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The risk of stroke in patients with acute myocardial infarction after thrombolytic and antithrombotic treatment
ABSTRACTS
J-point elevation on the ECG.Their surgical ICU length of stay was 2.41 +0.77 days. Group2 (43, age 3t.5 _+10 years) patients had an abnormalECG in addition to the admitting criteria above and had a surgical ICU length of stay of 2.47 +0.94 days. Group3 (183, age 40 +20 years) patients all required surgical ICU admissionfor noncardiac injuries and had four or more rib fractures, pulmonarycontusion,flail chest, age of morethan 60 years, or extrathoracicinjuries. Their surgical ICU length of stay was ten +22 days. None of the patients in Group 1 or 2 had cardiaccomplications and/or required any cardiactreatment. In Group3, 19 patients had cardiac complicationsrequiring treatment, although none had a cardiac death. It was noted that CK-MB values were insensitive in predicting myocardialcontusion and its complications. However, initial ECGwas a better predictor, with 44 patients in Group 3 having abnormal ECGsand cardiac complicationsdeveloping in 19 of them. The authors conclude that young trauma victims with normal initial ECGsand no major thoracic or extrathoracic injury did not benefit from surgical ICU admission.
Sheila M AIton, MD
reviewed by a radiologist and sonoF ogist and comparedwith data obtained from IV urography.Of the 101 patients with renal colic, 69 had ureteral calculus obstruction confirmed by IV urography.One patient had acute renal infarction due to an embolus, and 31 patients had normal IV urographyresults. Ultrasound identified ureteral calculi in only seven patients, comparedwith 61 patients identified with iV urography. The two reviewers identified the presenceof unilateral hydronephrosis on ultrasound imagesalone in 60 and 63 patients. There were no false-positive ultrasound interpretations. False-negativeultrasounds were due to grade one hydronephrosis. All patients with false-negative ultrasounds had spontaneouspassage of calculi and complete recovery. For the diagnosis of acute urinary tract obstruction, ultrasound combinedwith kidney, ureter, bladder radiographyyielded sensitivities of 94% and 97% for the two reviewers at a specificity of 90%. The authors concludethat ultrasound combinedwith kidney, ureter, bladder radiographycan safely and effectively replace IV urographyin the initial evaluation and follow-up of the great majority of patients with renal colic.
Jeffrey P Girkin, MD renal colic
Renal colic: Diagnosis and outcome HaddadMC, Sharif HS, ShahedMS, eta/ Radiology 184:83-88 Jul 1992 This study evaluatedthe usefulness of ultrasoundand kidney, ureter, bladder radiographyin patients with a history of renal colic to assess whether ultrasoundcan replace the standard intravenousurography in detection of acute urinary tract obstruction. In this study, 101 consecutivepatients with renal colic were evaluatedwith ultrasound followed immediatelyby IV urography. The ultrasoundimageswere
148/1521
against medical advice
Emergency department discharges against medical advice Dubow D, ProppD, NarasimhanK J EmergMed 10.'513-516 Jul 1992 This retrospectivestudy examined emergencyphysicians' documentation of key points when patients were dischargedagainst medical advice and evaluatedthese patients' perceptions of the emergency department experience.The records of 52 consecutiveagainst medical advice dischargeswere reviewed. The authors identified that the documentation on the records of these 52
patients was generally poor. Sixtyseven percent of the charts addressedthe competenceof the patient. In addition, the physicians documentedthat the patients understood their diagnosis in 36% of the charts, proposedtreatment in 44% of the charts, alternative therapy in 2% of the charts, and the clinical consequencesof refusing care in 57% of the charts. The discharge instructions included a referral to another physician 62% of the time. A follow-up telephone survey surprisingly showed that 70% of the 24 patients who could be contacted were satisfied with their interaction with the emergencyphysician. However, 82% of the follow-up group left becausethey did not agree with the physician's management plan and 75% of these patients would sign out against medical advice again in a repeat encounter. These results suggest that every chart should reflect that the patient understandsthe diagnosis,treatment offered, alternative therapy, and consequencesof declining therapy. The chart should also reflect that no patient signs out against medical advice unless he or she is judged to be competent.
Kristy A Genners,MD abdominal aortic aneurysm
Misdiagnosis of ruptured abdominal aortic aneurysms Marston WA, Ahlquist R, Johnson G Jr, et al J Vasc Surg 16:17-22 Jul 1992 The authors retrospectivelystudied 152 cases of ruptured abdominal aortic aneurysm(RAAA}during a 16year period to examinefactors associated with misdiagnosis. Misdiagnosis in the study was defined as delay in diagnosis of at least six hours or initial primary diagnosis other than RAAA. In the study, 46 (30%) of the cases were misdiagnosed.The most common misdiagnoseswere renal colic,
diverticulitis, gastrointestinal hemorrhage, acute myocardial infarction, and back pain. A pulsatile abdominal mass was found in 72% of those patients correctly diagnosedas compared with 26% of those patients who were misdiagnosed(P< .005). Abdominal pain, back pain, and shock were the most commonclinical findings in the misdiagnosed group, but rarely were all three present in the same patient (the classic triad of RAAA). Interestingly,there was no significant difference in mortality between the misdiagnosed and the correctly diagnosedgroups; however, this was probablythe result of a bias for the less severe RAAA patients to fall in the misdiagnosed category.The authors conclude that the diagnosis of RAAA must be consideredin all elderly patients presentingwith abdominal pain, back pain, or shock and that the absenceof a pulsatile abdominal mass was the most likely cause leading to an incorrect diagnosis.
ThomasJ Deskin, MD stroke; acute myocardial infarction; thrombolytic therapy
The risk of stroke in patients with acute myocardial infarction after thrombolytic and antithrombotic treatment Maggioni AP, FranzosiMG, Santoro E, et al N Engl J Med 327.1-6 Jul 1992 This study was undertakento determinethe incidenceof stroke in patients with acute myocardial infarction treated with different thrombolytic and antithrombotic protocols. Previousstudies have shown that thrombotytic therapy alone does not imposean excessive risk of stroke. Two large studies (GISSI-2and International Study Group) involving 20,768 patients hospitalizedfor myocardialinfarction
ANNALS OF EMERGENCY MEDICiNE
2 1 : 1 2 DECEMBER 1992
ABSTRACTS
were analyzed for evidence of stroke occurring during their hospitalization. Patients received either streptekinase or recombinant tissue plasminogen activator (t-PA) and subcutaneous heparin or no heparin. Ninety-one percent of the patients also received aspirin. A small but significant increase in the incidence of stroke (1.33% versus 0.94%) was observed in patients receiving t-PA versus streptokinase. No difference in incidence was noted when subcutaneous heparin was used. Anterior infarction, a higher Killip class, and older age increased the risk of stroke, while the use of aspirin lowered the risk. The authors conclude that thrombolytic therapy in the setting of acute myocardial infarction imparts a small risk of stroke and that risk is slightly greater when t-PA is used compared with streptokinase. The use of subcutaneous heparin does not increase the risk. Scott W Pauls, MD radiograph, chest
Bias and 'overcall' in interpreting chest radiographs in young febrile children gramer MS, Roberts-Brguer R, Williams RL Pediatrics 90.11-13 Jol 1992 This study examines the bias introduced by the treating physician's interpretation of pediatric chest radiographs on the official radiologist's reading. The readings (by pediatric attending staff or senior residents) of 287 chest radiographs of febrile children aged 3 to 24 months were compared with the readings by "official" pediatric radiologists who had available the initial emergency department interpretation and clinical history. This interpretation then was compared with that of a pediatric radiologist blinded to the initial reading. The study found that when the treating physicians' readings were positive for pneumonia the
DECEMBER1992
official radiologists' positivity rate was higher than the blind radiologist's rate (74.4% versus 51.8%, P< .005). Conversely,when the treating physicians' readings were negative, the official radiologists' positivity rate was lower than the blind radiologist's rate (8.5% versus 12.8%, P= NS). Clinical signs and symptoms recorded on the radiograph requisition did not result in significant reading discrepancy. The authors conclude that bias and overcall in the interpretation of these radiographs were introduced by the reading of the treating physician and that unnecessary antibiotic treatment and hospitalization may result from this bias. Paul W Lane, MD pulmonary embolism; chronic
probability, 100% had pulmonary embolism; 22% of patients with intermediate WQ scans had pulmonary embolism; 6% of patients with low probability V/Q scans had pulmonary embolism; and none of the patients with normal WQ scans had pulmonary embolism. The authors conclude that the value of the V/Q scan is diminished in chronic obstructive pulmonary disease patients because the majority will have scans of intermediate probability and will require further studies such as angiography. Although the frequency of high probability and norma/V/Q scans was greatly reduced, the predictive value of these scans was maintained, allowing for a satisfactory noninvasive diagnosis in these instances. Scott W McCufloch, MD
obstructive pulmonary disease
The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease Lesser BA, Looper KV, Stein PD, et al Chest 102.'17-22 Jul 1992 This study was conducted in 108 patients with chronic obstructive pulmonary disease to determine the clinical features and noninvasive tests that could be used to assess for pulmonary embolism. Twentyone of 108 patients were found to have pulmonary embolism. The diagnosis was made by angiography in 20 patients and at autopsy in one. Predisposing factors, clinical findings, roentgenegraphic abnormalities, and alveolar-arterial gradients could not distinguish between the group with pulmonary embolism and the group without it. Ventilation/ perfusion scans (V/Q) were performed on all patients. Five percent were read as high probability, 60% as intermediate, 30% as low, and 5% as normal. Of the 5% read as high
21:12 ANNALS 0FEMERGENCYMEDICJNE
cerebral hemorrhage
Emergency reversal of anticoagulation after intracerebral hemorrhage Fredriksson K,, Norrviog B, Strdmblad L-G Stroke 23.972-977 Jul 1992 This study evaluated, retrospectively and nonrandomly, 17 cases of anticoagulant-related intracranial hemorrhage. Each patient was treated with vitamin K and either fresh frozen plasma or prothrombin complex concentrate. In the group of patients treated with fresh frozen plasma (seven patients), the mean prothrombin time decreased from 2.97 to 1.74 international normalized ratio within 7.3 hours, compared with a decrease from 2.83 to 1.22 within 4.8 hours in the group receiving prothrombin complex concentrate (ten patients). This represents a four-to-five times more rapid response with prothrombin complex concentrate than with fresh frozen plasma (P< .001). Clinical progression of each patient was also evaluated using an eight-graded reaction
level scale. Patients receiving prothrombin complex concentrate progressed an average of 0.2 grades compared with 1.9 grades in those receiving fresh frozen plasma (P< .05). The authors conclude that treatment with prothrombin complex concentrate reverses anticoagulation more rapidly than fresh frozen plasma and this may be important in preventing further hemorrhage. They also note that the more rapid • response to prothrombin complex concentrate is probably a function of the higher effective doses of prothrembin complex concentrate given secondary to concerns about volume when using fresh frozen plasma (10 mL prothrombin complex concentrate is equivalent to 600 mL fresh frozen plasma). [Editor's note:Although clinical outcomes appeared to be better in the prothrombin complex concentrate group, the nonrandomized, retrospective design and smafl number of patients preclude drawing conclusions regarding efficacy. Considering the hazards of prothrombin complex concentrate use (hepatitis transmission and generalized thromboembofism), much additional study is needed before widespread use of this product for this problem.] Theodore G Lawson, MD trauma; triage
Comparative performance of the Baxt Trauma Triage Rule Emermao CL, Shade B, KubincanekJ Am J Emerg Med 10.294-297 Jul 1992 This retrospective review of a data base of trauma patients transported by the City of Cleveland Emergency Medical Services compared the performance of the Baxt Trauma Triage Rule versus three other trauma triage scoring systems: the Prehospitai index, the TriageRevised Trauma Score, and the CRAMS scale. The Baxt Trauma Triage Rule defines adult major trauma as patients with a systolic blood pressure less than 85 mm Hg,
1522/149
J-point elevation on the ECG.Their surgical ICU length of stay was 2.41 +0.77 days. Group2 (43, age 3t.5 _+10 years) patients had an abnormalECG in addition to the admitting criteria above and had a surgical ICU length of stay of 2.47 +0.94 days. Group3 (183, age 40 +20 years) patients all required surgical ICU admissionfor noncardiac injuries and had four or more rib fractures, pulmonarycontusion,flail chest, age of morethan 60 years, or extrathoracicinjuries. Their surgical ICU length of stay was ten +22 days. None of the patients in Group 1 or 2 had cardiaccomplications and/or required any cardiactreatment. In Group3, 19 patients had cardiac complicationsrequiring treatment, although none had a cardiac death. It was noted that CK-MB values were insensitive in predicting myocardialcontusion and its complications. However, initial ECGwas a better predictor, with 44 patients in Group 3 having abnormal ECGsand cardiac complicationsdeveloping in 19 of them. The authors conclude that young trauma victims with normal initial ECGsand no major thoracic or extrathoracic injury did not benefit from surgical ICU admission.
Sheila M AIton, MD
reviewed by a radiologist and sonoF ogist and comparedwith data obtained from IV urography.Of the 101 patients with renal colic, 69 had ureteral calculus obstruction confirmed by IV urography.One patient had acute renal infarction due to an embolus, and 31 patients had normal IV urographyresults. Ultrasound identified ureteral calculi in only seven patients, comparedwith 61 patients identified with iV urography. The two reviewers identified the presenceof unilateral hydronephrosis on ultrasound imagesalone in 60 and 63 patients. There were no false-positive ultrasound interpretations. False-negativeultrasounds were due to grade one hydronephrosis. All patients with false-negative ultrasounds had spontaneouspassage of calculi and complete recovery. For the diagnosis of acute urinary tract obstruction, ultrasound combinedwith kidney, ureter, bladder radiographyyielded sensitivities of 94% and 97% for the two reviewers at a specificity of 90%. The authors concludethat ultrasound combinedwith kidney, ureter, bladder radiographycan safely and effectively replace IV urographyin the initial evaluation and follow-up of the great majority of patients with renal colic.
Jeffrey P Girkin, MD renal colic
Renal colic: Diagnosis and outcome HaddadMC, Sharif HS, ShahedMS, eta/ Radiology 184:83-88 Jul 1992 This study evaluatedthe usefulness of ultrasoundand kidney, ureter, bladder radiographyin patients with a history of renal colic to assess whether ultrasoundcan replace the standard intravenousurography in detection of acute urinary tract obstruction. In this study, 101 consecutivepatients with renal colic were evaluatedwith ultrasound followed immediatelyby IV urography. The ultrasoundimageswere
148/1521
against medical advice
Emergency department discharges against medical advice Dubow D, ProppD, NarasimhanK J EmergMed 10.'513-516 Jul 1992 This retrospectivestudy examined emergencyphysicians' documentation of key points when patients were dischargedagainst medical advice and evaluatedthese patients' perceptions of the emergency department experience.The records of 52 consecutiveagainst medical advice dischargeswere reviewed. The authors identified that the documentation on the records of these 52
patients was generally poor. Sixtyseven percent of the charts addressedthe competenceof the patient. In addition, the physicians documentedthat the patients understood their diagnosis in 36% of the charts, proposedtreatment in 44% of the charts, alternative therapy in 2% of the charts, and the clinical consequencesof refusing care in 57% of the charts. The discharge instructions included a referral to another physician 62% of the time. A follow-up telephone survey surprisingly showed that 70% of the 24 patients who could be contacted were satisfied with their interaction with the emergencyphysician. However, 82% of the follow-up group left becausethey did not agree with the physician's management plan and 75% of these patients would sign out against medical advice again in a repeat encounter. These results suggest that every chart should reflect that the patient understandsthe diagnosis,treatment offered, alternative therapy, and consequencesof declining therapy. The chart should also reflect that no patient signs out against medical advice unless he or she is judged to be competent.
Kristy A Genners,MD abdominal aortic aneurysm
Misdiagnosis of ruptured abdominal aortic aneurysms Marston WA, Ahlquist R, Johnson G Jr, et al J Vasc Surg 16:17-22 Jul 1992 The authors retrospectivelystudied 152 cases of ruptured abdominal aortic aneurysm(RAAA}during a 16year period to examinefactors associated with misdiagnosis. Misdiagnosis in the study was defined as delay in diagnosis of at least six hours or initial primary diagnosis other than RAAA. In the study, 46 (30%) of the cases were misdiagnosed.The most common misdiagnoseswere renal colic,
diverticulitis, gastrointestinal hemorrhage, acute myocardial infarction, and back pain. A pulsatile abdominal mass was found in 72% of those patients correctly diagnosedas compared with 26% of those patients who were misdiagnosed(P< .005). Abdominal pain, back pain, and shock were the most commonclinical findings in the misdiagnosed group, but rarely were all three present in the same patient (the classic triad of RAAA). Interestingly,there was no significant difference in mortality between the misdiagnosed and the correctly diagnosedgroups; however, this was probablythe result of a bias for the less severe RAAA patients to fall in the misdiagnosed category.The authors conclude that the diagnosis of RAAA must be consideredin all elderly patients presentingwith abdominal pain, back pain, or shock and that the absenceof a pulsatile abdominal mass was the most likely cause leading to an incorrect diagnosis.
ThomasJ Deskin, MD stroke; acute myocardial infarction; thrombolytic therapy
The risk of stroke in patients with acute myocardial infarction after thrombolytic and antithrombotic treatment Maggioni AP, FranzosiMG, Santoro E, et al N Engl J Med 327.1-6 Jul 1992 This study was undertakento determinethe incidenceof stroke in patients with acute myocardial infarction treated with different thrombolytic and antithrombotic protocols. Previousstudies have shown that thrombotytic therapy alone does not imposean excessive risk of stroke. Two large studies (GISSI-2and International Study Group) involving 20,768 patients hospitalizedfor myocardialinfarction
ANNALS OF EMERGENCY MEDICiNE
2 1 : 1 2 DECEMBER 1992
ABSTRACTS
were analyzed for evidence of stroke occurring during their hospitalization. Patients received either streptekinase or recombinant tissue plasminogen activator (t-PA) and subcutaneous heparin or no heparin. Ninety-one percent of the patients also received aspirin. A small but significant increase in the incidence of stroke (1.33% versus 0.94%) was observed in patients receiving t-PA versus streptokinase. No difference in incidence was noted when subcutaneous heparin was used. Anterior infarction, a higher Killip class, and older age increased the risk of stroke, while the use of aspirin lowered the risk. The authors conclude that thrombolytic therapy in the setting of acute myocardial infarction imparts a small risk of stroke and that risk is slightly greater when t-PA is used compared with streptokinase. The use of subcutaneous heparin does not increase the risk. Scott W Pauls, MD radiograph, chest
Bias and 'overcall' in interpreting chest radiographs in young febrile children gramer MS, Roberts-Brguer R, Williams RL Pediatrics 90.11-13 Jol 1992 This study examines the bias introduced by the treating physician's interpretation of pediatric chest radiographs on the official radiologist's reading. The readings (by pediatric attending staff or senior residents) of 287 chest radiographs of febrile children aged 3 to 24 months were compared with the readings by "official" pediatric radiologists who had available the initial emergency department interpretation and clinical history. This interpretation then was compared with that of a pediatric radiologist blinded to the initial reading. The study found that when the treating physicians' readings were positive for pneumonia the
DECEMBER1992
official radiologists' positivity rate was higher than the blind radiologist's rate (74.4% versus 51.8%, P< .005). Conversely,when the treating physicians' readings were negative, the official radiologists' positivity rate was lower than the blind radiologist's rate (8.5% versus 12.8%, P= NS). Clinical signs and symptoms recorded on the radiograph requisition did not result in significant reading discrepancy. The authors conclude that bias and overcall in the interpretation of these radiographs were introduced by the reading of the treating physician and that unnecessary antibiotic treatment and hospitalization may result from this bias. Paul W Lane, MD pulmonary embolism; chronic
probability, 100% had pulmonary embolism; 22% of patients with intermediate WQ scans had pulmonary embolism; 6% of patients with low probability V/Q scans had pulmonary embolism; and none of the patients with normal WQ scans had pulmonary embolism. The authors conclude that the value of the V/Q scan is diminished in chronic obstructive pulmonary disease patients because the majority will have scans of intermediate probability and will require further studies such as angiography. Although the frequency of high probability and norma/V/Q scans was greatly reduced, the predictive value of these scans was maintained, allowing for a satisfactory noninvasive diagnosis in these instances. Scott W McCufloch, MD
obstructive pulmonary disease
The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease Lesser BA, Looper KV, Stein PD, et al Chest 102.'17-22 Jul 1992 This study was conducted in 108 patients with chronic obstructive pulmonary disease to determine the clinical features and noninvasive tests that could be used to assess for pulmonary embolism. Twentyone of 108 patients were found to have pulmonary embolism. The diagnosis was made by angiography in 20 patients and at autopsy in one. Predisposing factors, clinical findings, roentgenegraphic abnormalities, and alveolar-arterial gradients could not distinguish between the group with pulmonary embolism and the group without it. Ventilation/ perfusion scans (V/Q) were performed on all patients. Five percent were read as high probability, 60% as intermediate, 30% as low, and 5% as normal. Of the 5% read as high
21:12 ANNALS 0FEMERGENCYMEDICJNE
cerebral hemorrhage
Emergency reversal of anticoagulation after intracerebral hemorrhage Fredriksson K,, Norrviog B, Strdmblad L-G Stroke 23.972-977 Jul 1992 This study evaluated, retrospectively and nonrandomly, 17 cases of anticoagulant-related intracranial hemorrhage. Each patient was treated with vitamin K and either fresh frozen plasma or prothrombin complex concentrate. In the group of patients treated with fresh frozen plasma (seven patients), the mean prothrombin time decreased from 2.97 to 1.74 international normalized ratio within 7.3 hours, compared with a decrease from 2.83 to 1.22 within 4.8 hours in the group receiving prothrombin complex concentrate (ten patients). This represents a four-to-five times more rapid response with prothrombin complex concentrate than with fresh frozen plasma (P< .001). Clinical progression of each patient was also evaluated using an eight-graded reaction
level scale. Patients receiving prothrombin complex concentrate progressed an average of 0.2 grades compared with 1.9 grades in those receiving fresh frozen plasma (P< .05). The authors conclude that treatment with prothrombin complex concentrate reverses anticoagulation more rapidly than fresh frozen plasma and this may be important in preventing further hemorrhage. They also note that the more rapid • response to prothrombin complex concentrate is probably a function of the higher effective doses of prothrembin complex concentrate given secondary to concerns about volume when using fresh frozen plasma (10 mL prothrombin complex concentrate is equivalent to 600 mL fresh frozen plasma). [Editor's note:Although clinical outcomes appeared to be better in the prothrombin complex concentrate group, the nonrandomized, retrospective design and smafl number of patients preclude drawing conclusions regarding efficacy. Considering the hazards of prothrombin complex concentrate use (hepatitis transmission and generalized thromboembofism), much additional study is needed before widespread use of this product for this problem.] Theodore G Lawson, MD trauma; triage
Comparative performance of the Baxt Trauma Triage Rule Emermao CL, Shade B, KubincanekJ Am J Emerg Med 10.294-297 Jul 1992 This retrospective review of a data base of trauma patients transported by the City of Cleveland Emergency Medical Services compared the performance of the Baxt Trauma Triage Rule versus three other trauma triage scoring systems: the Prehospitai index, the TriageRevised Trauma Score, and the CRAMS scale. The Baxt Trauma Triage Rule defines adult major trauma as patients with a systolic blood pressure less than 85 mm Hg,
1522/149