Syndrome In Emergency Department Research Articles

Diagnosis, epilepsy treatment and supports for neurodevelopment in children with Dravet Syndrome: Caregiver reported experiences and needs

BackgroundDravet syndrome is a rare infantile onset epilepsy syndrome encompassing treatment resistant epilepsy and neurodevelopmental difficulties. There is limited data regarding caregiver experiences of diagnosis, treatment and supports for the associated neurodevelopmental problems. MethodSemi-structured interviews were conducted with caregivers of 36/48 children (75% of total population in Sweden) with Dravet syndrome. Data was analysed using thematic analysis. ResultsRegarding the diagnostic experience, themes were: Delays in diagnostic process, genetic testing not optimal, communication of Dravet syndrome diagnosis and support and information soon after diagnosis. Caregivers felt that delays in diagnosis and testing could have been avoided whilst experiences of communication of diagnosis and support after diagnosis varied. In terms of treatment for seizures, the themes were: Satisfied with treatment, emergency treatment, treatment with antiseizure medications, strategies to control seizures via temperature regulation/avoidance of infections and use of equipment and aids. Caregivers were in the main accepting that seizures in Dravet syndrome are very difficult to treat and that seizure freedom is often an unachievable goal. Many felt frustrated that they were expected to take responsibility with respect to choice of medication. They often employed strategies (e.g., avoidance of physical activity) to reduce seizures or their impact. In terms of supports for neurodevelopmental problems, the themes were: Struggled to access support, lack of integrated healthcare and satisfaction with school. Many caregivers felt that accessing necessary supports for their children and developmental and behavioural needs was a struggle and that the provision of support often lacked integration e.g., lack of collaboration between child’s disability service and school. Caregivers also expressed a desire that there would be better knowledge of Dravet syndrome in emergency departments and schools, that care would be better integrated and that there would be more supports for assessment and interventions regarding the associated neurodevelopmental problems. ConclusionThe responses of caregivers of children with Dravet syndrome highlight the need for supports from diagnosis for both epilepsy and neurodevelopmental problems. Good examples of provision were identified but parents often felt they lacked support and support often came from providers who lacked knowledge of the syndrome. Collaboration between medical, disability and school services was often lacking.

Protocolo de actuación en el paciente agitado en urgencias

Agitation in patients is an important, common psychiatric syndrome in emergency departments that requires immediate attention. The initial treatment is based on diagnostic suspicion and is aimed at containing the episode of agitation and establishing safety measures to avoid self-aggressive or hetero-aggressive harm. Verbal de-escalation is the first step, followed by chemical and/or mechanical restraint according to the intensity of symptoms and the degree of patient collaboration. There are different pharmacological strategies which include the use of antipsychotics and benzodiazepines. There are also other newer pharmacological agents whose use is not as widespread, though they are no less effective, such as ketamine.

A rare case of Flood syndrome in emergency department: A case report and review of recent reported cases

Introduction:Flood syndrome is a rare and potentially fatal complication of liver cirrhosis with gross ascites.Case presentation:We present a case of Flood syndrome in a gentleman with alcoholic cirrhosis and ascites who had sudden spontaneous rupture of umbilical hernia, resulting in sudden gush of ascitic fluid from the hernia. The wound was cleaned and covered in sterile dressing and was admitted for further management. His umbilical hernia wound was closed at bedside by General Surgery team and he underwent ultrasound‐guided ascitic drain insertion by Interventional Radiology. His stay was complicated by bacterial peritonitis which was treated with intravenous antibiotic. Patient eventually recovered and was discharged well.Discussion:Flood syndrome has high complication and mortality rate. Recent reported cases were reviewed, focusing on the causes of cirrhosis, complications of Flood syndrome, treatments provided and the outcomes.Conclusion:There is currently no standard guideline for the management of Flood syndrome which falls in the grey area between medical and surgical management. Proper medical management with early surgical consultation is important to reduce the morbidity and mortality for these patients.

Abstract 14045: Implementation of High-Sensitivity Cardiac Troponin Assay in Emergency Department Increases Myocardial Infarction Diagnosis and Utilization of Invasive Cardiac Procedures: An Insight From Middle East/ Gulf Region

Introduction: Utilization of high-sensitivity cardiac troponin T (hsT) assays facilitates evaluation of patients with suspected acute coronary syndrome in emergency department (ED) by expediting clinical-decision making and disposition. While the utility of (hsT) has been previously shown, data from the Middle East/ Gulf region (MEG) are limited. We aimed to evaluate the association between hsT implementation and changes in resource use at a tertiary care center in MEG. Methods: Consecutive patients evaluated in ED using hsT (hsT era) or conventional troponin assays (pre-hsT era) were identified. Discharge diagnosis of myocardial infarction (MI), utilization of invasive and non-invasive testing (cardiac CT, perfusion imaging and stress echocardiography) during index admission was determined using ICD codes. Unadjusted rates of these outcomes in addition to in-hospital mortality were compared before and after adoption of hsT assays using appropriate tests. Results: Among 21,149 and 18,979 ED encounters before and after implementation hsT, mean patient age was 53.8 ± 18.1 and 53.3 ±17.8, (P=.09), respectively. The introduction of hsT assay was associated with a 23% increase in MI diagnosis (3.7% vs 3.0%; P<.001), 13% increase in invasive angiography use (4.4% vs. 3.9%; P=.02), and a concomitant 70% reduction in use of non-invasive studies (0.02% vs. 0.07%; P=.02). Additionally, mortality during index admission was significantly higher in the hsT era (1.3% vs. 1.1%; P=.01). Conclusion: Introduction of hsT assay at a single-center in MEG increased MI diagnosis and identified patients who are at increased risk of death. Furthermore, it was associated with greater use of invasive cardiac procedures. Whether more aggressive management during index hospitalization in this population is associated with favorable long-term outcomes requires additional studies.

Prediction of disorders with significant coronary lesions using machine learning in patients admitted with chest symptom.

BackgroundThe early prediction of significant coronary artery lesion, including coronary vasospasm, have yet to be studied. It is essential to discern the disorders with significant coronary lesions (SCDs) requiring coronary angiography from mimicking disease. We aimed to determine which of all clinical variables were more important using conventional logistic regression (cLR) and machine learning (ML).MaterialsOf 3382 patients with chest pain/discomfort or dyspnea in whom CAG was performed, 1893 were included. All clinical data were divided as follows (i): Demographics, history, and physical examination; (ii): (i) plus electrocardiography; and (iii): (ii) plus echocardiography, and analyzed by cLR and ML.ResultsIn multivariable analysis via cLR, the AUC and accuracy of the model using the final 20 variables were 0.795 and 72.62%, respectively. In multivariable analysis via ML, the best AUCs in the internal validation were 0.8 with (i), 0.81 with (ii), 0.83 with (iii), and in external validation, the best AUCs were 0.71 with (i), 0.74 with (ii), and 0.79 with (iii). The best AUCs and accuracy of the fittest model including 21 importance variables by ML were 0.81 and 72.48% in internal validation; and 0.75 and 70.5% in external validation, respectively. The importance variables in ML and cLR were similar, but slightly different and the additional discriminators via ML were found.ConclusionThe assessment using the fittest importance variables can assist physicians in differentiating mimicking diseases in which coronary angiography may not be required in patients suspected of having acute coronary syndrome in emergency department.

The effect of aromatherapy with peppermint essential oil on anxiety of cardiac patients in emergency department: A placebo-controlled study

IntroductionAnxiety is an unpleasant feeling that increases the myocardial oxygen demand in acute coronary syndrome. This study aimed to evaluate the effect of peppermint aromatherapy on anxiety in patients with acute coronary syndrome in the emergency department. Materials and methodsIn this clinical trial study, 64 patients with acute coronary syndrome were randomly divided into intervention and control groups. In the intervention group, a cotton ball was soaked in 100% peppermint essential oil and placed about 20 cm from the patient's nose for 1 h while in the control group, the cotton ball was soaked in water. Anxiety was measured before and after the intervention with The Spielberger state-trait anxiety inventory. The data were analyzed in SPSS ver.23 software. ResultsNo significant difference was observed between the two groups in terms of patients’ demographic data. The mean score of trait and state anxiety before the intervention was not significantly different between the two groups. After the intervention, anxiety was significantly lower in the intervention group (37.72 ± 10.41) compared to the control group (42.62 ± 5.99) (P = 0.021). Results indicated a significant decrease in anxiety after the intervention (P < 0.001) in the intervention group. Such a difference was not significant in the control group. ConclusionPeppermint essential oil inhalation significantly reduces anxiety of patients with acute coronary syndrome in emergency department.

Sex and ethnicity-based differences in symptoms of acute coronary syndrome in emergency departments

Rapid identification of acute coronary syndrome (ACS) symptoms is critical for timely treatment initiation. Little evidence exists regarding sex differences in ACS symptoms among common ethnicities in Canada. We examined the association of sex and self-reported ethnicity with suspected ACS symptoms.

Type 1 myocardial infarction rapid screening scale for emergency triage in patients with non-traumatic chest pain: A study of 1928 cases with coronary angiography

IntroductionThe effectiveness of treatment and prognosis of patients with type 1 myocardial infarction are highly correlated with time of diagnosis. This study aimed to develop a type 1 MI rapid screening scale (T1MIrs scale) suitable for emergency pre-diagnosis. MethodsA total of 1928 patients who underwent coronary angiography were enrolled. Multivariate regression analysis was used to identify the independent risk factors of type 1 MI. And the T1MIrs scale was developed and evaluated according to the multivariate regression result. ResultsThe incidence of type 1 MI was 23.3% in the population with suspected acute coronary syndrome. After 5 adjusting for relevant factors, MEWS score (OR = 1.809, 95%CI 1.623–2.016, P < .001), typical symptoms (OR = 9.826, 95%CI 7.379–13.084, P < .001), male (OR = 2.184, 95%CI 1.602–2.979, P < .001), age (OR = 1.021, 95%CI 1.009–1.033, P = .001), history of diabetes (OR = 2.174, 95%CI 1.594–2.963, P < .001) and current smoker (OR = 2.498, 95%CI 1.550–4.026, P < .001) were the independent risk factors for type 1 MI. The T1MIrs scale is established based on risk factors, with a range of 0–8 points. The incidence of type 1 MI is ascending with the scale (0.3% vs. 3.7% vs. 14.3% vs. 34.9% vs. 57% vs. 76.4% vs. 84.2% vs. 87.5% vs. 100%, P for trend <0.001). ConclusionsType 1 MI is common in patients with suspected acute coronary syndrome in emergency department. The T1MIrs scale could act as a rapid pre-examination triage of suspected population in emergency department, which is meaningful to screen out type 1 MI patients as soon as possible.

Clinical and electrocardiographic profile of patients presenting with acute coronary syndrome in emergency department in a Tertiary Care Hospital.

Objectives: To assess the clinical characteristics and diagnosis of ACS for timely, management and further prevention from coronary events. Study Design: Cross sectional study. Setting: Emergency Department (ED) of Punjab Institute of Cardiology (PIC) Lahore. Period: November 2017 to January 2018. Material &amp; Methods: Included 170 diagnosed patients of ACS of both sexes presenting within approximately four hours of symptoms. At presentation ECG and initial blood samples were taken from all patients for base line and Troponin T estimation. All the patients included in the study were properly examined and complete history was taken. Blood samples of patients for diagnosis of NSTEMI were also drawn at 8hrs of arrival. The patients were categorized into STEMI, NSTEMI and UA on the basis of history, ECG and cardiac Troponin T. Results were analyzed statistically. A p-value ≤ 0.05 was considered statistically significant. Results: A total of 170 patients with established diagnosis of ACS were included. The mean age of the patients was 56 years. There was a very strong male predominance (81.76%). The major modifiable risk factors were hypertension (54.71%) and smoking (35.88%), followed by hyperlipidemia (35.29%) and diabetes (32.35%). A previous history of IHD in patients and family history of IHD were equally present (37.65%). A large proportion of patients belonged to middle class (54.12%) and lower (41.18%). Typical pain chest pain was present in 90% and majority of patients enrolled in this study had a diagnosis of myocardial infarction 77.05% and the remainder had unstable angina. We found a higher percentage of ST elevation MI in the patients with MI (84.73%), majority had anterior AMI. Of all patients, 1.77% expired during hospital stay. Conclusion: The majority of ACS patients in our country are male with STEMI. The major risk factors are hypertension, family history of IHD, smoking, hyperlipidemia and diabetes. 90% patients present with typical chest pain while remaining 10% atypical symptoms which must be of prime consideration to assess ACS.

Problems of differential diagnosis of acute coronary syndrome at prehospital stage in patients without ST segment elevation (literature review)

The article discusses the issues of prehospital diagnosis of acute coronary syndrome without ST segment elevation. A large number of errors that worsen the outcomes of the disease and the difficulties associated with the overload in patients with suspected acute coronary syndrome in emergency departments are indicated. The experience and prospects of studying the prehospital use of markers of myocardial necrosis are evaluated.

Management of acute coronary syndrome in emergency departments: a cross sectional multicenter study (Tunisia)

BackgroundWe aimed to describe diagnosed acute coronary syndrome (ACS) and its care management and outcomes in emergency departments (EDs) and to determine related cardiovascular risk factors (CVRFs).MethodsWe conducted a cross sectional multicenter study that included 1173 adults admitted to EDs for acute chest pain (ACP) in 2015 at 14 sites in Tunisia. Data included patients’ baseline characteristics, diagnosis, treatment and output.ResultsACS represented 49.7% of non-traumatic chest pain [95% CI: 46.7–52.6]; 74.2% of ACS cases were unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI). Males represented 67.4% of patients with ACS (p < 0.001). The median age was 60 years (IQR 52–70). Emergency medical service transportation was used in 11.9% of cases. The median duration between chest pain onset and ED arrival was two hours (Inter quartile ranges (IQR) 2–4 h). The age-standardized prevalence rate was 69.9/100,000 PY; the rate was 96.24 in men and 43.7 in women. In the multivariable analysis, CVRFs related to ST segment elevation myocardial infarction were age correlated to sex and active smoking. CVRFs related to UA/NSTEMI were age correlated to sex, familial and personal vascular history and type 2 diabetes. We reported 27 cases of major adverse cardiovascular events (20.0%) in patients with STEMI and 36 in patients with UA/NSTEMI (9.1%).ConclusionHalf of the patients consulting EDs with ACP had ACS. Emergency medical service transportation calls were rare. Management delays were acceptable. The risk of developing an UA/NSTEMI was equal to the number of CVRFs + 1. To improve patient outcomes, it is necessary to increase adherence to international management guidelines.

Development and validation of a modified quick SOFA scale for risk assessment in sepsis syndrome.

Sepsis is a severe clinical syndrome owing to its high mortality. Quick Sequential Organ Failure Assessment (qSOFA) score has been proposed for the prediction of fatal outcomes in sepsis syndrome in emergency departments. Due to the low predictive performance of the qSOFA score, we propose a modification to the score by adding age. We conducted a multicenter, retrospective cohort study among regional referral centers from various regions of the country. Participants recruited data of patients admitted to emergency departments and obtained a diagnosis of sepsis syndrome. Crude in-hospital mortality was the primary endpoint. A generalized mixed-effects model with random intercepts produced estimates for adverse outcomes. Model-based recursive partitioning demonstrated the effects and thresholds of significant covariates. Scores were internally validated. The H measure compared performances of scores. A total of 580 patients from 22 centers were included for further analysis. Stages of sepsis, age, time to antibiotics, and administration of carbapenem for empirical treatment were entered the final model. Among these, severe sepsis (OR, 4.40; CIs, 2.35–8.21), septic shock (OR, 8.78; CIs, 4.37–17.66), age (OR, 1.03; CIs, 1.02–1.05) and time to antibiotics (OR, 1.05; CIs, 1.01–1.10) were significantly associated with fatal outcomes. A decision tree demonstrated the thresholds for age. We modified the quick Sequential Organ Failure Assessment (mod-qSOFA) score by adding age (> 50 years old = one point) and compared this to the conventional score. H-measures for qSOFA and mod-qSOFA were found to be 0.11 and 0.14, respectively, whereas AUCs of both scores were 0.64. We propose the use of the modified qSOFA score for early risk assessment among sepsis patients for improved triage and management of this fatal syndrome.

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Acute aortic syndrome and bedside ultrasonography in emergency department

Acute aortic syndrome and bedside ultrasonography in emergency department

Cannabis Hyperemesis Syndrome in the Emergency Department: How Can a Specialized Addiction Team Be Useful? A Pilot Study

BackgroundChronic cannabis users may experience cyclical episodes of nausea and vomiting and learned behavior of hot bathing. This clinical condition, known as cannabis hyperemesis syndrome, was first reported in 2004. ObjectiveOur aim was to promote early recognition of this syndrome in emergency departments (EDs) and to increase referral to addiction specialists. MethodsCannabis abusers were admitted to the ED for vomiting or abdominal pain from June 1, 2014 to January 1, 2015 and diagnosed with cannabis hyperemesis syndrome by a specialized addiction team. Then, medical records were examined retrospectively. ResultsSeven young adults were included. Their mean age was 24.7 years (range 17−39 years) and the majority were men (male-to-female ratio 1.2). Biological and toxicological blood samples were taken in all patients. Tetrahydrocannabinol blood level was measured in 4 patients, with a mean blood concentration of 11.6 ng/mL. Radiographic examination including abdominal computed tomography and brain imaging were negative, as was upper endoscopy. Five patients compulsively took hot baths in an attempt to decrease the symptoms. Treatment was symptomatic. Five patients have started follow-up with the specialized addiction team. ConclusionsCannabis hyperemesis syndrome is still under-diagnosed 10 years after it was first described. Physicians should be aware of this syndrome to avoid repeated hospitalizations or esophageal complications. Greater awareness should lead to prompt treatment and prevention of future recurrence through cannabis cessation. Addiction specialists, as well as medical toxicologists, are experts in the management of cannabis abusers and can help re-establish the role of medical care in this population in collaboration with emergency physicians.

Comparison of Rates of Coronary Angiography and Combined Testing Procedures in Patients Seen in the Emergency Room With Chest Pain (But No Objective Acute Coronary Syndrome Findings) Having Coronary Computed Tomography Versus Exercise Stress Testing

Coronary computed tomography angiography (CCTA) appears comparable to standard care, including exercise stress testing (EST), in diagnosing acute coronary syndrome in emergency department (ED) patients with chest pain but may increase downstream testing. The objective of this study was to investigate rates of post-CCTA versus post-EST testing for (1) invasive angiography and (2) all combined cardiac testing. This was a retrospective cohort study performed at 2 urban Canadian EDs involving patients aged up to 65years with chest pain but no objective ACS findings that were evaluated with CCTA or EST at the physician's discretion. The primary outcome was the proportion of patients who had 30-day invasive angiography in each group; secondary outcomes included all subsequent 30-day cardiac testing, including nuclear medicine scanning. From July 1, 2012, to June 30, 2014, we collected 1,700 patients: 521 CCTA and 1,179 EST. Demographics and risk factors were similar in both cohorts. In the following 30days, 30 CCTA (5.8%) and 297 EST (25.2%) patients underwent any type of additional cardiac testing (difference 19.4%, 95% CI 16.0 to 22.6), whereas 12 CCTA (2.3%) and 20 EST patients (1.7%) underwent angiography (difference 0.6%, 95% CI-0.8% to 2.6%). No patients in either group died or had a myocardial infarction within 30days. For ED patients with chest pain who underwent brief observation, CCTA and EST had similar 30-day angiography rates, but CCTA patients underwent significantly less overall cardiac investigations.

Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review protocol.

REVIEW QUESTION / OBJECTIVE The objective of this review is to assess the sensitivity and specificity of the Manchester Triage System in the evaluation of adult patients with acute coronary syndrome in emergency departments. INCLUSION CRITERIA Types of participants This review will consider studies that include adult patients (over 18 years) who have sought emergency care with any complaint, have been classified by the Manchester Triage System, and have received a medical diagnosis of Acute coronary syndrome. Studies involving children (18 years or under) will be excluded, as although the instrument can be used for evaluating children, this is a population with very specific characteristics, and the inclusion of studies conducted on children could bias the results. Furthermore, Acute coronary syndrome generally affects the adult population and incidences are highly related to risk factors such as age, sex, smoking, hypertension and diabetes. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the use of the Manchester Triage System without modifications in risk classification of patients. No comparator will be used. Types of outcomes This review will consider studies that include the following outcome measures: Priority level established by the Manchester Triage System in the evaluation of patients with medical diagnosis of Acute coronary syndrome. Analysis of the sensitivity or specificity of Manchester Triage System in the evaluation of patients with Acute coronary syndrome. The Manchester Triage System can be seen as a test; in the case of evaluation of patients with Acute coronary TRUNCATED AT 250 WORDS

Prognostic Value of Undetectable hs Troponin T in Suspected Acute Coronary Syndrome

BackgroundThe search for improved strategies for safe and early discharge of patients with suspected acute coronary syndrome in emergency departments is ongoing. This Biomarkers in Cardiology (BIC)-8 biomarker substudy evaluated the usefulness of high-sensitivity troponin T (hsTnT) below or above the limit of detection (LoD) in low-to-intermediate-risk patients with suspected acute coronary syndrome in the emergency department. MethodsPatients were categorized into hsTnT ≥ the 99th percentile, between the 99th percentile and LoD, or undetectable hsTnT (<LoD). HsTnT and copeptin were measured at admission, using a copeptin cut-off of 10 pmol/L. The primary endpoint was death and myocardial infarction within 90 days after admission. ResultsOf 882 patients with all biomarker results, 577 (65.4%) had detectable hsTnT levels (≥LoD). Among the 305 patients (34.6%) with undetectable hsTnT, no myocardial infarctions or deaths occurred within 90 days. In patients with detectable hsTnT at admission (≥LoD but ≤99th percentile), the combined endpoint occurred in 1.5% (6/410) of the copeptin-negative patients and in 6.3% (6/96) of copeptin-positive patients within 90 days (hazard ratio 4.39; 95% confidence interval, 1.42-13.61; P = .01). In patients with an initially elevated hsTnT (≥14 ng/L), 9.7% (3/31) of the copeptin-negative patients and 15.4% (4/26) of the copeptin-positive patients experienced the combined endpoint (hazard ratio 1.61; 95% confidence interval, 0.36-7.17; P = .536). ConclusionsIn low-to-intermediate-risk patients with suspected acute coronary syndrome, undetectable hsTnT values at admission allow a safe discharge without occurrence of death or myocardial infarction within 90 days.

Rapid rule out of myocardial infarction with the use of copeptin as a biomarker for cardiac injury.

Copeptin is a non-specific marker of an endogenous stress response. A dual biomarker marker approach involving the simultaneous use of troponin and copeptin assays may assist early exclusion of acute coronary syndrome in Australian emergency departments. The utility and limitations of this approach are discussed.

Impact of a decision rule on duration of continuous cardiac monitoring of patients with suspected acute coronary syndrome in an emergency department

To determine the effect of introducing a decision rule on the duration of continuous cardiac monitoring (CCM) for patients with suspected acute coronary syndrome in an adult emergency department (ED). This was a retrospective observational study of 220 patients with suspected acute coronary syndrome made up of two consecutive cohorts collected before and after introduction in July 2010 of a decision rule that made use of a new high-sensitivity troponin T assay. The primary outcome was median CCM duration in the ED (CCMED). Secondary outcomes were median duration of CCM in the first 24 h, rate of adverse events, proportion of patients after the intervention who had the rule adhered to, and estimated median CCMED had the decision rule been adhered to by all patients. The decision rule was adhered to in 59.3% (95% confidence interval 49.8-68.1) of patients post-intervention. There was no statistically or clinically significant difference in median CCMED before (240 min, interquartile range 156-313) and after (230 min interquartile range 145-353) introduction of the decision rule (P = 0.74) nor in CCM in the first 24 h (908 min vs 929 min). Seven (3.2%, 95% confidence interval 1.4-6.6) adverse events occurred overall. All three patients with adverse events after the intervention were monitored in ED according to the decision rule. Introduction of this decision rule did not decrease the median CCMED. All adverse events after the intervention occurred in appropriately monitored patients, including patients with initially negative high-sensitivity troponin T, suggesting that the decision rule would not compromise patient safety.