Role of Doppler Ultrasonography in the Triage of Acute Scrotum in the Emergency Department

Objective. The purpose of this study was to examine the triage role of scrotal Doppler ultrasonography (DUS) as the primary preoperative diagnostic tool in patients presenting to the emergency department (ED) with acute scrotum. Methods. Patients who presented to the ED with acute scrotum and underwent scrotal DUS in the ultrasound unit over a 3‐year period (2004–2007) were included in the study. Patient characteristics, DUS findings, and clinical management were retrospectively collected and reviewed. Doppler ultrasonographic diagnoses were compared with histopathologic findings for patients who underwent exploration and with final diagnoses at the time of discharge for patients undergoing medical treatment. Results. A total of 620 consecutive patients with 669 DUS examinations were included. The most common scrotal DUS diagnoses were epididymitis, hydrocele, varicocele, and orchitis. Scrotal trauma was present in 77 cases. Hospitalization followed the initial ED evaluation for 155 patients; 68 underwent surgery. Testicular torsion was ultrasonographically suspected in 20 patients and confirmed in 18. Scrotal malignancy was incidentally diagnosed in 13 patients and testicular hematoma in 8. Doppler ultrasonography for the diagnosis of testicular torsion had 94% sensitivity, 96% specificity, 95.5% accuracy, an 89.4% positive predictive value (PPV), and a 98% negative predictive value (NPV). Doppler ultrasonography for the diagnosis of testicular malignancy had 92% sensitivity, 95% specificity, 94% accuracy, a 78.5% PPV, and a 98% NPV. Conclusions. Scrotal DUS is a highly sensitive preoperative diagnostic tool, thereby validating its routine use in the initial triage of patients with acute scrotum presenting to the ED.     

Importance of evaluating organ parenchyma during screening abdominal ultrasonography after blunt trauma.

OBJECTIVE: To determine the benefit of screening ultrasonography for parenchymal abnormalities as well as free fluid during screening abdominal ultrasonography in patients with blunt trauma. METHODS: A total of 2693 patients with blunt trauma who were triaged to a level 1 trauma center underwent screening abdominal ultrasonography in the resuscitation suite. Examinations were performed by experienced sonographers and included a screen for free intraperitoneal fluid and evaluation of the abdominal organ parenchyma and heart for traumatic injury. Screening ultrasonographic findings were reviewed and compared with findings from autopsy, laparotomy, diagnostic peritoneal lavage, computed tomography, repeated ultrasonography, cystography, and clinical outcome. Imaging studies of all patients with confirmed or suspected injuries were reviewed to identify those in whom parenchymal findings aided diagnosis. RESULTS: One hundred seventy-two patients were found to have evidence of abdominal injury due to blunt trauma on the basis of clinical data, imaging, laparotomy, or autopsy. Forty-four of these patients had no sonographic evidence of hemoperitoneum at the time of initial ultrasonography. Screening ultrasonographic findings were positive for injury in 19 of 44 patients on the basis of parenchymal findings or small retroperitoneal collections of fluid thought to be indicative of trauma. In the remaining 25 patients, screening ultrasonography showed no abnormalities, and injuries were detected by repeated ultrasonography, subsequent computed tomography, or diagnostic peritoneal lavage performed for suspected occult injury on the basis of clinical parameters. In addition, 47 of 126 injured patients with sonographically detected free fluid had parenchymal findings that helped localize injury. Sixteen of those patients were taken to the operating room on the basis of clinical and sonographic findings without undergoing computed tomography. CONCLUSIONS: The inability to show injuries with no hemoperitoneum or with delayed hemoperitoneum has been shown to be a limitation of ultrasonography in patients with blunt trauma. In our series, 26% of all patients with documented injuries had no free fluid visible on screening ultrasonography Attention to findings other than free fluid allowed detection in 43% of injured patients without sonographic evidence of hemoperitoneum.     

Prevalence,documentation, and communication of incidental findings in focused assessment with sonography for trauma (FAST) examinations

BackgroundAs the focused assessment with sonography for trauma (FAST) examination becomes increasingly ubiquitous in the emergency department (ED), a parallel increase in incidental findings can also be expected. The purpose of this study was to determine the prevalence, documentation, and communication of incidental findings on emergency physician-performed FAST examinations.MethodsRetrospective review at two academic EDs. Adult trauma patients undergoing FAST examinations used for clinical decision-making at the bedside were identified from an ED ultrasound image archival system. Expert sonologists reviewed ultrasound images for incidental findings, as well as electronic medical records for demographic information, mechanism of injury, type of incidental findings, documentation of incidental findings, and communication of incidental findings to the patient.ResultsA total of 1,452 FAST examinations were reviewed. One hundred and thirty-seven patients with incidental findings were identified (9.4%); 7 patients had an additional incidental finding. Renal cysts were most common (49/144, 34.0%), followed by pelvic cysts in women (32/144, 22.2%). While 31/144 (21.5%) incidental findings were identified and documented in the ultrasound reports or medical records by ED providers, only 6/137 (4.4%) patients were noted to be informed of their incidental findings.ConclusionIncidental findings were often encountered in FAST examinations, with cysts of the kidneys and pelvis being the most common findings. A vast majority of incidental findings were not documented or noted to be communicated to patients, which can be a barrier to follow-up care.     

Color Doppler Ultrasonography by Emergency Physicians for the Diagnosis of Acute Deep Venous Thrombosis

Objectives : To assess the feasibility of emergency physicians' (EPs') performing color-flow Doppler ultra-sonographic vascular studies in the ED to diagnose deep venous thrombosis (DVT), after a modest training program.
Methods : A retrospective observational review was performed of the performance of color-flow Doppler ultrasonographic vascular studies by EPs. Prior to the study period, venous Doppler studies were not available at off-hours. Two attending EPs were trained by the hospital's vascular laboratory by observing studies and then performing 25–30 studies successfully. They were then available to examine all patients presenting to the ED at off-hours who were suspected of having DVT. Patients were admitted or released from the ED based on the examination results. All patients were to have formal vascular laboratory studies the next day. The study was performed at a university hospital ED and evaluated all patients who underwent off-hour examinations from January 1993 to February 1994. The examiners were aware of the clinical scenario. Results : Of 23 eligible patients, 15 completed the protocol with a follow-up next-day study. Based on the follow-up study, the ED examination was 100% sensitive (7 true positives) and 75% specific (6 true negatives). The 2 false-positive studies were for patients with old DVT. The 8 patients without follow-up studies were not included in the analysis, although 4 of these patients had negative studies and unremarkable clinical outcomes.
Conclusions : These preliminary findings suggest that Doppler ultrasonographic studies of the lower extremity veins by EPs can be used to make admission decisions when formal studies are not available. Confirmatory studies should be performed. EPs may overread acute thrombosis in the setting of old venous disease. Issues of cost and logistics remain to be resolved.     

Prevalence and Significance of Nonthromboembolic Findings on Chest Computed Tomography Angiography Performed to Rule Out Pulmonary Embolism: A Multicenter Study of 1,025 Emergency Department Patients

OBJECTIVES: To evaluate the hypothesis that computed tomography (CT) angiography often yields a result interpreted as an alternative diagnosis to pulmonary embolism (PE) in emergency department (ED) patients. METHODS: This was a multicenter, retrospective, and secondary analysis of consecutive patients in three academic emergency departments. ED patients with symptoms suspicious for PE were included. CT angiography was ordered at the discretion of the treating physician; patients were identified by query of the electronic medical record. Board-certified radiologists gave CT readings, which were reviewed by two independent emergency physicians who categorized the non-PE findings into one of four acuity categories: A = requiring specific and immediate intervention, B = requiring specific action on follow-up, C = requiring no action, and D = indeterminate findings. RESULTS: The prevalence of PE among the 1,025 patients studied was 10% (95% CI = 8% to 12%). In the 921 patients without PE, the mean prevalences (ranges between sites) of concordant categorized non-PE findings were: A = 7% (range 3%-11%), B = 10% (7%-13%), C = 17% (10%-20%), D = 4% (0%-8%), and no ancillary finding = 41% (29% to 45%). The most common category A findings included infiltrate or consolidation suggesting pneumonia (81%), aortic aneurysm or dissection (7%), and mass suggesting undiagnosed malignancy (7%). The overall unweighted agreement was 80% (kappa = 0.72) and weighted agreement was 93% (kappa(w) = 0.84). CONCLUSIONS: In ED patients with suspected PE, the CT angiogram frequently provides evidence suggesting an important alternative diagnosis to PE. Pulmonary infiltrate suggesting pneumonia was the most common non-PE finding.     

Untreated Hypertension and the Emergency Department: A Chance to Intervene?

Objectives:  Untreated hypertension (HTN) is a major public health problem. Screening for untreated HTN in the emergency department (ED) may lead to appropriate treatment of more patients. The authors investigated the accuracy of identifying HTN in the ED, the proportion of ED patients with untreated HTN, patient characteristics predicting untreated HTN, and provider documentation of untreated HTN.
Methods:  The authors performed a retrospective cross-sectional study on a random sample of 2,061 adults treated at an urban academic ED. The validity of six candidate definitions of HTN in the ED was assessed in a subsample using outpatient clinic records as the reference standard. "Untreated HTN" was HTN without a HTN medication listed in the ED history. "Documentation of untreated HTN was documentation of HTN as a visit problem, specific referral for HTN, or ED discharge with a HTN" information sheet or a HTN medication. Multivariable logistic regression was used to determine associations.
Results:  The preferred definition of HTN in the ED had sensitivity of 86% (95% confidence interval [CI] = 80% to 90%), specificity of 78% (95% CI = 69% to 85%), and accuracy of 83% (95% CI = 78% to 87%). Of the 42% (95% CI = 40% to 44%) of ED patients with HTN, 43% (95% CI = 39% to 46%) had untreated HTN. Patients who were younger and male, without primary care physicians, with fewer prior ED visits, and without cardiovascular comorbidities, had higher odds of untreated HTN. Of those with untreated HTN, 8% (95% CI = 5% to 11%) had their untreated HTN documented.
Conclusions:  Untreated HTN was common in the ED but rarely documented. Providers can use ED blood pressures along with patient characteristics to identify those with untreated HTN for referral to primary care.     

Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center

Objectives: Incidental findings found on computed tomography (CT) scan during the Emergency Department evaluation of trauma patients are often benign, but their presence must always be communicated to patients, who should be referred for follow-up care. Our objective was to quantify the frequency of these incidental CT findings in trauma patients. A secondary goal was to determine how often these lesions were communicated to patients and how often patients were referred for follow-up. Methods: We performed a retrospective chart review of 500 consecutive patients presenting as trauma activations. Subjects received head, chest, or abdomen/pelvis CT scans at our hospital. Patients were identified using our trauma registry. Final CT reports were examined and discharge summaries were reviewed for basic demographics. Scans with incidental findings prompted detailed secondary review of discharge summaries to determine follow-up. Investigators reviewed incidental findings and classified them into three groups by clinical importance, using predetermined criteria. Results: Of the 500 patient charts identified for review, 480 (96%) were available, yielding 1930 CT reports for analysis. Incidental findings were noted in 211 of 480 (43%) patients and on 285 (15%) of the 1930 CT studies performed for the 480 patients. Of available patient records, only 27% of patient charts had mention of the finding in the discharge summary, had documentation of an in-hospital workup, or had documentation of a referral for follow-up. Most-concerning lesions, such as suspected malignancies or aortic aneurysms, accounted for 15% of all incidental findings and were referred for follow-up in only 49% of cases. Conclusions: Incidental findings were noted in 15% of trauma CT scans. Follow-up was poor, even for potentially serious findings. Further studies should examine the long-term outcome of patients with these findings.     

Confirmation of endotracheal intubation by combined ultrasonographic methods in the emergency department

Objectives: The objective of the present study was to investigate whether the combined use of transcricothyroid membrane ultrasonography and ultrasonographic evaluation for pleural sliding is useful for verifying endotracheal intubation in the ED. Methods: We performed a prospective clinical trial in the ED from January to July 2008. All patients enrolled in the present study had been admitted to the ED owing to severe airway problems. A linear probe was placed horizontally over the cricothyroid membrane (dynamic phase) during the intubation process. Endotracheal intubation was confirmed by ultrasonographic lung sliding. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Results: Thirty patients (17 men, 13 women; mean age 59.6 ± 16.7 [SD] years) were enrolled in the study. Of the 30, 7 had a history of trauma. Four trauma patients were diagnosed with haemopneumothorax. The ratio of initial oesophageal‐to‐endotracheal intubation was 3:27. Sensitivity, specificity, PPV and NPV for endotracheal intubation were 96.3%, 100%, 100% and 75%, respectively. After verification by ultrasonographic lung sliding, sensitivity, specificity, PPV and NPV were each 100%. Conclusions: The combination of transcricothyroid membrane ultrasonography and ultrasonographic lung‐sliding evaluation could be useful in confirming endotracheal intubation in the ED.     

急性创伤致肩袖撕裂的超声诊断

目的探讨肩袖撕裂的超声特征，评价超声检查肩袖撕裂的应用价值。方法对33例急性创伤后疑诊肩袖损伤者行超声检查，并与磁共振、肩关节造影或手术结果进行比较。结果肩袖撕裂的超声主要表现为：肩袖不显示，肩袖部分缺失，肩袖内局灶性异常回声，肩袖局部变薄。超声诊断的敏感性92％(22／24)，特异性82％(9／11)，准确性94％(31／33)。结论超声诊断肩袖撕裂有较高的应用价值，可作为急性肩部创伤而X线检查正常患者的首选检查方法。     

Emergency Department compression ultrasound to diagnose proximal deep vein thrombosis

Emergency Department (ED) patients with suspected deep vein thrombosis (DVT) require an objective vascular study such as ultrasound (US) to confirm the diagnosis prior to treatment or disposition. A simple compression US test of the common femoral vein and popliteal vein reliably detects proximal DVT in symptomatic patients. Application of compression US in the ED by Emergency Physicians (EPs) has been tested in a single previous study. We evaluated the ability of ED compression US, performed by EPs, to diagnose proximal DVT as compared to duplex US performed in a vascular laboratory. A prospective, observational study was conducted on a convenience sample of patients presenting to an ED with lower extremity symptoms and signs suggestive of DVT. Patients with a history of DVT in the symptomatic extremity were excluded. Final diagnosis of DVT was made by color-flow duplex US performed in a vascular laboratory. ED compression US was performed by one of six EP sonographers. In compression US, DVT was diagnosed by the inability to compress the common femoral vein or popliteal vein. The examination was considered indeterminate if the veins could not be clearly identified or compressibility was equivocal. For statistical analysis, an indeterminate examination was considered positive. In those cases where ED compression US was discordant with duplex US, and not indeterminate, we retrospectively reviewed the US findings. There were 76 patients who completed the study, and 18 patients (24%) were diagnosed with DVT by duplex US, among whom ED compression US was positive in 14, negative in 2, and indeterminate in 2. Among 58 patients diagnosed without DVT by duplex US, there were 4 false-positive ED compression US examinations and 10 indeterminate examinations. In all, ED compression US was indeterminate in 12 patients (15.8%). Compared to duplex US, ED compression US had a sensitivity of 88.9% (95% C.I. 65.3-98.6%) and specificity of 75.9% (62.8-86.1). Negative predictive value was 95.7% (85.2-99.5). Among ED patients with the clinical diagnosis of possible DVT, negative ED compression US greatly reduces the likelihood of DVT, such that discharge and outpatient follow-up can be considered. Because of limited specificity, positive results require confirmation, but may justify immediate treatment pending follow-up testing. Indeterminate results can be expected in a significant number of patients and mandate further testing prior to disposition.     

Droperidol for acute migraine headache.

The use of intramuscular droperidol to treat acute migraine headache has not been previously reported in the emergency medicine literature. It is a promising therapy for migraine. The authors performed a pilot review of all patients receiving droperidol for migraine in our emergency department (ED) to evaluate its efficacy. We used a retrospective case series, in a suburban ED with an annual patient census of 48,000. All patients with a discharge diagnosis of migraine headache who were treated with i.m. droperidol during a consecutive 5-month period in our ED were identified. All patients received droperidol 2.5 mg intramuscular. As per ED protocol, their clinical progress was closely followed and documented at 30 minutes after drug administration (t30). Demographic and clinical variables were recorded on a standardized, closed-question, data collection instrument. The primary outcome measurement was relief of symptoms at t30 to the point that the patient felt well enough to go home without further ED intervention (symptomatic relief). Thirty-seven patients were treated (84% female), with an ED diagnosis of acute migraine with droperidol during the study period. The mean age was 36 +/- 12 years. Analgesics had been used within 24 hours before ED presentation by 62% of patients. At t30, 30 (81%) patients had symptomatic relief, 2 (5%) felt partial relief but required rescue medication, and 5 (14%) had no relief of symptoms. Drowsiness (14%) and mild akathisia (8%) were the only adverse reactions observed following drug administration. Droperidol 2.5 mg intramuscular may be a safe and effective therapy for the ED management of acute migraine headache. Randomized, controlled trials are warranted to further validate the findings of this preliminary study.     

Pain Scores Improve Analgesic Administration Patterns for Trauma Patients in the Emergency Department

OBJECTIVE: To determine the efficacy of pain scores in improving pain management practices for trauma patients in the emergency department (ED). METHODS: A prospective, observational study of analgesic administration to trauma patients was conducted over a nine-week period following educational intervention and introduction of verbal pain scores (VPSs). All ED nursing and physician staff in an urban Level I trauma center were trained to use the 0-10 VPS. Patients younger than 12 years old, having a Glasgow Coma Scale score (GCS) <8, or requiring intubation were excluded from analysis. Demographics, mechanism of injury, vital signs, pain scores, and analgesic data were extracted from a computerized ED database and patients' records. The staff was blinded to the ongoing study. RESULTS: There were 150 patients studied (183 consecutive trauma patients seen; 33 patients excluded per criteria). Pain scores were documented for 73% of the patients. Overall, 53% (95% confidence interval [CI] = 45% to 61%) of the patients received analgesics in the ED. Of the patients who had pain scores documented, 60% (95% CI = 51% to 69%) received analgesics, whereas 33% (95% CI = 18% to 47%) of the patients without pain scores received analgesics. No patient with a VPS < 4 received analgesics, whereas 72% of patients with a VPS > 4 and 82% with a VPS > 7 received analgesics. Mean time to analgesic administration was 68 minutes (95% CI = 49 to 87). CONCLUSIONS: Pain assessment using VPS increased the likelihood of analgesic administration to trauma patients with higher pain scores in the ED.     

The acute asthmatic patient in the ED: To admit or discharge

Treating asthma in the emergency department (ED) always involves the potentially difficult decision as to whether to discharge the patient, to continue treatment, or to admit to the hospital. The following are useful guidelines. (1) The duration of the bronchospasm, frequency of visits, history of previous endotracheal intubation, pulse rate, and accessory muscle use are findings affecting successful discharge from the ED. (2) Patients with peak expiratory flow rate (PEFR) of <20% and who do not respond to inhalant therapy, with PEFR values persisting at <40% of predicted, will require 4 or more days to resolve and should be admitted to the hospital. (3) Patients with a PEFR between 40% and 70% of predicted after initial inhalant therapy may well be responsive to steroids in the ED, but an ED will adequately need to care for the patient for 5 to 12 hours while waiting for the onset of action of glucocorticoids. Discharged with glucocorticoids, this group has a 6% relapse rate within 10 days of the ED visit. (4) Patients with a PEFR of ≥70% have a 14% relapse rate after discharge without glucocorticoids. Other reasons to consider admission are penumonia, barotrauma, lability, prominent psychiatric difficulties, poor access to medications, poor educability, fear of steroids, patients on glucocorticoids or those who have recently stopped glucocorticoids, and evening discharges of patients from the ED, which all predispose to relapses of acute asthma. To decrease the relapse rate, provocative factors should be reviewed with the patient, as well as access to medication and use of spacers, inhaler techniques, PEFR meters, self-management plans, and referral to a defined appointment at 24 to 48 hours of the ED visit.     

Guardian Availability in Children Evaluated in the Emergency Department for Blunt Head Trauma

Background: Enrolling children in research studies in the emergency department (ED) is typically dependent on the presence of a guardian to provide written informed consent. Objectives: The objectives were to determine the rate of guardian availability during the initial ED evaluation of children with nontrivial blunt head trauma, to identify the reasons why a guardian is unavailable, and to compare clinical factors in patients with and without a guardian present during initial ED evaluation. Methods: This was a prospective study of children (<18 years of age) presenting to a single Level 1 trauma center after nontrivial blunt head trauma over a 10‐month period. Physicians documented patient history and physical examination findings onto a structured data form after initial evaluation. The data form contained data points regarding the presence or absence of the patient’s guardian during the initial ED evaluation. For those children for whom the guardian was not available during the initial ED evaluation, the physicians completing the data forms documented the reasons for the absence. Results: The authors enrolled 602 patients, of whom 271 (45%, 95% confidence interval [CI] = 41% to 49%) did not have a guardian available during the initial ED evaluation. In these 271 patients, 261 had reasons documented for lack of guardian availability, 43 of whom had multiple reasons. The most common of these was that the guardian did not ride in the ambulance (51%). Those patients without a guardian available were more likely to be older (mean age, 11.4 years vs. 7.6 years; p < 0.001), be victims of a motor vehicle collision (MVC; 130/268 [49%] vs. 35/328 [11%]; p < 0.001), have a Glasgow Coma Scale (GCS) score <14 (21/269 [7.8%] vs. 11/331 [3.3%]; p = 0.02), and undergo cranial computed tomography (CT) scanning (224/271 [83%] vs. 213/331 [64%]; p < 0.001). Multivariate analysis identified similar independent risk factors for lack of guardian presence. Conclusions: Nearly one‐half of children with nontrivial blunt head trauma evaluated in the ED may not have a guardian available during their initial ED evaluation. Patients whose guardians are not available at the time of initial ED evaluation are older and have more severe mechanisms of injury and more serious head trauma. ED research studies of pediatric trauma patients that require written informed consent from a guardian at the time of initial ED evaluation and treatment may have difficulty enrolling targeted sample size numbers and will likely be limited by enrollment bias.     

Spectrum of acute allergic diseases in an emergency department: An evaluation of one years’ experience

Objective: There is limited available literature on the incidence of allergic diseases in ED. The objective of this study was to investigate the clinical records of patients admitted to the ED with a suspected allergic reaction. Methods: A 1 year retrospective study was carried out and data were collected from the patients’ computerized medical reports. Results: A total of 324 patients were admitted for an allergic event. Of those, 165 patients (50.9%) were female and their mean age was 55 ± 18.5 years. Diagnoses included: asthma in 100 patients (30.9%); hymenoptera allergy in 78 patients (24.1%); food allergy in 31 patients (9.5%); drug allergy in 25 patients (7.7%); and allergic conjunctivitis in 12 patients (3.7%). No diagnosis was found in the medical records of 78 patients (24.1%). Anaphylactic shock was observed in 12 patients (3.7%) with a diagnosis of food allergy (six cases), drug allergy (three cases) and hymenoptera allergy (three cases). Ninety patients (27.7%) were hospitalized in the following units: 38 in allergy unit (42.2%); 20 in intensive care unit (22.2%); 10 in pulmonary unit (11.1%); eight in the dermatology unit (8.9%); six in the internal medicine unit (6.7%); and eight in other units (8.9%). Overall, 42 patients (12.9%) were evaluated by an allergologist after ED discharge with positive allergy results in 28 cases (66.6%). Conclusions: Acute allergic diseases are not rare in ED, representing 1% of the annual visits in our series. A low rate of allergologist referral was observed. Emergency physicians must work closely with allergologists to ensure a better evaluation, long‐term care and preventive management of patients with allergic diseases admitted to the ED.     

Analysis of referral diagnoses of patients with normal coronary angiogram]

BACKGROUND AND AIMS: Angiography permits an evaluation of the morphology of the coronary artery, stratification of risk and optimal therapeutic management in patients with suspected coronary artery disease (CAD). The sophisticated apparatus, cost and invasiveness of the procedure necessitate well-considered application of this method. In spite of an exact documentation of the patient's medical history and careful establishment of the indication, the results of angiography are often normal. Therefore, it appears important to analyse the referral diagnoses in patients with normal coronary angiograms. PATIENTS AND METHODS: We studied 1000 consecutive patients (625 men, 375 women, mean age 63.1 years) who underwent coronary angiography at our institution from January to May 1998. All patients were included in the retrospective analysis of the referral diagnoses. RESULTS: 875 patients (554 men, 321 women) were referred due to suspected CAD; 173 of these had normal angiographic findings (20%; 73 men, 100 women; mean age 58.4 years). The referral diagnoses were as follows: unstable angina in 62 patients (36%), stable angina in 40 patients (23%), chest pain and pathological findings of non-invasive testing in 32 patients (19%), atypical chest pain in 25 patients (14%), previous myocardial infarction and multiple risk factors in 7 patients each (4% each). Gender-related differences were remarkable. Only 73 of the 554 referred men (13%) had normal angiographic findings, whereas in women the rate of normal results was more than twofold higher, i.e. 100 of the 321 referred women (31%) had normal angiographic findings (p < 0.01). CONCLUSIONS: Among 875 patients referred to our catheter laboratory for coronary angiography due to suspected CAD, normal angiographic results were documented in 20%. The high frequency of the referral diagnosis 'unstable angina' and 'pathological result of noninvasive testing' was as remarkable as the high proportion of women among patients with normal findings.     

Trauma Patients Can Be Safely Extubated in the Emergency Department

Background: Many trauma patients are intubated for conditions that fully resolve during their emergency department (ED) stay. Often, these patients remain intubated until after they leave the ED. Objective: The objective of this study was to examine the prognosis of patients extubated in the ED. Methods: Data from the records of adult trauma patients who were intubated and then extubated in the ED at a single trauma referral center were prospectively collected for a quality initiative. Two trained abstractors retrospectively recorded these data as well as additional information from the trauma registry and patient charts. The primary outcome was the need for unplanned reintubation during hospitalization. Additional outcomes were disposition and complications from the extubation. Results: There were 50 eligible patients identified and included in the study. Reasons for the intubation included combative behavior or decreased mental status before computed axial tomography (CT) scan in 24 patients (48%), sedation before the performance of a painful procedure in 18 patients (36%), and seizures before CT scan in 3 patients (6%). None of the patients (0%; 95% confidence interval 0–6%) required unplanned reintubation. Eight (16%) of the patients were able to be discharged from the ED before admission. Conclusions: Although our findings must be verified in larger, controlled studies, it may be safe to extubate patients in the ED, if the condition necessitating intubation has fully resolved. This practice may reduce admission rates and limit the need for intensive care unit beds for the patients who are admitted.