Diagnostic yield of syncope investigation (initiated) in the emergency department: a pilot study.

OBJECTIVE: To determine the diagnostic yield of investigations in patients presenting to the emergency department (ED) with syncope. To determine the cause of the syncope. PATIENTS AND METHODS: We retrospectively identified consecutive patients presenting to the ED who underwent investigations for syncope at a 1900 bed university teaching hospital during 4 months. From the medical records we abstracted clinical information, results of testing and the cause of syncope. RESULTS: A total of 117 patients participated in the study. The mean age was 57 year (range 6-93 year), and 45% were male. Diagnostic procedures most often performed were blood analysis, ECG, chest X-ray and Holter monitoring (respectively in 94.1%, 88.8%, 74.4% and 36,8% of the patients). The corresponding diagnostic yield for these test was 4.5%, 6.7%, 0% and 16.3%. Other procedures were (% of patients; diagnostic yield): Ct scan of the head (35.1%; 0%), transthoracic echocardiogram (24.8%; 6.9%), ECG monitoring (24.8%; 27.6%), EEG (19.7%; 0%), neurovascular imaging (19.7%; 0%), abdominal ultrasound (11.1%; 0%), Ct scan of the chest (11.1%; 23.1%), head up tilt test (7.7%; 11.1%), carotid sinus massage (3.4%; 0%), pulmonary ventilation perfusion scintigraphy (2.6%; 33%) and exercise test (1.7%; 0%). The most common cause of syncope was neurocardiogenic (58,5% of patients), followed by orthostatic (11.1%), cardiac (11.1%), unknown (9.3%), hyperventilation (3.4%), pulmonary embolism (2.5%), drug related (2.5%) and others (1.7%). CONCLUSION: Patients admitted in the ED for syncope undergo various investigations. However, the diagnostic yield is poor.The most common cause of syncope is neurocardiogenic, followed by orthostatic and cardiac.

Clinical trials in an emergency setting: implications from the fifth version of the Declaration of Helsinki.

Everybody agrees that research is crucial to improve the quality of emergency care. Consent of human subjects for participation in research requires that they fully understand their role and risk, not be coerced, and be allowed to withdraw at any time without penalty. In an emergency situation, informed consent is not always possible but the need for good research data is very high. Here is the ethical difficulty, and a real conflict of values: a population that might ultimately benefit from research cannot consent to the research and are thus excluded from the potential therapeutical advances. Patients at high risk of morbidity or death, with cardiac arrest, shock, head injury, or altered mental status, are evidently incapable of providing an adequate consent, but nevertheless are often in the greatest need of innovative therapy and might be willing to assume some risk for potential benefit. In an attempt to resolve this dilemma, the new version of the Declaration of Helsinki presents updated requirements for the waiver of informed consent and the protection of human subjects in emergency research.

Is a lung perfusion scan obtained by using single photon emission computed tomography able to improve the radionuclide diagnosis of pulmonary embolism?

Planar pulmonary scintigraphy is still regularly performed for the evaluation of pulmonary embolism (PE). However, only about 50-80% of cases can be resolved by this approach. This study evaluates the ability of tomographic acquisition (single photon emission computed tomography, SPECT) of the perfusion scan to improve the radionuclide diagnosis of PE. One hundred and fourteen consecutive patients with a suspicion of PE underwent planar and SPECT lung perfusion scans as well as planar ventilation scans. The final diagnosis was obtained by using an algorithm, including D-dimer measurement, leg ultrasonography, a V/Q scan and chest spiral computed tomography, as well as the patient outcome. A planar perfusion scan was considered positive for PE in the presence of one or more wedge shaped defect, while SPECT was considered positive with one or more wedge shaped defect with sharp borders, three-plane visualization, whatever the photopenia. A definite diagnosis was achieved in 70 patients. After exclusion of four 'non-diagnostic' SPECT images, the prevalence of PE was 23% (n =15). Intraobserver and interobserver reproducibilities were 91%/94% and 79%/88% for planar/SPECT images, respectively. The sensitivities for PE diagnosis were similar for planar and SPECT perfusion scans (80%), whereas SPECT had a higher specificity (96% vs 78%; P =0.01). SPECT correctly classified 8/9 intermediate and 31/32 low probability V/Q scans as negative. It is concluded that lung perfusion SPECT is readily performed and reproducible. A negative study eliminates the need for a combined V/Q study and most of the 'non-diagnostic' V/Q probabilities can be solved with a perfusion image obtained by using tomography.

Survey of non-invasive ventilation for acute exacerbation of chronic obstructive pulmonary disease patients in emergency departments in Belgium.

A study was undertaken to assess the availability and use of non-invasive ventilation (NIV) for the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) in emergency departments in Belgium. A questionnaire was sent to the head physicians of 145 emergency departments (EDs) found in the list of the Belgian College of Emergency Physicians (BeCEP). Ninety eight questionnaires were analysed (representing 68% of the questionnaires sent). NIV was used in 49% of the EDs. In the hospitals where NIV was not used, the most important reasons given were no available equipment in 71%, lack of experience with this form of treatment in 32.7%, and more time consuming for physicians and nursing staff in 22.8%. Only 3.8% of the physicians doubted the benefit of NIV treatment. In the hospitals where NIV was used, the patient was watched during the first hour by one nurse only in 19.6%, by one physician in 8.6% and by a nurse and a physician in 54.5%. NIV was used for more than 4 h in 33% of EDs. Pressure-controlled ventilation (with home respirators) was used more often than volume-controlled ventilation.

Delayed diagnosis of meningitis caused by beta-haemolytic group G. Streptococcus in an older woman.

A case of meningitis caused by group G beta-hemolytic Streptococcus (dysgalactiae, subspecies equisimilis) is reported in an 83-year-old woman. Streptococci species other than Streptococcus pneumoniae are seldom found in patients with acute bacterial meningitis, therefore, our discussion is focused on this rare organism. The question of the diagnosis of meningitis in the elderly is also addressed.

Acute dyspnea in a woman with swelling of the left leg treated with low molecular weight heparine.

A case of rectus sheath hematoma diagnosed initially as probable pulmonary embolism in a patient on anticoagulation with low molecular weight heparins for swelling of the left leg is presented. Prompt consideration of this hematoma in the emergency department is important to avoid unnecessary and potentially dangerous treatment.

Non-invasive positive pressure ventilation for exacerbation of chronic obstructive pulmonary patients in the emergency department.

Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) commonly present to the emergency department for treatment. Some of them, despite appropriate therapy become more dyspnoeic with increasing acute respiratory failure. The requirement for intubation and mechanical ventilation is for these patients often associated with a prolonged and complicated intensive care unit stay and has been associated with morbidity and mortality rates in excess. Non-invasive ventilation (NIV) emerged recently as a means of reducing those complications. NIV can be a safe and effective means of augmenting ventilation and decreasing inspiratory work in many patients with acute exacerbation of COPD. NIV is generally started in the intensive care unit. Except for a few negative studies, the overall compending studies seem to be in favour of the utilization of NIV in cases of exacerbation of COPD patients. There are few published data on the question whether NIV could or should be started earlier and initiated in the emergency department. It seems that NIV treatment could be an effective addition to standard treatment especially for acute exacerbation of COPD. A more extensive and routine use of non-invasive ventilation in the emergency department requires further study.

Hantavirus infections: clinical presentation in the emergency room.

We present a retrospective review of Hantavirus infection in the emergency department. Thirteen cases of Hantavirus infections with renal syndrome from July 1989 to August 1999 were analysed. The diagnosis was confirmed by detection of Hantavirus antibodies in all cases. Fever, chills and headaches were universally present. Intense back pain was associated in 77% of the patients. Thrombocytopenia, abnormal urinalysis, hypertransaminasaemia, increased lactate dehydrogenase were the principal biological patterns. All these parameters returned to their normal level, and all the patients recovered a normal renal function without sequels. The management is supportive. Only one patient in our series had to be dialysed. Hantavirus disease should be included in the differential diagnosis of acute renal failure with thrombocytopenia, particularly in patients with suspected exposure in known endemic areas. The differential diagnosis of any perplexing case of undifferentiated febrile illness with acute renal failure and thrombocytopenia should include Hantavirus infection.

Epidemiological profile of geriatric patients admitted to the emergency department of a university hospital localized in a rural area.

The number of geriatric patients admitted to the accident and emergency department is growing. These patients also present increasing functional dependence and a large panel of associated diseases and associated problems. For the purpose of describing this phenomenon, we prospectively studied the epidemiology of patients 75 years and older entering the emergency department of a university hospital localized in a rural area. From January 1996 up to January 1997, 1298 patients aged 75 years or older were admitted to the emergency department. This age group represented 12.3% of all the patients admitted during the period. The gender distribution was almost equal: 56% were female and 44% male. Most of them (75%) were referred by their general practitioner although 15% came spontaneously. The most common complaints were, in decreasing order: general condition impairment (21.5%), dyspnoea (15%), falls and traumas (15%), abdominal problems (13%), thoracic pain (9%), syncope, dizziness (7%) and stroke (5.5%). Hospitalization was necessary in 69% of cases. Among the patients coming spontaneously a larger proportion (55%) were sent back home compared with only 25% of those referred by their general practitioner.

Ingestion of antacid tablets (Rennie) and acute confusion.

The authors describe a case of milk-alkali syndrome in a man who consumed antacid tablets (Rennie) for chronic epigastric pain. Simultaneous occurrence of hypercalcemia, metabolic alkalosis, and renal insufficiency, in conjunction with the appropriate history of ingestion of calcium carbonate-containing antacids, was suggestive of the syndrome. The syndrome became uncommon with the advent of modern ulcer therapy, but currently is increasing in frequency with the calcium supplementation drugs taken to prevent osteoporosis. This syndrome may produce life-threatening hypercalcemia.

Viral brachial neuritis in emergency medicine.

Brachial plexus neuritis is a rare neurologic disease that may be overlooked in emergency medicine because other conditions are much more common. We report a case of brachial plexus neuropathy due to cytomegalovirus infection. The diagnosis was based on history, clinical findings, laboratory tests, and electromyography. Early diagnosis and adequate treatment is important to avoid unnecessary investigation, prevent complications (especially adhesive capsulitis of the shoulder), and reassure the patient.

A young man with recurrent syncopes, right bundle branch block and ST segment elevation.

We report on the case of a 33-year-old man with recurrent syncopes appearing suddenly due to sustained monomorphic ventricular tachycardias. The electrocardiogram (ECG) showed a right bundle branch block pattern and ST segment elevation in the precordial leads V1 to V2, not explained by ischemia, electrolyte disturbances, toxic ingestion, or structural heart disease (coronary and right ventricle angiograms as well as biopsies of the right ventricle were normal). ECG image was compatible with the so-called Brugada syndrome, first described in 1992. This entity is very rare. Missed diagnosis can be disastrous because life-threatening ventricular arrhythmias often develop in patients.