Proposed clinical scale for the diagnosis of acute coronary syndrome in patients with an inconclusive electrocardiogram and myocardial injury biomarkers. / Propuesta de una escala clínica para el diagnóstico de síndrome coronario agudo en pacientes con electrocardiograma y biomarcadores de lesión miocárdica no concluyentes.

RATIONALE: Acute coronary syndrome (ACS) requires improved diagnostic accuracy through useful, safe and easy-to-apply tools. OBJECTIVES: To obtain an assessment scale for the diagnosis of ACS in patients with chest pain and nondiagnostic electrocardiogram and troponin concentrations. METHODS: A prospective cohort study included 286 patients treated in the emergency department for chest pain, with normal electrocardiogram and troponin levels. Using multiple logistic regression, we obtained the independent predictors for the diagnosis of ACS. The assessment scale's discriminative power was assessed with the area under the ROC curve. RESULTS: The diagnosis of ACS was confirmed in 103 patients (36%). The final predictive model included 3 endpoints: a history of coronary artery disease, hyperlipidaemia and a score≥6 points on the Geleijnse scale. The area under the ROC curve for the final model was 0.90 (95% confidence interval [95% CI] 0.85-0.93). A threshold of 5 points achieved a sensitivity of 76.7% (95% CI 68-84), a specificity of 91.8% (95% CI 87-95), a positive likelihood ratio of 9.36 (95% CI 5.70-15.40), a negative likelihood ratio of 0.25 (95% CI 18.00-36.00) and an overall diagnostic accuracy of 86.4% (95% CI 82-90). The predictive model was superior to the Geleijnse scale alone. CONCLUSIONS: The final scale showed good discriminative capacity for diagnosing ACS and could therefore be of interest for identifying ACS in emergency departments. Nevertheless, the scale needs to be validated in larger multicentre studies.

Diagnostic validity of hand gestures in chest pain of coronary origin. / Validez diagnóstica del lenguaje de las manos en el dolor torácico de origen coronario.

OBJECTIVES: To determine the frequency of 3 hand gestures by patients with chest pain and determine the diagnostic validity of the gestures in acute coronary syndrome. PATIENTS AND METHODS: A prospective study was conducted on 383 adult patients treated for chest pain in an emergency department. We observed certain hand gestures, previously referred to in the medical literature as characteristic of coronary pain (gesture 1: a clenched fist held over the sternal area or Levine's sign; gesture 2: open hand located over the same area; gesture 3: both hands placed in the centre of the chest), as well as other gestures. We analysed their association with the coronary origin of the pain. RESULTS: We confirmed the coronary origin of the pain in 164 (43%) patients (ACS group). The other 219 patients (57%) did not have a coronary origin for the pain (nonACS group). Eighty-nine percent of the patients identified their pain with one of the 3 classical gestures. The most frequent gesture was number 2, both overall (59%) and by group (60% ACS group; 57.5% nonACS group). There was no significant association between the type of gesture and the final diagnosis (P=.172). The greater specificity corresponded to Levine's sign (90%), followed by other gestures (86%) and gesture 3 (81%). CONCLUSIONS: Although 89% of the patients expressed their chest pain with one of the 3 manual gestures classically associated with coronary pain, none achieved sufficient diagnostic accuracy to be used as indicative of this type of pain.

[Value of plasma C-reactive protein and lactate dehydrogenase levels in the diagnosis of intestinal obstruction in an emergency department]. / Proteína C reactiva y lactato deshidrogenasa en el diagnóstico de la obstrucción intestinal en un servicio de urgencias.

BACKGROUND: Intestinal obstruction is one of the most frequent surgical emergencies. Its diagnosis is essentially based on clinical history, physical exploration and image tests. The aim of this study was to analyze the diagnostic value of acute phase reactants in patients with benign versus malign intestinal obstruction. METHOD: Historical cohort study of 53 patients who underwent surgery because of intestinal obstruction and/or non-obstructive colorectal cancer. The patients were placed in three groups: group 1 (colorectal cancer with intestinal obstruction) (n=23), group 2 (benign intestinal obstruction)(n=10) and group 3 (non-obstructive cancer of the colon)(n=20). We determined the initial plasma values of the C-reactive protein (CRP) and the lactate dehydrogenase (LDH)enzyme. RESULTS: CRP was quantitatively higher in patients with benign intestinal obstruction (group 2) (p=0.001), while LDH was quantitatively higher in group 1 (patients with obstructive cancer). The plasma levels of LDH were significantly greater in the groups with intestinal obstruction (groups 1 and 2) than in patients without obstruction (p<0.001). Plasma levels of CRP above 11 mg/l and of LDH above 317 U/L showed an acceptable diagnostic value for differentiating patients with intestinal obstruction, with areas under the ROC curve of 80% (CI 95% = 68-92%) and 86% (CI 95%= 75-96%)respectively. Their diagnostic value for differentiating benign or malign origin is lower, with areas under the ROC curve of 56% for levels of CRP > 24 ng/l (CI 95% = 30-82%) and 52% (CI 95% = 29-74%) for levels of LDH > 359 U/L. CONCLUSION: Determination of plasma concentrations of CRP can help in the diagnosis of intestinal obstruction and indicate its benign or malign origin in emergency services.

[Complexity of emergency care in XXI century Spain]. / Complejidad de la asistencia urgente en la España del siglo XXI.

In this article, the authors explore the factors that, in their opinion, currently explain the complexity of emergency care in Spain. Since the start of the XXI century, and in spite of the fact that accident and emergency medicine in the world is undergoing considerable scientific-technical progress, accident and emergency care in Spain is immersed in a care maelstrom acting on a terrain that is ill-prepared for the successive emergent technological advances to take root and develop. This problem is due to the persistence of numerous obstacles preventing progress, with the lack of specialisation and the corporate spirit of the management boards of some scientific societies playing a principal and direct role in this. Due to all of this, advances are frequently achieved more through inertia, or through the overflow of information from other disciplines, than due to the initiative of the professionals of emergency medicine in Spain. Similarly, there is a growing tendency amongst these professionals to move to other disciplines or fields of care that offer better working conditions or simply better professional expectations.

[Chin numbness as initial manifestation of systemic cancer]. / Hipoestesia mentoniana como manifestación inicial de cáncer sistémico.

This issue describe the clinical picture of a man who consulted by hypoanaesthesia in the chin area that was secondary to a lung cancer. The most common primary cancers associated with mental neuropathy are haematological malignancies, breast and lung cancers. The presence o mental neuropathy must not be considered an "banal" symptom. It should be quickly recognised in order to research the presence of cancer.

[Increase of blood levels of creatine kinase following intramuscular injection]. / Elevación de las concentraciones séricas de creatincinasa tras inyección intramuscular.

BACKGROUND: To analyze the effect of intramuscular injections of drugs on serum creatine kinase (CK) and to evaluate the possible existence of factors that lead to predict the probability of appearance of serum CK increase after injection. PATIENTS, MATERIAL AND METHODS: One hundred and seventy six consecutive patients admitted to a short-term medical ward for non-cardiac reasons who had normal serum CK levels, were selected for the study. 120 of them, selected for random allocation, received a single 0 multiple injections of drugs (with broad use in emergency medicine) in the gluteal muscle (group IM). The remaining 56 patients were the group control, in all the cases serum CK was measured at 0, 6, 12, 24 and 48 h since the admission. RESULTS: A significant elevation of serum CK levels occurred in 58.3% cases of group IM. The higher ratio of cases with increment of CK levels was observed after the injection of chlorpromazine (100%), followed of diclofenac (74.2%), metamizol (60%) and multiple drugs (60%). In most cases the highest increment was observed at 12 h after injection. A tenfold increase in serum CK level was found after intramuscular injection of diclofenac. There were significant differences between the elevation or not of serum CK and the type of drug administered (p < 0.05), sex (p < 0.05), and the solvent of the drug injected (p < 0.05). A higher probability of serum CK elevation was observed in men (p = 0.009) and when the solvent of the drug injected was ethanol (p = 0.0499). CONCLUSIONS: There is a high probability of serum CK increment after intramuscular injection of drugs. The sex and the solvent of the drug injected have influence on this probability. The magnitude of this enzymatic increment depends on the kind of the drug injected, being non steroidal anti-inflammatory drugs those higher serum CK increment have been produced in the present study.

[Acute rhabdomyolysis and tetraparesis secondary to hypokalemia due to ingested licorice]. / Rabdomiólisis aguda y tetraparesia secundarias a hipocaliemia por ingesta de regaliz.

The glycirrinic acid, a common component of the natural licorice, has a potent mineralacorticoid effect (primary pseudohyperaldosteronism) which may cause severe hypokalemia and acute rhabdomyolysis. We present the case of a 36-years-old patient who, as the result of the intake of five daily licorice sticks (25 gr/day) for one month, developed analytical and clinical signs of acute rhabdomyolysis associated to the typical disorders of mineralcorticoid excess, that is, severe hypokalemia, arterial hypertension and metabolic alkalosis. The relevance of this clinical case lies on the low frequency of this finding and on the need that physicians working at emergency care centers must be aware of the onset of acute tetraparesis related to hypokalemia secondary to licorice ingesta. The early detection of this pathology is essential, since it will result in the beginning of an specific treatment, avoiding thus, as far as possible, the severe complications that might appear.

[The clinical usefulness and efficacy of adenosine triphosphate in an emergency service]. / Utilidad y eficacia clínica del adenosín trifosfato en un servicio de Urgencias.

We studied 89 patients diagnosed in our emergency department of paroxysmal supraventricular tachycardia, to describe the efficacy and safety of intravenous adenosine triphosphate (ATP) in their treatment. All received a first bolus of 10 mg of ATP and if no electrical response was observed, a second dose of 20 mg. This treatment was successful in 91% of the patients, lasting of 26.9 seconds to resolve the episode, and in the 53% of the patients with the first dose. In 9% of the patients ATP did not resolve the episode but allowed to diagnose it, which in five patients was atrial flutter, in 2 Wolff-Parkinson-White syndrome and in one atrial fibrillation. Adverse effects appeared in 25.6% of the cases, being in all transitory and banal. ATP is a very effective and safe drug for the treatment of patients with PSVT.