Closed reduction of constrained total hip arthroplasty in the ED.

A dislocated hip prosthesis is a common occurrence in the Emergency Department. To combat this problem, orthopedists use constraint devices in an attempt to reduce the incidence of dislocation. However, when these devices fail, a more complicated case arises. We discuss a case report in which a patient presented with a dislocation of his hip after implantation of a constrained total hip arthroplasty. We describe a closed reduction procedure using deep sedation, fluoroscopy, and adequate assistance.

The Internet Tracking Registry of Acute Coronary Syndromes (i*trACS): a multicenter registry of patients with suspicion of acute coronary syndromes reported using the standardized reporting guidelines for emergency department chest pain studies.

STUDY OBJECTIVE: Observational studies of well-described patient populations presenting to emergency departments (EDs) with suspicion of acute coronary syndrome are necessary to understand the relationships between patients' signs and symptoms, cardiac risk profile, test results, practice patterns, and outcomes. We describe the methods for data collection and the ED population enrolled in a multicenter registry of patients with chest pain. METHODS: Patients older than 18 years, presenting to one of 8 EDs in the United States or 1 ED in Singapore, and with possible acute coronary syndrome were enrolled in the Internet Tracking Registry of Acute Coronary Syndromes between June 1999 and August 2001. Prospective data, including presenting signs and symptoms, ECG findings, and the ED physician's initial impression of risk, were systematically collected. Medical record review or daily follow-up was used to obtain cardiac biomarker results, invasive and noninvasive testing, treatments, procedures, and inhospital outcomes. Thirty-day outcomes were determined by telephone follow-up and medical record review. RESULTS: The registry includes 15,608 patients, with 17,713 visits. Chest pain was the chief complaint in 71% of visits. The ECG was diagnostic of ischemia or infarction in 10.1% and positive cardiac biomarkers were observed in 10% of visits. Forty-three percent of patients were sent home directly from the ED. Of admitted patients, 5% died by 30 days, and 3% had documented coronary artery disease or had undergone percutaneous coronary intervention or coronary artery bypass grafting within 30 days. For patients discharged directly from the ED, 0.4% died or had a documented myocardial infarction within 30 days. Coronary artery bypass graft surgery, percutaneous coronary intervention, or a diagnosis of coronary artery disease was found in 0.5% of discharged patients. CONCLUSION: A unique description of undifferentiated ED chest pain patients with suspected acute coronary syndrome is provided. The data set can be used to generate and explore hypotheses to improve understanding of the complex relationships between presentation, treatment, testing, intervention and outcomes.

Prospective evaluation of emergency department patients with potential coronary syndromes using initial absolute CK-MB vs. CK-MB relative index.

We compared the predictive properties of an initial absolute creatine kinase-MB (CK-MB) to creatine kinase-MB relative index (CK-MB RI) for detecting acute myocardial infarction (AMI), acute coronary syndromes (ACS), and serious cardiac events (SCE). Consecutive patients > 24 years of age with chest pain who received an electrocardiogram (EKG) as part of their Emergency Department (ED) evaluation had CK and CK-MB drawn at presentation. Patients were followed prospectively during their hospital course. The main outcome was AMI, ACS or SCE (death, AMI, dysrhythmias, CHF, PTCA/stent, CABG) within 30 days. The sensitivity, specificity, PPV and NPV of CK-MB and CK-MB RI to predict AMI, ACS, and SCE were calculated with 95% CIs. We enrolled 2028 patients. There were 105 patients (5.2%) with AMI, 266 (13.1%) with ACS, and 150 with SCE (7.4%). Absolute CK-MB had a higher sensitivity than CK-MB RI for AMI (52.0 vs. 46.9, respectively), ACS (23.5 vs. 20.8, respectively), and SCE (39.6 vs. 36.0, respectively), but a lower specificity than CK-MB RI for AMI (93.2 vs. 96.1, respectively), ACS (93.1 vs. 96.1, respectively) and SCE (93.3 vs. 96.3, respectively); and lower PPV for AMI (35.7 vs. 46.5, respectively), ACS (42.0 vs. 53.4, respectively) and SCE (38.5 vs. 50.5, respectively). The negative predictive values were similar for all outcomes. We conclude that the risk stratification of ED chest pain patients by absolute CK-MB has higher sensitivity, similar NPV, but a lower specificity and PPV than CK-MB relative index for detection of AMI, ACS, and SCE. The optimal test depends upon the relative importance of the sensitivity or specificity for clinical decision-making in an individual patient.