Complications in Emergency Department Patients with Acute Coronary Syndrome with Contemporary Care.

INTRODUCTION: With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. The aim of this study was to analyze the complications in contemporary emergency department (ED) patients with ACS and to map patient management. METHODS: This observational study was a secondary analysis of data collected in the ESC-TROP trial (NCT03421873) that included 26,545 consecutive chest pain patients ≥18 years at five Swedish EDs. Complications were defined as the following within 30 days: death, cardiac arrest, cardiogenic shock, pulmonary edema, severe ventricular arrhythmia, high-degree atrioventricular (AV) block that required a pacemaker, and mechanical complications such as papillary muscle rupture, cardiac tamponade, or ventricular septum defects (VSDs). Complications were identified via diagnosis and/or intervention codes in the database, and manual chart review was performed in cases with complications. RESULTS: Of all 26,545 patients, 2,463 (9.3%) were diagnosed with ACS, and 151 of these (6.1%) suffered any complication within 30 days. Mean age was higher in patients with (79.2 years) than without (69.4 years) complications, and more were female (39.7% vs. 33.0%). Eighty-four (3.4% of all ACS patients) patients died, 33 (1.3%) had cardiac arrest, 22 (0.9%) respiratory failure, 13 (0.5%) high-degree AV block, 10 (0.4%) cardiogenic shock, 12 (0.5%) severe ventricular arrhythmia, and 2 each (<0.1%) had VSD or cardiac tamponade. Almost 30% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 80 (53%) of the patients with complications underwent coronary angiography and 62 (41%) were revascularized with percutaneous coronary intervention or coronary artery bypass grafting. CONCLUSION: With current care, serious complications occurred in only 6 out of 100 ACS patients, and 2 of these complications were present already at the ED. Four out of 10 ACS patients with complications were not admitted to the CCU/ICU and about half did not undergo coronary angiography. Further research is needed to improve risk assessment in ED ACS patients, which may allow more effective use of cardiac monitoring and hospital resources.

Prior electrocardiograms not useful for machine learning predictions of major adverse cardiac events in emergency department chest pain patients.

At the emergency department (ED), it is important to quickly and accurately determine which patients are likely to have a major adverse cardiac event (MACE). Machine learning (ML) models can be used to aid physicians in detecting MACE, and improving the performance of such models is an active area of research. In this study, we sought to determine if ML models can be improved by including a prior electrocardiogram (ECG) from each patient. To that end, we trained several models to predict MACE within 30 days, both with and without prior ECGs, using data collected from 19,499 consecutive patients with chest pain, from five EDs in southern Sweden, between the years 2017 and 2018. Our results indicate no improvement in AUC from prior ECGs. This was consistent across models, both with and without additional clinical input variables, for different patient subgroups, and for different subsets of the outcome. While contradicting current best practices for manual ECG analysis, the results are positive in the sense that ML models with fewer inputs are more easily and widely applicable in practice.

[Undergraduate teaching, training and examination of critical emergency management]. / Simulatorträning ger nya läkare självförtroende vid akuta tillstånd.

Current national objectives of Swedish medical schools state that new doctors should be able to independently start rapid and appropriate early treatment and diagnostic assessment in life-threatening situations. Since 2017 more than one thousand senior undergraduate students at Lund University have undergone compulsory five-week training in initial management of potentially reversible medical emergency conditions. The students participate in thematic full-scale simulations of life-threatening bedside challenges associated with chest or abdominal pain, vital organ dysfunction, and major trauma, and also take part in lectures, case-based seminars and clinical emergency practice under individual supervision. The course is concluded by a structured simulation-based holistic examination, designed to test individual abilities of relevant decision-making, rapid and appropriate bedside action, and professional approach.

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study.

BACKGROUND: Traumatic brain injury (TBI) is a common injury and constitutes up to 3% of emergency department (ED) visits. Current studies show that TBI is most commonly inflicted in older patients after ground-level falls. These patients often take medications affecting coagulation such as anticoagulants or antiplatelet drugs. Guidelines for ED TBI-management assume that anticoagulation therapy (ACT) confers a higher risk of traumatic intracranial hemorrhage (TICH) than antiplatelet therapy (APT). However, recent studies have challenged this. This study aimed to evaluate if oral anticoagulation and platelet inhibitors affected rate of TICH in head-trauma patients with ground-level falls. METHODS: This was a retrospective review of medical records during January 1, 2017 to December 31, 2017 and January 1 2020 to December 31, 2020 of all patients seeking ED care because of head-trauma. Patients ≥ 18 years with ground-level falls were included. RESULTS: The study included 1938 head-trauma patients with ground-level falls. Median age of patients with TICH was 81 years. The RR for TICH in APT-patients compared to patients without medication affecting coagulation was 1.72 (p = 0.01) (95% Confidence Interval (CI) 1.13-2.60) and 1.08 (p = 0.73), (95% CI 0.70-1.67) in ACT-patients. APT was independently associated with TICH in regression analysis (OR 1.59 (95% CI 1.02-2.49), p = 0.041). CONCLUSION: This study adds to the growing evidence that APT-patients with ground-level falls might have as high or higher risk of TICH than ACT-patients. This is not addressed in the current guidelines which may need to be updated. We therefore recommend broad prospective studies.

Microwave scan and brain biomarkers to rule out intracranial hemorrhage: study protocol of a planned prospective study (MBI01).

PURPOSE: The aim of this planned study is to evaluate the ability of a cranial microwave scanner in conjunction with nine brain biomarkers (Aß40, Aß42, GFAP, H-FABP, S100B, NF-L, NSE, UCH-L1 and IL-10) to detect and rule out traumatic intracranial hemorrhage in an emergency department setting. Traumatic brain injury is a world-wide topic of interest for researchers and clinicians. It affects 2% of the population per annum and presents challenges for physicians as patients' initial signs and symptoms do not always correlate with the extent of brain injury. The gold standard for diagnosis of intracranial hemorrhage is head computerized tomography (CT) with the drawbacks of high cost and radiation exposure. A fast, secure way of diagnosing without these drawbacks has potential to make care more effective and reduce cost. METHODS: Study will be prospective and enroll adult, consenting patients with head trauma who seek emergency department care. Only patients where the treating physician prescribes a head-CT will be included. The microwave scan and blood sampling will be performed in close temporal proximity to the CT scan. Results will be analyzed with sensitivity, specificity and receiver operator characteristics analysis to provide the best combination of a number of biomarkers and the microwave scan. CONCLUSION: This study will explore the diagnostic accuracy of a head microwave scanner in combination with biomarkers in ruling out intracranial hemorrhage in traumatic brain injury patients presenting to the emergency department. Potentially, this combined diagnostic approach could achieve both high sensitivity and high specificity, thereby reducing the need of CT-head scans when managing these patients. CLINICALTRIALS: gov identifier: NCT04666766. Registered December 11, 2020.

PR interval prolongation and 1-year mortality among emergency department patients: a multicentre transnational cohort study.

OBJECTIVES: Emerging evidence supports that PR interval prolongation is associated with increased mortality. However, most previous studies have limited confounder control, and clinical impact in a population of acute ill patients is unknown. The aim of this study was to investigate whether 1-year all-cause mortality was increased in patients presenting with PR interval prolongation in the emergency department (ED). DESIGN AND SETTING: We conducted a register-based cohort study in two Swedish and two Danish EDs. We included all adult patients with an ECG performed at arrival to the Danish EDs during March 2013 to May 2014 and Swedish EDs during January 2010 to January 2011. Using propensity score matching, we analysed HR for 1-year all-cause mortality comparing patients with PR interval prolongation (>200 ms) and normal PR interval (120-200 ms). PARTICIPANTS AND RESULTS: We included 106 124 patients. PR interval prolongation occurred in 8.9% (95% CI 8.7% to 9.0%); these patients were older and had more comorbidity than those with a normal PR interval. The absolute 1-year risk of death was 13% (95% CI 12.3% to 13.7%) for patients with PR interval prolongation and 7.9% (95% CI 7.7% to 8.0%) for those without. After confounder adjustments by propensity score matching, PR interval prolongation showed no association with 1-year mortality with a HR of 1.00 (95% CI 0.93% to 1.08%). CONCLUSION: PR interval prolongation does not constitute an independent risk factor for 1-year mortality in ED patients.

Diagnostic accuracy of the HEART Pathway and EDACS-ADP when combined with a 0-hour/1-hour hs-cTnT protocol for assessment of acute chest pain patients.

BACKGROUND/AIM: In ED chest pain patients, a 0-hour/1-hour protocol based on high sensitivity cardiac troponin T (hs-cTnT) tests combined with clinical risk stratification in diagnosing acute coronary syndrome is recommended. Two of the most promising risk stratification tools are the History, ECG, Age, Risk Factors and Troponin (HEART) and Emergency Department Assessment of Chest Pain (EDAC) scores. Few studies have assessed the diagnostic accuracy of the 0-hour/1-hour hs-cTnT protocol when combined with HEART score, and none with EDACS. In ED chest pain patients, we aimed to evaluate the diagnostic accuracy of a 0-hour/1-hour hs-cTnT protocol combined the HEART Pathway, or the EDACS accelerated diagnostic pathway (EDACS-ADP). METHODS: This was a secondary analysis of data from a prospective observational study enrolling 1167 ED chest pain patients who visited the ED at Skåne University Hospital in Lund, Sweden in the period between February 2013 and April 2014. HEART and EDAC scores were assessed together with hs-cTnT at 0 and 1 hour and compared with HEART score alone. Sensitivity, specificity, negative predictive value (NPV) and likelihood ratios were evaluated. The primary outcome was major adverse cardiac events (MACE) including unstable angina within 30 days. The secondary outcome was index visit acute myocardial infarction (AMI). RESULTS: A total of 939 patients were included in the final analysis. When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The NPV for index visit AMI were 100%, 99.8% and 99.2%, respectively. CONCLUSION: The combination of the HEART Pathway or the EDACS-ADP with a 0-hour/1-hour hs-cTnT protocol allows safe and early rule-out in a large proportion of ED chest pain patients.

Machine learning compared with rule-in/rule-out algorithms and logistic regression to predict acute myocardial infarction based on troponin T concentrations.

OBJECTIVE: Computerized decision-support tools may improve diagnosis of acute myocardial infarction (AMI) among patients presenting with chest pain at the emergency department (ED). The primary aim was to assess the predictive accuracy of machine learning algorithms based on paired high-sensitivity cardiac troponin T (hs-cTnT) concentrations with varying sampling times, age, and sex in order to rule in or out AMI. METHODS: In this register-based, cross-sectional diagnostic study conducted retrospectively based on 5695 chest pain patients at 2 hospitals in Sweden 2013-2014 we used 5-fold cross-validation 200 times in order to compare the performance of an artificial neural network (ANN) with European guideline-recommended 0/1- and 0/3-hour algorithms for hs-cTnT and with logistic regression without interaction terms. Primary outcome was the size of the intermediate risk group where AMI could not be ruled in or out, while holding the sensitivity (rule-out) and specificity (rule-in) constant across models. RESULTS: ANN and logistic regression had similar (95%) areas under the receiver operating characteristics curve. In patients (n = 4171) where the timing requirements (0/1 or 0/3 hour) for the sampling were met, using ANN led to a relative decrease of 9.2% (95% confidence interval 4.4% to 13.8%; from 24.5% to 22.2% of all tested patients) in the size of the intermediate group compared to the recommended algorithms. By contrast, using logistic regression did not substantially decrease the size of the intermediate group. CONCLUSION: Machine learning algorithms allow for flexibility in sampling and have the potential to improve risk assessment among chest pain patients at the ED.

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.

BACKGROUND: Studies carried out in simulated environments suggest that checklists improve the management of surgical and intensive care crises. Whether checklists improve the management of medical crises simulated in actual emergency departments (EDs) is unknown. METHODS: Eight crises (anaphylactic shock, life-threatening asthma exacerbation, haemorrhagic shock from upper gastrointestinal bleeding, septic shock, calcium channel blocker poisoning, tricyclic antidepressant poisoning, status epilepticus, increased intracranial pressure) were simulated twice (once with and once without checklist access) in each of four EDs-of which two belong to an academic centre-and managed by resuscitation teams during their clinical shifts. A checklist for each crisis listing emergency interventions was derived from current authoritative sources. Checklists were displayed on a screen visible to all team members. Crisis and checklist access were allocated according to permuted block randomisation. No team member managed the same crisis more than once. The primary outcome measure was the percentage of indicated emergency interventions performed. RESULTS: A total of 138 participants composing 41 resuscitation teams performed 76 simulations (38 with and 38 without checklist access) including 631 interventions. Median percentage of interventions performed was 38.8% (95% CI 35% to 46%) without checklist access and 85.7% (95% CI 80% to 88%) with checklist access (p=7.5×10-8). The benefit of checklist access was similar in the four EDs and independent of senior physician and senior nurse experience, type of crisis and use of usual cognitive aids. On a Likert scale of 1-6, most participants agreed (gave a score of 5 or 6) with the statement 'I would use the checklist if I got a similar case in reality'. CONCLUSION: In this multi-institution study, checklists markedly improved local resuscitation teams' management of medical crises simulated in situ, and most personnel reported that they would use the checklists if they had a similar case in reality.

Low diagnostic yield of ST elevation myocardial infarction amplitude criteria in chest pain patients at the emergency department.

OBJECTIVES: To evaluate the diagnostic yield of the ECG criteria for ST-elevation myocardial infarction in a large cohort of emergency department chest pain patients, and to determine whether extended ECG criteria or reciprocal ST depression can improve accuracy. Design: Observational, register-based diagnostic study on the accuracy of ECG criteria for ST-elevation myocardial infarction. Between Jan 2010 and Dec 2014 all patients aged ≥30 years with chest pain who had an ECG recorded within 4 h at two emergency departments in Sweden were included. Exclusion criteria were: ECG with poor technical quality; QRS duration ≥120 ms; ECG signs of left ventricular hypertrophy; or previous coronary artery bypass surgery. Conventional and extended ECG criteria were applied to all patients. The main outcome was acute myocardial infarction (AMI) and an occluded/near-occluded coronary artery at angiography. Results: Finally, 19932 patients were included. Conventional ECG criteria for ST elevation myocardial infarction were fulfilled in 502 patients, and extended criteria in 1249 patients. Sensitivity for conventional ECG criteria in diagnosing AMI with coronary occlusion/near-occlusion was 17%, specificity 98% and positive predictive value 12%. Corresponding data for extended ECG criteria were 30%, 94% and 8%. When reciprocal ST depression was added to the criteria, the positive predictive value rose to 24% for the conventional and 23% for the extended criteria. Conclusions: In unselected chest pain patients at the emergency department, the diagnostic yield of both conventional and extended ECG criteria for ST-elevation myocardial infarction is low. The PPV can be increased by also considering reciprocal ST depression.

Effectiveness and Safety of the European Society of Cardiology 0-/1-h Troponin Rule-Out Protocol: The Design of the ESC-TROP Multicenter Implementation Study.

Chest pain is one of the most common complaints at the emergency department (ED), and it is commonly the perceived likelihood of acute coronary syndrome (ACS) that drives management. Guidelines from the European Society of Cardiology (ESC) recommend the use of a 0-/1-h high-sensitivity cardiac troponin T (hs-cTnT) protocol to rule out or in ACS, but this is mostly based on observational studies. The aim of the ESC-TROP trial is to determine the safety and effectiveness of the ESC 0-/1-h hs-cTnT protocol when implemented in routine care. Adult chest pain patients at 5 EDs in the Skåne Region, Sweden, are included in the trial. The 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and electrocardiography (ECG) is implemented at 3 EDs, and the other 2 EDs act as concurrent controls. Outcomes will be evaluated during the 10 months after the implementation and the corresponding 10 months of the previous year. The 2 co-primary outcomes are (a) acute myocardial infarction (AMI) and all-cause death within 30 days in patients discharged from the ED, and (b) ED length of stay of the same patients. Secondary outcomes include the proportion of chest pain patients discharged from the ED and the number of ruled-out patients undergoing objective testing within 30 days. The ESC-TROP trial will determine the performance and applicability of the 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and ECG when implemented in routine ED care. It will provide evidence whether 0-/1-h hs-cTnT testing is safe, effective, and feasible, and whether widespread implementation as recommended by ESC guidelines should be supported.

Diagnostic Accuracy of History and Physical Examination for Predicting Major Adverse Cardiac Events Within 30 Days in Patients With Acute Chest Pain.

BACKGROUND: The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results. OBJECTIVE: The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30 days. METHODS: This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE. RESULTS: Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24 h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors. CONCLUSIONS: No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24 h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.

A simple clinical assessment is superior to systematic triage in prediction of mortality in the emergency department.

OBJECTIVE: To compare the Danish Emergency Process Triage (DEPT) with a quick clinical assessment (Eyeball triage) as predictors of short-term mortality in patients in the emergency department (ED). METHODS: The investigation was designed as a prospective cohort study conducted at North Zealand University Hospital. All patient visits to the ED from September 2013 to December 2013 except minor injuries were included. DEPT was performed by nurses. Eyeball triage was a quick non-systematic clinical assessment based on patient appearance performed by phlebotomists. Both triage methods categorised patients as green (not urgent), yellow, orange or red (most urgent). Primary analysis assessed the association between triage level and 30-day mortality for each triage method. Secondary analyses investigated the relation between triage level and 48-hour mortality as well as the agreement between DEPT and Eyeball triage. RESULTS: A total of 6383 patient visits were included. DEPT was performed for 6290 (98.5%) and Eyeball triage for 6382 (~100%) of the patient visits. Only patients with both triage assessments were included. The hazard ratio (HR) for 48-hour mortality for patients categorised as yellow was 0.9 (95% CI 0.4 to 1.9) for DEPT compared with 4.2 (95% CI 1.2 to 14.6) for Eyeball triage (green is reference). For orange the HR for DEPT was 2.2 (95% CI 1.1 to 4.4) and 17.1 (95% CI 5.1 to 57.1) for Eyeball triage. For red the HR was 30.9 (95% CI 12.3 to 77.4) for DEPT and 128.7 (95% CI 37.9 to 436.8) for Eyeball triage. For 30-day mortality the HR for patients categorised as yellow was 1.7 (95% CI 1.2 to 2.4) for DEPT and 2.4 (95% CI 1.6 to 3.5) for Eyeball triage. For orange the HR was 2.6 (95% CI 1.8 to 3.6) for DEPT and 7.6 (95% CI 5.1 to 11.2) for Eyeball triage, and for red the HR was 19.1 (95% CI 10.4 to 35.2) for DEPT and 27.1 (95% CI 16.9 to 43.5) for Eyeball triage. Agreement between the two systems was poor (kappa 0.05). CONCLUSION: Agreement between formalised triage and clinical assessment is poor. A simple clinical assessment by phlebotomists is superior to a formalised triage system to predict short-term mortality in ED patients.

Association between QTc prolongation and mortality in patients with suspected poisoning in the emergency department: a transnational propensity score matched cohort study.

OBJECTIVES: Poisoning is a frequent cause of admission to the emergency department (ED) and may involve drugs known to prolong the QT interval. This study aims to describe the prevalence of QTc prolongation among ED patients with suspected poisoning and to calculate the absolute and relative risk of mortality or cardiac arrest associated with a prolonged QTc interval. METHODS: We performed a register-based cohort study, including all adult first-time contacts with suspected poisoning to the ED of two Swedish hospitals (January 2010-December 2014) and two Danish hospitals (March 2013-April 2014). We used propensity score matching to calculate HRs for all-cause mortality or cardiac arrest (combined endpoint) within 30 days after contact comparing patients with a prolonged QTc interval (≥450 ms men, ≥460 ms women) with patients with a QTc interval of <440 ms. RESULTS: Among all first-time contacts with suspected poisoning that had an ECG recorded within 4 hours after arrival (n=3869), QTc prolongation occurred in 6.5%. The overall mortality after a 30-day follow-up period was 0.8% (95% CI 0.6 to 1.2), with an absolute risk of mortality or cardiac arrest in patients with QTc prolongation of 3.2% (95% CI 1.4 to 6.1). A prolonged QTc interval on arrival was associated with a HR of 3.6 (95% CI 1.0 to 12.2). CONCLUSION: In the ED, a prolonged QTc interval in patients arriving with suspected poisoning seems to be associated with a threefold increased risk of 30-day all-cause mortality or cardiac arrest.

Goda resultat när akutläkare diagnostiserade djup ventrombos - DVT-diagnostik kan utföras med ultraljud på akuten, enligt pilotstudie vid Lasarettet i Ystad.

Good outcomes when emergency physicians diagnosed deep vein thrombosis Deep vein thrombosis of the lower limb is best diagnosed with ultrasound. Internationally, several studies have shown promising and often equal results when emergency physicians have been compared with radiologists in diagnosing thrombosis. Our results confirm these findings in a non-academic hospital and for the first time in a Swedish setting. Our findings form the basis for a multi-centre study on new diagnostic routines in patients with suspected proximal deep vein thrombosis in the emergency department, potentially resulting in faster and more resource-effective management.