The American journal of emergency medicine
-
Each year hundreds of thousands of children receive care in emergency departments after head injury. Minor head injuries account for a majority of these injuries. The prevalence, morbidity, and costs associated with pediatric minor head injuries make it an important topic. We review the management of pediatric minor head injury, emphasizing current areas of controversy, including criteria for neuroimaging, indications for hospitalization, the role of anticonvulsant therapy, and the long-term neurobehavioral sequelae of pediatric minor head injury.
-
Patients with acute cardiogenic pulmonary edema (ACPE) are commonly seen in the emergency department (ED). Although the majority of patients respond to conventional medical therapy, some patients require at least temporary ventilatory support. ⋯ The past 2 decades have witnessed increasing interest in methods of noninvasive ventilatory support (NVS), notably continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). We review the physiological consequences, clinical efficacy, and practical limitations of CPAP and BiPAP in the management of ACPE.
-
Comparative Study
Delta CK-MB outperforms delta troponin I at 2 hours during the ED rule out of acute myocardial infarction.
It has been shown that a rise in creatine kinase MB bank (CK-MB) of > or = + 1.6 ng/mL in 2 hours is more sensitive and equally specific for detection of acute myocardial infarction (AMI) as compared with a 2-hour CK-MB > or = 6 ng/mL during the emergency department (ED) evaluation of chest pain. Because cardiac specific troponin I (cTnI) is thought to have similar early release kinetics as compared with CK-MB mass, we undertook a retrospective cohort study in 578 chest pain patients whose baseline CK-MB and cTnI was less than two times the hospital's upper limits of normal and who underwent a 2-hour CK-MB and cTnI to compare sensitivities and specificities of the 2-hour delta CK-MB (deltaCK-MB) and delta cTnI (delta cTnI) for AMI and 30-day Adverse Outcome (AO). Thirty day AO was defined as AMI, life-threatening complication, death, or percutaneous transluminal coronary angioplasty (PTCA)/coronary artery bypass graft (CABG) within 30 days of ED presentation. ⋯ There were no differences in specificities for AMI and 30-day AO. Combining the two tests (MBdelta > or = +1.5 ng/mL and/or a deltaTnI > or = +0.2 ng/mL) resulted in an incremental increase in sensitivity of 89.5% for AMI and 61.9% for AO (P < .005). Patients with either a rise in CK-MB of > or = +1.5 ng/mL or rise in cTnI of > or = +0.2 ng/mL in 2 hours should receive consideration for aggressive antiischemic therapy and further diagnostic testing before making an exclusionary diagnosis of nonischemic chest pain.
-
In this article we try to determine how frequently emergency physicians (EPs) suspected the diagnosis in acute aortic dissection (AD). In this retrospective descriptive study, we identified all patients with the final diagnosis of AD initially evaluated in 1 of 3 emergency departments (EDs) over a 5-year period. Patients were included if AD was not suspected before ED evaluation. ⋯ EPs suspected AD in 12 of 14 (86%) cases of chest and back pain and in 5 of 11 (45%) of chest pain. Thirteen of 39 (33%) painful presentations involved abdominal pain; EPs suspected AD in 1 of 13 (8%). EPs suspected the diagnosis in 43% of acute AD; location of pain was most predictive of a suspected diagnosis.
-
In this article we seek to evaluate the diagnostic accuracy of emergency physicians performing emergency ultrasonography in the setting of an emergency medicine training program. A prospective observational study was performed at an inner city Level I trauma center with an emergency medicine residency training program. From July 1994 to December 1996 a convenience sample of ultrasound exams was recorded. ⋯ Four hundred and fifty-six ultrasound examinations were videotaped and entered into the study; 408 (89%) of the studies performed were determined to be "acceptable." The diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) of these studies were as follows: cardiac, to rule out effusion (n = 67; 0.83, 0.98, 0.88, 0.98); transabdominal, to rule out abdominal aortic aneurysms (AAA), cholelithiasis, or free peritoneal fluid (n = 263; 0.91, 0.89, 0.88, 0.92); renal, to rule out hydronephrosis (n = 45; 0.94, 0.96, 0.94, 0.96); pelvic, to rule in intrauterine pregnancy (n = 33; 1.0, 0.90, 0.96, 1.0). The 48 "technically limited studies" included: 39 transabdominal (33 gallbladder, 1 abdominal aortic aneurysm, 5 free peritoneal fluid), 6 cardiac, 2 renal, and 1 pelvic ultrasound. This study suggests that emergency physicians with a minimal amount of training display acceptable technical skill and interpretive acumen in their approach to emergency ultrasonography.