Clinical correlates and prognostic significance of early negative exercise tolerance test in patients with acute chest pain seen in the hospital emergency department.

An exercise tolerance test (ETT) is often performed to identify patients for early discharge after observation for acute chest pain, but the safety of this strategy is unproven. We prospectively studied 276 low-risk patients who underwent an ETT within 48 hours after presentation to the emergency department with acute chest pain. The ETT was considered negative if subjects achieved at least stage I of the Bruce protocol and the electrocardiogram showed no evidence of ischemia. There were no complications associated with ETT performance. The ETT was negative in 195 patients (71%); there was no identifiable subsets of patients at very low probability of an abnormal test. During the 6-month follow-up, patients with a negative ETT had fewer additional visits to the emergency department (17% vs 21%, respectively; p < 0.05) and fewer readmissions to the hospital (12% vs 17%; p < 0.01) than those with positive or inconclusive ETTs. No patient with a negative ETT died and only 4 patients with a negative ETT experienced a major cardiac event (myocardial infarction, coronary angioplasty, or bypass) within 6 months. Among these 4 patients, only 1 had an event within 4 months. In conclusion, our results suggest that ETT can be safely used to identify patients at low risk of subsequent events. Patients without a clearly negative test are at increased risk for readmission and cardiac events, and should be reevaluated either during the same admission or shortly after discharge.

Prehospital thrombolysis: an idea whose time has come.

Aggressive reperfusion therapy for myocardial infarction (MI) characterized by acute ST-segment elevation leads to improved patient outcome. Furthermore, use of thrombolytic therapy is highly time-dependent: reperfusion therapy is beneficial within 12 h, but the earlier it is administered, the more beneficial it is. Thus, the focus of both prehospital and emergency department management of patients with acute MI is on rapid identification and treatment. There are many components to the time delays between the onset of symptoms of acute MI and the achievement of reperfusion in the occluded infarct-related artery. Time delays occur with both the patient and the prehospital emergency medical system, although patient delays are more significant. This article focuses on the prehospital management of acute MI, including (1) the rationale for rapid reperfusion in patients with acute MI, (2) the factors related to time delays in patient presentation to the hospital, and (3) strategies for reducing time delays, both patient- and medical system-based.

Emergency department thrombolysis critical pathway reduces door-to-drug times in acute myocardial infarction.

BACKGROUND: Rapid time to treatment with thrombolytic therapy is an important determinant of survival in acute myocardial infarction (AMI). HYPOTHESIS: We hypothesized that establishment of an AMI thrombolysis critical pathway in the Emergency Department could successfully reduce the "door-to-drug" time, the time between patient arrival and start of thrombolysis. METHODS AND RESULTS: Before establishment of the AMI critical pathway, median door-to-drug time was 73 min, which was reduced to 37 min after critical pathway implementation (p < 0.05). The percentage of patients treated within 30 min rose from 0% prior to establishment of the pathway to 43% (p = 0.03). Similarly, the percentage treated in within 45 min rose from 0 to 67% (p = 0.0005). Door-to-drug times were longer for women than for men (median 105 min for women vs. 70 min for men before pathway implementation). The pathway reduced door-to-drug time for both genders, but the median door-to-drug times were higher for women than for men (Mann-Whitney p = 0.013). The difference between men and women was 35 min before establishment of the pathway to 10 min by the end of the study period. CONCLUSIONS: Our critical pathway was successful in reducing door-to-drug times. We observed a "gender gap" in door-to-drug times, with longer mean times for women, which was reduced by the AMI critical pathway. Thus, our data provide support for the use of critical pathways to reduce door-to-drug times, as recommended by the National Heart Attack Alert Program.

Cricothyroidotomy.

Cricothyroidotomy is a technique used to gain emergency access to the airway through the cricothyroid membrane. Although its use should be reserved for specific circumstances, the procedure is safe and can be performed rapidly. Knowledge of the anatomy of the anterior neck and a specific sequence for performing the cricothyroidotomy generally will result in a good success rate and acceptable complications.

Management of the difficult airway in the trauma patient.

Airway management of the multiple trauma patient presents a series of challenges. By definition, many trauma patients present difficult airways that require a different approach and formulation of a planned series of steps before airway management is initiated. Recognition of specific attributes of the difficult airway, knowledge of appropriate techniques, familiarity with various devices, and prompt recognition of failed airway circumstances are necessary for optimal patient outcome. This article reviews the attributes of the difficult airway, the definition of the failed airway, and devices and techniques to be used in the management of difficult and failed airways in the trauma patient.

Airway management.

The approach to airway management in the multiple trauma patient has changed significantly over the past decade. A number of central controversies have been identified, and the debates continue. This article identifies the major controversies in trauma airway management, reviews and summarizes relevant literature, and presents specific recommendations and supporting arguments. Particular emphasis is placed upon the role of endotracheal intubation, use of neuromuscular blocking agents, and the issue of neuromuscular blockade versus rapid tranquilization of the combative trauma patient.

Blindness following minor head trauma in children: a report of two cases with a review of the literature.

The spectrum of closed head injury ranging from asymptomatic to lethal is well described in the literature. In a small number of cases, dramatic neurologic symptoms normally associated with cerebrovascular accident or vascular headache may arise following apparently insignificant head trauma. We report two cases of young males who developed transient blindness accompanied by significant neurologic abnormality following trivial head injuries. These phenomena are previously well documented, and it is believed that in certain individuals, minor head trauma can induce a type of migraine equivalent known as "footballer's migraine" or "posttraumatic cortical blindness." Current knowledge of these two conditions is reviewed.

Acute pericarditis.

There are many causes of acute pericarditis (inflammation of the pericardium) and diagnosis is often difficult owing to the dynamic nature of the disease. History and physical examination, augmented by radiographic and ECG studies, will allow the diagnosis to be made in the majority of cases. The ECG typically undergoes a four-stage evolution, and frequent reassessment of the patient is essential. Outpatient treatment is usually successful, although a subgroup of these patients require hospitalization.

Hyperkalemia: ECG manifestations and clinical considerations.

Hyperkalemia is a common cause of electrolyte induced cardiac conduction disturbance. A well-defined series of changes at the cellular level leads to characteristic evolutionary changes in the surface electrocardiogram. Initial high T waves and shortened intervals give way to prolongation of conduction and lethal dysrhythmias as the serum potassium level rises. The patterns of electrocardiographic changes associated with hyperkalemia are reviewed and an outline of appropriate therapeutic interventions.

"Cotton fever": a benign febrile syndrome in intravenous drug abusers.

Cotton fever is a benign, self-limited syndrome that may mimic sepsis in intravenous drug addicts. We present an illustrative case and a review of the literature. Serious illness such as pneumonia and infectious endocarditis must always be considered in febrile addicts. However, trivial illness accounts for 16% to 26% of such fevers. Recent evidence suggests that emergency physicians are able to diagnose trivial illness with 93% specificity in febrile adult drug addicts. Short-term observation units may be an alternative to hospital admission for febrile drug users with a presumptive diagnosis of trivial illness and in those in whom the diagnosis of cotton fever is entertained.

QT interval prolongation.

The QT interval is a function of ventricular repolarization time and is measured from the onset of the QRS complex to the end of the T wave. The length of this interval is inversely related to heart rate. A prolonged QT interval is most often secondary to the use of Type I antidysrhythmic medications (quinidine, procainamide). It is also associated with phenothiazines, organophosphates, hypocalcemia, liquid protein diets and the congenital long QT syndromes. QT prolongation is associated with a variety of ventricular dysrhythmias, most characteristically Torsades des pointes. Treatment consists of correction of the underlying metabolic disorder or discontinuation of the offending medication.

Traumatic dislocation of the knee.

Traumatic dislocation of the knee is an uncommon orthopedic injury affecting primarily young males who have been subjected to major trauma. The presentation may be subtle and the diagnosis is frequently overlooked. The high frequency of associated limb-threatening vascular injury mandates careful search for and aggressive treatment of this entity, as misdiagnosis of the knee injury or failure to pursue evaluation of the vascular status of the limb will result in a large number of potentially avoidable amputations.

Case report: Brown-Séquard's syndrome associated with histiocytic lymphoma.

Brown-Séquard's syndrome is a rare spinal cord lesion usually produced by penetrating injuries in which ipsilateral hemiparesis and loss of position sense is associated with loss of pain and temperature sensation on the opposite side of the body. Reported here is an unusual cause of the syndrome, and a review of the pathophysiology of the syndrome is presented.

Acute mesenteric ischemia in a middle-aged patient: case report and discussion.

Mesenteric ischemia usually occurs in elderly patients, especially those with predisposing factors. It has also been described in young patients using oral contraceptive pills or illicit drugs. We present a case of a middle-aged woman who developed acute focal ischemia of the small intestine without predisposing factors. The unusual presentation of this patient, combined with her relative youth, obscured the diagnosis, which was ultimately made at laparotomy. The diagnosis of mesenteric ischemia should be considered in patients of any age presenting with recurrent or severe abdominal pain, particularly when no alternative cause is apparent. The definitive study to diagnose mesenteric ischemia is angiography. Unless identified early in its course, the condition may progress to frank infarction with a significant increase in morbidity and mortality. Because of this, an aggressive approach to the diagnosis and therapy of mesenteric ischemia is essential.

Delay in thrombolysis administration: causes of extended door-to-drug times and the asymptote effect.

We retrospectively analyzed medical records and critical pathway data forms of all patients who received thrombolytic therapy for acute myocardial infarction (AMI) over a 2 1/2-year period. The time spent by each patient in the emergency department (ED) prior to receiving thrombolytic therapy (the door-to-drug time) was determined. Records of those patients with door-to-drug times exceeding the median were closely examined to determine the cause of treatment delays. Results indicated that treatment delays resulted from delays in obtaining the initial electrocardiogram (24%), atypical presentations (11%), the need to rule out a potential contraindication (11%), the need to confirm the diagnosis (14%), and miscellaneous causes (8%). Many patients had no identifiable reason for their delay (32%). A certain population of AMI patients either do not satisfy thrombolytic criteria upon initial ED presentation or require prolonged evaluation to investigate possible contraindications to thrombolysis such as aortic dissection. The inclusion of patients in this separate population in a general analysis of median door-to-drug times results in an artificial asymptote effect and may confound quality initiatives.

Case report: common femoral artery occlusion following blunt trauma in a child.

Vascular injury from blunt trauma is infrequently seen in children unless associated with major trauma. This case report is an example of a significant vascular injury in the setting of minor trauma. The consequences of missing such an injury as well as some of the difficulties encountered in establishing the diagnosis are discussed.