The American journal of emergency medicine
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Multicenter Study Comparative Study Clinical Trial
Clinical features, triage, and outcome of patients presenting to the ED with suspected acute coronary syndromes but without pain: a multicenter study.
We studied the impact on triage and outcome of patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndromes (ACS) but without a complaint of pain. Data from a prospective clinical trial of patients with symptoms suggesting an ACS in the EDs of 10 US hospitals comparing patient demographics, clinical variables, and outcomes was used to perform a secondary analysis. Of 10,783 subjects, a final diagnosis of an ACS was confirmed in 24% of which 35% had acute myocardial infarction (AMI) and 65% unstable angina pectoris (UAP). ⋯ We concluded that age and heart failure are independently associated with painless ACS, in addition to diabetes among those with AMI. Lack of pain predicts increased hospital mortality in patients with ACI through mechanisms that remain to be elucidated. There is a need for greater awareness in the general public of the different manifestations of ACS to enhance the recognition of and prompt response to their symptoms.
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The study objectives were to examine the differences between Peak Expiratory Flow (PEF) formulae in the literature and to assess the potential impact of those differences on the interpretation of clinical guidelines for asthma management. We calculated 100% PEF values for hypothetical patients at the 50(th) percentile for height and weight and classified the percent predicted PEF into severity groups according to national asthma guidelines. ⋯ Predicted PEF varied widely across formulae and choice of formula may alter guideline-based care. We propose recently published population-based equations as the reference standard for future asthma guidelines.
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Review Case Reports
Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma.
Abdominal injury from significant blunt trauma can include injury to bowel, kidneys, liver, and spleen. In approximately 5% of all injuries one of the diaphragms is ruptured. Diaphragmatic rupture may not be easily detected and this can lead to significant morbidity and even mortality. ⋯ Although not typically part of the basic Focused Abdominal Sonography for Trauma (FAST) examination, ultrasonographic diagnosis of diaphragmatic rupture is possible with little added time to the examination. We present 3 cases of diaphragmatic rupture discovered shortly after the patients' arrival, on initial trauma evaluation with the FAST. A discussion of previous literature and ultrasound technique for diagnosis follows the cases.
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Review Case Reports
Orthopedic pitfalls in the ED: Achilles tendon rupture.
Achilles tendon rupture is a relatively uncommon occurrence in a general ED population. The history can be subtle, and physical findings may not be clear-cut. ⋯ The emergency physician needs to remain vigilant for this diagnosis to avoid this orthopedic pitfall. This review article examines the clinical presentation, diagnostic technique, and management options applicable to the emergency physician in the treatment of Achilles tendon rupture.
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The Advanced Trauma Life Support (ATLS) course sponsored by the American College of Surgeons Committee On Trauma (ACSCOT) presents a standardized method of initial trauma care. This study attempted to measure any changes in morbidity and mortality in trauma patients after the introduction of ATLS training. Over a 3-year period (May 1996 to September 1997-pre-ATLS period; December 1997 to April 1999-post-ATLS period), 63 trauma patients with an Injury Severity Scale (ISS) > or =16 (n = 31, pre-ATLS and n = 32, post-ATLS) were prospectively studied in two community teaching hospitals. ⋯ There was a significant difference in mortality during the first 60 minutes after admission: 0.0% post-ATLS versus 24.2% pre-ATLS (P = .002, Fisher exact test (95% confidence interval ranged from 12-45% in the pre-ATLS group and 0-11% in the post-ATLS group). According to the TRISS methodology (a worldwide-accepted mathematical method to calculate chances of survival through logistical regression),ATLS improved outcome from sub-"Major Trauma Outcome Study" (MTOS) standard results (z = -2.9 to a MTOS standard result z = -0.49). Our data demonstrate that introduction of the ATLS program significantly improved trauma patient outcome in the first hour after admission, as well as improvement from sub-MTOS standard to MTOS standard levels.