Arterial pH selectively predicts critical care needs in emergency department obese patients with acute dyspnea: A prospective comparative study.

INTRODUCTION: Obese patients with acute dyspnea may be prone to misorientation from the emergency department (ED), due to impaired gas exchange evaluation and altered basal respiratory profiles. This study aims to evaluate the prognostic value of arterial blood pH in obese ED patients with acute dyspnea in comparison to non-obese counterparts. METHODS: Single-center observational study of a cohort of 400 consecutive ED patients with acute dyspnea. The primary endpoint was a composite of Intensive Care Unit admission (with critical care needs) or in ED mortality. Predictors of the primary endpoint were assessed using multivariable logistic regression and ROC curve analysis, in obese (BMI ≥ 30 kg·m-2) and non-obese patients. RESULTS: 252 patients who had arterial blood gas testing were analyzed including 76 (30%) obese comparable to non-obese in terms of clinical history. 51 patients were admitted to ICU and 2 deceased before admission (20 obese (26%) vs 33 non-obese (19%); p = 0.17). Factors associated with ICU admission were arterial blood pH (pH < 7.36 vs pH ≥ 7.36) and gender. In multivariate models adjusted for risk factors, pH remained the sole independent predictor in obese patients, with no predictive value in non-obese patients (ROC AUC: 0.74, 95% CI [0.60; 0.87], optimal threshold for pH: 7.36, odds ratio: 10.5 [95% CI 3.18; 34.68]). CONCLUSION: Arterial blood pH may selectively predict critical care needs in ED obese patients with acute dyspnea, in comparison to non-obese. A falsely reassuring pH < 7.36 should be regarded as a marker of severity when assessing acute dyspnea in obese ED patients.

Point of Care Cardiac Troponin Assay Analytical Performances for their Use in Clinical Routine.

BACKGROUND: We report the analytical and clinical performances of the Alere Triage Cardiac3© Panel on the Triage MeterPro© instrument, comparing concordance with hs-cTnT results from central laboratory above the respective 99th percentiles and determining the clinical sensitivity within the framework of AMI. METHODS: The concordance was obtained with these two methods among unselected patients admitted to both the emergency and cardiology departments. RESULTS: The LoD of the assay is 0.010 µg/L. At 99th percentile (0.02 µg/L) the CV was found to be 18%, below the clinically acceptable cutoff of 20%. In the overall population, ROC AUC was not significantly different between the central laboratory assay and POC assay, with 0.952 (95% CI, 0.918 - 0.952) for hs-cTnT concentrations at presentation and 0.953 (95% CI, 0.912 - 0.953) for cTnI. Sensitivity and specificity of hs-cTnT vs. cTnI for AMI (n = 32) were 97% and 78% vs. 91% and 86%, respectively. Our results indicated 90.4% concordance between the two methods using the 99th percentile specific for each assay. The Kappa coefficient was higher than 0.75, and the strength of agreement could be considered to be good. CONCLUSIONS: The results of cTnI Alere assays provide similar clinical classification of patients, particularly for the AMI group as compared to the central laboratory hs-cTnT assay and could be suitable for clinical in accordance with the recommendations of Global Task Force guidelines.

Early rule out of acute myocardial infarction in ED patients: value of combined high-sensitivity cardiac troponin T and ultrasensitive copeptin assays at admission.

OBJECTIVE: We sought to evaluate the added value of ultrasensitive copeptin (us-copeptin) for early rule out of acute myocardial infarction in a prospective cohort of emergency department (ED) patients with acute chest pain. METHODS: This was a prospective study including consecutive patients with acute chest pain presenting to the ED within 12 hours of symptom onset. High-sensitivity cardiac troponin T (hs-cTnT, Roche Diagnostics, Meylan, France) and us-copeptin (ThermoFisher Scientific, Clichy, France) were blindly assayed from venous blood samples obtained at admission. Diagnosis was made by 2 ED physicians using all available data and serial cardiac troponin I as the biochemical standard. Diagnostic performances of us-copeptin combined with hs-cTnT were assessed using logistic regression. Analysis was conducted in all patients and in patients without ST-elevation myocardial infarction. RESULTS: A total of 194 patients were included (age, 61 [48-75] years; male sex, 63%). Acute myocardial infarction occurred in 52 (27%) patients, including non-ST-elevation myocardial infarction (NSTEMI) in 25 (13%). Patients with acute myocardial infarction had higher levels of hs-cTnT (50 [95% confidence interval, 19-173] ng/L) and us-copeptin (30 [13-113] pmol/L) at admission compared with those without (P < .05). Combination of markers significantly improved receiver operating characteristic area under the curve (from 0.89 [0.85-0.92] for hs-cTnT alone to 0.93 [0.89-0.97], P = .018). Sensitivity and negative predictive value were increased, particularly for NSTEMI diagnosis (sensitivity, 76% [54.9-90.6] to 96% [79.6-99.9]; negative predictive value, 95% [90.4-98.3] to 98.9% [94.2 to 100]). CONCLUSION: Assessment of us-copeptin combined with hs-cTnT on ED admission could allow safe and early rule out of NSTEMI for patients with negative results on both markers and help identify patients who may be suitable for discharge.

Chest compressions performed by ED staff: a randomized cross-over simulation study on the floor and on a stretcher.

BACKGROUND: Multiple factors may contribute to the observed survival variability following in-hospital cardiopulmonary resuscitation (CPR). While in-hospital CPR is most often performed on patients lying on a bed or stretcher, CPR training uses primarily manikins placed on the floor. We analyzed the quality of external chest compressions (ECC) in simulated cardiac arrest scenarios occurring both on a stretcher and on the floor. METHODS: Prospective cross-over simulation study enrolling ED nurses and nurse's aides as part of an annual evaluation. Simulated CPR was performed in the 2 rescuer-mode for 2 min, both kneeling on the floor, and standing beside a knee high stretcher. The order of position was randomized. ECC parameters were compared. RESULTS: ED nurses (n=48) and nurse's aides (n=26) performed 128 scenarios. Mean ECC depth was 32 ± 13 mm on the floor and 27 ± 11 mm on a stretcher (∆: 5 mm, 95%CI [3-7], P<.001). Participants last trained within a year (n=17) developed deeper ECCs than their colleagues (n=47) in both positions (floor: 39 ± 12 mm vs stretcher: 34 ± 11 mm (p=0.016) for those trained within the year, and floor: 29 ± 12 mm vs stretcher: 24 ± 10 mm (P<.001) for those trained over a year ago). CONCLUSIONS: The quality of chest compressions performed by ED staff was below 2005 guideline standards, with decreased ECC depth during CPR on a stretcher. Annual refresher courses should be implemented in the ED, with a focus on obtaining required ECC depth while standing next to a stretcher.

Breath analyzer screening of emergency department patients suspected of alcohol intoxication.

BACKGROUND: Acute alcohol intoxication is a frequent cause of emergency department (ED) visits. Evaluating a patient's alcohol intoxication is commonly based on both a physical examination and determination of blood alcohol concentration (BAC). OBJECTIVE: To demonstrate the feasibility and usefulness of using a last-generation infrared breath analyzer as a non-invasive and rapid screening tool for alcohol intoxication in the ED. METHODS: Adult patients suspected of acute alcohol intoxication were prospectively enrolled over 10 days. Breath alcohol concentrations (BrAC) were measured using a handheld infrared breath analyzer. BAC was determined simultaneously by automated enzymatic analysis of a venous blood sample. The relationship between BAC and BrAC values was examined by both linear regression and Bland-Altman analysis. RESULTS: The study included 54 patients (mean age 40±14 years, sex ratio M/F of 3/1). Breath and blood alcohol concentrations ranged from 0 to 1.44 mg/L and from 0 to 4.40 g/L (0-440 mg/dL), respectively. The mean individual BAC/BrAC ratio was 2615±387, 95% confidence interval 2509-2714, which is 30% higher than the legal ratio in France (2000). The correlation between both measurements was excellent: r=0.95 (0.92-0.97). Linear regression revealed BAC=0.026+1.29 (BrAC×2000) and BAC=0.026+0.99 (BrAC×2615). Mean BAC-BrAC differences and limits of agreement were 0.49 g/L [-0.35, 1.34] (or 49 mg/dL [-35, 134] and 0.01 g/L [-0.68, 0.71] (or 1 mg/dL [-68, 71]), for the 2000 and 2615 ratios, respectively. CONCLUSION: The calculated conversion coefficient provided a satisfactory determination of blood alcohol concentration. Breath alcohol testing, using appropriate BAC/BrAC conversion, different from the legal BAC/BrAC, could be a reliable alternative for routine screening and management of alcohol intoxication in the ED.

Emergency department management of suspected carbon monoxide poisoning: role of pulse CO-oximetry.

BACKGROUND: The RAD-57 pulse CO-oximeter is a lightweight device allowing noninvasive measurement of blood carboxyhemoglobin (S(pCO)). We assessed the diagnostic value of pulse CO-oximetry, comparing S(pCO) values from the RAD-57 to standard laboratory blood carboxyhemoglobin (COHb) measurement in emergency department patients with suspected carbon monoxide (CO) poisoning. METHODS: This was a prospective, diagnostic accuracy study according to the Standards for the Reporting of Diagnostic Accuracy Studies criteria in consecutive adult emergency department patients with suspected CO poisoning. S(pCO) was measured with the RAD-57 simultaneously with blood sampling for laboratory blood gas analysis. We made no changes to our standard management of CO poisoning. Blood COHb > 5% for non-smokers, and > 10% for smokers were applied as the reference standard. RESULTS: We included 93 subjects: 37 smokers and 56 non-smokers. CO poisoning was diagnosed in 26 subjects (28%). The S(pCO) values ranged from 1% to 30%, with a median of 4% (IQR 2.7-7.3%). The COHb values ranged from 0% to 34%, with a median of 5% (IQR 2-9%). The mean differences between the COHb and S(pCO) values were -0.2% ± 3.3% (95% limits of agreement of -6.7% and 6.3%) for the whole cohort, -0.7% (limits of agreement -7.7% and 6.2%) for the non-smokers, and 0.6% (limits of agreement -5.0% and 6.2%) for the smokers. The optimal thresholds for detecting CO poisoning were S(pCO) of 9% and 6% for smokers and non-smokers, respectively. CONCLUSIONS: S(pCO) measured with the RAD-57 was not a substitute for standard blood COHb measurement. However, noninvasive pulse CO-oximetry could be useful as a first-line screening test, enabling rapid detection and management of CO-poisoned patients in the emergency department.