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A probabilistic approach to the diagnosis of deep venous thrombosis in hospitalized patients
RESEARCH FORUM ABSTRACTS
However, comparison of the doses commonly used has not been undertaken. Our primary interest is to compare the effectiveness of droperidol at 3 doses. A secondary purpose is to monitor the QTc for all patients receiving droperidol. Methods: This was a prospective, randomized study of droperidol as a treatment for nausea and vomiting set in an urban teaching hospital ([100,000 patient visits/ year). All adult patients presenting with nausea and vomiting who were to receive an antiemetic intravenously were eligible. Exclusion criteria included pregnancy, mental handicaps, and QTc greater than 440 msec. Patients were randomized to receive 0.625 mg, 1.25 mg, or 2.5 mg of droperidol intravenously. Visual analog scales (VAS) assessed the patient’s degree of nausea and somnolence at 0 and 60 minutes. Any extrapyramidal reactions and dysrhythmias were recorded. A rhythm strip was completed before and after treatment. Data were analyzed using descriptive statistics and analysis of variance. Results: A total of 26 patients have been enrolled thus far (0.625-mg group, n=6; 1.25-mg group, n=15; 2.5-mg group, n=5). The mean change in nausea VAS for droperidol 0.625 mg was –44.2 mm (95% confidence interval [CI] 9.9 to 78.4), for 1.25 mg was –30.4 mm (95% CI 19.0 to 41.7), and for 2.5 mg was –45.0 mm (95% CI 20.2 to 69.8; P=.34). The mean change in somnolence VAS for droperidol 0.625 mg was 0.0 mm (95% CI –26.5 to 26.5), for 1.25 mg was 4.8 mm (95% CI –12.6 to 22.5), and for 2.5 mg was 20.0 mm (95% CI 0 –56.5 to 60.5; P=.95). The mean change in QTc for 0.625 mg was –0.021 mm (95% CI –0.134 to 0.091), 1.25 mg was 0.013 mm (95% CI –0.009 to 0.034), and 2.5 mg was –0.055 mm (95% CI –0.293 to 0.183; P=.35). Adverse events occurred in 0 of 6 of the 0.625-mg group, 2 (13%) of 15 of the 1.25-mg group, and 1 (20%) of 5 of the 2.5-mg group (P=.54). Conclusion: Nausea and vomiting symptoms were reduced equally with the 3 droperidol doses. No significant change in QTc occurred for any group. The frequency of adverse events increased with larger droperidol doses.
422
Empiric Acyclovir Is Uncommonly Initiated in the Emergency Department to Patients With Symptoms of Encephalitis
Benson PC, Swadron SP/Keck School of Medicine, University of Southern California, Los Angeles, CA Study objectives: Patients presenting to our emergency department (ED) with signs of encephalitis rarely receive empiric acyclovir before admission. However, emergency physicians are very likely to initiate prompt empiric antibiotic therapy. The clinical relevance of these relatively short delays, if any, is unknown and should be researched further. We evaluate the initiation of empiric acyclovir to patients presenting to the adult and pediatric EDs with symptoms of encephalitis. Methods: We conducted an explicit retrospective chart review of 90 patients discharged with a diagnosis of encephalitis. Of the 90 cases reviewed, those cases that met the inclusion criteria of neuropsychiatric abnormality, fever, and a cerebrospinal fluid pleocytosis with a negative Gram stain at emergency physician evaluation (n=24) were evaluated for ED initiation of empiric acyclovir. A secondary outcome measured was initiation of empiric antibiotics. Results: Of the 24 patients who met the inclusion criteria, 6 (25%) received empiric acyclovir while in the ED, 3 pediatric (25%) and 3 adult (25%) patients. The remaining 18 (75%) did not receive acyclovir in the ED and experienced delays of 14.4 hours in the adult ED and 3.5 hours in the pediatric ED until acyclovir was initiated as inpatient medication to the remaining patients. This discrepancy could be explained by the shorter time for the patients to reach the inpatient setting from the pediatric department. Twenty-four (100%) patients received empiric antibiotic therapy, with an average delay of 29.5 minutes. Conclusion: Patients presenting to our ED with signs of encephalitis rarely receive empiric acyclovir before admission. However, emergency physicians are very likely to initiate prompt empiric antibiotic therapy. The clinical relevance of these relatively short delays, if any, is unknown and should be researched further.
423
A Probabilistic Approach to the Diagnosis of Deep Venous Thrombosis in Hospitalized Patients
Mumoli N, Cei M, Busoni A, Verzuri M/Livorno Hospital, Livorno, Italy; Siena University, Siena, Italy Study objectives: Although clinical diagnosis of deep vein thrombosis (DVT) has been regarded as equivocal, the use of symptoms scores may increase the probability of instrumental confirmation and help the clinician in therapeutic decisions, especially when a compression ultrasonographic scanning is not immediately
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
available. We propose a new and simple score based on a retrospective analysis of our inpatients. Methods: One hundred fifty-four patients of 1,650 consecutively admitted in our emergency department underwent a Doppler ultrasonographic evaluation for suspected DVT. We revised medical histories, clinical examinations, and laboratory data of all patients. Odds ratios (ORs; with confidence intervals) were calculated for all relevant variables (age, risk factors, physical examination, alternative diagnosis, 2 D-dimer). Statistical analysis was performed with x analysis. A new score, named HOOD (History, Objective, Other diagnosis, and Dimer), was then developed. Results: A DVT was confirmed in 96 (62.3%) of 154 patients. Sex and age older than 70 years (OR 0.69) were not predictive of DVT. The presence of 2 or more risk factors (OR 3.15), 1 or more signs of DVT (OR 6.2), and D-dimer value greater than cutoff (OR 4.2) were all strong predictors of the ultrasonographic results. A HOOD score of 1 or less was not associated with thrombosis, whereas a score of 2 or more was highly predictive of DVT (OR 6.41; sensitivity 0.96, specificity 0.52; positive and negative predictive value 0.75 and 0.88, respectively). Conclusion: DVT can be predicted by a simple clinical score. When compression ultrasonographic scanning is not immediately available, a treatment with heparin should not delayed in patients with high clinical probability of DVT. Currently, the clinical suspicion of DVT is made by gestalt or by use of scores that divide cases into 3 groups of risk (ie, low, intermediate, and high risk). However, the generation of ‘‘intermediate’’ group risk is of little, if any, value because the need of objective confirmation cannot be avoided. We propose a clinical method that segregates patients into 2 clearly distinct groups of risk, in 1 of which initial treatment could be probably safely omitted (a prospective confirmation is awaited, of course).
424
Patient Sex and Quality of Emergency Department Care for Patients With Acute Myocardial Infarction
Vinson DR, Magid DJ, Padgett TG, Van der Vlugt TM, Go AS, Masoudi FA, Rumsfeld JS, Tricomi AJ, Crounse L, Lyons EE, Ho PM, Brand DW/The Permanente Medical Group, Sacramento, CA; Kaiser Permanente of Colorado, University of Colorado Health Sciences Center, Denver, CO; The Permanente Medical Group, Kaiser Hospital, San Francisco, CA; Kaiser Permanente Santa Clara, Santa Clara, CA; Kaiser Permanente of Northern California, Oakland, CA; Denver Health Medical Center, Denver, CO; VA Medical Center, University of Colorado Health Science Center, Denver, CO Study objectives: Although previous studies have shown that women are less likely than men to undergo invasive procedures to treat coronary artery disease, less is known about sex differences in the medical treatment of acute myocardial infarction in the emergency department (ED). The objective of this study is to assess differences in rates of use of aspirin, b-blockers, and reperfusion therapy between male and female ED acute myocardial infarction (AMI) patients with no contraindications to these therapies. Methods: This was a cohort study of 2,216 consecutive, enzyme-confirmed AMI patients presenting to 1 of 5 community EDs in Colorado and California from July 2000 through June 2002. ED and inpatient records were abstracted to obtain information on the use of aspirin, b-blockers, reperfusion therapy, contraindications to these treatments, patient characteristics, and clinical factors. Hierarchical multivariable regression was used to evaluate the relationship between sex and the receipt of aspirin, b-blockers, and reperfusion therapy in ideal candidates while adjusting for patient and hospital characteristics, and inhospital clustering. Results: There were 849 women and 1,367 men in the study sample. Female patients were older than male patients (women, 73.4 years versus men, 66.1 years; P\.001). Women more often had a history of hypertension, congestive heart failure, and chronic obstructive pulmonary disease and less often had a history of smoking, hyperlipidemia, and previous cardiac disease. Compared with men, women were less likely to be administered aspirin (women 76.3 versus men 81.3, P\.01), b-blockers (women 51.7 versus men 61.4, P\.01), and reperfusion therapy (women 64.0 versus men 72.8, P\.05). However, after adjustment for age there was no longer a significant relationship between sex and the use of aspirin (relative risk [RR] 0.91, 95% confidence interval [CI] 0.73 to 1.14), b-blockers (RR 0.82, 95% CI 0.62 to 1.08), or reperfusion therapy (RR 0.99, 95% CI 0.63 to 1.54). In models that adjusted for additional demographic, clinical, and hospital characteristics, there remained no association between sex and process of care. Conclusion: Women with AMI cared for in the ED have a lower likelihood of receiving aspirin, b-blocker, and reperfusion therapy. However, this association
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However, comparison of the doses commonly used has not been undertaken. Our primary interest is to compare the effectiveness of droperidol at 3 doses. A secondary purpose is to monitor the QTc for all patients receiving droperidol. Methods: This was a prospective, randomized study of droperidol as a treatment for nausea and vomiting set in an urban teaching hospital ([100,000 patient visits/ year). All adult patients presenting with nausea and vomiting who were to receive an antiemetic intravenously were eligible. Exclusion criteria included pregnancy, mental handicaps, and QTc greater than 440 msec. Patients were randomized to receive 0.625 mg, 1.25 mg, or 2.5 mg of droperidol intravenously. Visual analog scales (VAS) assessed the patient’s degree of nausea and somnolence at 0 and 60 minutes. Any extrapyramidal reactions and dysrhythmias were recorded. A rhythm strip was completed before and after treatment. Data were analyzed using descriptive statistics and analysis of variance. Results: A total of 26 patients have been enrolled thus far (0.625-mg group, n=6; 1.25-mg group, n=15; 2.5-mg group, n=5). The mean change in nausea VAS for droperidol 0.625 mg was –44.2 mm (95% confidence interval [CI] 9.9 to 78.4), for 1.25 mg was –30.4 mm (95% CI 19.0 to 41.7), and for 2.5 mg was –45.0 mm (95% CI 20.2 to 69.8; P=.34). The mean change in somnolence VAS for droperidol 0.625 mg was 0.0 mm (95% CI –26.5 to 26.5), for 1.25 mg was 4.8 mm (95% CI –12.6 to 22.5), and for 2.5 mg was 20.0 mm (95% CI 0 –56.5 to 60.5; P=.95). The mean change in QTc for 0.625 mg was –0.021 mm (95% CI –0.134 to 0.091), 1.25 mg was 0.013 mm (95% CI –0.009 to 0.034), and 2.5 mg was –0.055 mm (95% CI –0.293 to 0.183; P=.35). Adverse events occurred in 0 of 6 of the 0.625-mg group, 2 (13%) of 15 of the 1.25-mg group, and 1 (20%) of 5 of the 2.5-mg group (P=.54). Conclusion: Nausea and vomiting symptoms were reduced equally with the 3 droperidol doses. No significant change in QTc occurred for any group. The frequency of adverse events increased with larger droperidol doses.
422
Empiric Acyclovir Is Uncommonly Initiated in the Emergency Department to Patients With Symptoms of Encephalitis
Benson PC, Swadron SP/Keck School of Medicine, University of Southern California, Los Angeles, CA Study objectives: Patients presenting to our emergency department (ED) with signs of encephalitis rarely receive empiric acyclovir before admission. However, emergency physicians are very likely to initiate prompt empiric antibiotic therapy. The clinical relevance of these relatively short delays, if any, is unknown and should be researched further. We evaluate the initiation of empiric acyclovir to patients presenting to the adult and pediatric EDs with symptoms of encephalitis. Methods: We conducted an explicit retrospective chart review of 90 patients discharged with a diagnosis of encephalitis. Of the 90 cases reviewed, those cases that met the inclusion criteria of neuropsychiatric abnormality, fever, and a cerebrospinal fluid pleocytosis with a negative Gram stain at emergency physician evaluation (n=24) were evaluated for ED initiation of empiric acyclovir. A secondary outcome measured was initiation of empiric antibiotics. Results: Of the 24 patients who met the inclusion criteria, 6 (25%) received empiric acyclovir while in the ED, 3 pediatric (25%) and 3 adult (25%) patients. The remaining 18 (75%) did not receive acyclovir in the ED and experienced delays of 14.4 hours in the adult ED and 3.5 hours in the pediatric ED until acyclovir was initiated as inpatient medication to the remaining patients. This discrepancy could be explained by the shorter time for the patients to reach the inpatient setting from the pediatric department. Twenty-four (100%) patients received empiric antibiotic therapy, with an average delay of 29.5 minutes. Conclusion: Patients presenting to our ED with signs of encephalitis rarely receive empiric acyclovir before admission. However, emergency physicians are very likely to initiate prompt empiric antibiotic therapy. The clinical relevance of these relatively short delays, if any, is unknown and should be researched further.
423
A Probabilistic Approach to the Diagnosis of Deep Venous Thrombosis in Hospitalized Patients
Mumoli N, Cei M, Busoni A, Verzuri M/Livorno Hospital, Livorno, Italy; Siena University, Siena, Italy Study objectives: Although clinical diagnosis of deep vein thrombosis (DVT) has been regarded as equivocal, the use of symptoms scores may increase the probability of instrumental confirmation and help the clinician in therapeutic decisions, especially when a compression ultrasonographic scanning is not immediately
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
available. We propose a new and simple score based on a retrospective analysis of our inpatients. Methods: One hundred fifty-four patients of 1,650 consecutively admitted in our emergency department underwent a Doppler ultrasonographic evaluation for suspected DVT. We revised medical histories, clinical examinations, and laboratory data of all patients. Odds ratios (ORs; with confidence intervals) were calculated for all relevant variables (age, risk factors, physical examination, alternative diagnosis, 2 D-dimer). Statistical analysis was performed with x analysis. A new score, named HOOD (History, Objective, Other diagnosis, and Dimer), was then developed. Results: A DVT was confirmed in 96 (62.3%) of 154 patients. Sex and age older than 70 years (OR 0.69) were not predictive of DVT. The presence of 2 or more risk factors (OR 3.15), 1 or more signs of DVT (OR 6.2), and D-dimer value greater than cutoff (OR 4.2) were all strong predictors of the ultrasonographic results. A HOOD score of 1 or less was not associated with thrombosis, whereas a score of 2 or more was highly predictive of DVT (OR 6.41; sensitivity 0.96, specificity 0.52; positive and negative predictive value 0.75 and 0.88, respectively). Conclusion: DVT can be predicted by a simple clinical score. When compression ultrasonographic scanning is not immediately available, a treatment with heparin should not delayed in patients with high clinical probability of DVT. Currently, the clinical suspicion of DVT is made by gestalt or by use of scores that divide cases into 3 groups of risk (ie, low, intermediate, and high risk). However, the generation of ‘‘intermediate’’ group risk is of little, if any, value because the need of objective confirmation cannot be avoided. We propose a clinical method that segregates patients into 2 clearly distinct groups of risk, in 1 of which initial treatment could be probably safely omitted (a prospective confirmation is awaited, of course).
424
Patient Sex and Quality of Emergency Department Care for Patients With Acute Myocardial Infarction
Vinson DR, Magid DJ, Padgett TG, Van der Vlugt TM, Go AS, Masoudi FA, Rumsfeld JS, Tricomi AJ, Crounse L, Lyons EE, Ho PM, Brand DW/The Permanente Medical Group, Sacramento, CA; Kaiser Permanente of Colorado, University of Colorado Health Sciences Center, Denver, CO; The Permanente Medical Group, Kaiser Hospital, San Francisco, CA; Kaiser Permanente Santa Clara, Santa Clara, CA; Kaiser Permanente of Northern California, Oakland, CA; Denver Health Medical Center, Denver, CO; VA Medical Center, University of Colorado Health Science Center, Denver, CO Study objectives: Although previous studies have shown that women are less likely than men to undergo invasive procedures to treat coronary artery disease, less is known about sex differences in the medical treatment of acute myocardial infarction in the emergency department (ED). The objective of this study is to assess differences in rates of use of aspirin, b-blockers, and reperfusion therapy between male and female ED acute myocardial infarction (AMI) patients with no contraindications to these therapies. Methods: This was a cohort study of 2,216 consecutive, enzyme-confirmed AMI patients presenting to 1 of 5 community EDs in Colorado and California from July 2000 through June 2002. ED and inpatient records were abstracted to obtain information on the use of aspirin, b-blockers, reperfusion therapy, contraindications to these treatments, patient characteristics, and clinical factors. Hierarchical multivariable regression was used to evaluate the relationship between sex and the receipt of aspirin, b-blockers, and reperfusion therapy in ideal candidates while adjusting for patient and hospital characteristics, and inhospital clustering. Results: There were 849 women and 1,367 men in the study sample. Female patients were older than male patients (women, 73.4 years versus men, 66.1 years; P\.001). Women more often had a history of hypertension, congestive heart failure, and chronic obstructive pulmonary disease and less often had a history of smoking, hyperlipidemia, and previous cardiac disease. Compared with men, women were less likely to be administered aspirin (women 76.3 versus men 81.3, P\.01), b-blockers (women 51.7 versus men 61.4, P\.01), and reperfusion therapy (women 64.0 versus men 72.8, P\.05). However, after adjustment for age there was no longer a significant relationship between sex and the use of aspirin (relative risk [RR] 0.91, 95% confidence interval [CI] 0.73 to 1.14), b-blockers (RR 0.82, 95% CI 0.62 to 1.08), or reperfusion therapy (RR 0.99, 95% CI 0.63 to 1.54). In models that adjusted for additional demographic, clinical, and hospital characteristics, there remained no association between sex and process of care. Conclusion: Women with AMI cared for in the ED have a lower likelihood of receiving aspirin, b-blocker, and reperfusion therapy. However, this association
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