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Early detection of acute myocardial infarction: Additional diagnostic information from serum concentrations of myoglobin in patients without S-T elevation
Abstracts fibrillation remains the most important factor relative to survival. This study supports these facts. The peripheral administration of drugs is of dubious value, irrespective of the drug given. It is unclear how the authors arrived at their recommendation for greater than three shocks. The data do not appear to support this.
97 as a general prognostic index. Further, the authors assert that the risk-benefit analysis of thrombolytic agents in Group 1 typ patients weighs strongly against their use. [Scott
PGUj’IlSki,
MD]
Many hospitals today face not only bed shortages but critical care nurse shortages. This study supports the more rational use of limited resources. If the ED is housing multiple CCU admits, priority for the next available CCU bed should be given to Category 2 patients. Editor’s
Note:
0 RIB FRACTURES IN CHILDREN: A MARKER OF SEVERE TRAUMA. Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. J Trauma. 1990;30:695-700. Chest injuries are associated with the second highest mortality rate for children younger than 15 years of age. Trauma registry data of 2,080 children ages 0 to 14 years with blunt or penetrating trauma consecutively admitted to a Level 1 pediatric trauma center were reviewed to assess the importance of multiple rib fractures as a marker of severe injury in children. Only 33 (1.6%) of the study group sustained rib fractures, yet this group represented 25% of all trauma-related deaths. Thoracic injury was present in 104 children of whom 32% had concomitant rib fractures. Causes of rib fractures in order were: traffic injuries, primarily pedestrian; child abuse; and falls. Child abuse accounted for 63% of rib fractures in children under three years of age. The mortality rate among children with rib fractures was 42%, compared to 2% among those without rib fractures. Severity of injury was related to the number of ribs fractured, with multiple rib fractures making multisystem injury significantly more likely. The mortality rate for children with combined rib fractures and head injury was 71%. [Merle Miller, MD]
0 DOES THE EMERGENCY ROOM ELECTROCARDIOGRAM IDENTIFY PATIENTS WITH SUSPECTED MYOCARDIAL INFARCTION WHO ARE AT LOW RISK OF ACUTE COMPLICATIONS? Bell MR, Montarello JK, Steele PM. Aust NZ J Med. 1990;20:564-9. Patients presenting to the emergency department with a history suspicious for acute myocardial infarction (AMI), with or without significant electrocardiogram (ECG) findings, are admitted to coronary care units (CCU) out of concern for life-threatening complications. The authors of this prospective study, involving 410 consecutive patients admitted to the CCU with chest pain, sought to determine the prognostic value of the emergency department ECG in terms of further morbidity and mortality. Patients with minimal or no ECG changes were assigned to Group 1, and those with definite ECG findings were assigned to Group 2. Of the patients in Group 1, 27.7% had an acute myocardial infarction (AMI) confirmed as compared with 84% in Group 2; coronary care unit (CCU) mortality was 0.7% and lo%, respectively, while the overall hospital mortality was 2.1% and 13.0%, respectively. Further, only 19.9% of Group 1 patients had complications in the CCU (dysrhythmia, cardiac failure, cardiogenic shock, recurrent angina) compared with 57.6% of Group 2 patients. The authors conclude that the emergency department ECG can identify patients presenting with suspected AM1 who are at low risk for development of immediate, life-threatening complications. The ECG can reliably be used both to determine priority for admission to the CCU and
0 TRACHEOBRONCHIAL FOREIGN BODIES IN ADULTS. Limper AH, Prakash UBS. Ann Intern Med. 1990;112:604-9. This retrospective analysis looked at 60 consecutive cases of nonasphyxiating tracheobronchial foreign bodies in adults presenting at the Mayo Clinic. Results indicated a male-tofemale ratio of 2.4:1 and a predominance of cases in the 7th decade. Twenty-five had underlying impairment of protective airway mechanisms such as loss of consciousness, sedative or alcohol use, or primary neurological disorders. The nature of the foreign body was variable, with food items (24), most commonly peanuts (7), leading the list. Objects were divided into medical and dental appliances (19) and miscellaneous items (17) including pins, coins, pull-tabs, and so forth. Presenting symptoms included cough (45/48), fever (11). hemoptysis (9). dyspnea (8). and no pulmonary symptoms (1). Patients presented from 1 hour to 13 years (median = 10 days) after aspiration. Standard chest x-ray study was useful in locating the foreign body in 41/57 cases, most often in the right lower lobe, although a significant number were found in all lobes. All but 3 patients were successfully treated by bronchoscopy, with the rigid bronchoscope being much more successful (98%) than fiberoptic bronchoscopy (60%). The most important diagnostic factor leading to the discovery of tracheobronchial foreign body aspiration is clinical suspicion. Although most adults are aware of the aspiration. occult aspirations may remain undetected for years with recurrent symptoms of cough, hemoptysis, dyspnea, and infiltration particularly if the object is relatively radiolucent. Treatment is always prompt removal of the object. Bronchoscopy was successful in 57 of 60 cases in this study. Fiberoptic bronchoscopy offers advantages with objects impacted distally or with cervical or maxillofacial trauma, but in general, rigid bronchoscopy offers advantages of more versatile instruments, better airway control, and rapidity: and in this study was distinctly more successful. [Peter Pruett. Mn]
0 EARLY DETECTION OF ACUTE MYOCARDIAL INFARCTION: ADDITIONAL DIAGNOSTIC INFORMATION FROM SERUM CONCENTRATIONS OF MYOGLOBIN IN PATIENTS WITHOUT S-T ELEVATION. Ohman EM, Casey C, Bengtson JR, F’ryor D. Tormey W. Horgan JH. Brit Heart J. 1990;63:335-8. S-T elevation, the criterion generally used to diagnose acute myocardial injury (MI), may be absent in a significant percentage of patients presenting to the emergency department. The authors undertook this study to establish early markers of MI, in particular looking at creatinine kinase
98 (CK), the MB isoenzyme (MB), and myoglobin (MG). Eightytwo consecutive patients presenting to the emergency department and given a clinical diagnosis of suspected acute MI were entered, and 50 were diagnosed as having an MI by the World Health Organization criteria. The patients with MI had a higher incidence of S-T elevation on admission ECG (64% compared with 1 I%), a higher CK (77 IU/L compared with 34), a higher MB (7 compared with 4), and a higher MG (136 kg/L compared with 34). Elevated MG was the strongest individual predictor of myocardial infarction. Serum MG was also analyzed by a semiquantitative rapid latex agglutination kit; this analysis was positive in 57% of patients with MI and negative in 96% of patients without MI. Unlike previous myoglobin assays, this test can be performed in 10 minutes. The authors suggest that new myoglobin assays may be more beneficial than CK and MB isoenzyme determinations in diagnosing acute MI, especially when combined with the ECG. [Mark Radlauer, MD]
0 HOSPITALIZATION DECISION IN FEBRILE INTRAVENOUS DRUG USERS. Samet J, Shevitz A, Fowle J, Singer D. Am J Med. 19908953-7. The frequency and predictors of occult major illness in febrile IV drug users (IVDUs) presenting to the Boston City Hospital emergency department was studied. From January 1988 to January 1989, all patients with a history of IVDU who presented with fever greater than 37.8 “C were admitted to the hospital (296 patients), and the hospital course was followed in 283 (96%). Of these, 180 patients (64%) were correctly diagnosed with major illnesses in the emergency department. Of the remaining 103 (36%), 92 (32%) were eventually diagnosed with a minor illness, and 11 (4%) had an occult major illness. Of the 11, 7 were felt to have endocarditis, 2 pneumonia, 1 disseminated intravascular coagulation (DIC), and 1 deep venous thrombosis (DVT). Three univariate predictors were significantly associated with occult major illness: last use of intravenous drugs less than 5 days prior to admission, fever greater than 38.8 “C, and urine proteinuria greater than trace. Physician prediction of illness severity at admission only weakly correlated with actual outcome. Blood culture was felt to be the best identifier of occult major illness. [Mark Radlauer, MD]
0 THE INFLUENCE OF AGE VS PEAK SERUM CONCENTRATION ON LIFE-THREATENING EVENTS AFTER CHRONIC THEOPHYLLINE INTOXICATION. Shannon M, Lovejoy F. Arch Intern Med. 1990;150: 2045-8. This prospective study was designed to identify risk factors for the development of seizures and cardiac dysrhythmias in chronic, unintentional theophylline intoxication by monitoring the clinical course of 72 consecutive patients referred to a regional poison center. The median age was 47.5 years. The median peak theophylline concentration was 230 FmollL, with a range of 167 to 722 pmol/L. Eighteen patients had admission hypokalemia. All patients received activated charcoal, although the first dose was vomited by 50% of the patients. Hemodialysis or hemoperfusion was performed in 5 patients with very high theophylline levels. In a total of 28
The Journal of Emergency Medicine patients, 8 seizures and 22 cardiac dysrhythmias occurred. There was no difference in the median peak theophylline concentration between the patients with and without lifethreatening events (LTE). Yet there was a progressive increase in the risk of a LTE as the age of the patient increased. There was a 16.7-fold greater risk of developing a LTE in patients older than 75 years old compared to those less than 25 years old. All of the 6 deaths occurred in patients older than 70 years old. It was concluded that theophylline should be used cautiously in the elderly. In theophylline toxicity, the age of the patient should be considered; more aggressive therapy (hemoperfusion) may be indicated for the older patient at even lower theophylline levels than currently recommended. [Harold L. Skaggs, Jr., MD]
0 HIGH-DOSE INTRAMUSCULAR TRIAMCINOLONE IN SEVERE, CHRONIC, LIFE-THREATENING ASTHMA. Ogirala RG, Aldreich TK, Prezant DJ, Sinnett MJ, Enden JB, Williams MH Jr. N Engl J Med. 1991;324: 585-9. Recurrent emergency department visits are most common for those asthmatics with a more severe, chronic, and lifethreatening form of this disease. They require more frequent hospitalization, sometimes intubation, and most are dependent on the use of chronic oral corticosteroids. A doubleblind, placebo-controlled, crossover study that spanned all seasons was performed with 12 patients to compare the effects of high-dose intramuscular triamcinolone with oral prednisone in patients with severe chronic asthma. The results showed significantly improved peak expiratory flow rates in the triamcinolone treatment group as compared to the prednisone group. No patients were hospitalized during the triamcinolone period, but 21 emergency department visits, 10 hospitalizations and 2 episodes of ventilatory failure occurred during the prednisone period. The total steroid dose was significantly smaller during the triamcinolone period as compared to the prednisone period. However, the steroidal side effects were more pronounced after treatment with triamcinolone than after treatment with prednisone. The conclusions are that high-dose intramuscular triamcinolone is more effective than low-dose prednisone in patients with severe, chronic, life-threatening asthma, but steroidal side effects are somewhat worse. [Jeffrey S. Smowton, MD]
0 EMERGENCY CENTER ULTRASONOGRAPHY IN THE EVALUATION OF HEMOPERITONEUM. Kimura A, Otsuka T. J Trauma. 1991;31:20-3. The reliability of ultrasonographic (US) detection of hemoperitoneum in blunt abdominal trauma was evaluated in a prospective study of 72 patients. Examinations were performed by various physicians, ranging from postgraduate year 2 (PGY2) to PGY8. An anechoic space in Morrison’s pouch or Douglas’s cul de sac was interpreted as positive for hemoperitoneum. Screening for hemothorax, cardiac tamponade, and injury to the liver, spleen, and kidneys was also performed. Independent of examiner, the sensitivity, specificity, and accuracy of US in detecting hemoperitoneum were 86.7%, lOO%, and 97.2%. respectively. There were two false-negative studies. One had 5 mL of blood on diagnostic peritoneal lavage (DPL), but no laparotomy was done. The other had an injury to the superior mesenteric vein detected
97 as a general prognostic index. Further, the authors assert that the risk-benefit analysis of thrombolytic agents in Group 1 typ patients weighs strongly against their use. [Scott
PGUj’IlSki,
MD]
Many hospitals today face not only bed shortages but critical care nurse shortages. This study supports the more rational use of limited resources. If the ED is housing multiple CCU admits, priority for the next available CCU bed should be given to Category 2 patients. Editor’s
Note:
0 RIB FRACTURES IN CHILDREN: A MARKER OF SEVERE TRAUMA. Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. J Trauma. 1990;30:695-700. Chest injuries are associated with the second highest mortality rate for children younger than 15 years of age. Trauma registry data of 2,080 children ages 0 to 14 years with blunt or penetrating trauma consecutively admitted to a Level 1 pediatric trauma center were reviewed to assess the importance of multiple rib fractures as a marker of severe injury in children. Only 33 (1.6%) of the study group sustained rib fractures, yet this group represented 25% of all trauma-related deaths. Thoracic injury was present in 104 children of whom 32% had concomitant rib fractures. Causes of rib fractures in order were: traffic injuries, primarily pedestrian; child abuse; and falls. Child abuse accounted for 63% of rib fractures in children under three years of age. The mortality rate among children with rib fractures was 42%, compared to 2% among those without rib fractures. Severity of injury was related to the number of ribs fractured, with multiple rib fractures making multisystem injury significantly more likely. The mortality rate for children with combined rib fractures and head injury was 71%. [Merle Miller, MD]
0 DOES THE EMERGENCY ROOM ELECTROCARDIOGRAM IDENTIFY PATIENTS WITH SUSPECTED MYOCARDIAL INFARCTION WHO ARE AT LOW RISK OF ACUTE COMPLICATIONS? Bell MR, Montarello JK, Steele PM. Aust NZ J Med. 1990;20:564-9. Patients presenting to the emergency department with a history suspicious for acute myocardial infarction (AMI), with or without significant electrocardiogram (ECG) findings, are admitted to coronary care units (CCU) out of concern for life-threatening complications. The authors of this prospective study, involving 410 consecutive patients admitted to the CCU with chest pain, sought to determine the prognostic value of the emergency department ECG in terms of further morbidity and mortality. Patients with minimal or no ECG changes were assigned to Group 1, and those with definite ECG findings were assigned to Group 2. Of the patients in Group 1, 27.7% had an acute myocardial infarction (AMI) confirmed as compared with 84% in Group 2; coronary care unit (CCU) mortality was 0.7% and lo%, respectively, while the overall hospital mortality was 2.1% and 13.0%, respectively. Further, only 19.9% of Group 1 patients had complications in the CCU (dysrhythmia, cardiac failure, cardiogenic shock, recurrent angina) compared with 57.6% of Group 2 patients. The authors conclude that the emergency department ECG can identify patients presenting with suspected AM1 who are at low risk for development of immediate, life-threatening complications. The ECG can reliably be used both to determine priority for admission to the CCU and
0 TRACHEOBRONCHIAL FOREIGN BODIES IN ADULTS. Limper AH, Prakash UBS. Ann Intern Med. 1990;112:604-9. This retrospective analysis looked at 60 consecutive cases of nonasphyxiating tracheobronchial foreign bodies in adults presenting at the Mayo Clinic. Results indicated a male-tofemale ratio of 2.4:1 and a predominance of cases in the 7th decade. Twenty-five had underlying impairment of protective airway mechanisms such as loss of consciousness, sedative or alcohol use, or primary neurological disorders. The nature of the foreign body was variable, with food items (24), most commonly peanuts (7), leading the list. Objects were divided into medical and dental appliances (19) and miscellaneous items (17) including pins, coins, pull-tabs, and so forth. Presenting symptoms included cough (45/48), fever (11). hemoptysis (9). dyspnea (8). and no pulmonary symptoms (1). Patients presented from 1 hour to 13 years (median = 10 days) after aspiration. Standard chest x-ray study was useful in locating the foreign body in 41/57 cases, most often in the right lower lobe, although a significant number were found in all lobes. All but 3 patients were successfully treated by bronchoscopy, with the rigid bronchoscope being much more successful (98%) than fiberoptic bronchoscopy (60%). The most important diagnostic factor leading to the discovery of tracheobronchial foreign body aspiration is clinical suspicion. Although most adults are aware of the aspiration. occult aspirations may remain undetected for years with recurrent symptoms of cough, hemoptysis, dyspnea, and infiltration particularly if the object is relatively radiolucent. Treatment is always prompt removal of the object. Bronchoscopy was successful in 57 of 60 cases in this study. Fiberoptic bronchoscopy offers advantages with objects impacted distally or with cervical or maxillofacial trauma, but in general, rigid bronchoscopy offers advantages of more versatile instruments, better airway control, and rapidity: and in this study was distinctly more successful. [Peter Pruett. Mn]
0 EARLY DETECTION OF ACUTE MYOCARDIAL INFARCTION: ADDITIONAL DIAGNOSTIC INFORMATION FROM SERUM CONCENTRATIONS OF MYOGLOBIN IN PATIENTS WITHOUT S-T ELEVATION. Ohman EM, Casey C, Bengtson JR, F’ryor D. Tormey W. Horgan JH. Brit Heart J. 1990;63:335-8. S-T elevation, the criterion generally used to diagnose acute myocardial injury (MI), may be absent in a significant percentage of patients presenting to the emergency department. The authors undertook this study to establish early markers of MI, in particular looking at creatinine kinase
98 (CK), the MB isoenzyme (MB), and myoglobin (MG). Eightytwo consecutive patients presenting to the emergency department and given a clinical diagnosis of suspected acute MI were entered, and 50 were diagnosed as having an MI by the World Health Organization criteria. The patients with MI had a higher incidence of S-T elevation on admission ECG (64% compared with 1 I%), a higher CK (77 IU/L compared with 34), a higher MB (7 compared with 4), and a higher MG (136 kg/L compared with 34). Elevated MG was the strongest individual predictor of myocardial infarction. Serum MG was also analyzed by a semiquantitative rapid latex agglutination kit; this analysis was positive in 57% of patients with MI and negative in 96% of patients without MI. Unlike previous myoglobin assays, this test can be performed in 10 minutes. The authors suggest that new myoglobin assays may be more beneficial than CK and MB isoenzyme determinations in diagnosing acute MI, especially when combined with the ECG. [Mark Radlauer, MD]
0 HOSPITALIZATION DECISION IN FEBRILE INTRAVENOUS DRUG USERS. Samet J, Shevitz A, Fowle J, Singer D. Am J Med. 19908953-7. The frequency and predictors of occult major illness in febrile IV drug users (IVDUs) presenting to the Boston City Hospital emergency department was studied. From January 1988 to January 1989, all patients with a history of IVDU who presented with fever greater than 37.8 “C were admitted to the hospital (296 patients), and the hospital course was followed in 283 (96%). Of these, 180 patients (64%) were correctly diagnosed with major illnesses in the emergency department. Of the remaining 103 (36%), 92 (32%) were eventually diagnosed with a minor illness, and 11 (4%) had an occult major illness. Of the 11, 7 were felt to have endocarditis, 2 pneumonia, 1 disseminated intravascular coagulation (DIC), and 1 deep venous thrombosis (DVT). Three univariate predictors were significantly associated with occult major illness: last use of intravenous drugs less than 5 days prior to admission, fever greater than 38.8 “C, and urine proteinuria greater than trace. Physician prediction of illness severity at admission only weakly correlated with actual outcome. Blood culture was felt to be the best identifier of occult major illness. [Mark Radlauer, MD]
0 THE INFLUENCE OF AGE VS PEAK SERUM CONCENTRATION ON LIFE-THREATENING EVENTS AFTER CHRONIC THEOPHYLLINE INTOXICATION. Shannon M, Lovejoy F. Arch Intern Med. 1990;150: 2045-8. This prospective study was designed to identify risk factors for the development of seizures and cardiac dysrhythmias in chronic, unintentional theophylline intoxication by monitoring the clinical course of 72 consecutive patients referred to a regional poison center. The median age was 47.5 years. The median peak theophylline concentration was 230 FmollL, with a range of 167 to 722 pmol/L. Eighteen patients had admission hypokalemia. All patients received activated charcoal, although the first dose was vomited by 50% of the patients. Hemodialysis or hemoperfusion was performed in 5 patients with very high theophylline levels. In a total of 28
The Journal of Emergency Medicine patients, 8 seizures and 22 cardiac dysrhythmias occurred. There was no difference in the median peak theophylline concentration between the patients with and without lifethreatening events (LTE). Yet there was a progressive increase in the risk of a LTE as the age of the patient increased. There was a 16.7-fold greater risk of developing a LTE in patients older than 75 years old compared to those less than 25 years old. All of the 6 deaths occurred in patients older than 70 years old. It was concluded that theophylline should be used cautiously in the elderly. In theophylline toxicity, the age of the patient should be considered; more aggressive therapy (hemoperfusion) may be indicated for the older patient at even lower theophylline levels than currently recommended. [Harold L. Skaggs, Jr., MD]
0 HIGH-DOSE INTRAMUSCULAR TRIAMCINOLONE IN SEVERE, CHRONIC, LIFE-THREATENING ASTHMA. Ogirala RG, Aldreich TK, Prezant DJ, Sinnett MJ, Enden JB, Williams MH Jr. N Engl J Med. 1991;324: 585-9. Recurrent emergency department visits are most common for those asthmatics with a more severe, chronic, and lifethreatening form of this disease. They require more frequent hospitalization, sometimes intubation, and most are dependent on the use of chronic oral corticosteroids. A doubleblind, placebo-controlled, crossover study that spanned all seasons was performed with 12 patients to compare the effects of high-dose intramuscular triamcinolone with oral prednisone in patients with severe chronic asthma. The results showed significantly improved peak expiratory flow rates in the triamcinolone treatment group as compared to the prednisone group. No patients were hospitalized during the triamcinolone period, but 21 emergency department visits, 10 hospitalizations and 2 episodes of ventilatory failure occurred during the prednisone period. The total steroid dose was significantly smaller during the triamcinolone period as compared to the prednisone period. However, the steroidal side effects were more pronounced after treatment with triamcinolone than after treatment with prednisone. The conclusions are that high-dose intramuscular triamcinolone is more effective than low-dose prednisone in patients with severe, chronic, life-threatening asthma, but steroidal side effects are somewhat worse. [Jeffrey S. Smowton, MD]
0 EMERGENCY CENTER ULTRASONOGRAPHY IN THE EVALUATION OF HEMOPERITONEUM. Kimura A, Otsuka T. J Trauma. 1991;31:20-3. The reliability of ultrasonographic (US) detection of hemoperitoneum in blunt abdominal trauma was evaluated in a prospective study of 72 patients. Examinations were performed by various physicians, ranging from postgraduate year 2 (PGY2) to PGY8. An anechoic space in Morrison’s pouch or Douglas’s cul de sac was interpreted as positive for hemoperitoneum. Screening for hemothorax, cardiac tamponade, and injury to the liver, spleen, and kidneys was also performed. Independent of examiner, the sensitivity, specificity, and accuracy of US in detecting hemoperitoneum were 86.7%, lOO%, and 97.2%. respectively. There were two false-negative studies. One had 5 mL of blood on diagnostic peritoneal lavage (DPL), but no laparotomy was done. The other had an injury to the superior mesenteric vein detected