endpoint was all-cause mortality. All patients were followed up for at least 3 years or until the occurrence of death. The area under the receiver operating characteristic curve (AUC) was used to evaluate the predictive ability of each score at different time points.

Results

For in-hospital death, the AUC were 0.67 for TIMI RS, 0.73 for GRACE RS, and 0.79 for SOFA score (P < 0.001, respectively). However, the SOFA score and GRACE RS were significantly better for predicting the 1-year (P < 0.001, respectively) and 3-year (P < 0.001, respectively) mortality than the TIMI RS was. Multivariate Cox regression analysis revealed that the SOFA score was an independent predictor of long-term mortality in AMI patients [hazard ratio (HR), 1.313; 95% CI, 1.191–1.447].

Conclusions

The SOFA score provides potentially valuable prognostic information on clinical outcome when applied to patients with AMI. Compared with TIMI RS, both SOFA score and GRACE RS provide better discrimination for long-term mortality in patients presenting with AMI.     

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

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.     

Unrecognized Carbon Monoxide poisoning Leads To a Multiple-Casualty Incident

Background

Carbon monoxide (CO) is regarded as a leading cause of morbidity and mortality. It endangers not only patients, but also health care professionals, especially emergency medical services (EMS) personnel because CO exposure is often unknown at the time EMS is called.

Objective

Our objective was to report a case of unrecognized CO exposure during the treatment of a patient that finally led to the hospitalization of 11 EMS personnel.

Case Report

A 71-year-old man was found unconscious in the basement of his house. EMS was called and, due to ST-segment elevations on electrocardiogram, the patient was treated for acute coronary syndrome. Unknown to EMS personnel, ongoing CO exposure was the cause of the patient's symptoms. EMS staff finally had to be evacuated by firefighters, and a total of 12 persons, including the initial patient, had to be hospitalized.

Conclusions

In the prehospital setting, hazardous environments always have to be considered as potential causes of a patient's altered status. Together with the correct use of modern equipment, such as permanently switched-on CO detectors, this can help avoid harm to both patients and staff.     

Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients

Objective

Guidelines recommend treating patients with a new or presumed new left bundle-branch block (LBBB) similar to those with an acute ST-segment elevation myocardial infarction. It is often unclear which emergency department (ED) patients with potentially ischemic symptoms actually have an acute myocardial infarction (AMI), even in the setting of LBBB. Our null hypothesis was that in ED patients with potential AMI, the presence of a new or presumed new LBBB would not predict an increased likelihood of AMI.

Methods

This was an observational cohort study. Patients older than 30 years who presented with chest pain or other ischemic equivalent and had an electrocardiogram (ECG) to evaluate potential acute coronary syndrome (ACS) were enrolled. Data collected include demographics, history, ECG, and cardiac markers. Electrocardiograms were classified according to the standardized guidelines, including LBBB not known to be old (new or presumed new LBBB), LBBB known to be old, or no LBBB. The hospital course was followed, and 30-day follow-up was performed on all patients. Our main outcome was AMI.

Results

There were 7937 visits (mean age, 54.3 ± 15 years, 57% female, 68% black): 55 had new or presumed new LBBB, 136 had old LBBB, and 7746 had no LBBB. The rate of AMI was not significantly different between the 3 groups (7.3% vs 5.2% vs 6.1%; P = .75). Revascularization (7.8% vs old 5.2% vs 4.3%; P = .04) and coronary artery disease were more common in patients with new or presumed new LBBB (19.2% vs 11.9% vs 10.1%; P = .0004).

Conclusions

Despite guideline recommendations that patients with potential ACS and new or presumed new LBBB should be treated similar to STEMI, ED patients with a new or presumed new LBBB are not at increased risk of AMI. In fact, the presence of LBBB, whether new or old, did not predict AMI. Caution should be used in applying recommendations derived from patients with definite AMI to ED patients with potential ACS that may or may not be sustaining an AMI.     

Characteristics and outcomes of injured patients presenting by private vehicle in a state trauma system

Background

Previous studies have demonstrated lower mortality among patients transported to single urban trauma centers by private vehicle (PV) compared with Emergency Medical Services (EMS). We sought to describe the characteristics and outcomes of injured patients transported by PV in a state trauma system compared to patients transported by EMS.

Methods

We performed a retrospective cohort study of state trauma registry data for patients admitted to all Pennsylvania trauma centers over 5 years (1/2003 to 12/2007). Our primary exposure of interest was prehospital mode of transport and our primary outcome of interest was in-hospital mortality. Unadjusted analyses were performed as were adjusted analyses controlling for injury severity. Data are presented as percents, odds ratios (ORs), and 95% confidence intervals.

Results

Of the 91 132 patients analyzed, 9.6% were transported to the emergency department by PV and 90.4% by EMS. Overall Injury Severity Score (ISS) was 13.3 ± 11.0 (ISS for EMS 13.7 ± 11.3, PV 9.2 ± 7.1, P < .001), and 6.6% of patients died (EMS 7.1%, PV 1.5%, P < .001). After adjusting for injury severity, patients transported by EMS were more likely to die than PV patients (OR 1.9 [95% CI 1.5-2.4]). This effect persisted in blunt, penetrating, advanced life support, and basic life support subgroups, but not in the severely injured (ISS > 15, ISS > 25) subgroups.

Conclusions

Nearly 10% of injured patients arrive at trauma centers by private vehicle. Transport of injured patients by EMS was associated with higher mortality than PV transport. This may reflect the effects of prehospital time, prehospital interventions, or other confounders.     

Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram

Aim

The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin.

Methods

Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged.

End Point

The end points are cardiac events at short- and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization.

Results

Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P < .001), as follows: in-hospital, 23% vs 10%, (P < .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P < .001).

Conclusions

One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.     

Early prediction of acute kidney injury in patients with acute myocardial injury

Introduction

Previous studies have revealed that acute myocardial infarction (AMI) with acute kidney injury (AKI), about 17%, is strongly related to long-term mortality and heart failure. The dynamic changes in renal function during AMI are strongly related to long-term mortality and heart failure.

Objectives

Our study used clinical parameters and AKI biomarkers including neutrophil gelatinase–associated lipocalin, interleukin (IL)-6, IL-18, and cystatin C to evaluate prognostic relevance of AKI in the setting of AMI.

Methods

This prospective study was conducted from November 2009 to January 2011 and enrolled sequential 96 patients with catheter-proven AMI; it was approved by the institutional review board of Chang Gung Memorial Hospital, Taiwan (institutional review board no. 99-0140B) and conformed to the tenets of the Declaration of Helsinki. The definition of AKI is the elevation of serum creatinine of more than 0.3 mg/dL within 48 hours.

Results

Our results show that the incidence of AKI after AMI is 17.7% (17 patients). The following could be statistically related to AKI after AMI: age (P = .012), cardiac functions (Killip stage and echocardiogram; P = .003 each), Thrombolysis in Myocardial Infarction (TIMI) flow grade (P < .001), stenting (P < .001), neutrophil gelatinase–associated lipocalin (P = .005), IL-6 (P = .01), IL-18 (P = .002), and cystatin C (P = .002) in serum. The TIMI flow grade and serum cystatin C were shown to be important predictors by using multivariate analysis. Both TIMI flow lower than grade 2 and serum cystatin C of more than 1364 mg/L could be used to predict AKI (both overall correctness, 0.78). Moreover, IL-6 in serum is also associated with the major cardiovascular events after AMI (P = .02), as demonstrated in our study.

Conclusion

In conclusion, the worse TIMI flow and high plasma cystatin C can be used to predict AKI after AMI. Moreover, IL-6 can also be used as a 30-day major cardiovascular event indicator after AMI. A larger prospective and longitudinal study should follow the relationship between AKI predictors after AMI.     

Algorithm for probable acute coronary syndrome using high-sensitivity troponin T assay vs fourth-generation troponin T assay

Background

Chest pain represents between 5% and 10% of annual visits to emergency departments (EDs) and near 25% of hospitalizations. Characterization of chest pain is sometimes difficult, and strategies should focus on preventing inappropriate discharge of patients with acute coronary syndrome. The goal of our study is to compare negative predictive value of the algorithm in the chest pain unit using the fourth-generation troponin T assay (4GTT) vs high-sensitivity troponin T assay (HSTT).

Methods

We included 600 patients with probable acute coronary syndrome, who were discharged from the chest pain unit without an acute coronary syndrome: 300 patients in the 4GTT group and 300 patients in the HSTT group. Clinical and laboratory variables were analyzed. All the patients were followed up at 30 days, and the cardiovascular events were recorded.

Results

Major cardiac events occurred in only 3 (1.2%) in the HSTT group vs 5 (1.7%) in the 4GTT group (P, nonsignificant). The negative predictive value was 99% in both groups. Emergency department length of stay was 4.3 ± 2.6 hours in HSTT group vs 10 ± 3.4 hours in the 4GTT group (P = .01).

Conclusion

The algorithm in the chest pain unit using HSTT showed to have the same negative predictive value as the algorithm with the 4GTT but with a shorter stay in the ED.     

Effect of Delay in Hospital Presentation on Clinical and Imaging Findings in Acute Pulmonary Thromboembolism

Background

There is limited information on the extent and clinical importance of the delay in hospital presentation of acute pulmonary thromboembolism (PTE).

Objective

The aim of this study was to investigate the delay in hospital presentation of PTE and its association with clinical and imaging findings in PTE.

Methods

This prospective study was conducted on patients admitted to our hospital with a diagnosis of acute PTE between September 2007 and September 2011. Relationships between delay in hospital presentation and clinical findings, risk factors, imaging findings, and in-hospital mortality were analyzed.

Results

Of the 195 patients enrolled, 84 (43.1%) patients presented 3 days after the onset of symptoms. Patients with chest pain, history of immobility for more than 3 days, recent surgery, and estrogen use had significantly less delayed presentation. Right ventricular dysfunction was significantly more frequent in patients with delayed presentation (odds ratio [OR] = 2.38; 95% confidence interval [CI] 1.27−4.44; p = 0.006); however, no relationship was found between delay in presentation and pulmonary computed tomographic angiography or color Doppler sonography findings. Patients with delayed presentation were at higher risk of in-hospital mortality (OR = 4.32; 95% CI 1.12−16.49; p = 0.021).

Conclusions

Our study showed that a significant portion of patients with acute PTE had delayed presentation. Also, patients with delayed presentation had worse echocardiographic findings and higher in-hospital mortality.     

Prospective evaluation of the treatment of pain in the ED using computerized physician order entry

Background

Treatment of pain in the emergency department (ED) is a significant area of focus, as previous studies have noted generally inadequate treatment of pain in ED patients. Previous studies have not evaluated the impact of computerized physician order entry (CPOE) on the treatment of pain in the ED. We sought to evaluate treatment of pain before and after implementation of CPOE in an academic ED.

Methods

We prospectively enrolled a convenience sample of patients presenting to the ED with a pain-related complaint in 4-month periods before and after CPOE implementation. We compared numbers who received pain medications, time from registration to administration of pain medication, and repeat dosing of pain medication.

Results

Six hundred forty-six ED patients participated in the pre-CPOE period, whereas 592 patients participated post-CPOE. Similar numbers of patients received pain medications in the pre-CPOE and post-CPOE periods (55% vs 59%; P = .139), whereas those in the post-CPOE period were more likely to receive a repeat dose of pain medications (10.5% vs 17.6%; P < .001).

Conclusion

The use of CPOE in the ED may offer modest benefits in the treatment of patients with pain-related complaints.     

Prehospital neurologic deterioration is independent predictor of outcome in traumatic brain injury: analysis from National Trauma Data Bank

Background

The prevalence and impact of prehospital neurologic deterioration (PhND) in patients with traumatic brain injury (TBI) have not been investigated. We aimed to determine the prevalence of PhND during emergency medical service (EMS) transportation among patients with TBI and its impact on patient's outcome.

Methods

We used the National Trauma Data Bank, using data files from 2009 to 2010 to identify patients with TBI through International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The initial Glasgow Coma Scale (GCS) score ascertained at the scene by EMS was compared with the subsequent GCS score evaluation in the emergency department (ED) to identify neurologic deterioration (defined as a decrease in GCS of ≥ 2 points). Patients' demographics, initial injury severity score (ISS), admission GCS score, and hospital outcome were compared between patients with PhND and patients without neurologic deterioration.

Results

A total of 257?127 patients with TBI were identified. Among patients with TBI, 22?254 patients had PhND, which comprised 9% of all patients with TBI. The mean of GCS score decrease during EMS transport was 5 points (± 3). Patients without PhND tended to have higher GCS recorded by EMS (median, 15 vs 12; P < .0001). Patients with TBI who had PhND had significantly higher hospital length of stay and intensive care unit days after adjusting for baseline characteristics and EMS GCS score, EMS transport time, type of injury, presence of intracranial hemorrhages, and ED ISS (P < .0001). These patients had higher rate of in-hospital mortality after adjusting for the same variables (odds ratio, 2.30; 95% confidence interval, 2.18-2.41).

Conclusion

Prehospital neurologic deterioration occurs in 9% of patients with TBI. It is more prevalent in men and associated with lower EMS GCS level and higher ED ISS. Prehospital neurologic deterioration is an independent predictor of worse hospital outcome and higher resource use in patients with TBI.     

Assessment of the Addition of Prehospital Continuous Positive Airway Pressure (CPAP) to an Urban Emergency Medical Services (EMS) System in Persons with Severe Respiratory Distress

Background

The use of continuous positive airway pressure (CPAP)-assisted ventilation in the prehospital setting has not been well studied.

Objectives

The purpose of this study was to measure the efficacy of adding prehospital CPAP to an urban emergency medical services (EMS) respiratory distress protocol for persons with respiratory distress.

Methods

An historical cohort analysis of consecutive EMS patients presenting during the years 2005–2010. Groups were matched for severity of respiratory distress. Physiologic variables were the primary outcomes obtained from first responders and upon triage in the Emergency Department. Additional outcomes included endotracheal intubation rate, hospital mortality, overall hospital length of stay (LOS), intensive care unit (ICU) admission, and ICU LOS.

Results

There were a total of 410 consecutive patients with predetermined criteria for severe respiratory distress, 235 historical controls matched with 175 post-implementation patients, entered in the study. The average age was 67 years; 54% were men. There were significant median differences in heart and respiratory rates favoring the historical cohort (all p < 0.05). There were no significant differences in intubation rate, overall hospital LOS, ICU admission rate, ICU LOS, or hospital mortality (all p > 0.05). Patients who were continued on non-invasive ventilatory assistance had a significantly improved rate of intubation and ICU LOS (all p < 0.05).

Conclusion

The addition of CPAP to an EMS prehospital respiratory distress protocol resulted in improved heart and respiratory rates. Though not statistically significant, decrease in overall and ICU LOS were observed. Patients with continued ventilatory assistance seemed to have improved rates of intubation and ICU LOS.