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Can elevated troponin I levels predict complicated clinical course and in-hospital mortality in patients with acute pulmonary embolism?
242 the best management of non-bleeding patients presenting with coumarin-associated coagulopathy is based on the results of studies that used the elevated INR as a surrogate marker for the risk of bleeding. However, there is more than sufficient evidence to support the belief that excessively prolonged INR values are an independent predictor of major bleeding. Most of these studies had a small sample size, used different baseline INR values to include the patients, used different outcomes, and used different doses of vitamin K. However, until strong clinical evidence becomes available, we can conclude that there are sufficient data based on surrogate outcomes to justify the routine use of vitamin K in patients presenting with warfarinassociated coagulopathy. Conclusions: The ED was successful and in the treatment of Warfarin bleedings. INR levels fail to predict the outcome of the patients.
Differential Diagnosis between Viral and Bacterial Meningitis in Children H. De Cauwer, L. Eykens, J. Hellinckx, LJM Mortelmans, Dept of Neurology, Clinical Biology, Pediatrics, Emergency Medicine, AZ KLINA, Brasschaat, Belgium Introduction: the differential diagnosis between viral (VM) and bacterial (BM) meningitis is very difficult, especially in children where clinical symptoms and clinical examination can’t differentiate between VM and BM. As a result of this most pediatricians administer antibiotics till cultures remain negative. Objective: to determine discriminative parameters between VM and BM. Methods: retrospective study. Data from children with meningitis in the period 1997–2005 were reviewed. The results of cerebrospinal fluid (CSF) and peripheral blood examination were analyzed (VM: n ⫽ 26, BM: n ⫽ 18). In 16/26 children with VM antibiotics were started. Statistical analyses were performed using Statview. Mann-Whitney U test for 2 unpaired groups. Results: An elevated polymorphonuclear cell count in CSF is found in BM. In VM however the cell count is very variable. CRP in peripheral blood is raised in BM (p ⬍ 0.0001). Another good discriminating parameter is lactate in CSF, strongly elevated in BM (p ⬍ 0.01 in children, only available in samples of last two years), although also in VM some samples showed lactate ⬎ 3 mmol/l. Protein levels were elevated in BM, normal in VM (p ⬍ 0.01). Glucose-level: NS. We developed a formula based on CRP (⬍ or ⬎ 3 mg%), glucose (⬍ or ⬎ 52 mg%) and neutrophilic count (⬍ or ⬎ 80%): 3 patients with VM should be treated with antibiotics, and in no patient with BM should antibiotics be withheld. Discussion: the differential diagnosis between VM and BM often is very difficult. This is certainly the case in children where the different parameters examined in CSF are less discriminative than in adults. As a result of this in 16/26 children with VM, antibiotics were administered till cultures remained negative. Combination of neutrophilic count, glucose in CSF and CRP in peripheral blood resulted in a discriminative formula: had it been used, only 3 VM patients would have received antibiotics.
The Journal of Emergency Medicine Intravenous thrombolysis in the acute ischemic stroke: an experience in the department of emergency medicine Dr.ssa Bruscoli M. Dr. Burberi F., Dr. Pratesi M, Dr. Rosselli A. Background: The thrombolytic treatment of acute ischemic stroke needs to take place in a short space of time. This requires good organization of the emergency in and outside of the hospital involving specialized units. Objectives: We aimed to determine if our Critical Care Medicine and Surgery Department’s organization provided with an intensive care unit, and the contribution of territorial doctors from the imaging department and analysis laboratory would be able to safely administer thrombolytic therapy. We used the SITS-MOST protocol. Methods: Between February 2004 and May 2005 we treated 26 acute ischemic stroke patients with r-TPA. 9 males and 17 females; mean age: 70.2; time from the beginning of symptoms to the injection: 135.5 mins. Results: We calculated the NIHSS scale at T0 (before thrombolysis), after 2 h of the treatment (T2), at 24 hours (T24) and after 7 days (T7). We also calculated the Rankin scale after 3 months. The mean NIHSS results were as follows: At T0: 16.1 points, at T2h: 14.1; at T24h: 12.2; at T7: 9.4. The mean Rankin scale after 3 months was: 2.55 ⫾ 1.99 (in 22 patients who completed follow-up). Of the 22 patients who completed the follow-up: none had a fatal brain hemmorhage; 3 patients (11.5%) died from infectious complications and comorbidity; 7 patients (42.3%) had no disability (Rankin scale 0 –2). Conclusions: Although we only treated a small number of patients, we can demonstrate clinical improvement in those treated. The mortality rate and autonomy at three months after treatment were similar to those obtained in the expert centres, and are in agreement with data from existing literature. We are the second stroke treatment center in Italy based on the number of treated patients. We suggest that thrombolytic therapy in acute ischemic stroke will be utilized more in Italy if the Golden Hour specialists are directly involved, that is the emergency physicians.
Can elevated troponin I levels predict complicated clinical course and in-hospital mortality in patients with acute pulmonary embolism? Ersin Aksay, MD, Sedat Yanturali, MD, Selahattin Kiyan, MD Background: Despite recent advances in diagnosis and treatment, evaluation of risk and appropriate management of patients with acute pulmonary embolism (PE) remains a difficult task in clinical practice. The patients with a high-risk for cardiovascular mortality are candidates for thrombolysis, and identification of these patients is important. Therefore risk assessment is an essential step in the emergency department (ED) management of patients with PE. Objective: The purpose of this study was to evaluate the value of elevated cardiac troponin I (cTnI) for prediction of complicated clinical course and in-hospital mortality in patients with confirmed acute PE. Methods: This study was a retrospective chart review of patients diagnosed as having PE in whom cTnI determination was obtained at ED presentation between January 2002 and May 2005. Clinical characteristics, echocardiographic right ventric-
Abstracts ular (RV) dysfunction, in-hospital mortality and adverse clinical events including need for inotropic support, mechanical ventilation, and thrombolysis were compared in patients with elevated cTnI levels versus patients with normal cTnI levels. Results: Fifty-seven patients with confirmed PE were reviewed in this study. Twenty-one (37%) patients had elevated cTnI levels. Elevated cTnI levels were associated with in-hospital mortality (p ⫽ 0.03), complicated clinical course (p ⬍ 0.001) and RV dysfunction (p ⬍ 0.001). In patients with elevated cTnI levels, in-hospital mortality (odds ratio 3.75, 95% CI, 1.09 to 12.84), hypotension (odds ratio 10.00, 95% CI, 2.32 to 43.04), thrombolysis (odds ratio 15.45, 95% CI, 2.92 to 81.56), need for mechanical ventilation (odds ratio 8.5, 95% CI, 1.56 to 46.07), and need for inotropic support (odds ratio 3.81, 95% CI, 1.04 to 13.81) were more prevalent. The patients with elevated cTnI levels had more seriously abnormal vital signs (respiratory rate, pulse rate, oxygen saturation, and systolic blood pressure) at ED presentation. Negative predictive value of elevated cTnI levels for complicated clinical course was 86%. Conclusion: Our results indicate that elevated cTnI levels are associated with higher risk of in-hospital mortality and complicated clinical courses. Troponin I may play an important role for the risk assessment of patients with PE in the ED. The idea that an elevation in cTnI level is valuable for the risk stratification of patients with PE needs to be examined in larger prospective studies.
Results of a pilot program for teaching basic cardiopulmonary resuscitation to high school students in Barcelona O. Miro´, X. Jime´nez-Fa`brega, X. Escalada-Roig, Salvador Previously printed in Medicina Clinica. See Medicina Clinica for full abstract.
Allergic reaction to local anesthetic in dental patients M. Androutsou-Pantziou, E. Palli, M. Kandilorou Background: Emergency medical situations can occur while practicing dentistry even to the most experienced dentist. Reasons for these conditions include dental interventions that take more time to finish than usual or these interventions that need drug administration, such as an anesthetic or sedatives that may cause complications if precautions are not taken. Complications that can occur during dental interventions are patient allergic reactions to local anesthetics. The correct evaluation of the patient before the intervention, cooperation of the patient’s primary care physician and a crash cart with medications and supplies are useful in the dental office. Objective: The purpose of this study is to describe the epidemiology and treatment of allergic reactions to local anesthetics in a series of dental patients treated at a single practice. Methods: In the past decade in our dental practice, we saw 2500 outpatients. 2000 patients had simple dental procedures, 500 had complicated maxillofacial procedures. The mean age of patients was 45.2 ⫹/⫺ 8.6 years of age. Local anesthetic was used in 1500 patients (40%). Allergic reactions were present in 20 patients (1.33%). Nobody reported a history of allergies to local anes-
243 thetics. Results: The mean age of the patients who had allergic reactions was 42.3 ⫹/⫺ 8.1 years. Mild allergic reactions were present in 17 of them, with facial erythema, and urticaria in the nasal mucosa. Three patients had more severe reactions, such as skin reactions, vocal hoarseness, and edema. They were administrated antihistamines orally. The more severe reactions were treated with adrenaline subcutaneous, and 250 mg solucortef I.V. In those patients with severe reactions an oropharyngeal tube was placed, O2 was administered, and the patient was transported to the emergency department. Conclusions: Allergic reactions are rare in dental practice, however they may occur, and can potentially be life-threatening. To prevent such complications, a complete medical history, including drug allergies should be taken. The dentist should be prepared through training to reduce and at the same time manage unwanted side effects. The dentist also has to make the diagnosis rapidly and treat the patient. Serious reactions are extremely infrequent and, when treated properly, unlikely to result in significant morbidity or mortality.
First step in the chain of survival-accuracy in 112-calls Bach A, Christensen EF Background: The first link in the “chain of survival” is activation of emergency medical services. Few dispatch studies have presented data. In Denmark, 112, is the national emergency phone-number for medical emergencies, fire, and police. Outside the capital area, police receive 112-calls and request ambulances by electronic messages to ambulance services. A basic life support (BLS) ambulance is always sent, and in addition, advanced life support by an anesthesiologist staffed Mobile Emergency Care Unit (MECU) can be requested to life-threatening emergencies. “Loss of consciousness” is one of the predefined criteria for requesting the MECU. Objectives: The aim of this study was to evaluate 112-call takers ability to identify life-threatening cases and to evaluate correct dispatch of the MECU. We focused on the 112-call takers report “unconscious patient” which was defined as correct when Glasgow Coma Scale (GCS) score was ⬍ 9 at MECU arrival. Methods: Prospective cohort study. Data from police 112-calls were retrieved and linked to the MECU database containing patients records. Results: During the six month study period 2272 emergency calls with MECU dispatch were identified. In 1608 cases both 112-data and GCS score were recorded. A total of 593 patients were reported as being unconscious of whom 207 had a GCS score ⬍ 9. 1015 patients were reported as being conscious of whom 43 had a GCS score ⬍ 9. Accuracy of 112-report of “unconsciousness” in terms of sensitivity was 82.8% and specificity 71.6%. Positive predictive value (patients reported unconscious and found with a GCS score ⬍ 9) was 34.9%. Conclusions: Accuracy was fair considering the MECU dispatch in addition to a BLS ambulance. Positive predictive value was low, indicating MECU over-triage. This indicates the need for further medical dispatch training for 112-call takers.
Differential Diagnosis between Viral and Bacterial Meningitis in Children H. De Cauwer, L. Eykens, J. Hellinckx, LJM Mortelmans, Dept of Neurology, Clinical Biology, Pediatrics, Emergency Medicine, AZ KLINA, Brasschaat, Belgium Introduction: the differential diagnosis between viral (VM) and bacterial (BM) meningitis is very difficult, especially in children where clinical symptoms and clinical examination can’t differentiate between VM and BM. As a result of this most pediatricians administer antibiotics till cultures remain negative. Objective: to determine discriminative parameters between VM and BM. Methods: retrospective study. Data from children with meningitis in the period 1997–2005 were reviewed. The results of cerebrospinal fluid (CSF) and peripheral blood examination were analyzed (VM: n ⫽ 26, BM: n ⫽ 18). In 16/26 children with VM antibiotics were started. Statistical analyses were performed using Statview. Mann-Whitney U test for 2 unpaired groups. Results: An elevated polymorphonuclear cell count in CSF is found in BM. In VM however the cell count is very variable. CRP in peripheral blood is raised in BM (p ⬍ 0.0001). Another good discriminating parameter is lactate in CSF, strongly elevated in BM (p ⬍ 0.01 in children, only available in samples of last two years), although also in VM some samples showed lactate ⬎ 3 mmol/l. Protein levels were elevated in BM, normal in VM (p ⬍ 0.01). Glucose-level: NS. We developed a formula based on CRP (⬍ or ⬎ 3 mg%), glucose (⬍ or ⬎ 52 mg%) and neutrophilic count (⬍ or ⬎ 80%): 3 patients with VM should be treated with antibiotics, and in no patient with BM should antibiotics be withheld. Discussion: the differential diagnosis between VM and BM often is very difficult. This is certainly the case in children where the different parameters examined in CSF are less discriminative than in adults. As a result of this in 16/26 children with VM, antibiotics were administered till cultures remained negative. Combination of neutrophilic count, glucose in CSF and CRP in peripheral blood resulted in a discriminative formula: had it been used, only 3 VM patients would have received antibiotics.
The Journal of Emergency Medicine Intravenous thrombolysis in the acute ischemic stroke: an experience in the department of emergency medicine Dr.ssa Bruscoli M. Dr. Burberi F., Dr. Pratesi M, Dr. Rosselli A. Background: The thrombolytic treatment of acute ischemic stroke needs to take place in a short space of time. This requires good organization of the emergency in and outside of the hospital involving specialized units. Objectives: We aimed to determine if our Critical Care Medicine and Surgery Department’s organization provided with an intensive care unit, and the contribution of territorial doctors from the imaging department and analysis laboratory would be able to safely administer thrombolytic therapy. We used the SITS-MOST protocol. Methods: Between February 2004 and May 2005 we treated 26 acute ischemic stroke patients with r-TPA. 9 males and 17 females; mean age: 70.2; time from the beginning of symptoms to the injection: 135.5 mins. Results: We calculated the NIHSS scale at T0 (before thrombolysis), after 2 h of the treatment (T2), at 24 hours (T24) and after 7 days (T7). We also calculated the Rankin scale after 3 months. The mean NIHSS results were as follows: At T0: 16.1 points, at T2h: 14.1; at T24h: 12.2; at T7: 9.4. The mean Rankin scale after 3 months was: 2.55 ⫾ 1.99 (in 22 patients who completed follow-up). Of the 22 patients who completed the follow-up: none had a fatal brain hemmorhage; 3 patients (11.5%) died from infectious complications and comorbidity; 7 patients (42.3%) had no disability (Rankin scale 0 –2). Conclusions: Although we only treated a small number of patients, we can demonstrate clinical improvement in those treated. The mortality rate and autonomy at three months after treatment were similar to those obtained in the expert centres, and are in agreement with data from existing literature. We are the second stroke treatment center in Italy based on the number of treated patients. We suggest that thrombolytic therapy in acute ischemic stroke will be utilized more in Italy if the Golden Hour specialists are directly involved, that is the emergency physicians.
Can elevated troponin I levels predict complicated clinical course and in-hospital mortality in patients with acute pulmonary embolism? Ersin Aksay, MD, Sedat Yanturali, MD, Selahattin Kiyan, MD Background: Despite recent advances in diagnosis and treatment, evaluation of risk and appropriate management of patients with acute pulmonary embolism (PE) remains a difficult task in clinical practice. The patients with a high-risk for cardiovascular mortality are candidates for thrombolysis, and identification of these patients is important. Therefore risk assessment is an essential step in the emergency department (ED) management of patients with PE. Objective: The purpose of this study was to evaluate the value of elevated cardiac troponin I (cTnI) for prediction of complicated clinical course and in-hospital mortality in patients with confirmed acute PE. Methods: This study was a retrospective chart review of patients diagnosed as having PE in whom cTnI determination was obtained at ED presentation between January 2002 and May 2005. Clinical characteristics, echocardiographic right ventric-
Abstracts ular (RV) dysfunction, in-hospital mortality and adverse clinical events including need for inotropic support, mechanical ventilation, and thrombolysis were compared in patients with elevated cTnI levels versus patients with normal cTnI levels. Results: Fifty-seven patients with confirmed PE were reviewed in this study. Twenty-one (37%) patients had elevated cTnI levels. Elevated cTnI levels were associated with in-hospital mortality (p ⫽ 0.03), complicated clinical course (p ⬍ 0.001) and RV dysfunction (p ⬍ 0.001). In patients with elevated cTnI levels, in-hospital mortality (odds ratio 3.75, 95% CI, 1.09 to 12.84), hypotension (odds ratio 10.00, 95% CI, 2.32 to 43.04), thrombolysis (odds ratio 15.45, 95% CI, 2.92 to 81.56), need for mechanical ventilation (odds ratio 8.5, 95% CI, 1.56 to 46.07), and need for inotropic support (odds ratio 3.81, 95% CI, 1.04 to 13.81) were more prevalent. The patients with elevated cTnI levels had more seriously abnormal vital signs (respiratory rate, pulse rate, oxygen saturation, and systolic blood pressure) at ED presentation. Negative predictive value of elevated cTnI levels for complicated clinical course was 86%. Conclusion: Our results indicate that elevated cTnI levels are associated with higher risk of in-hospital mortality and complicated clinical courses. Troponin I may play an important role for the risk assessment of patients with PE in the ED. The idea that an elevation in cTnI level is valuable for the risk stratification of patients with PE needs to be examined in larger prospective studies.
Results of a pilot program for teaching basic cardiopulmonary resuscitation to high school students in Barcelona O. Miro´, X. Jime´nez-Fa`brega, X. Escalada-Roig, Salvador Previously printed in Medicina Clinica. See Medicina Clinica for full abstract.
Allergic reaction to local anesthetic in dental patients M. Androutsou-Pantziou, E. Palli, M. Kandilorou Background: Emergency medical situations can occur while practicing dentistry even to the most experienced dentist. Reasons for these conditions include dental interventions that take more time to finish than usual or these interventions that need drug administration, such as an anesthetic or sedatives that may cause complications if precautions are not taken. Complications that can occur during dental interventions are patient allergic reactions to local anesthetics. The correct evaluation of the patient before the intervention, cooperation of the patient’s primary care physician and a crash cart with medications and supplies are useful in the dental office. Objective: The purpose of this study is to describe the epidemiology and treatment of allergic reactions to local anesthetics in a series of dental patients treated at a single practice. Methods: In the past decade in our dental practice, we saw 2500 outpatients. 2000 patients had simple dental procedures, 500 had complicated maxillofacial procedures. The mean age of patients was 45.2 ⫹/⫺ 8.6 years of age. Local anesthetic was used in 1500 patients (40%). Allergic reactions were present in 20 patients (1.33%). Nobody reported a history of allergies to local anes-
243 thetics. Results: The mean age of the patients who had allergic reactions was 42.3 ⫹/⫺ 8.1 years. Mild allergic reactions were present in 17 of them, with facial erythema, and urticaria in the nasal mucosa. Three patients had more severe reactions, such as skin reactions, vocal hoarseness, and edema. They were administrated antihistamines orally. The more severe reactions were treated with adrenaline subcutaneous, and 250 mg solucortef I.V. In those patients with severe reactions an oropharyngeal tube was placed, O2 was administered, and the patient was transported to the emergency department. Conclusions: Allergic reactions are rare in dental practice, however they may occur, and can potentially be life-threatening. To prevent such complications, a complete medical history, including drug allergies should be taken. The dentist should be prepared through training to reduce and at the same time manage unwanted side effects. The dentist also has to make the diagnosis rapidly and treat the patient. Serious reactions are extremely infrequent and, when treated properly, unlikely to result in significant morbidity or mortality.
First step in the chain of survival-accuracy in 112-calls Bach A, Christensen EF Background: The first link in the “chain of survival” is activation of emergency medical services. Few dispatch studies have presented data. In Denmark, 112, is the national emergency phone-number for medical emergencies, fire, and police. Outside the capital area, police receive 112-calls and request ambulances by electronic messages to ambulance services. A basic life support (BLS) ambulance is always sent, and in addition, advanced life support by an anesthesiologist staffed Mobile Emergency Care Unit (MECU) can be requested to life-threatening emergencies. “Loss of consciousness” is one of the predefined criteria for requesting the MECU. Objectives: The aim of this study was to evaluate 112-call takers ability to identify life-threatening cases and to evaluate correct dispatch of the MECU. We focused on the 112-call takers report “unconscious patient” which was defined as correct when Glasgow Coma Scale (GCS) score was ⬍ 9 at MECU arrival. Methods: Prospective cohort study. Data from police 112-calls were retrieved and linked to the MECU database containing patients records. Results: During the six month study period 2272 emergency calls with MECU dispatch were identified. In 1608 cases both 112-data and GCS score were recorded. A total of 593 patients were reported as being unconscious of whom 207 had a GCS score ⬍ 9. 1015 patients were reported as being conscious of whom 43 had a GCS score ⬍ 9. Accuracy of 112-report of “unconsciousness” in terms of sensitivity was 82.8% and specificity 71.6%. Positive predictive value (patients reported unconscious and found with a GCS score ⬍ 9) was 34.9%. Conclusions: Accuracy was fair considering the MECU dispatch in addition to a BLS ambulance. Positive predictive value was low, indicating MECU over-triage. This indicates the need for further medical dispatch training for 112-call takers.