Initial Emergency Department Evaluation Research Articles

A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments.

To determine the feasibility of a conservative (expectant) approach to major blunt renal laceration with urinary extravasation and devitalized renal segments. All patients treated conservatively who presented between 1990 and 1999 with major renal laceration (grade 4 and 5) were retrospectively reviewed to determine whether urinary extravasation and devitalized segments adversely affected the outcome. For each patient the data collected included the initial emergency department evaluation, findings on computed tomography, associated injuries, duration of hospital stay, transfusion requirements, complications and follow-up imaging. Of 20 patients who sustained blunt trauma resulting in a major renal laceration (five grade 5 and 15 grade 4) with urinary extravasation, 11 had coexisting devitalized segments. There was a statistically significant difference in the length of hospital stay (16.3 vs 7.3 days), blood transfusions (six vs two patients, P < 0.08) and the need for delayed surgical intervention (nine vs two, P < 0.01) between patients with and with no devitalized segments, respectively. Urinary extravasation spontaneously resolved in two of 11 patients with and in seven of nine with no devitalized segment, respectively (P < 0.05) Urinary extravasation will resolve spontaneously in most patients with blunt renal trauma, and expectant treatment does not adversely affect the outcome or prolong hospitalization. In patients who present with a major renal laceration associated with devascularized segments, conservative management is feasible in those who are clinically stable with blunt trauma. However, the physician must be especially aware of the probable complications within this subset of patients.

Which chest pain patients potentially benefit from continuous 12-lead ST-segment monitoring with automated serial ECG?

A prospective observational study was performed in 678 chest pain patients with suspected acute coronary ischemic syndrome (ACS) and absence of clinical and ECG criteria for emergent reperfusion therapy on presentation to determine how often continuous 12-lead ST-segment monitoring with automated serial ECG (SECG) results in a significant change in therapy during the initial emergency department (ED) evaluation in typical high- and low-risk chest pain patients. After initial history, physical, and ECG were obtained, patients were grouped into high and low risk subgroups based on ED physician's assessment of likelihood of ACS. Significant change in therapy was defined as thrombolytic drug administration, emergent percutaneous coronary angioplasty (PTCA), and intensive anti-ischemic therapy with intravenous heparin and/or intravenous nitroglycerin. SECG monitoring was continued until either the patient was taken for emergent PTCA or until 2-hour serum markers measurements were obtained. A total of 26 patients therapy was changed secondary to SECG monitoring which represented 14.6% of high-risk patients and 1.1% of low-risk patients. New injury (21 patients) and new ischemia (4 patients) were the only SECG findings that led to a change in therapy. SECG monitoring had a 15.2 times increased odds of changing therapy in the high risk patients as compared with the low risk patients ( P < .0001; 95% CI 6.1 to 38.2). Chest pain evaluation protocols that exclude these high risk ED patients from SECG monitoring should be reevaluated. Our data also suggests that researchers designing randomized studies to show utility of SECG monitoring should focus on the high-risk patients. (Am J Emerg Med 2000;18:773-778.

SELECTIVE NONOPERATIVE MANAGEMENT OF BLUNT GRADE 5 RENAL INJURY

We determined the feasibility of a nonoperative approach to blunt grade 5 renal injury. We retrospectively reviewed the records of all patients with grade 5 renal injury who presented to our level 1 trauma center from 1993 to 1998. Those treated nonoperatively and surgically were assigned to groups 1 and 2, respectively. Each group was compared with respect to the initial emergency department evaluation, computerized tomography findings, associated injuries, duration of hospital stay and intensive care unit stay, transfusion requirements, complications and followup imaging. Of 218 renal injuries evaluated 13 were grade 5. In group 1, 6 patients were treated nonoperatively and in group 2, 7 underwent exploration. Each group had similar average hospitalization (12.0 and 12.8 days, respectively). Patients in group 1 had fewer intensive care unit days (4.3 versus 9.0), significantly lower transfusion requirements (2.7 versus 25.2 units, p = 0.0124) and fewer complications during the hospital course. Followup computerized tomography of nonoperatively managed cases revealed functioning renal parenchyma with resolution of retroperitoneal hematoma. Conservative management of blunt grade 5 renal injury is feasible in patients who are hemodynamically stable at presentation.

Serial creatinine kinase (CK) MB testing during the emergency department evaluation of chest pain: Utility of a 2-hour ΔCK-MB of +1.6 ng/ml

Background Traditional methods of using creatinine kinase (CK)-MB to diagnose acute myocardial necrosis rely on the total CK-MB exceeding a threshold of normalcy before being considered diagnostic. Because the CK-MB rapid immunoassay is both sensitive and precise, a small difference between two serial samples over an appropriate time interval may result in an increased sensitivity for acute myocardial infarction (AMI) compared with traditional methods if an appropriate cutoff value is chosen.Methods and Results Baseline and 2-hour CK-MB immunoassay measurements were performed in 710 patients with chest pain whose baseline CK-MB was less than two times upper limits of normal (<12 ng/ml) to determine whether a rise in CK-MB ≥+1.6 ng/ml is more sensitive and specific than an abnormal 2-hour CK-MB in the detection of patients with AMI during the initial emergency department evaluation of chest pain. The baseline (MB0) or 2-hour (MB2) CK-MB was considered positive if the CK-MB level was ≥6 ng/ml. MBΔ was defined as the difference of MB2 and MB0 and was considered positive if the value was ≥+1.6 ng/ml. A positive MB2 was more sensitive for the detection of AMI (75.2% vs 17.7%; p < 0.0001) than a positive MB0. A positive MBΔ was more sensitive for the detection of AMI (93.8% vs 75.2%; p < 0.0001) than a positive MB2. There were no statistically significant differences in specificities for AMI for any test modality.Conclusions A rise in CK-MB of ≥+1.6 ng/ml in 2 hours is a useful marker of AMI during the initial emergency department evaluation of patients with chest pain. (Am Heart J 1998;136:237-44.)

Comparison of Arterial and Venous Blood Gas Values in the Initial Emergency Department Evaluation of Patients With Diabetic Ketoacidosis

Study objective: To determine whether venous blood gas values can replace arterial gas values in the initial emergency department evaluation of patients with suspected diabetic ketoacidosis. Methods: This prospective comparison was performed in an adult university teaching hospital ED. Samples for arterial and venous blood gas analysis were obtained during initial ED evaluations. The venous gas samples were collected with samples for other blood tests at the time of intravenous line insertion. Both arterial and venous samples were obtained before the initiation of treatment. Result: Data from 44 episodes of diabetic ketoacidosis in 38 patients were analyzed. Laboratory findings of those patients with diabetic ketoacidosis were as follows (mean±SD): arterial pH, 7.20±.14; venous pH, 7.17±.13; serum glucose, 33.8±16 mmol/L (609±288 mg/dL); arterial HCO 3 –, 11.0±6.0 mmol; venous HCO 3 –, 12.8±5.5 mmol/L; serum CO 2, 11.8±5.0 mmol/L; and anion gap, 26.7±7.6 mmol/L. The mean difference between arterial and venous pH values was 0.03 (range 0.0 to 0.11). Arterial and venous pH results ( r=.9689) and arterial and venous HCO 3 – results ( r=.9543) were highly correlated and showed a high measure of agreement. Conclusion: Venous blood gas measurements accurately demonstrate the degree of acidosis of adult ED patients presenting with diabetic ketoacidosis. [Brandenburg MA, Dire DH: Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis. Ann Emerg Med April 1998; 31:459-465.]

Usefulness of Automated Serial 12-Lead ECG Monitoring During the Initial Emergency Department Evaluation of Patients With Chest Pain

Study objective: To determine whether the use of automated serial 12-lead ECG monitoring (SECG) is more sensitive and specific than the initial 12-lead ECG in the detection of injury and ischemia in patients with acute coronary syndromes (ACS) during the initial ED evaluation of patients with chest pain. Methods: A prospective observational study was performed in 1,000 patients with chest pain who were admitted to a university teaching hospital and who underwent continuous ST-segment monitoring with SECG during the initial ED evaluation. The initial ECG was obtained on presentation, and SECG readings were obtained at least every 20 minutes during the ED evaluation. Diagnostic abnormalities on the initial ECG were defined as injury or ischemia. Diagnostic changes on SECG were defined as evolving injury, evolving ischemia, new injury, or new ischemia. ACS was defined as acute myocardial infarction (AMI), recent myocardial infarction, or unstable angina. Results: A diagnostic SECG was more sensitive than a diagnostic initial ECG for detection of AMI (68.1% versus 55.4%; P<.0001) and ACS (34.2% versus 27.5%; P<.0001). A diagnostic SECG was more specific than a diagnostic initial ECG for detection of ACS (99.4% versus 97.1%; P<.01). SECG detected injury in an additional 16.2% of AMI patients compared with the initial ECG (61.8% versus 45.6%; P<.0001; 95% confidence interval for difference of proportions, 10.9% to 21.4%). Conclusion: SECG during the initial ED evaluation is more sensitive and more specific than the initial ECG in the identification of ACS. Patients with a diagnostic SECG need intensive antiischemic therapy, evaluation for reperfusion therapy, and admission to an ICU. [Fesmire FM, Percy RF, Bardoner JB, Wharton DR, Calhoun FB: Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain. Ann Emerg Med January 1998;31:3-11.]

BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage.

To develop an outcome prediction tool (BLEED: ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, unstable comorbid disease) for clinical use in patients with either acute upper or acute lower gastrointestinal (GI) hemorrhage. A cohort study. Barnes Hospital and Jewish Hospital, two private university-affiliated teaching hospitals in St. Louis, MO. Four hundred sixty-five patients with either acute upper or acute lower GI hemorrhage admitted from the emergency department. Admission of patients to the intensive care unit or hospital ward was determined by emergency department physicians, without use or knowledge of BLEED criteria. Patients meeting any BLEED criteria at their initial assessment in the emergency department were classified as "high-risk." All other patients were classified as "low-risk." The main outcome measure was the occurrence of an inhospital complication, defined as recurrent GI hemorrhage, surgery to control the source of hemorrhage, and hospital mortality. Patients classified as high-risk had significantly greater rates of inhospital complications at both Barnes Hospital (relative risk, 2.47; 95% confidence interval, 1.38 to 4.44; p < .001) and Jewish Hospital (relative risk, 8.94; 95% confidence interval, 3.92 to 20.41; p < .001) compared with patients classified as low-risk. Patients classified as high-risk at either hospital were significantly more likely to develop additional organ system derangements, require a greater number of transfused units of packed red blood cells, and have longer hospital stays compared with patients classified as low-risk (p < .006). The BLEED classification also identified a greater frequency of intensive care admission for both low-risk (RR, 4.21; 95% Cl, 2.24 to 7.89) and high-risk (relative risk, 1.58; 95% confidence interval, 1.23 to 2.02) patients at Barnes Hospital compared with those patients at Jewish Hospital, although no beneficial effects on patient outcome were reported. The BLEED classification, applied at initial emergency department evaluation and before admission, predicts hospital outcomes for patients with acute upper or lower GI hemorrhage. This outcome prediction tool also identified variations in intensive care utilization between two hospitals.

ST-segment instability preceding simultaneous cardiac arrest and AMI in a patient undergoing continuous 12-lead ECG monitoring

Little data exist concerning the actual onset time (time zero) in sudden death (SD) and acute myocardial infarction (AMI). Most studies have focused on describing the warning arrhythmias that occur before SD and AMI and have relied on retrospective analyses of fortuitous data obtained from patients who experience these adverse outcomes while undergoing routine ambulatory holter monitoring. Because of the limitations of holter monitoring, little information is known concerning the actual incidence of ST-segment changes preceding SD and AMI. The first case of simultaneous onset of silent SD and AMI occurring in a patient undergoing continuous 12-lead electrocardiograph (ECG) monitoring during his initial emergency department evaluation is reported. Analyses of the serial 12-lead electrocardiographs showed extensive transient silent ST-segment elevations and depressions preceding cardiac arrest and AMI and provided insight in the pathogenesis of SD and AMI. Continuous 12-lead ECG monitoring can identify patients at high risk for SD and AMI and allow physicians to intervene before the development of life-threatening conditions.

SECONDARY SURVEY FOLLOWING BLUNT TRAUMA

Computerized tomographic (CT) scanning for blunt abdominal trauma has focused on initial emergency department evaluation. At our institution, CT scanning is often used on a delayed basis for unexplained drops in hematocrit, investigation of bony injuries, or subtle abdominal findings. We reviewed 268 such scans. Over 32 months, 487 CT scans were done for 5258 blunt trauma admissions. Of these scans, 268 (55%) were done 8-72 hours after admission on patients under observation. Scanning indications were a falling hematocrit (67%), associated injuries (28%), and abdominal tenderness (5%). Fifty of the 268 scans (19%) were positive for intra-abdominal abnormalities. Pleural effusions were seen in 82 (31%). Sixteen abdominal explorations were done. There was no difference in the pre-scan hematocrit drop in patients with normal scans (6.6%), positive scans (6.8%), and those who were explored (6.4%). There was one false positive (0.4%) and two false negative scans (0.8%). Conclusions. (1) A significant number of occult injuries, some life threatening, are detected by delayed CT scans. (2) Hematocrit drop under observation is not a good predictor of occult intra-abdominal injury. (3) Delayed CT scanning for occult abdominal injury is cost effective.

Continuous 12-lead electrocardiograph monitoring in the emergency department

Many patients presenting to the emergency department with suspected acute myocardial infarction have an initial electrocardiogram (ECG) nondiagnostic for acute injury or ischemia. Continuous ST segment monitoring devices have been used by physicians in the past to diagnose ischemia in the ambulatory outpatient population and to identify coronary occlusion in postthrombolytic and postsurgical patients. We report three patients with suspected acute myocardial infarction who underwent real-time continuous 12-lead ST segment monitoring with frequent serial ECGs on a microprocessor-controlled device during their initial emergency department evaluation. Continuous 12-lead ECG monitoring revealed significant changes on the ECG in all three cases presented, with a resultant change in emergency department therapy. Interestingly, all of these patients had significant ECG changes in the absence of recurrence of chest pain. We believe real-time continuous 12-lead ST segment monitoring with frequent serial ECGs can identify patients with an initially nondiagnostic or atypical ECG who may benefit from early interventional therapy.

Outpatient Assessment of Infants With Bronchiolitis

Two hundred thirteen infants younger than 13 months with bronchiolitis were prospectively followed up to identify the historical, physical, and laboratory clues at initial emergency department evaluation that would help to predict disease severity. Based on their total course of illness, the patients were classified as having mild (139 patients) or severe (74 patients) disease, and the initial emergency department evaluation findings of these two groups were compared. Six independent clinical and laboratory findings were identified that were strongly associated with more severe illness: (1) "ill" or "toxic" general appearance; (2) oxygen saturation less than 95%, as determined by pulse oximetry; (3) gestational age, younger than 34 weeks; (4) respiratory rate, 70/min or greater; (5) atelectasis on a chest roentgenogram; and (6) age, younger than 3 months. The infant's oxygen saturation as determined by pulse oximetry was the single best objective predictor of more severe disease.

Application of Clinical Indicators in the Emergency Department

Clinical indicators were developed and used to assess the quality of patient care resulting from the system of shared responsibility between emergency department (ED) and radiology department faculty physicians for interpretation of ED roentgenograms. The first indicator--all discrepancies in roentgenogram interpretation between ED and radiology department faculty--measured an overall discrepancy rate of 3.3% (776 films). Three hundred fifty-two apparent discrepancies were not related to the accuracy with which ED faculty interpreted films, resulting in a revised overall discrepancy rate of 1.8%. The second indicator--undesirable patient care outcomes as a result of delayed accurate radiological diagnosis--measured an occurrence rate of 0 after clinical reevaluation of more than 99% of patients within 24 hours of initial ED evaluation. Aspects of the development and use of clinical indicators are discussed in relationship to the broader monitoring and evaluating process necessary for the continuous improvement of patient care.

The utility of the presence or absence of chest pain in patients with suspected acute myocardial infarction

In 422 patients admitted from the emergency department (ED) for suspected acute myocardial infarction, the hypothesis that chest pain that persists on arrival in the ED or recurs during the initial ED evaluation is a useful predictor of acute myocardial infarction (AMI) and complications of coronary ischemia was tested. Compared with patients whose chest pain spontaneously ceased before arrival in the ED, patients whose chest pain persisted or recurred during the initial ED evaluation had a 2.3 times greater risk of interventions ( P < .001), a 1.7 times greater risk of complications ( P = .045), a 3.8 times greater risk of life-threatening complications ( P = .04), and a 2.4 times greater risk of AMI ( P = .005). A third group of patients with suspected AMI never experienced chest pain. This group of patients who never experienced chest pain had a three times higher risk of death ( P = .02) compared with patients whose chest pain persisted or recurred in the ED, and a 2.1 times greater risk of intervention ( P = .01), a 5.2 times greater risk of life-threatening complication ( P = .015), and a 7.9 times greater risk of death ( P = .025) compared with patients whose chest pain resolved before arrival in the ED. It was concluded that patients with chest pain that resolves spontaneously before arrival to the ED have a better in-hospital prognosis than any other group.

A retrospective review of black widow spider envenomation

Because there are few recent studies of black widow spider (Latrodectus Mactans) envenomation, a six-year retrospective study was conducted by patients admitted to or discharged from our hospital with this diagnosis. Fourteen patients with apparently severe envenomation were found and reviewed for the frequency of presenting signs and symptoms, the use of laboratory and radiographic studies, and the effectiveness of drug therapies. The most frequent symptoms were bite site pain (79%), abdominal pain (71%), and lower extremity weakness (57%). The most frequent signs were bite site lesions and abdominal tenderness or rigidity (71%). Laboratory and radiographic studies did not influence the initial emergency department evaluation. All drug therapies resulted in good clinical outcome despite two complications, and we therefore believe that the use of antivenom for symptomatic relief should be discouraged.

Traumatic disruption of the brachiocephalic artery

We report the case of a patient presenting with blunt chest and head injuries. Initial emergency department evaluation revealed a pulmonary contusion and suspected closed head injuries. Computed tomographic scan of the head was unremarkable. An angiogram performed to further investigate the nature of his head injuries revealed a disruption of the brachiocephalic artery. The lesion was surgically repaired in the operating room and the patient was moved to the intensive care unit, where he remained comatose and died from complications of his head and chest injuries on the seventh post-operative day. The pathophysiology and clinical manifestations of injuries to the brachiocephalic artery are discussed.