The American journal of emergency medicine
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A recent editorial criticized emergency medicine researchers who study the treatment of acute migraine for failing to standardize patients according to definitions provided by the International Headache Society (IHS). In fact, most emergency medicine-based studies of migraine therapies have not used IHS Criteria (IHSC) for patient inclusion and are not uniform in the definition of acute migraine. The purpose of this study was to determine the percentage of patients with complaint of headache who present to the emergency department with a prior diagnosis of migraine and/or emergency department discharge diagnosis of acute migraine that meet IHSC. ⋯ Less than half of patients with a prior diagnosis and/or final emergency discharge diagnosis of acute migraine met IHSC. Our findings raise concerns about the external validity of prior emergency department-based research of acute migraine therapy and the utility of the IHSC for future research. Modification of the IHSC for emergency medicine research should be considered.
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Comparative Study
Electrocardiographic ST segment elevation: a comparison of AMI and non-AMI ECG syndromes.
Chest pain (CP) patients presenting to the ED may manifest electrocardiographic ST segment elevation (STE). AMI (acute myocardial infarction) is a less frequent cause of such abnormality and one of many patterns responsible for ST segment elevation in ED CP patients. We performed a retrospective comparative review of the electrocardiographic features of various STE syndromes, focusing on differences between AMI and non-AMI syndromes. ⋯ Non-AMI causes of STE account for the majority of electrocardiographic syndromes encountered in ED chest pain patients. These findings alone are not adequate to determine the electrocardiographic cause of the ST segment elevation in chest pain patients. When determining AMI versus non-AMI with the ECG, these various findings should be used in the consideration of the overall clinical picture (history, examination, and electrocardiogram) in chest pain patients with ST segment elevation.
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The objective of this study was to evaluate a progesterone cutpoint of 5.0 ng/mL ability to identify abnormal pregnancy (abnormal intrauterine pregnancy and ectopic pregnancy) as well as ectopic pregnancy alone in 2 subclasses of indeterminate ultrasounds. This was a prospective observational study of emergency department patients with abdominal pain or vaginal bleeding and an indeterminate transvaginal ultrasound. Two subclasses of indeterminate ultrasounds were eligible: those with an empty uterus and a beta-human chorionic gonadotropin value <3,000 mIU/mL and those with a nonspecific fluid collection. ⋯ The sensitivity and specificity of progesterone identifying abnormal pregnancy were 84% and 97%, respectively. The sensitivity and specificity of progesterone identifying ectopic pregnancy were 88% and 40%, respectively. In the 2 subclasses, the progesterone cutpoint was both sensitive and specific in identifying abnormal pregnancy and was sensitive but only moderately specific for identifying ectopic pregnancy.
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Two double-blind, placebo-controlled, prospective randomized trials in the emergency department (ED) setting have examined the use of metoclopramide for the prevention of opiate-induced nausea and vomiting. Both showed a low incidence of vomiting in the control group. This prospective observational study in 205 unselected ED patients with acute pain syndromes measured nausea and vomiting before intravenous opiate administration and 30 and 60 minutes posttreatment. ⋯ Corresponding figures for nausea were 4.9% at 30 minutes and 9.3% at 60 minutes, with more than 75% of patients rating their nausea as mild. Prevalence of both nausea and vomiting were higher at baseline than after analgesia. These data support the findings of previous randomized trials that the incidence of nausea and vomiting after intravenous opiate analgesia in the ED is low and argues against routine use of prophylactic antiemetic administration in combination with opiate analgesia.
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Wellens' syndrome is a pattern of electrocardiographic T-wave changes associated with critical, proximal left anterior descending (LAD) artery stenosis. The syndrome is also referred to as LAD coronary T-wave syndrome. Syndrome criteria include T-wave changes plus a history of anginal chest pain without serum marker abnormalities; patients lack Q waves and significant ST-segment elevation; such patients show normal precordial R-wave progression. ⋯ The T-wave abnormalities are persistent and may remain in place for hours to weeks; the clinician likely will encounter these changes in the sensation-free patient. With definitive management of the stenosis, the changes resolve with normalization of the electrocardiogram. It is vital that the physician recognize these changes and the association with critical LAD obstruction and significant risk for anterior wall myocardial infarction.