Accuracy of Emergency Physicians for Detection of Regional Wall Motion Abnormalities in Patients With Chest Pain Without ST-Elevation Myocardial Infarction.

OBJECTIVES: Our aim was to evaluate the accuracy of emergency physicians (EPs) in the detection of regional wall motion abnormalities (RWMAs) using focused cardiac ultrasound (FOCUS) in patients suspected of non-having ST-elevation myocardial infarction. METHODS: We prospectively enrolled patients with chest pain. Three EPs underwent didactics and hands-on-training, of 3 hours each, by an experienced cardiologist, on detecting RWMAs using 2-dimensional echocardiography. They performed a FOCUS examination to evaluate for RWMAs and recorded the echo images. Our reference standard for the detection of RWMAs was accepted as a blinded cardiologist review of the prerecorded video clips. We calculated the corrected sample size and inter-rater agreement between the EPs (82 and 0.83, respectively). The analysis of the study was performed on 89 patients. RESULTS: Eighty-nine patients with chest pain were screened. Emergency physicians demonstrated the detection of RWMAs with good sensitivity and even excellent specificity: 76.9% (95% confidence interval [CI], 56.4%- 91.0%) and 92.1% (95% CI, 82.4%-97.4%), respectively. The accuracy of FOCUS was 87.6% (95% CI, 79.0%-93.7%). The area under the curve from a receiver operating characteristic curve analysis, which evaluated the EPs' rate of detecting the presence or absence of RWMAs, was 0.845 (95% CI, 0.753-0.913). CONCLUSIONS: Our study results suggest that EPs with training in bedside echocardiography can accurately rule in patients with RWMAs in suspected non-ST-elevation myocardial infarction cases.

Ultrasonography of jugular vein as a marker of hypovolemia in healthy volunteers.

BACKGROUND: Our aim in this study was to use ultrasonography of internal jugular vein (IJV) instead of visual estimation by eye and to get more precise estimation of central venous pressure at supine position for estimating blood loss in healthy volunteers. METHODS: The values of the sonographic IJV collapse index and corrected IJV longitudinal length (cIJV LL) (vertical height of the jugular vein from the sternal angle of Louis plus 5 cm) were compared before and after blood donation. The correlations between the mean arterial pressure, pulse rate, IJV collapse index, and cIJV LL were analyzed using SPSS version 15.0 (SPSS, Chicago, IL) and G*Power version 3.1.2. (Franz Faul, Universitat Kiel, Germany) was used for power and sample size analysis. RESULTS: A total of 80 volunteers were enrolled in the study. The medians of cIJV LLs before and after blood donation were 6.67 (95% confidence interval [CI], 6.72-7.07) and 5.98 (95% CI, 6.09-6.40), respectively. The medians of IJV collapse indices before and after blood donation were 32.74 (95% CI, 32.73-39.50) and 38.88 (95% CI, 35.54-42.95), respectively. Preliminary results of our study revealed that cIJV LL and IJV collapse index were not well correlated (Spearman ρ correlation coefficient, 0.257; r = 0.128). CONCLUSION: Although, the IJV collapse index was not found to be a useful parameter for evaluation of hypovolemia, cIJV LL is more valuable marker for the detection of blood loss at bedside.

Neuroprotective effects of progesterone in spinal cord ischemia in rabbits.

BACKGROUND: This experimental study was performed to investigate the neuroprotective effects of progesterone on spinal cord ischemia in rabbits. METHODS: Eighteen female New Zealand white rabbits were used in this study. Rabbits were randomized into 3 groups. Spinal cord ischemia was induced by clamping the abdominal aorta from a point just inferior to the left renal artery to the aortic bifurcation for a period of 30 minutes. Group 1 served as the control group, and groups 2 and 3 received intraperitoneal progesterone immediately after the onset of reperfusion, at a dose of 8 mg/kg. Two hours after reperfusion, the animals in group 1 were killed. Four hours after reperfusion, the animals in group 2 were killed, and 6 hours after reperfusion, the group 3 rabbits were killed. Spinal cords were removed and fixed in 10% formalin in a phosphate buffer. Neuronal injury was evaluated by a pathologist who was blinded to the treatment groups, and 5 sections per animal were evaluated. The number of intact large motor neuron cells in the ventral grey matter region was counted. RESULTS: The analysis revealed that the average mean arterial pressure for group 1 was significantly higher than that for group 2, and the mean sacrificed pressure value for group 1 was significantly higher than that for group 3 (P < .05). The number of intact neurons in group 1 was significantly lower than the number of intact neurons found in both groups 2 and 3 (P < .05). No other statistically significant differences were found between the groups. CONCLUSION: The findings from the present study indicate that progesterone effectively protects the spinal cord tissues against ischemic damage in the setting of decreased perfusion.

Ability of emergency physicians to detect early ischemic changes of acute ischemic stroke on cranial computed tomography.

OBJECTIVE: The objective of this study was to evaluate the ability of emergency physicians (EPs) to diagnose early ischemic changes due acute ischemic stroke on cranial computed tomography (CT). SUBJECTS AND METHODS: Three EPs interpreted CT scans obtained within 3 h of symptom onset in 50 patients with acute stroke. The CT scans were interpreted by the EPs and compared to official neuroradiologist reports as a gold standard. ĸ statistics were calculated to determine agreement among the three readers. Sensitivities and specificities were analyzed for each reader. RESULTS: The EPs' sensitivities were 50, 45.5, and 45.5%, and specificities were 64.3, 82.1, and 64.3%, respectively. Focal parenchymal hypodensity was the criterion for which the EPs were the most sensitive (77.3%). The ability of EPs to recognize early ischemic changes on CT scans in acute ischemic stroke was moderate based on sensitivities. CONCLUSION: Based on this study, EPs must be trained especially for recognizing early ischemic changes in acute ischemic stroke to improve their accuracy of interpretation.

Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart failure.

INTRODUCTION: The identification of diastolic heart failure (DHF) is important for determining the prognosis of congestive heart failure patients. This study attempted to determine the accuracy of emergency physicians who performed bedside echocardiography (BECH) in patients with diastolic dysfunction. METHODS: Three attending emergency physicians underwent 3 h of didactic and 3 h of hands-on training taught by a cardiology specialist for the echocardiographic diagnostic criteria of DHF. Between February and April 2010, the emergency physicians performed BECH for patients presenting with dyspnoea, and echocardiographic views were recorded. Our gold standard for the diagnosis of diastolic dysfunction was the cardiologists' echocardiography report. Results were compared with χ(2) testing. RESULTS: Of the 69 enrolled patients, 51 were diagnosed as having diastolic dysfunction by emergency physicians. The sensitivity of BECH was 89% (77-95) and specificity was 80% (51-95) with 95% CI. The accuracy of the emergency physicians' echocardiographic diagnosis was 87%. CONCLUSION: BECH performed by emergency physicians may serve as an objective, rapid, non-invasive tool in the assessment of patients presenting with dyspnoea in ED.

Paramedic-performed Focused Assessment with Sonography in Trauma (FAST) in the emergency department.

BACKGROUND: Our objective was to evaluate the accuracy of paramedic-performed Focused Assessment with Sonography in Trauma (PFAST) for detection of free fluid in patients admitted to the Emergency Department (ED) following trauma. METHODS: After four hours of didactic and four hours of hands-on training, four paramedics prospectively evaluated trauma patients. Our gold standard was the official radiologist reports of ultrasonography and computerized abdominal tomography (CAT). The sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of PFAST were calculated and analyzed using SPSS 15.0 with ?2 testing. RESULTS: One hundred and twenty-seven patients were evaluated by the paramedics. Fourteen patients had positive free fluid in the abdomen. Of these, 11 were corroborated by radiology reports and CAT (true positives), and three were found to be negative (false positives). In 113 cases, PFAST was negative for free fluid. Of these, 111 were determined not to have free fluid (true negatives), whereas free fluid was detected by CAT in 2 (false negatives). The sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of PFAST were 84.62, 97.37, 32.15, 0.16, and 203.50, respectively. CONCLUSION: Our study shows that paramedics can perform FAST in hospital Eds with a high degree of accuracy.

Do we routinely need cranial computed tomography for mild head injuries in Turkey?

The objectives of this study were to determine the role of clinical parameters in detecting intracranial injury and to find out whether cranial computed tomography (CT) is routinely needed for mild head injury (MHI) in Turkey. This retrospective study was conducted by reviewing the records of patients with MHI who underwent cranial CT in our emergency department. We carried out multiple logistic regression analysis, and odds ratios with 95% confidence intervals were calculated by using SPSS 15.0. This study included 923 patients. Positive cranial CT findings were determined in 17 patients (1.8%) and six of them (0.6%) underwent surgery. Statistically significant correlations were found among headache, presence of clinical findings of skull fracture, focal neurological deficit and positive cranial CT findings. Although the incidence of the intracranial lesions, especially those requiring surgery, is low in MHI, the liberal use of CT scanning in MHI seems to be justified in countries such as Turkey.