Highly Sensitive ED Protocol for Identifying Low-Risk Patients with Chest Pain
Implementation of a new accelerated diagnostic protocol could reduce emergency department length of stay and hospitalization rate.
Protocols to facilitate safe early discharge from the emergency department (ED) for low-risk patients with chest pain have limitations, including lack of validation and variable sensitivity. The prospective, observational, multinational Asia-Pacific Evaluation of Chest Pain Trial assessed a new, accelerated diagnostic protocol in consecutive adult ED patients who had at least 5 minutes of chest, neck, jaw, or arm pain or discomfort without obvious noncardiac cause and who did not have ST-segment-elevation myocardial infarction (STEMI).
The protocol included Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiogram (ECG), and point-of-care biomarker testing (within 2 hours after arrival) for troponin I, creatine kinase MB, and myoglobin. Patients with TIMI scores of 0, no new ischemic changes on initial ECG, and normal biomarker panels were classified as low risk.
Among 3582 patients who completed 30-day follow-up, 421 (11.8%) had major adverse cardiac events within 30 days, most often non-STEMI (10.1%). Of 352 patients (9.8%) who were classified as low risk, 3 (0.9%) had major adverse cardiac events. The protocol had a sensitivity of 99.3% for identifying low-risk patients, a specificity of 11.0%, and a negative predictive value (NPV) of 99.1%. Had TIMI score not been included, NPV would have been 96.7%, and an additional 44 patients with major adverse cardiac events would have been missed.
Comment:
This study demonstrates that the combination of no new ischemic changes on initial ECG, normal point-of-care biomarker panel within 2 hours, and low pretest probability (TIMI score of 0) identifies patients who can safely be discharged from the ED. However, several issues about use of the protocol remain to be addressed, including performance relative to other protocols, whether use of laboratory biomarker testing improves accuracy, effect on patient care costs and hospital stay, and malpractice risk.
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John A. Marx, MD, FAAEMPublished in Journal Watch Emergency Medicine March 25, 2011
Citation(s): Than M et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): A prospective observational validation study. Lancet 2011 Mar 26; 377:107.
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Background
Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome.
Methods
This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279.
Findings
3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11·8%) patients had a major adverse cardiac event. The ADP classified 352 (9·8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0·9%) of these patients, giving the ADP a sensitivity of 99·3% (95% CI 97·9—99·8), a negative predictive value of 99·1% (97·3—99·8), and a specificity of 11·0% (10·0—12·2).
Interpretation
This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60310-3/abstract
2011年3月25日 星期五
2011年3月12日 星期六
斷層掃描會延誤剖腹手術的時機嗎？
Abdominal Computed Tomography in Hypotensive Trauma Patients Delays Laparotomy and Increases Mortality
Authors urge caution in using this diagnostic tool for patients with blunt or penetrating trauma.
Computed tomography (CT) of the abdomen is being used increasingly in trauma patients, and, although it is highly accurate, its use in certain patients might delay definitive care, specifically laparotomy. To determine the risk that performing abdominal CT will delay laparotomy, researchers reviewed data from the National Trauma Data Bank from 2002 through 2006. Patients (age, above 14 years) with systolic blood pressure below 90 mm Hg on emergency department (ED) arrival and abdominal Abbreviated Injury Scale (AIS) score above 3 who underwent laparotomy within 90 minutes of ED arrival were included in the analysis. Patients transferred from other hospitals and those with significant brain injury (head AIS score above 3) were excluded.
Among 3218 patients, the median Injury Severity Score was 25, and the overall mortality rate was 32%; 446 patients (14%) underwent abdominal CT before laparotomy. The mortality rate was significantly higher in patients who underwent abdominal CT prior to laparotomy than in those who did not (44.8% vs. 29.5%). In logistic regression analysis, abdominal CT was independently associated with risk for death (odds ratio, 1.71), especially among patients who underwent laparotomy within 30 minutes after ED arrival (OR, 7.6).
Comment:
The authors did not assess the influence of ultrasound, diagnostic peritoneal lavage, or presence of pelvic fracture on surgical decision making. However, these findings reinforce that abdominal CT generally is not indicated for hypotensive patients with penetrating trauma or hypotensive patients with blunt trauma and a positive ultrasound or peritoneal lavage result and no pelvic fracture.
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John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine March 11, 2011
Citation(s): Neal MD et al. Over reliance on computed tomography imaging in patients with severe abdominal injury: Is the delay worth the risk? J Trauma 2011 Feb; 70:278.
Authors urge caution in using this diagnostic tool for patients with blunt or penetrating trauma.
Computed tomography (CT) of the abdomen is being used increasingly in trauma patients, and, although it is highly accurate, its use in certain patients might delay definitive care, specifically laparotomy. To determine the risk that performing abdominal CT will delay laparotomy, researchers reviewed data from the National Trauma Data Bank from 2002 through 2006. Patients (age, above 14 years) with systolic blood pressure below 90 mm Hg on emergency department (ED) arrival and abdominal Abbreviated Injury Scale (AIS) score above 3 who underwent laparotomy within 90 minutes of ED arrival were included in the analysis. Patients transferred from other hospitals and those with significant brain injury (head AIS score above 3) were excluded.
Among 3218 patients, the median Injury Severity Score was 25, and the overall mortality rate was 32%; 446 patients (14%) underwent abdominal CT before laparotomy. The mortality rate was significantly higher in patients who underwent abdominal CT prior to laparotomy than in those who did not (44.8% vs. 29.5%). In logistic regression analysis, abdominal CT was independently associated with risk for death (odds ratio, 1.71), especially among patients who underwent laparotomy within 30 minutes after ED arrival (OR, 7.6).
Comment:
The authors did not assess the influence of ultrasound, diagnostic peritoneal lavage, or presence of pelvic fracture on surgical decision making. However, these findings reinforce that abdominal CT generally is not indicated for hypotensive patients with penetrating trauma or hypotensive patients with blunt trauma and a positive ultrasound or peritoneal lavage result and no pelvic fracture.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine March 11, 2011
Citation(s): Neal MD et al. Over reliance on computed tomography imaging in patients with severe abdominal injury: Is the delay worth the risk? J Trauma 2011 Feb; 70:278.
2011年3月5日 星期六
20歲以下非心因性OHCA，要壓胸也要吹氣
Compression-Only CPR Is Less Effective Than Conventional CPR in Some Patients
Among patients with out-of-hospital cardiac arrest in Japan, compression-only cardiopulmonary resuscitation was less effective than conventional CPR in patients younger than 20 with noncardiac causes of arrest.
Findings of several large studies led to guideline revisions recommending that untrained bystanders perform compression-only cardiopulmonary resuscitation (CPR) for adults with out-of-hospital cardiac arrest. Researchers in Japan analyzed a nationwide emergency medical services database to compare outcomes between patients with bystander-witnessed out-of-hospital cardiac arrest who received conventional CPR (19,328 patients) and those who received chest compression-only CPR (27,707 patients) during a 3-year period.
Rates of both overall 1-month survival and neurologically favorable 1-month survival were significantly higher in patients who received conventional CPR (adjusted odds ratio, 1.17 in each case). In analysis by age and cause of arrest, the benefit of conventional CPR was limited to patients younger than 20 with noncardiac causes. In analysis by time from arrest to start of CPR and cause of arrest, the benefit of conventional CPR over compression-only CPR increased with time to CPR among patients with noncardiac causes and among patients with all causes combined, but not among those with cardiac causes.
Comment:
This large study confirms that conventional CPR is the preferred technique for children, who have a higher proportion of noncardiac causes of arrest than adults. For adults, evidence supports compression-only CPR by bystanders. Outcomes in adults likely would be better with compression-only CPR by trained providers, too, but this is not yet proven; so guidelines continue to recommend conventional CPR by trained healthcare providers.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine March 4, 2011
Citation(s):
Ogawa T et al. Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: Nationwide population based observational study. BMJ 2011 Jan 27; 342:c7106. (http://dx.doi.org/10.1136/bmj.c7106)
Among patients with out-of-hospital cardiac arrest in Japan, compression-only cardiopulmonary resuscitation was less effective than conventional CPR in patients younger than 20 with noncardiac causes of arrest.
Findings of several large studies led to guideline revisions recommending that untrained bystanders perform compression-only cardiopulmonary resuscitation (CPR) for adults with out-of-hospital cardiac arrest. Researchers in Japan analyzed a nationwide emergency medical services database to compare outcomes between patients with bystander-witnessed out-of-hospital cardiac arrest who received conventional CPR (19,328 patients) and those who received chest compression-only CPR (27,707 patients) during a 3-year period.
Rates of both overall 1-month survival and neurologically favorable 1-month survival were significantly higher in patients who received conventional CPR (adjusted odds ratio, 1.17 in each case). In analysis by age and cause of arrest, the benefit of conventional CPR was limited to patients younger than 20 with noncardiac causes. In analysis by time from arrest to start of CPR and cause of arrest, the benefit of conventional CPR over compression-only CPR increased with time to CPR among patients with noncardiac causes and among patients with all causes combined, but not among those with cardiac causes.
Comment:
This large study confirms that conventional CPR is the preferred technique for children, who have a higher proportion of noncardiac causes of arrest than adults. For adults, evidence supports compression-only CPR by bystanders. Outcomes in adults likely would be better with compression-only CPR by trained providers, too, but this is not yet proven; so guidelines continue to recommend conventional CPR by trained healthcare providers.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine March 4, 2011
Citation(s):
Ogawa T et al. Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: Nationwide population based observational study. BMJ 2011 Jan 27; 342:c7106. (http://dx.doi.org/10.1136/bmj.c7106)
2011年3月4日 星期五
抽血發現的甲狀腺功能低下〔TSH高〕，要不要治療？
Raised TSH: to treat or not to treat?
Do you treat people with subclinical hypothyroidism?
You are supposed to, according to current guidelines.
The rationale for treating when serum thyroid stimulating hormone (TSH) is above 10 mIU/l is to alleviate mild symptoms, prevent progression to overt hypothyroidism, and lower cardiovascular risk.
Modest TSH elevations (below 7.0 mIU/l) may not warrant treatment. Large scale randomised clinical trials are needed to determine the effects of L-thyroxine treatment on coronary heart disease and related mortality in people who have subclinical hypothyroidism.
The current position seems to be that TSH levels above 10 mIU/l warrant treatment, levels of 7-10 mIU/l warrant consideration, while with levels below 7 mIU/l it may be justifiable to wait and see.
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Source: Evidence-Based Medicine 2011;16:31-32
Do you treat people with subclinical hypothyroidism?
You are supposed to, according to current guidelines.
The rationale for treating when serum thyroid stimulating hormone (TSH) is above 10 mIU/l is to alleviate mild symptoms, prevent progression to overt hypothyroidism, and lower cardiovascular risk.
Modest TSH elevations (below 7.0 mIU/l) may not warrant treatment. Large scale randomised clinical trials are needed to determine the effects of L-thyroxine treatment on coronary heart disease and related mortality in people who have subclinical hypothyroidism.
The current position seems to be that TSH levels above 10 mIU/l warrant treatment, levels of 7-10 mIU/l warrant consideration, while with levels below 7 mIU/l it may be justifiable to wait and see.
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Source: Evidence-Based Medicine 2011;16:31-32
2011年2月18日 星期五
H1N1 使用類固醇可能有害！
Severe H1N1 Influenza Infection: Hold the Corticosteroids!
An observational European study shows that corticosteroids increased risk for pneumonia and conferred no mortality benefit in patients with severe H1N1 infection.
Use of corticosteroids to mitigate the cytokine storm that might contribute to poor outcomes in otherwise healthy people with pandemic H1N1 influenza infection is controversial, even in those with acute respiratory distress syndrome (ARDS). In a prospective observational study, investigators evaluated the effect of corticosteroids on outcomes in 220 intensive care unit (ICU) patients who were enrolled in the European Society of Intensive Care Medicine H1N1 registry from June 2009 through February 2010. H1N1 influenza A infection was confirmed in 194 patients, probable in 2, and suspected in 24. All patients received antivirals, and 78% were mechanically ventilated.
The 126 patients (57%) who received corticosteroids on ICU admission (dosages equivalent to >24 mg/day of methylprednisone or >30 mg/day of prednisone), compared to patients who did not, were significantly older, more likely to have comorbid pulmonary conditions, and more likely to be chronic corticosteroid users. Although patients who received corticosteroids on ICU admission were significantly more likely to contract hospital-acquired pneumonia (26% vs. 14%; odds ratio, 2.2) and to die in the ICU (46% vs. 18%; OR, 3.8), the association with mortality was no longer present after adjustment for severity of disease and other confounding variables (age, asthma, chronic obstructive pulmonary disease, chronic corticosteroid use). Results were similar when the analysis was limited to the 74% of patients with ARDS.
Comment: This study is limited by its observational nature, variable dosing of oseltamivir, and that patients who received "rescue" corticosteroids after ICU admission were not considered part of the corticosteroid group. For now, corticosteroids do not seem helpful - and might be harmful - in patients with H1N1 influenza.
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Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine February 18, 2011
Citation(s): Martin-Loeches I et al. Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection. Intensive Care Med 2011 Feb; 37:272.
An observational European study shows that corticosteroids increased risk for pneumonia and conferred no mortality benefit in patients with severe H1N1 infection.
Use of corticosteroids to mitigate the cytokine storm that might contribute to poor outcomes in otherwise healthy people with pandemic H1N1 influenza infection is controversial, even in those with acute respiratory distress syndrome (ARDS). In a prospective observational study, investigators evaluated the effect of corticosteroids on outcomes in 220 intensive care unit (ICU) patients who were enrolled in the European Society of Intensive Care Medicine H1N1 registry from June 2009 through February 2010. H1N1 influenza A infection was confirmed in 194 patients, probable in 2, and suspected in 24. All patients received antivirals, and 78% were mechanically ventilated.
The 126 patients (57%) who received corticosteroids on ICU admission (dosages equivalent to >24 mg/day of methylprednisone or >30 mg/day of prednisone), compared to patients who did not, were significantly older, more likely to have comorbid pulmonary conditions, and more likely to be chronic corticosteroid users. Although patients who received corticosteroids on ICU admission were significantly more likely to contract hospital-acquired pneumonia (26% vs. 14%; odds ratio, 2.2) and to die in the ICU (46% vs. 18%; OR, 3.8), the association with mortality was no longer present after adjustment for severity of disease and other confounding variables (age, asthma, chronic obstructive pulmonary disease, chronic corticosteroid use). Results were similar when the analysis was limited to the 74% of patients with ARDS.
Comment: This study is limited by its observational nature, variable dosing of oseltamivir, and that patients who received "rescue" corticosteroids after ICU admission were not considered part of the corticosteroid group. For now, corticosteroids do not seem helpful - and might be harmful - in patients with H1N1 influenza.
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Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine February 18, 2011
Citation(s): Martin-Loeches I et al. Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection. Intensive Care Med 2011 Feb; 37:272.
2011年1月28日 星期五
高壓氧治療CO中毒，效果沒想像中好？！
Is Hyperbaric Oxygen Therapy Beneficial in Carbon Monoxide Poisoning?
HBO therapy did not add benefit to normobaric oxygen therapy in these studies.
In two parallel prospective randomized studies, researchers evaluated the effectiveness of hyperbaric oxygen therapy (HBOT) in patients (age, ≥15 years) with acute isolated carbon monoxide (CO) poisoning who presented to an academic hospital in France between 1989 and 2000. In trial A (mild poisoning), 179 patients with transient loss of consciousness received normobaric oxygen therapy (NBOT) for 6 hours or NBOT for 4 hours plus one session of HBOT. In trial B (severe poisoning), 206 comatose patients (Glasgow Coma Scale score below 8) received NBOT for 4 hours plus either one or two HBOT sessions. Each HBOT session lasted 2 hours in a multiplace chamber at 2.0 atmospheres absolute; interval between sessions was 6 to 12 hours. At baseline, 82% of patients in trial A and 65% in trial B had headaches, and 4% and 10%, respectively, had seizures.
At 1 month, patients completed a symptom questionnaire and were evaluated by an intensivist with neurology training who was blinded to treatment group. Complete recovery was defined as absence of patient-reported symptoms and normal physical and neuropsychological exam, "moderate sequelae" was defined as one or more self-reported symptoms, and "severe sequelae" was defined as any objective physical exam finding. In trial A, complete recovery rates were similar in the two groups (approximately 60%), and no patient in either group had severe sequelae. In trial B, complete recovery rates were significantly lower in the group that received two HBOT sessions than in the group that received one session (47% vs. 68%; unadjusted odds ratio, 0.42).
Comment:
The trial A findings support the teaching that most patients with mild CO poisoning will improve after removal from the exposure and treatment with high-flow oxygen. The trial B finding is surprising and suggests that HBOT might not benefit even those patients with severe toxicity. Pending a larger trial with clearer toxicity definitions, physicians should contact a regional poison center or HBOT referral center to discuss with consultants the best approach for an individual patient with known CO poisoning, particularly when the treatment might involve transfer of an unstable patient.
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Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine January 28, 2011
Citation(s):
Annane D et al. Hyperbaric oxygen therapy for acute domestic carbon monoxide poisoning: Two randomized controlled trials. Intensive Care Med 2010 Dec 2; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-010-2093-0)
HBO therapy did not add benefit to normobaric oxygen therapy in these studies.
In two parallel prospective randomized studies, researchers evaluated the effectiveness of hyperbaric oxygen therapy (HBOT) in patients (age, ≥15 years) with acute isolated carbon monoxide (CO) poisoning who presented to an academic hospital in France between 1989 and 2000. In trial A (mild poisoning), 179 patients with transient loss of consciousness received normobaric oxygen therapy (NBOT) for 6 hours or NBOT for 4 hours plus one session of HBOT. In trial B (severe poisoning), 206 comatose patients (Glasgow Coma Scale score below 8) received NBOT for 4 hours plus either one or two HBOT sessions. Each HBOT session lasted 2 hours in a multiplace chamber at 2.0 atmospheres absolute; interval between sessions was 6 to 12 hours. At baseline, 82% of patients in trial A and 65% in trial B had headaches, and 4% and 10%, respectively, had seizures.
At 1 month, patients completed a symptom questionnaire and were evaluated by an intensivist with neurology training who was blinded to treatment group. Complete recovery was defined as absence of patient-reported symptoms and normal physical and neuropsychological exam, "moderate sequelae" was defined as one or more self-reported symptoms, and "severe sequelae" was defined as any objective physical exam finding. In trial A, complete recovery rates were similar in the two groups (approximately 60%), and no patient in either group had severe sequelae. In trial B, complete recovery rates were significantly lower in the group that received two HBOT sessions than in the group that received one session (47% vs. 68%; unadjusted odds ratio, 0.42).
Comment:
The trial A findings support the teaching that most patients with mild CO poisoning will improve after removal from the exposure and treatment with high-flow oxygen. The trial B finding is surprising and suggests that HBOT might not benefit even those patients with severe toxicity. Pending a larger trial with clearer toxicity definitions, physicians should contact a regional poison center or HBOT referral center to discuss with consultants the best approach for an individual patient with known CO poisoning, particularly when the treatment might involve transfer of an unstable patient.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine January 28, 2011
Citation(s):
Annane D et al. Hyperbaric oxygen therapy for acute domestic carbon monoxide poisoning: Two randomized controlled trials. Intensive Care Med 2010 Dec 2; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-010-2093-0)
2011年1月25日 星期二
小兒急救 - 新版的指引
Updated Recommendations for Pediatric Resuscitation
The 2010 International Liaison Committee on Resuscitation Pediatric Task Force has updated the 2005 treatment recommendations for pediatric resuscitation. Highlights include the following:
These consensus recommendations are based on a thorough evaluation of the literature, and emergency physicians should know them.
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Katherine Bakes, MD
Published in Journal Watch Emergency Medicine January 21, 2011
Citation(s): Kleinman ME et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010 Nov; 126:e1261.
The 2010 International Liaison Committee on Resuscitation Pediatric Task Force has updated the 2005 treatment recommendations for pediatric resuscitation. Highlights include the following:
- Initiate cardiopulmonary resuscitation (CPR) if there are no signs of life and a pulse is not palpated within 10 seconds.
- Provide conventional CPR (chest compressions with rescue breathing).
- Compress at least one third of the anterior-posterior dimension of the chest.
- Consider using cuffed tracheal tubes in infants and young children; cuff pressure should not exceed 25 cm H2O. Appropriate sized tubes by age are as follows:
# 3 mm for age ≤1 year
# 3.5 mm for age 1–2 years
# Age in years/4 + 3.5 mm for age >2 years - Modify or discontinue cricoid pressure if it impedes preintubation ventilation or intubation.
- Monitor capnography to confirm endotracheal tube position, recognizing that end-tidal CO2 in infants and children might be below detectable limits for colorimetric devices (85% sensitivity and 100% specificity).
- Consider use of an esophageal detector device in children weighing >20 kg.
- Use capnography monitoring to assess effectiveness of chest compressions.
- Avoid excessive ventilation, which can decrease cerebral perfusion pressure, rates of return of spontaneous circulation (ROSC), and survival rates.
- After ROSC, titrate oxygen concentration to limit the risk for toxic oxygen byproducts.
- For pediatric septic shock, include therapy directed at normalizing central venous oxygen saturation to ≥70%.
- Do not routinely use bicarbonate or calcium for pediatric cardiac arrest: Both agents are associated with decreased survival.
These consensus recommendations are based on a thorough evaluation of the literature, and emergency physicians should know them.
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Katherine Bakes, MD
Published in Journal Watch Emergency Medicine January 21, 2011
Citation(s): Kleinman ME et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010 Nov; 126:e1261.
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