RESEARCH FORUM ABSTRACTS
Results: Two hundred forty-seven blunt trauma patients were accrued prospectively. Forty-three TL fractures were identified in 24 patients (9.7%). Nine patients had noncontiguous fractures. Eight (7.8%) of the 103 group 1 patients had TL fractures. Seven of the 74 group 2 patients (9.5%) had fractures, 2 without pain or tenderness. Nine of the 24 group 3 patients (37.5%) had a fracture, and the remaining 46 group 4 patients had no missed fractures. The sensitivity for any positive indicator was 100% specificity 21%, positive predictive value 12%, and negative predictive value of 100%. Conclusion: Selective use of TL spine radiographs is appropriate. A larger prospective study is needed to further evaluate these criteria and to promote widespread guidelines.
176 Hemodynamic Evaluation of the Critically ,,1 in the Emergency Department: A Comparisonof Clinical Impression Versus Transesophageal Doppler Measurement Urrunaga JJ, Rivers E, Mullen M, Karriem-Norwood V, Nguyen HB, Knoblich B, Ritteninger W/Henry Ford Hospital, Detroit, MI Accurate hemodynamic assessment of the critically ill is important in the emergency department for appropriate diagnosis and therapeutic intervention. It is well established that vital signs are a poor indicator of tissue perfusion rendering clinical assessment less than desirable when critical decisions are warranted. Transesophageal Doppler or EDM (Deltex Medical, Irving, TX) allows for hemodynamic measurements of equal accuracy to the pulmonary artery catheter. Study objectives: The purpose of this study was to compare hemodynamic assessment of the clinician with esophageal Doppler monitoring in critically ill patients presenting to the ED. Methods: This was a prospective case series of adult critically ill patients presenting to a large urban ED and admitted to the ICU. Patients were included if they were intubated, sedated, mechanically ventilated with arterial and central venous catherization for blood and central venous pressure (CVP) measurement. The ED attending physician was asked to assess prdoad (volume status), cardiac output, contractility, and systemic vascular resistance (afierload) based on clinical assessment and hemodynamic data obtained from the arterial blood pressure and CVP. These variables were recorded as high, normal, or low. The EDM was placed and the same measurements were obtained after a steady-state reading for 30 seconds. These hemodynamic data were provided to the ED attending physician. Therapy before and after EDM was compared. Results: There were 34 patients enrolled with a mean age of 62.5_+12 years, a mean duration of ED stay of 6.2_+3 hours, and a 27% in hospital mortality. The clinician's agreement with EDM was 48% for volume status, 50% for cardiac output, 39% for contractility, and 48% for afterload. There was a 31% change in therapy after the EDM's hemodynamic assessment was provided to the ED attending physician. Conclusion: EDM is a less invasive alternative to puhnonary artery catheterization and feasible for ED use in the treatment of the critically ill. It provides more accurate information than clinician assessment in the ED even with invasive hemodynamic monitoring. It further leads to a significant change in therapy. Further study is warranted to determine the outcome significance of these findings.
77 Now Evaluate Chest Pain With 12-Lead Electrocardiograms and Rapid Markers for Early Recognition of Myocardial Infarctions in the Ambulance (NEW ERA) Dadkhah S, Fisch C, CrabbeG, Gilbert L, Marcotte MA, Lamothe J, Graft J, Aldinger G/St. Francis Hospital, Evanston,IL In the United States, more than 1 million patients die of acute myocardial infarctions (AMls) each year and approximately 30% of them never reached a hospital. Of all AMIs, 50% of ECGs are not diagnostic. It has been shown that patients experiencing AMIs have a delay of at least 100 minutes after the onset of symptoms to arrival in the emergency department, decreasing their chances of salvaging functional myocardium. Study objectives: This study was performed to evaluate the feasibility of combining the widely available 12-lead ECG with the new innovative rapid cardiac markers to diagnose AMI in the prehospital setting. Methods: This multicenter trial involved 5 hospitals (4 of which have emergency percutaneous transluminal coronary angioplasty capabilities) and 5 emergency medical services providers. Twelve-lead ECGs and Point-of-Care Rapid Cardiac Markers (Spectral Diagnostics) were performed before arrival in the ED. The result of the ECGs was transmitted while the results of the markers were telephoned in during transport. Results: Two hundred forty-seven consecutive patients (114 females) were enrolled. Twenty-eight (11.3%) patients had either positive ECGs or markers (rapid myoglobin and rapid creatine kinase isoenzyme MB or rapid myoglobin and rapid troponin I) in
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the ambulance; 17 (6.9%) patients had positive ECGs in the ambulance. Nineteen (7.7%) patients had positive markers. Thirty-seven (15%) patients were positive for AMIs in the ED. Forty-four (18%) Patients were diagnosed with AMIs before being discharged from the hospital. One patient was transported to the catheterization laboratory within 11 minutes of araval in the ED. Conclusion: it is feasible to diagnose AM1 with the use of 12-lead ECGs and rapid cardiac markers in the out-of-hospital setting. The interval between door to diagnosis is shortened allowing for earlier reperfusion strategies.
178 Department Do Age and Gender Affect J3-BlockerUtilization in Emergency Management of Acute Myocardial Infarction? Pancu DM, Lee DC, Salen PN, Roberts SF, Rudolph GS, RyaaJ, Heller MR, Arcona S/St. Luke's Hospital, North Shore University Hospital, Bethlehem, PA Study objective: To determine how age and gender afiects [~-blocker utilization in patients who present with acute myocardial infarction (AMI) to the emergency department. Methods: This is a retrospective cohort pilot study of consecutively enrolled patients (November 1995 to January 1997) presenting with AMI in a 50,000-visit academic ED. Patients were documented to have AM1 by symptoms and ECG. Charts were reviewed for age, gender, and [~-blocker therapy. [~-Blocker utilization was analyzed for gender and age (-<70 and >70 years). Results: Ninety patients met the inclusion criteria, 27 women and 63 men. The mean age was 60 years. The number of contraindications for patients _<70 years was 21% and for patients >70 years was 27% (P=.5); 18% of males and 33% of females had contraindications (P=. 1). Nineteen (28%) of 67 eligible patients received [3-blockers in the ED. Of the 67 patients _<70 years, 54 had no contraindication to ~-blockers and 18 (33%) received them in the ED; only 1 of the 16 patients in the group older than 70 years received [3-blockers, a statistically significant difference (P=.032). Sixteen (31%) of 52 males and 3 (16.7%) of 18 females were eligible for ~-blocker therapy and received ~-blockers in the ED (P=.25). Conclusion: Males versus females and patients -<70 versus patients >70 years show no difference in the frequency of contraindications to ~-blocker therapy. In the setting of AMI, age but not gender was an important factor in determining [~-blocker use.
179 andObStructive T h eShock r ain Pulmonary p y s uEmbolism: r v i Thrombolytic v a l Pivetti S, Aluffi E, Bonino L, Valpreda S, Urbino R, Tartaglino B, Navone F, Bonetto C, Antro C,
GaiV/Medicina d'Urgenza,A O San Giovanni Battista, Torino, Italy Study objectives: Shock resulting from massive pulmonary embolism (PE) shows a variable prevalence in literature, without general agreement about thrombolytic therapy effectiveness. The study objective was to appreciate the prevalence and main clinical features of obstructive shock (OS) in patients with PE admitted to our emergency department, and to evaluate thrombolytic therapy effectiveness (BAPE regimen). Methods: Two hundred eighty-five patients with PE were treated from June 1995 until April 1999; 30 (10.5%) of 285 had OS (17 female, 13 male, mean age 68_+8.5 years). In 93.7% of OS cases, we found at least 1 risk factor for venous thromboembolism and, in 65%, 2 or more risk factors. The clinical onset in 5 of 30 patients was cardiac arrest. We found right bundle branch block in 8 of 30 cases and S1Q3T3 pattern in 8 of 30 cases; in 9 of 30 cases the ECG was normal. Echocardiography, performed in 66% of patients, detected in all cases an enlarged and hypokinetic right ventricle; venous duplex ultrasound, performed in 76.6% of cases, detected deep venous thrombosis in 76%. Perfusion radionuclide lung scan, performed in 70.5% of cases, showed a high probability pattern in 96.6% (29/30) and intermediate pattern in i patient, n-Dimer assay was positive in all cases; arterial blood gas analysis detected hypoxemia in all cases. Results: Seventeen of 30 patients with OS were given thrombolysis according to BAPE regimen (recombinant tissue plasmmogen activator 0.6 mg/kg over 15 minutes); 13 of 30 patients with OS were not given thrombolysis because of absolute contraindications. Thrombolytic therapy decisionmaking rested on clinical data and echocardingraphy in 38~163 of cases and on echocardiography and lung scan in 61% of cases. The in-hospital overall death rate was 36.6% (11/30 patients); all 17 patients given thrombolysis were alive at discharge, whereas 11 (84.6%) of 13 patients not given thrombolysis died in the hospital. No severe complications of thrombolysis were observed Conclusion: We found OS in 10.5% of PE cases; all 17 patients given thrombolysis were alive and showed stable hemodynamic parameters at discharge, and 13 of
ANNALS OF EMERGENCYMEDICINE 34:4 OCTOBER1999, PART 2
RESEARCH FORUM ABSTRACTS
17 were alive at 1-year follow-up (the other 4 patients are on follow-up yet) In the non-thrombolysis-treated group, 11 of 13 patients died d u n n g their hospital stay. An expeditious clinical and instrumental diagnosis is of great relevance as a tool of decisionmaking, especially in thrombolyttc therapy. Furthermore, we found a 100% sensibility of D-dimer assay, hypoxemia as detected by arterial blood gas analysis, analysis, echocardiography, and perfusion radionuclide tung scan.
180
The Efficacyof Cardiac Monitoring in SyncopeAdmissionsFrom the EmergencyDepartment
Sipay SS, GordonJB, Silva JC, Sloan EP, 8ordo D/Resurrection Medical Center, University of Illinois, Chicago, IL Syncope encompasses etiologies ranging from benign to life-threatening Cardiac etiologies were thought to be uncommon; however, because of the potemia[ for sudden death, the current standard of therapy is to admit most patients to monitored beds. Study objective: To develop criteria differentiating the need for monitored versus general medical admission. The study was conducted in an urban teaching hospital with a high percentage of acutely ill elderly. Methods: We conducted a retrospective chart review of all ED patients admitted with syncope from December 1996 to May 1997. We identified 230 patients for the study, of whom 22 were excluded because of transfer to another institution or no documented Ioss of consciousness Of patients determined to have syncope of cardiac ongala, 25% of the charts `.','ere randomly selected and renewed by 3 outside facuhy members for verification. Results: The mean age was 73 )'ears (15 to 99 years) and 34% were male. Cardiac etiology was diagnosed in 47 patients (23%). Of these, dysrhythmias were found in 27 patients: sick sinus syndrome 10, symptomatic bradycardia 7, Wolff-ParkinsonWhite syndrome 1, new-onset atrial fibrillation 3, supraventricular tachycardta 3. and patients with ventricular tachycardia 3. Aortic stenosis was identified in 5 patients Myocardial infarction was diagnosed in 10 patients. Patients age >60 were 3 times more likely to be diagnosed with a cardiac etiology for their syncope (25 versus 10%, P<.07). Significant differences were found between the cardiac and noncardiae groups with regard to ECG rates <60 and > 100 (P=.017) and presence of any injury pattern (P=.003). Conclusion: It may be possible to detect high-risk patients based on initial ECG rate disturbances or presence of injury" pattern. Older patients were more likely to have syncope of cardiac etiology. However, cardiac dysrhythmias may occur in younger patients; therefore, it may still be necessary" to continue the practice of admitting to monitored beds.
181 Acute Myocardial Infarctionin PatientsWithoutST-Segment
How Many CK-MB Determinutions Are Necessary to Rule Out
Elevation? Bassan R. Gamarski R, Pimenta L. Scofano M. Fabricio M. Macaciel R/Pr6-CardiacoHospital, Rio de Janeiro, Brazil Strategies to rapidly rule out acute myocardial infarction (AMI) in patients ",~ath chest pain and no ST-segment elevation have been shov.'n to reduce both length of stay and costs, but the number of plasma creatine kinase isoenzyme MB (CK-MB) measurements for this purpose is still unclear. Objective: To determine the test accuracy of serial CK-MB measurements for AMI. and the time frame necessary to completely rule in/rule out the diagnosis. Methods: An algorithm using chest pain characterization, serial ECG, and CKMB levels (baseline, and 3, 6, and 9 hours after admission) was applied to 635 consecutive patients suspected of having AM1 or unstable angina who had neither ST-segment elevation nor left bundle branch block (LBBB) in their first ECG. Patients with ST depressionFf inversion or definite/probable angina plus a normal/nonspecific (NUNS) ECG were designated as medium-probability (MP) of AMI (n=408). Patients with NUNS ECG plus probable not angina were designated as low-probability (LP) (n=227) AMI was diagnosed by a typical CK-MB curve with or without ECG changes. Results: AMI was seen in 17% of patients in the MP group and in 2% of the LP group. Patients in the MP group had AMI completely ruled out at 9 hours (1% still had normal CK-MB levels at 6 hours), whereas those in the LP group had normal levels at 3 hours. The Table shows the diagnostic accuracy of CK-MB levels for AMI in both groups. Conclusion: A normal CK-MB level on admission does not rule out the diagnosis
OCTOBER 1999, PART 2 34:4 ANNALS OF EMERGENCYMEDICINE
of AMI in MP or LP patients v.ath chest pain and no ST elevation or LBBB. Further CK-MB determination is necessary up to 3 hours in LP patients and up to 9 hours in RiP patients to completely rule out AM[.
Table, abstract 181. Diagnostic Accuracy Sensitivity Negative predictive
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1st CK-MB
lst-Znd CK-MB
1st- 2nd-3rd CK-MB
MP (%) LP(%)
MP (%) LP (%)
MP (%) LP (%)
51 89
75 99
78 95
100 100
96 99
100 100
GenderDifferencesof Echocardiographic Findings in Acute Cardiogenic PulmonaryEdema
Silverman R. Goldman DA. Weg IL. Roth S, Campbell C, Simmons D, Watson M/Lung Island Jewish Medical Center, New Hyde Park. NY Stud)' objectives Gender-related differences in clinical outcome, patient characteristics, and echocardiographic findings have been reported in panents with congeslive beart failure Acute cardiogenic pulmonary edema (APE) is assumed to be caused by systolic dysfunction when patients present to emergency department with resultant management implications The objective is to charactenze the echocardiographic findings in patients `.,,lth APE by gender. Methods: An echocardiogram was performed `,,,1thin 72 hours of ED arrival in patients with APE APE was identified by clinical presentation, a diagnostic chest radiograph, and the onset of severe dyspnea ,.,.']thin 12 hours. Six contiguous myocardial segments were assessed for hypokinesis or akinesis Ejection fraction, degree of left vemncular hypertroph), and degree of mitral regurgitation ",,,'eremeasured Patients with APE and normal systolic function were considered to have diastolic dysfunction Results: Ninety-one patients were included. Mean age was 76 )'ears, 66% were female, and the mean time from ED arrival to echocardiography was 30 hours. Median length of stay was 7 days, and the in-hospital mortality rate was 10% (9/91). Ages of men did not differ from w o m e n / 7 4 versus 77 years, P=NS), nor did the time to echocardiography (27 versus 32 hours. P=NS). Men ",,.'eremore likely to have systolic dysfunction: 87% of men had an ejection fraction <55% versus 50% of women (P=.007) Men had a trend toward lower systolic blood pressure on arrival, with f 3% of men having systolic blood pressure <120 versus 3% of women (P=.077). There were no stguificam differences (P<.05) between men and women respectively, for the follo`.ving: degree of left venmcular hypertrophy _>mild (57% versus 68%), presence of mitra[ regurgmtation >_mild (63% versus 78%), _>1 wall motion abnormalities (74% versus 65%). myc,cardial infarction diagnosed in first 72 hours (19% versus 22%), length of stay (7 versus 7 days), and in-hospital death rate (10% versus 10%). Conclusion: Men presenting wnth APE `.,,'ere more likely to have systolic dysftmction than women, as well as a trend toward lower systobc blood pressure. Diastolic dysfunction `.,.'asmore common in women and should be considered in this population There was no gender-related outcome difference, although the ability of the stud)' to determine prognostic value of echocardiographic findings in gender is limited Oy the relatively few deaths.
183 With EquivocalChestPain?
Is Sestamibi Useful for Ideutilying Cardiac Disease in Putieuts
Johnson GA, RodriguezE. Yon Tramp C, Brown LH/State University of New York Health Science Center. Syracuse, NY Stud)' objective: To determine the sensitixap/and specificity of the sestamibi scan in identifying cardiac disease in emergency department patients wath equivocal chest pain Methods: This study was conducted in an urban ED with a volume of 41,000+. All patients presenting with chest pain are routinely assigned to 1 of 5 pathways. Two of those pathways are for patients v,.nh chest pain clearly of cardiac etiology, and 1 is for patients with chest pain that is clearly not cardiac in nature. The remaining 2 pathways are for patients ",vathchest pain of unknov.'n or unclear etiology. The patients assigned to those 2 pathways served as the sample for this stud)' All patients in the 2 equivocal pathways are evaluated ",,,ath 12-lead ECG and determination of troponin 1,
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