Safety and Effectiveness of the High-Sensitivity Cardiac Troponin HEART Pathway in Patients With Possible Acute Coronary Syndrome.

BACKGROUND: The HEART Pathway (History, Electrocardiogram, Age, Risk factors, Troponin) can be used with high-sensitivity cardiac troponin to risk stratify emergency department patients with possible acute coronary syndrome. However, data on whether a high-sensitivity HEART Pathway (hs-HP) are safe and effective is lacking. METHODS: An interrupted time series study was conducted at 5 North Carolina sites in 26 126 adult emergency department patients being investigated for possible acute coronary syndrome and without ST-segment-elevation myocardial infarction. Patients were accrued into 16-month preimplementation and postimplementation cohorts with a 6-month wash-in phase. Preimplementation (January 2019 to April 2020), the traditional HEART Pathway was used with 0- and 3-hour contemporary troponin measures (Siemens). In the postimplementation period (November 2020 to February 2022), a modified hs-HP was used with 0- and 2-hour high-sensitivity cardiac troponin (Beckman Coulter) measures. The primary safety and effectiveness outcomes were 30-day all-cause death or myocardial infarction and 30-day hospitalizations. These outcomes and early discharge rate (emergency department discharge without stress testing or coronary angiography) were determined from health records and death index data. Outcomes were compared preimplementation versus postimplementation using χ2 tests and multivariable logistic regression to adjust for potential confounders. RESULTS: Preimplementation and postimplementation cohorts included 12 317 and 13 809 patients, respectively, of them 52.7% (13 767/26 126) were female with a median age of 54 years (interquartile range, 42-66). Rates of 30-day death or MI were 6.8% (945/13 809) postimplementation and 7.7% (948/12 317) preimplementation (adjusted odds ratio, 1.00 [95% CI, 0.90-1.11]). hs-HP implementation was associated with 19.9% (95% CI, 18.7%-21.1%) higher early discharges (post versus pre: 63.6% versus 43.7%; adjusted odds ratio, 2.22 [95% CI, 2.10-2.35]). The hs-HP was also associated with 16.1% (95% CI, 14.9%-17.3%) lower 30-day hospitalizations (postimplementation versus preimplementation, 31.4% versus 47.5%; adjusted odds ratio, 0.51 [95% CI, 0.48-0.54]). Among early discharge patients, death or myocardial infarction occurred in 0.5% (41/8780) postimplementation versus 0.4% (22/5383) preimplementation (P=0.61). CONCLUSIONS: hs-HP implementation is associated with increased early discharges without increasing adverse events. These findings support the use of a modified hs-HP to improve chest pain care.

Sex and race differences in the performance of the European Society of Cardiology 0/1-h algorithm with high-sensitivity troponin T.

The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology (ESC) 0/1-h algorithm in sex and race subgroups of US Emergency Department (ED) patients is unclear. A pre-planned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 1-h hs-cTnT measures from eight US EDs (1/2017 to 9/2018) were stratified into rule-out, observation, and rule-in zones using the hs-cTnT ESC 0/1 algorithm. The primary outcome was adjudicated 30-day cardiac death or MI. The proportion with the primary outcome in each zone was compared between subgroups with Fisher's exact tests. The negative predictive value (NPV) of the ESC 0/1 rule-out zone for 30-day CDMI was calculated and compared between subgroups using Fisher's exact tests. Of the 1422 patients enrolled, 54.2% (770/1422) were male and 58.1% (826/1422) white with a mean age of 57.6 ± 12.8 years. At 30 days, cardiac death or myocardial infarction (MI) occurred in 12.9% (183/1422) of participants. Among patients stratified to the rule-out zone, 30-day cardiac death or MI occurred in 1.1% (5/436) of women versus 2.1% (8/436) of men (p = .40) and 1.2% (4/331) of non-white patients versus 1.8% (9/490) of white patients (p = .58). The NPV for 30-day cardiac death or MI was similar among women versus men (98.9% [95% confidence interval, CI: 97.3-99.6] vs. 97.9% [95% CI: 95.9-99.1]; p = .40) and among white versus non-white patients (98.8% [95% CI: 96.9-99.7] vs. 98.2% [95% CI: 96.5-99.2]; p = .39). NPVs <99% in each subgroup suggest the hs-cTnT ESC 0/1-h algorithm may not be safe for use in US EDs. Trial Registration: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).

Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease.

Importance: The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis). Objective: To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher. Design, Setting, and Participants: This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022. Interventions/Exposures: Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm. Main Outcomes and Measures: Cardiac death or MI at 30 days determined by expert adjudicators. Results: During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04). Conclusions and Relevance: Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.

Rural and socioeconomic differences in the effectiveness of the HEART Pathway accelerated diagnostic protocol.

BACKGROUND: The HEART Pathway is a validated accelerated diagnostic protocol (ADP) for patients with possible acute coronary syndrome (ACS). This study aimed to compare the safety and effectiveness of the HEART Pathway based on patient rurality (rural vs. urban) or socioeconomic status (SES). METHODS: We performed a preplanned subgroup analysis of the HEART Pathway Implementation Study. The primary outcomes were death or myocardial infarction (MI) and hospitalization at 30 days. Proportions were compared by SES and rurality with Fisher's exact tests. Logistic regression evaluated for interactions of ADP implementation with SES or rurality and changes in outcomes within subgroups. RESULTS: Among 7245 patients with rurality and SES data, 39.9% (2887/7245) were rural and 22.2% were low SES (1607/7245). The HEART Pathway identified patients as low risk in 32.2% (818/2540) of urban versus 28.1% (425/1512) of rural patients (p = 0.007) and 34.0% (311/915) of low SES versus 29.7% (932/3137) high SES patients (p = 0.02). Among low-risk patients, 30-day death or MI occurred in 0.6% (5/818) of urban versus 0.2% (1/425) rural (p = 0.67) and 0.6% (2/311) with low SES versus 0.4% (4/932) high SES (p = 0.64). Following implementation, 30-day hospitalization was reduced by 7.7% in urban patients (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.66-0.87), 10.6% in low SES patients (aOR 0.68, 95% CI 0.54-0.86), and 4.5% in high SES patients (aOR 0.83, 95% CI 0.73-0.94). However, rural patients had a nonsignificant 3.3% reduction in hospitalizations. CONCLUSIONS: HEART Pathway implementation decreased 30-day hospitalizations regardless of SES and for urban patients but not rural patients. The 30-day death or MI rate was similar among low-risk patients.

Derivation and validation of a high sensitivity troponin-T HEART pathway.

BACKGROUND: The HEART Pathway is widely used for chest pain risk stratification but has yet to be optimized for high sensitivity troponin T (hs-cTnT) assays. METHODS: We conducted a secondary analysis of STOP-CP, a prospective cohort study enrolling adult ED patients with symptoms suggestive of acute coronary syndrome at 8 sites in the United States (US). Patients had a 0- and 1-hour hs-cTnT measured and a HEAR score completed. A derivation set consisting of 729 randomly selected participants was used to derive a hs-cTnT HEART Pathway with rule-out, observation, and rule-in groups for 30-day cardiac death or myocardial infarction (MI). Optimal baseline and 1-hour troponin cutoffs were selected using generalized cross validation to achieve a negative predictive value (NPV) >99% for rule out and positive predictive value (PPV) >60% or maximum Youden index for rule-in. Optimal 0-1-hour delta values were derived using generalized cross validation to maximize the NPV for the rule-out group and PPV for the rule-in group. The hs-cTnT HEART Pathway performance was validated in the remaining cohort (n = 723). RESULTS: Among the 1452 patients, 30-day cardiac death or MI occurred in 12.7% (184/1452). Within the derivation cohort the optimal hs-cTnT HEART Pathway classified 36.5% (266/729) into the rule-out group, yielding a NPV of 99.2% (95% CI: 98.2-100) for 30-day cardiac death or MI. The rule-in group included 15.4% (112/729) with a PPV of 55.4% (95% CI: 46.2-64.6). In the validation cohort, the hs-cTnT HEART Pathway ruled-out 37.6% (272/723), of which 2 had 30-day cardiac death or MI, yielding a NPV of 99.3% (95% CI: 98.3-100). The rule-in group included 14.5% (105/723), yielding a PPV of 57.1% (95% CI: 47.7-66.6). CONCLUSIONS: A novel hs-cTnT HEART Pathway with serial 0- and 1-hour hs-cTnT measures has high NPV and moderate PPV for 30-day cardiac death or MI.

Clinical Characteristics of SARS-CoV-2 Acute Pulmonary Embolism and Adjusted D-dimer for Emergency Department Patients.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and acute pulmonary embolism (APE) present a diagnostic challenge in the emergency department (ED) setting. We aimed to identify key clinical characteristics and D-dimer thresholds associated with APE in SARS-CoV-2 positive ED patients. Methods: We performed a multicenter, retrospective cohort study for adult patients who were diagnosed with coronavirus 2019 (COVID-19) and had computed tomography pulmonary angiogram (CTPA) performed between March 17, 2020-January 31, 2021. We performed univariate analysis to determine numeric medians, chi-square values for association between clinical characteristic and positive CTPA. Logistic regression was used to determine the odds of a clinical characteristic being associated with a diagnosis of APE. Results: Of 408 patients who underwent CTPA, 29 (7.1%) were ultimately found to have APE. In multivariable analysis, patients with a body mass index greater than 32 (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.0 -19.3), a heart rate greater than 90 beats per minute (bpm) (OR 5.0, 95% CI 1.0-24.9), and a D-dimer greater than 1,500 micrograms per liter (µg/L) (OR 5.6, 95% CI 1.6-20.2) were significantly associated with pulmonary embolism. In our population that received a D-dimer and was SARS-CoV-2 positive, limiting CTPA to patients with a heart rate over 90 or a D-dimer value over 1500 µg/L would reduce testing 27.2% and not miss APE. Conclusion: In patients with acute COVID-19 infections, D-dimer at standard cutoffs was not usable. Limiting CTPA using a combination of heart rate greater than 90 bpm or D-dimer greater than 1,500 µg/L would significantly decrease imaging in this population.

Prehospital Comparison of the HEAR and HE-MACS Scores for 30-Day Adverse Cardiac Events.

OBJECTIVE: The History, Electrocardiogram (ECG), Age, and Risk factor (HEAR) and History and ECG-only Manchester Acute Coronary Syndromes (HE-MACS) risk scores can risk stratify chest pain patients without troponin measures. The objective of this study was to determine if either risk score could achieve the ≥99% negative predictive value (NPV) required to rule out major adverse cardiovascular events (MACE; a composite of all-cause death, myocardial infarction, or coronary revascularization) at 30 days or the ≥50% positive predictive value (PPV) indicative of a patient possibly needing interventional cardiology. METHODS: We performed a pre-planned secondary analysis of the prospective multisite PARAHEART (n = 462, 12/2016-1/2018) and RESCUE (n = 767, 4/2018-1/2019) trials, which accrued adults ≥21 years old with acute non-traumatic chest pain transported by emergency medical services (EMS). Paramedics prospectively completed risk assessment forms. Very low risk was defined by a HEAR score of 0-1 or HE-MACS probability <4%. The primary outcome was 30-day MACE, which was determined by adjudication (PARAHEART) or electronic record review (RESCUE). NPV and PPV with exact 95% confidence intervals (95%CI) for 30-day MACE were calculated for each risk score and compared using McNemar's tests. RESULTS: Among the PARAHEART and RESCUE cohorts, 30-day MACE occurred in 18.8% (87/462) and 6.9% (53/767) of patients, respectively. In PARAHEART, 7.8% (36/462) were very low risk by HEAR score vs. 7.8% (36/462) by HE-MACS (p = 1.0). The HEAR score had a NPV of 97.2% (95%CI 91.9-100.0) vs. 91.7% (95%CI 82.6-100.0) for HE-MACS (p = 0.15). The HEAR and HE-MACS PPVs were similar [46.4% (95%CI 28.0-64.9) vs. 33.3% (95%CI 13.2-53.5) (p = 0.26)]. In RESCUE, the HEAR score identified 14.2% (109/767) as low risk compared to 8.3% (64/767) by HE-MACS (p < 0.001). In this cohort, the HEAR and HE-MACS scores had similar NPVs [98.2% (95%CI 95.7-100.0) vs. 98.4% (95%CI 95.4-100.0) (p = 0.89)] and PPVs [16.2% (95%CI 6.2-32.0) vs. 22.6% (95%CI 12.3-36.2) (p = 0.41)]. CONCLUSIONS: In two prehospital chest pain cohorts, neither the HEAR score nor HE-MACS achieved sufficient NPV or PPV to rule out or rule in 30-day MACE.

Age differences in the safety and effectiveness of the HEART Pathway accelerated diagnostic protocol for acute chest pain.

BACKGROUND: The HEART Pathway is a validated protocol for risk stratifying emergency department (ED) patients with possible acute coronary syndrome (ACS). Its performance in different age groups is unknown. The objective of this study is to evaluate its safety and effectiveness among older adults. METHODS: A pre-planned subgroup analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time series accrued adult ED patients with possible ACS who were without ST-elevation across three US sites from 11/2013-01/2016. After implementation, providers prospectively used the HEART Pathway to stratify patients as low-risk or non-low-risk. Patients were classified as older adults (≥65 years), middle-aged (46-64 years), and young (21-45 years). Primary safety and effectiveness outcomes were 30-day death or MI and hospitalization at 30 days, determined from health records, insurance claims, and death index data. Fisher's exact test compared low-risk proportions between groups. Sensitivity for 30-day death or MI and adjusted odds ratios (aORs) for hospitalization and objective cardiac testing were calculated. RESULTS: The HEART Pathway implementation study accrued 8474 patients, of which 26.9% (2281/8474) were older adults, 45.5% (3862/8474) middle-aged, and 27.5% (2331/8474) were young. The HEART Pathway identified 7.4% (97/1303) of older adults, 32.0% (683/2131) of middle-aged, and 51.4% (681/1326) of young patients as low-risk (p < 0.001). The HEART Pathway was 98.8% (95% CI 97.1-100) sensitive for 30-day death or MI among older adults. Following implementation, the rate of 30-day hospitalization was similar among older adults (aOR 1.25, 95% CI 1.00-1.55) and cardiac testing increased (aOR 1.25, 95% CI 1.04-1.51). CONCLUSION: The HEART Pathway identified fewer older adults as low-risk and did not decrease hospitalizations in this age group.

Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter?

BACKGROUND: Despite negative troponins and nonischemic electrocardiograms (ECGs), patients at moderate risk for acute coronary syndrome (ACS) are frequently admitted. The objective of this study was to describe the major adverse cardiac event (MACE) rate in moderate-risk patients and how it differs based on history of coronary artery disease (CAD). METHODS: A secondary analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time-series study accrued adults with possible ACS from three sites (November 2013-January 2016). This analysis excluded low-risk patients determined by emergency providers' HEART Pathway assessments. Non-low-risk patients were further classified as high risk, based on elevated troponin measures or ischemic ECG findings or as moderate risk, based on HEAR score ≥ 4, negative troponin measures, and a nonischemic ECG. Moderate-risk patients were then stratified by the presence or absence of prior CAD (MI, revascularization, or ≥70% coronary stenosis). MACE (death, myocardial infarction, or revascularization) at 30 days was determined from health records, insurance claims, and death index data. MACE rates were compared among groups using a chi-square test and likelihood ratios (LRs) were calculated. RESULTS: Among 4,550 patients with HEART Pathway assessments, 24.8% (1,130/4,550) were high risk and 37.7% (1715/4550) were moderate risk. MACE at 30 days occurred in 3.1% (53/1,715; 95% confidence interval [CI] = 2.3% to 4.0%) of moderate-risk patients. Among moderate-risk patients, MACE occurred in 7.1% (36/508, 95% CI = 5.1% to 9.8%) of patients with known CAD versus 1.4% (17/1,207, 95% CI = 0.9% to 2.3%) in patients without known prior CAD (p < 0.0001). The negative LR for 30-day MACE among moderate-risk patients without prior CAD was 0.08 (95% CI = 0.05 to 0.12). CONCLUSION: MACE rates at 30 days were low among moderate-risk patients but were significantly higher among those with prior CAD.

Scoring systems for the triage and assessment of short-term cardiovascular risk in patients with acute chest pain.

Acute chest pain is a common emergency department (ED) chief complaint. Evaluating patients for acute coronary syndrome is challenging because missing the diagnosis carries substantial morbidity, mortality, and medicolegal consequences. However, over-testing is associated with increased cost, overcrowding, and possible iatrogenic harm. Over the past two decades, multiple risk scoring systems have been developed to help emergency providers evaluate patients with acute chest pain. The ideal risk score balances safety by achieving high sensitivity and negative predictive value for major adverse cardiovascular events while also being effective in identifying a large proportion of patients for early discharge from the ED. This review examines contemporary risk scores used to risk stratify patients with acute chest pain.

A Modified Delphi Study for Development of a Pediatric Curriculum for Emergency Medicine Residents.

OBJECTIVES: Emergency medicine (EM) trainees are expected to learn to provide acute care for patients of all ages. The American Council for Graduate Medical Education provides some guidance on topics related to caring for pediatric patients; however, education about pediatric topics varies across residency programs. The goal of this project was to develop a consensus curriculum for teaching pediatric emergency care. METHODS: We recruited 13 physicians from six academic health centers to participate in a three-round electronic modified Delphi project. Participants were selected on the basis of expertise with both EM resident education and pediatric emergency care. The first modified Delphi survey asked participants to generate the core knowledge, skills, and experiences needed to prepare EM residents to effectively treat children in an acute care setting. The qualitative data from the first round was reformulated into a second-round questionnaire. During the second round, participants used rating scales to prioritize the curriculum content proposed during the first round. In round 3, participants were asked to make a determination about each curriculum topic using a three-point scale labeled required, optional, or not needed. RESULTS: The first modified Delphi round yielded 400 knowledge topics, 206 clinical skills, and 44 specific types of experience residents need to prepare for acute pediatric patient care. These were narrowed to 153 topics, 84 skills, and 28 experiences through elimination of redundancy and two rounds of prioritization. The final lists contain topics classified by highly recommended, partially recommended, and not recommended. The partially recommended category is intended to help programs tailor their curriculum to the unique needs of their learners as well as account for variability between 3- and 4-year programs and the amount of time programs allocate to pediatric education. CONCLUSION: The modified Delphi process yielded the broad outline of a consensus core pediatric emergency care curriculum.

Combined Versus Detailed Evaluation Components in Medical Student Global Rating Indexes.

INTRODUCTION: To determine if there is any correlation between any of the 10 individual components of a global rating index on an emergency medicine (EM) student clerkship evaluation form. If there is correlation, to determine if a weighted average of highly correlated components loses predictive value for the final clerkship grade. METHODS: This study reviewed medical student evaluations collected over two years of a required fourth-year rotation in EM. Evaluation cards, comprised of a detailed 10-part evaluation, were completed after each shift. We used a correlation matrix between evaluation category average scores, using Spearman's rho, to determine if there was any correlation of the grades between any of the 10 items on the evaluation form. RESULTS: A total of 233 students completed the rotation over the two-year period of the study. There were strong correlations (>0.80) between assessment components of medical knowledge, history taking, physical exam, and differential diagnosis. There were also strong correlations between assessment components of team rapport, patient rapport, and motivation. When these highly correlated were combined to produce a four-component model, linear regression demonstrated similar predictive power in terms of final clerkship grade (R(2)=0.71, CI95=0.65-0.77 and R(2)=0.69, CI95=0.63-0.76 for the full and reduced models respectively). CONCLUSION: This study revealed that several components of the evaluation card had a high degree of correlation. Combining the correlated items, a reduced model containing four items (clinical skills, interpersonal skills, procedural skills, and documentation) was as predictive of the student's clinical grade as the full 10-item evaluation. Clerkship directors should be aware of the performance of their individual global rating scales when assessing medical student performance, especially if attempting to measure greater than four components.

Vitamin D deficiency in children with fractures.

OBJECTIVE: This study aimed to determine whether healthy children with fractures resulting from minor accidental trauma have a higher prevalence of vitamin D deficiency than that of healthy children without fractures. METHODS: This was a prospective case-control study of ambulatory children younger than 18 years with and without fractures in a pediatric emergency department. Evaluation included serum 25-hydroxyvitamin D (25(OH)D) level, complete metabolic panel, and phosphorus level. Vitamin D deficiency was defined as a 25(OH)D level of less than 20 ng/mL and insufficiency less than 30 ng/mL but 20 ng/mL or greater. A level of 30 ng/mL or greater was considered sufficient. Fisher exact test was used to test for association between 25(OH)D level and fracture status. Logistic regression was used to examine the relationship between 25(OH)D levels and the odds of fracture, conditioned on season, age, race, body weight percentile, history of fracture, multivitamin use, and estimated daily milk intake. RESULTS: The sample included 100 case and 100 control patients. There was no statistical difference in median 25(OH)D levels between fracture and control groups (26.7 vs 25.45 ng/mL, P = 0.84). There was no difference in the proportion of patients with sufficient 25(OH)D levels or in the distribution of sufficient, insufficient, and deficient. After adjusting for male sex and season of enrollment, vitamin D sufficiency was not a significant predictor of fracture status in a multiple variable logistic model (odds ratio, 0.94; 95% confidence interval, 0.51-1.77; Wald P = 0.859). CONCLUSIONS: We found no relationship between vitamin D deficiency and fracture risk in our study population.

Consensus development of a pediatric emergency medicine clerkship curriculum.

INTRODUCTION: As emergency medicine (EM) has become a more prominent feature in the clinical years of medical school training, national EM clerkship curricula have been published to address the need to standardize students' experiences in the field. However, current national student curricula in EM do not include core pediatric emergency medicine (PEM) concepts. METHODS: A workgroup was formed by the Clerkship Directors in Emergency Medicine and the Pediatric Interest Group of the Society of Academic Emergency Medicine to develop a consensus on the content to be covered in EM and PEM student courses. RESULTS: The consensus is presented with the goal of outlining principles of pediatric emergency care and prioritizing students' exposure to the most common and life-threatening illnesses and injuries. CONCLUSION: This consensus curriculum can serve as a guide to directors of PEM and EM courses to optimize PEM knowledge and skills education.

An unusual case of cerebral venous sinus thrombosis in a pediatric patient.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare, but potentially devastating illness. It is important for emergency physicians to be aware of the classic and most common risk factors leading to this illness, including genetic and acquired prothrombotic states, infection, inflammatory conditions, and certain drugs. OBJECTIVES: The objectives of this article are to discuss a case of CVST and describe the signs and symptoms of CVST as well as the radiologic modalities used to diagnose this disease. Finally, we will discuss the causes and risk factors that lead to this potentially devastating diagnosis. CASE REPORT: An 11-year-old girl was found unconscious and without pulses in an apparent drug overdose. Emergency Medical Services responders and Emergency Department personnel resuscitated the patient to a return of spontaneous circulation. The patient was intubated and admitted to the intensive care unit. As part of an altered mental status work-up, a magnetic resonance imaging scan of the head was performed and showed a cerebral venous sinus thrombosis. This was thought to be due to the drug overdose and the low-flow state that occurred during loss of circulation. After anticoagulation therapy and antibiotic treatment for sinusitis, the patient had a full recovery. CONCLUSION: Rapid diagnosis of CVST was essential to the appropriate care of this patient. Being aware of signs, symptoms, and risk factors leading to CVST will assist the emergency physician in making this diagnosis.

Lemierre syndrome.

Lemierre syndrome is a disease that presents with oropharyngeal infection, sepsis, internal jugular vein thrombosis, and septic emboli with the Gram-negative organism Fusobacterium necrophorum cultured as the etiologic agent. Clindamycin, metronidazole and ampicillin-sulbactam are effective antibiotic treatments, although the length of treatment has not been firmly established. The syndrome is seen less frequently in the current age of antibiotics. It is important, however, that physicians be aware of the syndrome as initiation of prompt antibiotic therapy, including anaerobic coverage, is essential for avoiding morbidity and mortality. We describe a case of Lemierre syndrome.