Are all troponin assays equivalent in the emergency department?

INTRODUCTION: Cardiac-specific troponins (cTn) are recently-introduced, sensitive and specific markers of myocardial injury, and their absence should allow to safely exclude a coronary event. Various assays are commercially available but the relative advantage of each is not clear. Our objective was to compare the reliability of the two most commonly used troponin assays (cTnI and cTnT), in the emergency department (ED) for clinical decision when myocardial infarction (MI) or acute coronary syndrome (ACS) is suspected. METHODS: This prospective study included all patients arriving at the ED over a six-month period with chest pain or symptoms suggesting MI or ACS, in which diagnosis could not be confirmed due to absence of characteristic ECG features. All patients were tested with at least one of the two troponin assays available at the ED. RESULTS: Of the 54 included patients, ten (19%) were eventually diagnosed with MI/ACS. Qualitative assays for cTnI and cTnT identified the MI/ACS patients by both assays (respective positive predictive values of 0.5 and 0.7, and negative predictive values of 1.0 and 0.9). However, these assays were only partially correlated (R equals 0.49) and differed significantly. The quantitative assay for cTnI, but not for cTnT, discerned those who had MI/ACS (group A) from those who had other condition (group B) by their troponin levels (MI/ACS - 17.2 plus or minus 23.8 ng/ml versus others - 0.37 plus or minus 0.91 ng/ml, p is less than 0.001). CONCLUSION: In the ED, bedside assays of troponins are invaluable tools for the clinician, and their use is cost-effective. However, in the recommended cutoffs levels, only troponin I but not troponin T allowed the safe discharge of patients not requiring acute hospital care.

[Injury from fireworks and firecrackers during holidays].

BACKGROUND: Every year during the holidays of the Arab and Druze population, and especially during Id el-Adha, scores of injured from firecrackers, crackers, skyrockets and other homemade explosive devices arrive at the Western Galilee Hospital. Similar casualties present during the Jewish Purim Festival. OBJECTIVES: To characterize the population of the injured and to analyze various aspects of this kind of accidents, in order to reduce injury and minimize disability. METHODS: A retrospective survey of records of all injured from firecrackers and similar devices during holidays that arrived at our hospital between 1999 and 2003 was conducted. Between 2001 and 2002 the trauma team, in cooperation with the local leadership, directed an education and information campaign in the community, in an attempt to reduce these injuries. RESULTS: During the study period, a decrease in the rate of injury was observed, which in the year 2003, reached a level of 50% of the 1999 figures. Of the injured, 53% were children (< or = 15 years old), 93% were Arab or Druze, and 93% were males. The rate of injuries from fireworks in 2003 was significantly lower than the mean rate of the years 1999, 2001, 2002 (p=0.045). The major cause of injury was firecrackers (67%) followed by fireworks (21%). Major injuries were to the extremities (58%), followed by facial and eye trauma (24%) and burns (11%). Of the casualties, 54% were lightly injured, 46% were hospitalized, 24% required surgical intervention and 7% lost fingers. Two individuals lost eyesight in one eye, but no fatalities occurred. CONCLUSIONS: The reduced rate of injury from fireworks and similar devices can be attributed to two major reasons: intervention by the trauma team and enforcement by the police and the Ministry of Trade and Industry. We recommend conducting a combined campaign of education and parental guidance with the involvement of community leaders and local media, and to increase law-enforcement. The organization of central firework displays in each community during this holiday should be considered.

Pain relief in major trauma patients: an Israeli perspective.

BACKGROUND: The pain of major trauma patients remains often unrelieved while in the emergency department. Our objective was to examine pain management in several trauma units, and to evaluate the impact of implementation of a trauma pain management protocol. METHODS: Current status was evaluated from questionnaires filled by trauma unit personnel of nine medical centers. In one, a pain management protocol was introduced. Staff and patients evaluated pain management before and after the protocol was instituted. RESULTS: About 80% of staff respondents from various centers were not aware of guidelines for pain management in trauma. The belief that pain assists diagnosis was the main reason (78.6%) for withholding analgesia. Large variability existed on what contraindicates analgesia, with the majority withholding analgesia in abdominal and multiple injuries. When administered, analgesia was delayed, and most commonly intramuscular meperidine was given. After the protocol's implementation, the personnel's awareness of analgesia increased, and consequently it was administered earlier and to more patients, mostly as intravenous morphine. Patients appreciated the timely analgesia (38% after vs. 14% before, p = 0.01), with fewer receiving none. Analgesia was considered beneficial by more patients (70% after vs. 23% before, p < 0.001), and enhanced cooperativity with personnel (p < 0.001). This was reflected in increased overall satisfaction with pain relief during the entire hospitalization. CONCLUSION: The importance of pain management protocols in major trauma was demonstrated by the response of personnel and patients.

Treatment of open tibial fractures with primary suture and Ilizarov fixation.

Thirty-two open tibial fractures were treated by irrigation, debridement, antibiotic therapy, primary closure when possible, and fixation with Ilizarov device. In the Gustilo classification, 11 were Grade I, 10 Grade II, 8 Grade IIIA, and 3 were Grade IIIB. No Grade IIIC fractures were treated in the period studied. Fifteen were in patients with multiple trauma, and in 17 patients the fracture was a single injury. All fractures healed with good anatomic alignment, except for 1 with 5 degrees angulation and another with 1-cm shortening. The healing time was 21.9 weeks in the single injury and 25.7 weeks in the patients with multiple trauma. Eleven patients had pin tract infection, and in 4 the pin had to be replaced. One patient had dermatitis near the fracture site. This treatment of open tibial fractures proved to be successful for anatomic restoration of the tibia and had a low complication rate. Primary closure should be considered a possible method of treatment in Types I to IIIA open fractures, together with the Ilizarov external fixator, if the wound edges can be approximated easily with no tension at the suture line.