- Email: [email protected]
89
Research Forum Abstracts
88
The Impact of the Gum Elastic Bougie on Emergency Department Cricothyrotomy Rate
Greene AE, Bair AE/UC Davis School of Medicine, Davis, CA; UC Davis Department of Emergency Medicine, Sacramento, CA
Study Objective: Difficult airway management is an important element of emergency medical care. Over the past decade multiple developments have contributed to the success of emergency department airway management. Despite such success, the cricothyrotomy (cric) rate has been consistently reported as approximately 1%. We sought to determine if the introduction of the gum elastic bougie (GEB) to the airway curriculum would impact the cric rate. Methods: We performed a historical experiment. We reviewed the cric rates before and after the introduction of the GEB into the airway teaching curriculum at our center. We included data from a 10 year period from 1995-2005. Emphasis on use of the GEB was introduced in 2000. We calculated the 5 year pre-GEB cric rate and compared it to the 5 year post-GEB cric rate. We used descriptive statistics with 95% confidence intervals to compare groups. Results: During the period before the introduction and emphasis on the GEB the cric rate was 1.1% (28 crics/2529 intubations) (95% CI, 0.7-1.6). The cric rate fell to 0.5% (12 crics/2366 intubations) (95% CI, 0.2-0.8) during the subsequent 5 years after the introduction. The decreased cric rate was associated with GEB use in 2.8% of airways managed in the ED. The use of other alternative airway devices was very infrequent. Conclusion: Since the introduction of the GEB into the airway teaching curriculum at our center, we observed a decreased cric rate. Given the relatively small numbers reported here a larger, multi-center trial would be likely be needed to demonstrate statistical significance.
89
Risk Stratification of Emergency Department Patients with Chest Pain Using C-Reactive Protein
Manini AF, McAfee AT, Noble VE, Bohan JS/Harvard Affiliated Emergency Medicine Residency, Boston, MA; Brigham and Women’s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: To determine whether initial serum C - reactive protein (CRP) is associated with outcomes for Emergency Department (ED) patients triaged to the Chest Pain Observation Unit (CPU). Methods: This prospective pilot-study evaluated ED patients at a university hospital with a 55,000 visit ED and a 10-bed CPU. ED patients with suspected myocardial ischemia were eligible who were considered by the attending to be low risk and triaged to the CPU after initially negative cardiac enzymes. Initial serum was drawn at the bedside and serum CRP (milligrams/deciliter) was measured. Adverse cardiac events included any of the following within 30 days: cardiac death, myocardial infarction (troponin I ⬎ 0.09 milligrams/deciliter), or coronary revascularization. Risk of outcome and exact 95% confidence intervals (CI) were calculated. A multivariable logistic regression model was used to control for demographics and cardiac risk factors. Results: 113 patients were enrolled, of whom 23 (20%) were lost to follow-up, leaving 90 patients (mean age 55, 63% female, 6% coronary artery disease, mean CRP 9.6) for analysis. Incidence of 30-day adverse cardiac events was 4% (CI 1.210.9) for all patients, 13.6% (CI 2.9-34.9) for CRP in the first quartile, and 1.5% (CI 0.03-8.0) for CRP above the first quartile. Logistic regression revealed that CRP was not correlated with adverse cardiac outcomes (p 0.33). Conclusion: Based on pilot data, serum CRP is not associated with 30-day adverse cardiac events for CPU patients. Further study is necessary to verify these findings.
90
Predicting AMI in Young Adults Presenting to the ED with Chest Pain
Rosin A, Christenson J, Chathampally Y/Darnall Army Community Hospital, San Antonio, TX; Metropolitan Hospital Center, NYC, TX
Study Objective: To define a set of clinical features that will identify a subset of patients under the age of 40 with AMI. Methods: This was a retrospective cohort study from the years 2001 to 2004. Adults between the ages 19 to 40 years admitted with a primary diagnosis of ACS were included. Patients where excluded if they had renal failure and their Troponin-I (TnI) levels or initial electrocardiogram were not available. Emergency department and hospital based electronic records were reviewed by one reviewer and data was extracted for demographics, cardiac risk factors,
S28 Annals of Emergency Medicine
associated symptoms, radiation, character and duration of pain, chest radiograph results, and any abnormality on the initial electrocardiogram. Spearman’s rank correlation with AMI as a function of all the independent variables was performed. Logistic regression and Receiver-operating curve (ROC) curve analysis were performed on the statistically significant variables. Finally, the sensitivity and specificity of the logistic regression model were calculated. Results: 1830 patients were admitted for chest pain during the study period. 175 met the inclusion criteria, of these 15 met the exclusion criteria. The mean age for the patients that had AMI and those that did not were 33.6 and 33.4, respectively. 56% and 52% of the patients with and without AMI were female, respectively. Of the 46 variables evaluated, only hyper-acute t wave (correlation coefficient r⫽0.261, p ⫽ 0.001), and radiation of pain to both arms (BA) (r⫽0.160, p ⫽ 0.044) or left arm (LA) (r⫽ ⫺0.158, p ⫽ 0.047) were statistically significant on the Spearman Rank Correlation. Pain radiation to BA was noted in less than 5% of the subjects, it was the first factors to be eliminated on backward elimination, and it was not significantly related to AMI on a contingency test. The final logistic regression model included only hyper-acute t wave and pain radiation to LA. Areas under ROC curves were 0.540 (95% CI: 0.411 to 0.669, p ⫽ 0.527), 0.545 (95% CI: 0.415 to 0.674, p ⫽ 0.478), 0.601 (95% CI: 0.487 to 0.715, p ⫽ 0.111), 0.0625 (95% CI: 0.506 to 0.743, p ⫽ 0.048) for hyperacute t wave, BA pain radiation, LA pain radiation, and composite index. Tests with ROC curve areas from 0.600 to ⬍ 0.700 are considered poor discriminators. The sensitivity of the logistic regression model was 0.800 (95% CI: 0737 to 0.863) and the specificity was 0.402 (95% CI: 0.325 to 0.479). Conclusion: In patients under the age of 40, no clinical feature by itself was a significant discriminator of AMI. It may be difficult to diagnose AMI in young patients in the ED using available clinical variables alone.
91
Patients’ Pain and Estimate of Their Risk for Cardiac Disease Do Not Predict Preferences for Cardiac Tests and Procedures
Takakuwa KM, Limkakeng Jr AT, Shofer FS, Hollander JE/Thomas Jefferson University, Philadelphia, PA; University of Pennsylvania, Philadelphia, PA
Study Objectives: Previous studies have suggested that patient preferences may partially explain differences in rates of cardiac tests and procedures. We sought to determine whether patients’ pain level or estimate of the likelihood of having cardiac disease influenced their preferences. We hypothesized that those with a higher pain level and those who perceived a higher likelihood of having cardiac disease would prefer more aggressive testing and be less likely to refuse cardiac tests and procedures. Methods: A convenience sample of patients age 40 years or older presenting with a chief complaint of chest pain was taken between 7/2005-11/2005 at two academic emergency departments. Patient pain ratings were assessed using a visual analog scale (VAS) (0-10 cm). Patients were asked to rate the likelihood that cardiac disease was the cause of their chest pain on a scale from 0-10. They were then asked to choose from a selection of hypothetical cardiac tests and procedures and asked whether their preference would change if a physician recommended a test or procedure. For analysis, patients were divided into two groups based on their VAS pain ratings (pain rating 0-3 compared to pain rating ⬎ 3) and based on their estimate of their likelihood of having cardiac disease (likelihood ratings 0-4 compared to likelihood ratings 5-10). Separate analyses of patient preferences were performed for pain ratings and likelihood ratings using chi-square tests, stratified upon whether or not a physician recommended the test or procedure. Results: 216 patients were enrolled. 104 patients rated their pain ⬎ 3 cm on the VAS. 139 patients rated their likelihood of cardiac disease between 5-10. There were no significant differences in preferences for ECG stress test versus MIBI stress test, cardiac catheterization versus angioplasty with or without stent, percutaneous coronary intervention versus coronary artery bypass grafting, or refusal of procedures between groups in either analysis. There were no significant differences between groups if a physician recommended the test or procedure in either analysis. Conclusion: Patients with higher pain ratings and those who estimate a higher likelihood of having cardiac disease are not more likely to prefer more aggressive cardiac tests or procedures nor are they more likely to refuse tests or procedures.
Volume , . : October
88
The Impact of the Gum Elastic Bougie on Emergency Department Cricothyrotomy Rate
Greene AE, Bair AE/UC Davis School of Medicine, Davis, CA; UC Davis Department of Emergency Medicine, Sacramento, CA
Study Objective: Difficult airway management is an important element of emergency medical care. Over the past decade multiple developments have contributed to the success of emergency department airway management. Despite such success, the cricothyrotomy (cric) rate has been consistently reported as approximately 1%. We sought to determine if the introduction of the gum elastic bougie (GEB) to the airway curriculum would impact the cric rate. Methods: We performed a historical experiment. We reviewed the cric rates before and after the introduction of the GEB into the airway teaching curriculum at our center. We included data from a 10 year period from 1995-2005. Emphasis on use of the GEB was introduced in 2000. We calculated the 5 year pre-GEB cric rate and compared it to the 5 year post-GEB cric rate. We used descriptive statistics with 95% confidence intervals to compare groups. Results: During the period before the introduction and emphasis on the GEB the cric rate was 1.1% (28 crics/2529 intubations) (95% CI, 0.7-1.6). The cric rate fell to 0.5% (12 crics/2366 intubations) (95% CI, 0.2-0.8) during the subsequent 5 years after the introduction. The decreased cric rate was associated with GEB use in 2.8% of airways managed in the ED. The use of other alternative airway devices was very infrequent. Conclusion: Since the introduction of the GEB into the airway teaching curriculum at our center, we observed a decreased cric rate. Given the relatively small numbers reported here a larger, multi-center trial would be likely be needed to demonstrate statistical significance.
89
Risk Stratification of Emergency Department Patients with Chest Pain Using C-Reactive Protein
Manini AF, McAfee AT, Noble VE, Bohan JS/Harvard Affiliated Emergency Medicine Residency, Boston, MA; Brigham and Women’s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: To determine whether initial serum C - reactive protein (CRP) is associated with outcomes for Emergency Department (ED) patients triaged to the Chest Pain Observation Unit (CPU). Methods: This prospective pilot-study evaluated ED patients at a university hospital with a 55,000 visit ED and a 10-bed CPU. ED patients with suspected myocardial ischemia were eligible who were considered by the attending to be low risk and triaged to the CPU after initially negative cardiac enzymes. Initial serum was drawn at the bedside and serum CRP (milligrams/deciliter) was measured. Adverse cardiac events included any of the following within 30 days: cardiac death, myocardial infarction (troponin I ⬎ 0.09 milligrams/deciliter), or coronary revascularization. Risk of outcome and exact 95% confidence intervals (CI) were calculated. A multivariable logistic regression model was used to control for demographics and cardiac risk factors. Results: 113 patients were enrolled, of whom 23 (20%) were lost to follow-up, leaving 90 patients (mean age 55, 63% female, 6% coronary artery disease, mean CRP 9.6) for analysis. Incidence of 30-day adverse cardiac events was 4% (CI 1.210.9) for all patients, 13.6% (CI 2.9-34.9) for CRP in the first quartile, and 1.5% (CI 0.03-8.0) for CRP above the first quartile. Logistic regression revealed that CRP was not correlated with adverse cardiac outcomes (p 0.33). Conclusion: Based on pilot data, serum CRP is not associated with 30-day adverse cardiac events for CPU patients. Further study is necessary to verify these findings.
90
Predicting AMI in Young Adults Presenting to the ED with Chest Pain
Rosin A, Christenson J, Chathampally Y/Darnall Army Community Hospital, San Antonio, TX; Metropolitan Hospital Center, NYC, TX
Study Objective: To define a set of clinical features that will identify a subset of patients under the age of 40 with AMI. Methods: This was a retrospective cohort study from the years 2001 to 2004. Adults between the ages 19 to 40 years admitted with a primary diagnosis of ACS were included. Patients where excluded if they had renal failure and their Troponin-I (TnI) levels or initial electrocardiogram were not available. Emergency department and hospital based electronic records were reviewed by one reviewer and data was extracted for demographics, cardiac risk factors,
S28 Annals of Emergency Medicine
associated symptoms, radiation, character and duration of pain, chest radiograph results, and any abnormality on the initial electrocardiogram. Spearman’s rank correlation with AMI as a function of all the independent variables was performed. Logistic regression and Receiver-operating curve (ROC) curve analysis were performed on the statistically significant variables. Finally, the sensitivity and specificity of the logistic regression model were calculated. Results: 1830 patients were admitted for chest pain during the study period. 175 met the inclusion criteria, of these 15 met the exclusion criteria. The mean age for the patients that had AMI and those that did not were 33.6 and 33.4, respectively. 56% and 52% of the patients with and without AMI were female, respectively. Of the 46 variables evaluated, only hyper-acute t wave (correlation coefficient r⫽0.261, p ⫽ 0.001), and radiation of pain to both arms (BA) (r⫽0.160, p ⫽ 0.044) or left arm (LA) (r⫽ ⫺0.158, p ⫽ 0.047) were statistically significant on the Spearman Rank Correlation. Pain radiation to BA was noted in less than 5% of the subjects, it was the first factors to be eliminated on backward elimination, and it was not significantly related to AMI on a contingency test. The final logistic regression model included only hyper-acute t wave and pain radiation to LA. Areas under ROC curves were 0.540 (95% CI: 0.411 to 0.669, p ⫽ 0.527), 0.545 (95% CI: 0.415 to 0.674, p ⫽ 0.478), 0.601 (95% CI: 0.487 to 0.715, p ⫽ 0.111), 0.0625 (95% CI: 0.506 to 0.743, p ⫽ 0.048) for hyperacute t wave, BA pain radiation, LA pain radiation, and composite index. Tests with ROC curve areas from 0.600 to ⬍ 0.700 are considered poor discriminators. The sensitivity of the logistic regression model was 0.800 (95% CI: 0737 to 0.863) and the specificity was 0.402 (95% CI: 0.325 to 0.479). Conclusion: In patients under the age of 40, no clinical feature by itself was a significant discriminator of AMI. It may be difficult to diagnose AMI in young patients in the ED using available clinical variables alone.
91
Patients’ Pain and Estimate of Their Risk for Cardiac Disease Do Not Predict Preferences for Cardiac Tests and Procedures
Takakuwa KM, Limkakeng Jr AT, Shofer FS, Hollander JE/Thomas Jefferson University, Philadelphia, PA; University of Pennsylvania, Philadelphia, PA
Study Objectives: Previous studies have suggested that patient preferences may partially explain differences in rates of cardiac tests and procedures. We sought to determine whether patients’ pain level or estimate of the likelihood of having cardiac disease influenced their preferences. We hypothesized that those with a higher pain level and those who perceived a higher likelihood of having cardiac disease would prefer more aggressive testing and be less likely to refuse cardiac tests and procedures. Methods: A convenience sample of patients age 40 years or older presenting with a chief complaint of chest pain was taken between 7/2005-11/2005 at two academic emergency departments. Patient pain ratings were assessed using a visual analog scale (VAS) (0-10 cm). Patients were asked to rate the likelihood that cardiac disease was the cause of their chest pain on a scale from 0-10. They were then asked to choose from a selection of hypothetical cardiac tests and procedures and asked whether their preference would change if a physician recommended a test or procedure. For analysis, patients were divided into two groups based on their VAS pain ratings (pain rating 0-3 compared to pain rating ⬎ 3) and based on their estimate of their likelihood of having cardiac disease (likelihood ratings 0-4 compared to likelihood ratings 5-10). Separate analyses of patient preferences were performed for pain ratings and likelihood ratings using chi-square tests, stratified upon whether or not a physician recommended the test or procedure. Results: 216 patients were enrolled. 104 patients rated their pain ⬎ 3 cm on the VAS. 139 patients rated their likelihood of cardiac disease between 5-10. There were no significant differences in preferences for ECG stress test versus MIBI stress test, cardiac catheterization versus angioplasty with or without stent, percutaneous coronary intervention versus coronary artery bypass grafting, or refusal of procedures between groups in either analysis. There were no significant differences between groups if a physician recommended the test or procedure in either analysis. Conclusion: Patients with higher pain ratings and those who estimate a higher likelihood of having cardiac disease are not more likely to prefer more aggressive cardiac tests or procedures nor are they more likely to refuse tests or procedures.
Volume , . : October