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Introduction Insufficient attention has been directed towards urosepsis. Notably, no protocols or clinical decision rules currently exist outlining the appropriate use of imaging in uroseptic patients. The primary objective of our study was to retrospectively evaluate uroseptic emergency department (ED) patients who underwent abdominal imaging, to report the proportion of patients with imaging findings necessitating emergent surgical consultation. Methods We retrospectively identified 1142 patients ≥ 18 years of age that presented to the ED from January 2009 to December 2012 with ICD9 code indicative of urosepsis. All included patients underwent ED-ordered abdominal computerized tomography (CT) or retroperitoneal ultrasound (US). Imaging and urinalysis (UA) results were categorized. We report proportions with odds ratios and 95% confidence intervals. Results Of 1142 patients, we excluded 80 for neg UA, 167 for < 2 SIRS (systemic inflammatory response syndrome), 320 for positive blood cultures, and 37 for incomplete data. This yielded 538 patients which the authors reviewed the results of the CT or US to determine the proportion who required emergent surgical consultation and who underwent surgical or interventional procedure. There were 243 (45%) that had CT or US results that necessitated emergency surgical consultation, of those 180 (33%) underwent surgical or interventional procedure. Similar rates of emergency surgical consultation occurred when sub-divided by positive versus equivocal UA, with 43% and 47%, respectively. Conclusions Forty-five percent of our abdominally imaged urosepsis cohort had imaging findings that necessitated emergent surgical consultation, with a similar proportion in the subset with positive versus equivocal UA. The utility of abdominal imaging in this population should be studied prospectively.

Objective The objective of the study is to determine if tamsulosin initiated in the emergency department (ED) decreases the time to ureteral stone passage at 1 week or time to pain resolution, compared to placebo. Methods We performed a prospective, randomized, double-blinded, placebo-controlled trial of tamsulosin vs placebo in ED patients with ureterolithiasis on computed tomography. Patients were identified and enrolled between April 2007 and February 2009 and were randomized to either 0.4 mg of tamsulosin or placebo for 1 week. We contacted participants using a telephone survey on post-ED visit days 1, 2, 3, and 7. The primary outcome was time to stone passage, with secondary outcomes being maximum pain score and amount of pain medication required. Results Of the 127 patients enrolled during this study, 15 were lost to follow-up, and 12 required surgical interventions before the 7-day mark, leaving 100 patients for analysis. Of the 100 patients, 53 received tamsulosin and 47 received placebo. There was no difference between groups in percentage of male, mean age, initial serum creatinine, average stone size, stone location, and history of prior stone. The probability that the patient did not pass a stone at 7 days was not different between tamsulosin and placebo, 62.1% (95% confidence interval, 49.1%-75.1%) vs 54.4% (95% confidence interval, 40.3%-68.6%; P = .58). There was no significant difference in the high pain score ( P = .12) or hydrocodone/acetaminophen intake ( P = .76) between treatment groups at any of the time points. Conclusion This study reveals no difference in the proportion of stone passage or high pain score and pain medication utilization at 7 days between tamsulosin and placebo.

ACADEMIC EMERGENCY MEDICINE 2011; 18:613–618 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Risk stratification of patients with potential acute coronary syndrome (ACS) is difficult. Patients with prior revascularization are considered higher risk, but they can also have symptoms from noncardiac causes. This study evaluated whether the presenting clinical characteristics were predictive of an increased risk of 30-day cardiovascular events in patients with prior revascularization presenting to the emergency department (ED) with symptoms of potential ACS. Methods: This was a secondary analysis of the DISPO-ACS study, a 2000-patient, four-site, randomized controlled trial of patients presenting with potential ACS. Process outcomes were evaluated using point-of-care cardiac markers compared to standard laboratory-based markers. Data included demographics, history, presenting symptoms, laboratory and electrocardiogram (ECG) results, hospital course, and 30-day cardiovascular events (death, acute myocardial infarction [AMI], revascularization). The association between presenting characteristics and 30-day cardiovascular events was assessed using univariable analysis and logistic regression; odds ratios (ORs) with 95% confidence intervals (CIs) are given. Results: Of 2,000 patients enrolled, 611 had prior revascularization (538 percutaneous coronary intervention [PCI], 232 coronary artery bypass graft [CABG], 159 both). The mean (±SD) age was 66 (±14) years, 44% were female, and 22% were black. By 30 days, 101 patients (17%) had cardiovascular events (81 during the index visit, 20 during follow-up). There were four deaths, 28 AMIs, and 67 revascularizations within 30 days; 20 patients had multiple endpoints. Being male (OR = 1.67, 95% CI = 1.07 to 2.62) or nonblack (OR = 1.95, 95% CI = 1.07 to 3.56) or having a family history of coronary artery disease (CAD; OR = 2.09, 95% CI = 1.32 to 3.3), elevated lipids (OR = 1.71, 95% CI = 1.04 to 2.82), prior AMI (OR = 1.79, 95% CI = 1.16 to 2.76), abnormal ECG on arrival (OR = 2.1, 95% CI = 1.33 to 3.34), and a positive initial troponin (OR = 14.7, 95% CI = 6.8 to 32.2) were predictive of cardiovascular events. The multivariable model found family history of CAD (OR = 2.06, 95% CI = 1.26 to 3.36), abnormal initial ECG (OR = 1.89, 95% CI = 1.16 to 3.09), and positive initial troponin (OR = 13.3, 95% CI = 5.9 to 29.6) remained predictive of 30-day cardiovascular events. Conclusions: In patients with prior revascularization, the initial ECG and early cardiac marker elevations, but not clinical presentation, predict odds of 30-day death, AMI, or revascularization.

Objectives: Some physicians prescribe corticosteroids as adjunctive therapy for patients with migraine headaches to decrease the rate of rebound headache. The efficacy of this practice has not been tested. Our objective is to determine the efficacy of single-dose dexamethasone as adjunctive therapy for emergency medicine patients with migraine headache in preventing headache recurrence at 3 and 30 days posttreatment. Methods: From November 2004 to November 2005, we conducted a multicenter, double-blinded, placebo-controlled randomized clinical trial of adult patients who met the International Headache Society definition of migraine headache. After informed consent, patients were randomly assigned to one of two groups: receiving either placebo or 24 mg dexamethasone intravenously. To ensure generalizability, all other aspects of patient care were left to the discretion of the emergency physician. Clinical and demographic information was obtained; and patients were subsequently contacted at both 3 and 30 days to determine headache recurrence, current functional disability, and need for return to the ED. Our primary outcome measures were the recurrence of migraine headache at 3 and 30 days. We used Fisher exact to test for statistical significance. Results: A total of 115 patients were enrolled, with 16 patients lost to follow-up at 3 days and 3 additional patients lost at 30 days. Baseline characteristics as well as adverse event profiles were equivalent in both study groups. At 3-day follow-up, 45% (95% confidence interval [CI] 31%-60%) of the placebo group had recurrence of their migraine compared with 35% (95% CI 24%-48%) in the dexamethasone group (P = .68). At 30-day follow-up, this relative reduction in migraine recurrence decreased to a 4% difference between the 2 groups (P = .68). Limitations include small sample size and significant proportion lost to follow-up. Conclusion: A single dose of dexamethasone as adjunctive therapy for migraine headache does not decrease the recurrence of migraines at 3 or 30 days.

Chromosomal mutants were isolated in Escherichia coli that altered carotenoid production from transformed carotenoid biosynthesis genes on a pACYC-derived plasmid (pPCB15). The mutations were mapped by sequencing. One group of mutations appeared to affect the cell metabolism without changing the copy number of the carotenoid synthesis plasmid. The other group of mutations either increased or decreased the copy number of the pPCB15 plasmid as determined by real-time PCR. The copy number change in most mutants was likely specific for ColE1-type plasmids for which copy number is controlled by a small antisense RNA. This collection of host strains would be useful for fine tuning expression of proteins and adjusting production of desired molecules without recloning to different vectors.

A tremendous amount of public resources are focused on improving cardiac arrest (OHCA) survival in public places, yet most OHCAs occur in private residences.A prospective, observational study of patients transported to seven urban and suburban hospitals and the individuals who called 911 at the time of a cardiac arrest (bystander) was performed. Bystanders (N=543) were interviewed via telephone beginning 2 weeks after the incident to obtain data regarding patient and bystander demographics, including cardiopulmonary resuscitation (CPR) training. Of all arrests 80.2% were in homes. Patients who arrested in public places were significantly younger (63.2 vs. 67.2, P0.02), more often had an initial rhythm of VF (63.0 vs. 37.7%, P0.001), were seen or heard to have collapsed by a bystander (74.8 vs. 48.1%, P0.001), received bystander CPR (60.2 vs. 28.6%, P0.001), and survived to DC (17.5 vs. 5.5%, P0.001). Patients who arrested at home were older and had an older bystander (55.4 vs. 41.3, P0.001). The bystander was less likely to be CPR trained (65.0 vs. 47.4%, P0.001), less likely to be trained within the last 5 years (49.2 vs. 17.9, P0.001), and less likely to perform CPR if trained (64.2 vs. 30.0%, P0.001). Collapse to shock intervals for public versus home VF patients were not different.Many important characteristics of cardiac arrest patients and the bystander differ in public versus private locations. Fundamentally different strategies are needed to improve survival from these events.

• Background Older persons are the group most likely to respond to cardiac arrests in private residences. • Objective To characterize the knowledge about, attitudes toward, and perceived self-efficacy of older persons in learning and providing cardiopulmonary resuscitation. • Methods A total of 2743 surveys were mailed to adults 55 years and older who resided in a single Michigan suburb. Data were collected on demographics, medical history, training in and willingness to provide cardiopulmonary resuscitation, and concerns about providing this intervention. • Results The 631 persons (24.6%) who responded were elderly (mean age, 73.5 years) and had a mean of 1.7 occupants per household. More than one third lived alone. Of all respondents, 275 (43.6%) had received training in cardiopulmonary resuscitation, 370 (58.6%) indicated a willingness to learn cardiopulmonary resuscitation, and 412 (65.3%) thought that they had the ability to perform this intervention. Respondents 80 years or younger were significantly more likely than respondents more than 80 years old to be willing to learn cardiopulmonary resuscitation (65.7% vs 19.0%, P < .001) and perceived themselves as able to perform it (73.0% vs 34.0%, P < .001). The absence of mouth-to-mouth ventilation as part of training had minimal impact on the willingness of either age group to receive training (61.2% vs 58.6%, P = .19). Perceived ability to learn and perform cardiopulmonary resuscitation did not vary with the medical history of the respondent or the respondent’s spouse. • Conclusion Adults 56 to 80 years old perceive themselves as able to perform cardiopulmonary resuscitation and are interested in receiving training.

Our primary objective was to compare use of analgesia for patients with and without fracture as a result of isolated lower extremity trauma, in the emergency department (ED). Our secondary objective was to compare the analgesic practices of emergency physicians (EPs) with that of physician assistants (PAs). We performed a prospective, blinded cohort study with the presence of fracture as the risk factor and provision of any pain medication while in the ED as the primary outcome. Included in the study were all patients who presented to a 90,000 visit suburban teaching hospital with an isolated lower extremity injury who received a radiograph of the foot or ankle over a 9-week period. We excluded patients without trauma, with multiple trauma, admitted, or seen by one of the investigators. Patients admitted and those with multiple trauma were excluded because these patients had contacts with multiple physicians and it is unlikely they would be able to differentiate which physician prescribed medication and if they were emergency personnel. We defined analgesia as any pain medication at any dose. One investigator preformed follow-up interviews using a standardized questionnaire 3 days after the visit. Patients expressed their recollection of their degree of pain using a verbal analog scale of 1 to 10. We report crude and adjusted odds ratios (OR). Of 516 consecutive patients, 111 met exclusion criteria and 3 had incomplete data. Of the remaining 405, we contacted 384 (95%) in an average of 3 +/- 1 days. Patients with and without fractures recalled their initial degree of pain similarly, with the mean initial pain scores on the verbal analog scale of 6.6 +/- 2.5 versus 6.8 +/- 2.1 respectively. Patients with a fracture were more likely to receive pain medication while in the ED (23% v 15% P =.047, OR 1.75 (CI 95% 1.02, 2.99). EPs gave some form of ED analgesia to 29% of patients, as compared with 10% of patients seen by PAs (OR = 3.58 CI 95% 2.05, 6.24). EPs provided a prescription to 44% of patients versus 21% of patients seen by PAs (OR = 2.91 CI 95% 1.85, 4.57). Our estimated adjusted ORs for providing analgesia in the ED were: fracture = 2.0 (CI 95% 1.13, 3.58); EP: 3.52 (CI 95% 1.98, 2.99); and for every additional point on the verbal pain scale: 1.28 (CI 95% 1.11, 1.48). Patients with fracture were more likely to receive pain, despite reporting identical degree of pain. EPs were more likely to provide analgesia than PAs.

Objective:Cardiac marker sensitivity depends on chest pain duration at the time of sampling. Our objective was to estimate the sensitivity, specificity, and likelihood ratios of early CK–MB and myoglobin assays in patients presenting to the emergency department (ED) with nondiagnostic ECGs, stratified by the duration of ongoing chest pain at the time of ED assessment.Methods:This was a prospective observational study carried out in 10 US and 2 Canadian EDs. Patients >25 years of age with ongoing chest pain and nondiagnostic ECGs were stratified by pain duration (0–4 h, 4–8 h, 8–12 h, >12 h). CK–MB and myoglobin assays were drawn at T = 0 (ED assessment) and T = 1 hr. Patients were followed for 7–14 days to identify all cases of acute myocardial infarction (AMI). ED test results were correlated with patient outcomes.Results:Of 5005 eligible patients, 565 had AMI. Pain duration was 0–4 h in 3014 patients, 4–8 h in 961, 8–12 h in 487, and >12 h in 543. Marker sensitivity increased with pain duration, ranging from 28%–77% for CK–MB and 39%–73% for myoglobin. The maximal sensitivity achieved by a T = 0 assay was 73%, and this was in patients with 8–12 or >12 h of ongoing pain. No combination of tests achieved 90% sensitivity in any pain duration strata.Conclusions:Regardless of chest pain duration, single assays and early serial markers (0+1 hr) do not rule out AMI; therefore, serial assays over longer observation periods are required. Likelihood ratios derived in this study will help physicians who use Bayesian analysis to determine post-test AMI likelihood in patients with chest pain.

Study Objective: We sought to describe the feasibility of an emergency department observation unit (EDOU) treatment protocol for the management of uncomplicated acute-onset atrial fibrillation (AAF). Methods: This descriptive case series took place at a major suburban, university-affiliated teaching hospital. Patients were prospectively enrolled in an EDOU treatment protocol if they had uncomplicated AAF that failed initial ED attempts to convert to sinus rhythm. In the EDOU, patients underwent ECG monitoring, serial creatine kianse MB measurements, and further rate control with optional electrical cardioversion. Primary outcomes measured were EDOU rate of conversion to sinus rhythm, rate of discharge home, length of stay, positive diagnostic outcomes, complications of AAF, and 7-day return visits. Results: Sixty-seven patients were studied. Patients were symptomatic for a median of 4.0 hours, had mean initial ED pulse rates of 137±23 beats/min, and spent 4.7±2.2 hours in the ED before transfer to the EDOU. While in the EDOU, 55 (82%) patients converted to sinus rhythm. Five (7%) patients were admitted because of positive test results: 2 for myocardial infarction, 2 for fever, and 1 for ventricular tachycardia. Twelve (18%) patients remained in atrial fibrillation, with 9 admitted and 3 discharged. Overall, 81% of patients were discharged in 11.8±7.0 hours, and 19% were admitted after 17.6±9.5 hours of observation. Three discharged patients returned within 7 days, 2 for uncomplicated recurrent AAF and 1 for chest pain subsequently found to be noncardiac in origin. There were no major complications attributable to the EDOU protocol. Conclusion: Selected patients with AAF for whom initial ED management fails can subsequently be managed in an EDOU with a high short-term conversion and discharge rate. [Koenig BO, Ross MA, Jackson RE. An emergency department observation unit protocol for acute-onset atrial fibrillation is feasible. Ann Emerg Med. April 2002;39:374-381.]

We derive a decision rule to partition emergency department patients with suspected pulmonary embolism (PE) into a small, high-risk group (40% pretest probability) that is unsafe for D -dimer testing and a larger group that is safe to have PE ruled out with either a whole-blood D -dimer plus alveolar deadspace measurement or a quantitative D -dimer assay.Nine hundred thirty-four patients with suspected PE were studied at 7 urban EDs in the United States. Patients were prospectively interviewed and examined for recognized symptoms, signs, and risk factors associated with PE. These data were collected before standard objective imaging for PE. Selected variables were analyzed by multivariate logistic analysis to determine factors associated with PE (P.05). A decision rule was then constructed to categorize approximately 80% of ED patients as safe for D -dimer testing.Pretest prevalence of PE was 19.4% (181/934; 95% confidence interval [CI] 16.3% to 21.7%). Six variables found to be significant on multivariate analysis were used to construct the decision rule. Unsafe patients had either a shock index (heart rate/systolic blood pressure) more than 1.0 or age older than 50 years, together with any one of the following conditions: unexplained hypoxemia (SaO (2)95%; no prior lung disease), unilateral leg swelling, recent major surgery, or hemoptysis. These criteria were met by 197 (21.0%) of 934 patients, and 83 of 197 (42.1%; 95% CI 35.3% to 49.6%) patients had PE. Exclusion of these 197 unsafe patients significantly decreased the probability of PE in the remaining 737 (79.0%) safe patients to 13.3% (95% CI 10.9% to 15.9%).Simple clinical criteria can permit safe D -dimer testing in the majority of ED patients with suspected PE. These criteria warrant prospective validation.

Objective: To estimate the cost effectiveness of a 7-year police automatic external defibrillator (AED) program in four suburban communities. Method: 10-year retrospective study (7/89–7/99) of patients of four suburban communities during two study periods: (1) police first response and advanced life support (ALS) care (No-AED) and; (2) AED equipped police first response (P-AED) with subsequent ALS care. Using the perspective of the communities, we obtained costs of AED program from police agencies. We estimated cost/life saved and cost/year lives saved using decreased time to VF shock by EMS. We performed a sensitivity analysis for estimates of potential benefit using estimated improved survival as a result of decreased EMS response interval and obtained survival data. We used literature-based estimates of life expectancy after cardiac arrest survival to estimate cost/year life saved. We used student's t -test and χ 2 to estimate differences between groups. Results: During the 10-year study period 208 patients met study criteria; (81 No-AED, 128 P-AED). The two groups were not different by patient age, ALS response interval, percent in VF, percent witnessed (WIT), or arrest location. Interval to first defibrillator equipped EMS vehicle arrival was less in the P-AED group (2.0 vs. 5.4 min, P P =0.02). Survival to DC was not statistically different with P-AED (11.9 vs. 9.9%, P =0.66) but this study was not powered to detect a difference. Estimated cost per life saved with P-AED varied from $23 542 to $70 342 and cost per year life saved ranged from $1582 to $16 060. Conclusion: Police AED appears to be a cost-effective intervention in these suburban communities which have relatively rapid EMS response intervals.

OBJECTIVES The purpose of this study was to assess whether the immediate availability of serum markers would increase the appropriate use of thrombolytic therapy. BACKGROUND Serum markers such as myoglobin and creatine kinase, MB fraction (CK-MB) are effective in detecting acute myocardial infarction (AMI) in the emergency setting. Appropriate candidates for thrombolytic therapy are not always identified in the emergency department (ED), as 20% to 30% of eligible patients go untreated, representing 10% to 15% of all patients with AMI. Patients presenting with chest pain consistent with acute coronary syndrome were evaluated in the EDs of 12 hospitals throughout North America. METHODS In this randomized, controlled clinical trial, physicians received either the immediate myoglobin/CK-MB results at 0 and 1 h after enrollment (stat) or conventional reporting of myoglobin/CK-MB 3 h or more after hospital admission (control). The primary end point was the comparison of the proportion of patients within the stat group versus control group who received appropriate thrombolytic therapy. Secondary end points included the emergent use of any reperfusion treatment in both groups, initial hospital disposition of patients (coronary care unit, monitor or nonmonitor beds) and the proportion of patients appropriately discharged from the ED. RESULTS Of 6,352 patients enrolled, 814 (12.8%) were diagnosed as having AMI. For patients having AMI, there were no statistically significant differences in the proportion of patients treated with thrombolytic therapy between the stat and control groups (15.1% vs. 17.1%, p = 0.45). When only patients with ST segment elevation on their initial electrocardiogram were compared, there were still no significant differences between the groups. Also, there was no difference in the hospital placement of patients in critical care and non–critical care beds. The availability of early markers was associated with more hospital admissions as compared to the control group, as the number of patients discharged from the ED was decreased in the stat versus control groups (28.4% vs. 31.5%, p = 0.023). CONCLUSIONS The availability of 0- and 1-h myoglobin and CK-MB results after ED evaluation had no effect on the use of thrombolytic therapy for patients presenting with AMI, and it slightly increased the number of patients admitted to the hospital who had no evidence of acute myocardial necrosis.

Study Objective: Emergency physicians frequently rely on normal findings from a lower extremity venous ultrasound examination as a method to decrease the probability of pulmonary embolism (PE) in outpatients with a nondiagnostic ventilation-perfusion lung scan (V/Q scan). The objective of this study was to evaluate the diagnostic utility of bilateral lower extremity venous ultrasound scanning in the diagnosis of PE in emergency department patients with a low-, moderate-, or indeterminate-probability (nondiagnostic) V/Q scan. Methods: This prospective, 2-center, descriptive study was conducted at the EDs of 2 large teaching hospitals. From an initial cohort of 570 nonreferred outpatients, a convenience sample of 156 patients who had both a nondiagnostic V/Q scan and a lower extremity venous ultrasound scan performed was selected as the study population. The sensitivity and specificity for a single lower extremity venous ultrasound scan and the posttest probability of PE were determined for the study population. Results: In the study population, the best-case sensitivity of the lower extremity venous ultrasound scan for PE was 54% (95% confidence interval [CI] 37% to 71%) and the specificity was 98% (95% CI 94% to 100%). The likelihood ratio of a positive test result was 27. The likelihood ratio of a negative test result was 0.49, yielding a lowest possible posttest probability of PE of 12% (95% CI 6% to 17%). Conclusion: This study demonstrates that the combination of a nondiagnostic (low, moderate, or indeterminate) V/Q scan plus a single negative result from lower extremity venous ultrasound examination, even in a best-case scenario, does not exclude the diagnosis of PE. [Daniel KR, Jackson RE, Kline JA. Utility of lower extremity venous ultrasound scanning in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. June 2000;35:547-554.]

Little peer-reviewed literature exists regarding the actions of the person who recognized and called 911 at the time of an out-of-hospital cardiac arrest (OHCA).To describe the characteristics of persons who recognized OHCAs and to assess the impact of their actions on survival.Subjects were a convenience sample of individuals who called 911 after a case of home OHCA in which the victim was transported to one of two suburban community teaching hospitals. A retrospective mail survey was conducted asking demographics, including age, race, educational level, prior first aid training, and actions upon recognition of OHCA, including phone calls made and caller estimate from collapse to 911 call. Callers whose initial action was calling 911 were compared with those who made other calls first. Outcomes (discharged alive, DC) were obtained from hospital records. Fisher's exact test and chi-square tests were used for analysis.Of 378 cases, 173 (45.8%) responded to the mail survey. The lay responders (LRs) who called 911 were younger than the victims (59.9 vs 68.0, p0.001) and were most commonly spouses (65.3%) or adult children (22.0%) of the patient. Most (84.7%) called 911 first at the time of recognition of arrest. A first call to 911 tended to predict DC (11.0% vs 0.0%, p = 0.13). When a phone call other than 911 was made first, there were no survivors (0/23). An estimated delay to 911 call of4 minutes was not associated with an adverse outcome (10.5% vs 6.9%, p = 0.49). There was no difference in demographic variables between immediate and delayed 911 callers.Lay responder demographics are similar to those of patients. In this study, an LR call to 911 first appears to be associated with improved OHCA survival. The LR estimates of delay to 911 call were not associated with increased mortality. The authors identified no patient or witness characteristics that were associated with a delay to calling 911 first.

The goal of trauma triage is to match resources to the needs of seriously injured patients. The trauma triage literature has used a variety of outcome measures to assess appropriate trauma activation. The objective of this study was to determine the agreement between procedural and nonprocedural outcome measures in a population of seriously injured patients transported to a single trauma center.Study authors reviewed all "level 2" trauma activations (January 2002-December 2003) at an American College of Surgeons (ACS) Level 1 trauma center. "Level 2" trauma activations were based on modified ACS Committee on Trauma (COT) triage criteria. Outcomes were classified as nonprocedural (Injury Severity Score [ISS]15 and intensive care unit [ICU] admission) and procedural (nonorthopedic emergent surgery, emergency chest tube placement, emergency department intubation, emergency department transfusion, or emergent interventional radiology care).Of 479 patients, five were transferred out of hospital. The remaining 474 were predominantly male (62%), with a mean age of 39.7 years. Their average ISS was 13.2. There were nine deaths. For all subjects, 144 (30%) were admitted to the ICU, 172 (36%) had an ISS15, 80 (17%) received an emergent procedure, and 46 (10%) went for emergent surgery. Kappas comparing agreement of ISS15 with emergent resuscitation and emergent surgery were 0.31 and 0.15, respectively. Kappas comparing ICU admission with emergent resuscitation and emergent surgery were 0.51 and 0.26, respectively.We identify moderate to poor agreement between nonprocedural and procedural outcomes of trauma triage in this population.

Objective. To compare EMS system characteristics and outcomes between nursing home (NH) patients and out-of-hospital cardiac arrest (OHCA) patients whose arrests occurred in a residence (home).Design. Prospective cohort study reviewing OHCA from July 1989 to December 1993. Variables were age, witnessed arrest, response intervals, automated external defibrillator (AED) use, and arrest rhythms. Outcomes were hospital admission and discharge. Pearson chi-square was used for analysis.Setting. Suburban EMS system.Subjects. Patients ≥ 19 years old with arrest of presumed cardiac cause, with locations at home or at a NH.Results. 2,348 total arrests were complete for analysis, 182 at a NH and 2,166 at home. BLS and ALS response intervals were shorter for the NH patients. The NH patients were more likely to receive CPR on collapse, were older (73.1 vs 67.5 years, p < 0.001), were less likely to have had an AED used (9.9% vs 30.0%, p < 0.001), and were more likely to have an arrest bradyasystolic rhythm (74.7% vs 5...

We sought to determine whether a patient's sex independently influences the interval from emergency department arrival to the initiation of thrombolytic therapy in acute myocardial infarction (AMI).We conducted a retrospective cohort study in two suburban EDs, one at a 929-bed tertiary care teaching hospital and the other at a 189-bed community hospital. Only patients found to be having an ST-segment-elevated AMI on their first ECG who were treated with a thrombolytic agent in the ED were eligible. We excluded patients who arrived at the ED after cardiac arrest or with a known AMI. We used as the main outcome measure the interval from ED arrival to initiation of thrombolytic therapy. Secondary outcome variables included time elapsed before ECG, interval between ECG and treatment, and 1-year mortality.Entry criteria were satisfied by 328 patients. The 88 women experienced a mean 23-minute delay to treatment initiation compared with men (P.01). This observation is not accounted for by age, race, time of day, medical history, sex of the physician, type of thrombolytic agent, hospital, or triage category. The longest delays were found in women treated by female physicians, although female physicians also waited longer than male physicians to administer thrombolytic therapy to men. The mean time elapsed before the first ECG was also 6 minutes longer for women (P.01) Women had an increased 1-year mortality rate that was fully explained by their advanced age at the time of AMI.We infer that a patient's sex may play a significant role in the observed delay in treatment for women. Our data, coupled with previously published work, strongly suggest a systematic negative effect for women in their interaction with the health care system during AMI. We suggest that variables other than systems issues affect the time elapsed before thrombolytic therapy.

Study objective: To validate criteria predicting ankle and midfoot fractures with 100% sensitivity. Design: Prospective validation study Setting: A 929-bed community teaching hospital with an annual census of 76,488 ED visits. Participants: Convenience sample of patients older than 18 years with acute ankle or midfoot injury. Interventions: Radiography was performed in each patient received after pertinent history and physical examination findings were recorded. Results: Five hundred seventy radiographs were obtained in 484 patients. Four hundred twenty-one were of the ankle, and 149 were of the foot. There were 93 ankle fractures and 29 midfoot fractures, giving a fracture yield of 22.1% for ankle films and 19.5% for foot films. Decision rules had sensitivity of 94.6% and specificity of 15.5% for ankle fractures and sensitivity of 93.1% and specificity of 11.5% for midfoot fractures. Prospective criteria failed to predict fracture in five of the ankle group and two of the midfoot group. Physicians predicting fracture solely on the basis of clinical suspicion had a sensitivity of 69% in ankle injuries and 76% in midfoot injuries. Conclusion: We were unable to validate with 100% sensitivity the Ottawa rules predicting ankle and midfoot fractures. However, the Ottawa rules were more sensitive than clinical suspicion alone. [Lucchesi GM, Jackson RE, Peacock WF, Cerasani C, Swor RA: Sensitivity of the Ottawa rules. Ann Emerg Med July 1995;26:1-5.]

Introduction:Recent studies have documented decreased time to emergency department (ED) thrombolytic therapy with the use of prehospital electrocardiography.Purpose:Is the time to ED diagnosis and treatment of acute myocardial infarction (AMI) patients with thrombolytic agents decreased by emergency medical services (EMS) transport when compared with those transported by other means (non-EMS)?Design:Retrospective, case-control studyPopulation:The AMI patients treated with thrombolytic agents at a 34,000-visit, community hospital ED during 1992.Methods:Review of records of patients who received thrombolytic therapy for AMI. Statistical analysis was performed using “Student's” t-test and Yates corrected Chi-square (X2).Results:Eighty-seven patients received thrombolytic agents for AMI during 1992; 33 arrived by ambulance, 54 arrived by other methods. There were no differences in age, gender, or time of ED arrival among these groups. Ambulance patients received standard advanced life support (ALS) care, but not a 12-lead electrocardiogram (ECG) or thrombolytic agents. Ambulance patients experienced a significantly shorter time to first ECG (12.9 ±9.1 min. versus 20.8 ±25.3 win.; p = .028) and received thrombolytic therapy sooner than did controls (56.0 ±31.5 min. versus 78.0 ±63.4 min.; p = .018). There was no difference in time from diagnosis to treatment between these groups.Conclusion:Emergency medical services transport of AMI patients in this study decreased time to diagnosis and treatment and may be a confounder in studies that assess the value of field EMS interventions. Non-EMS AMI patients did not receive as rapid diagnosis and treatment, and emergency physicians should evaluate and address this issue in their departments.

Study objective Point-of-care testing reduces time to cardiac marker results in patients evaluated for acute coronary syndromes, yet evidence this translates to a decreased length of stay is lacking. We hypothesized that point-of-care testing decreases length of stay in patients being evaluated for acute coronary syndromes in the emergency department (ED). Methods Patients being evaluated for possible acute coronary syndromes at 4 EDs in the United States were randomized to having point-of-care markers as well as central laboratory markers, or central laboratory markers only (laboratory arm). Point-of-care markers were obtained using early serial testing at presentation and at 90, 180, and 360 minutes as required by the treating physician. Evaluation, treatment, and disposition decisions were at the treating physician's discretion. Length of stay was from presentation to the time of departure from the ED, either to an inpatient setting or to home. Results There were 1,000 patients in each study arm. There were 520 patients discharged home from the ED. Median (interquartile range) time to discharge home was 4.6 hours (3.5 to 6.1 hours) in laboratory patients and 4.5 hours (3.5 to 6.1 hours) in point-of-care patients. Median (interquartile range) time to transfer to an inpatient setting for admitted patients was 5.5 hours (4.2 to 7.5 hours) in laboratory patients, and 5.4 hours (4.1 to 7.3 hours) in point-of-care patients. At one site, time to transfer to the floor was reduced in the point-of-care arm compared with the laboratory arm (difference in medians 0.45 hours; 95% confidence interval [CI] –0.14 to 1.04 hours). At one site, time to ED departure for discharged patients was higher in the point-of-care arm than the laboratory arm (difference in medians 1.25 hours; 95% CI 0.13 to 2.36 hours). Conclusion The effect of point-of-care testing on length of stay in the ED varies between settings. At one site, point-of-care testing decreased time to admission, whereas at another, point-of-care testing increased time to discharge. Potential effects of point-of-care testing on patient throughput should be considered in the full context of ED operations.

A simple method is needed to risk stratify normotensive patients with pulmonary embolism. We studied whether bedside clinical data can predict in-hospital complications from pulmonary embolism.We performed a multicenter derivation phase, followed by validation in a single center. All patients were normotensive; the diagnosis of pulmonary embolism was established by objective imaging. Classification and regression analysis was performed to derive a decision tree from 27 parameters recorded from 207 patients. The validation study was conducted on a separate group of 96 patients to determine the derived criterion's diagnostic accuracy for in-hospital complications (cardiogenic shock, respiratory failure, or death).Mortality in the derivation phase was 4% (n = 8) at 24 hours and 10% (n = 21) at 30 days. A room-air pulse oximetry reading95% was the most important predictor of death; mortality was 2% (95% confidence interval [CI]: 0% to 6%) in patients with pulse oximetryor=95% versus 20% (95% CI: 12% to 29%) with pulse oximetry95%. In the validation phase, the room-air pulse oximetry was95% at the time of diagnosis in 9 of 10 patients who developed an in-hospital complication (sensitivity, 90%) andor=95% in 55 of 86 patients without complications (specificity, 64%).Mortality from pulmonary embolism in normotensive patients is high. A room-air pulse oximetry readingor=95% at diagnosis is associated with a significantly lower probability of in-hospital complications from pulmonary embolism.

Older people are trained infrequently in cardiopulmonary resuscitation (CPR), yet are more likely to witness a cardiac arrest. Older people who are CPR trained perform CPR when witnessing a cardiac arrest. Objective: To assess whether elderly adults (>55 years) who receive chest-compression only cardiopulmonary resuscitation (CC-CPR) training display equivalent skill retention rates compared with those who receive traditional CPR instruction. We also identified factors associated with 3 months skill retention at 3 months in both groups. Methods: Older adults in a suburban hospital Older Adult Services program were invited to participate in an experimental CPR course. The 2 h course was modelled after the AHA Friends and Family course, and used one of two standardized video scenarios. Seventy four subjects were randomized to CC-CPR ( n =36) or traditional CPR ( n =38) training. Participation consisted of initial training, followed by a 3 months return videotaped assessment. Three months skill competence was assessed either by consensus between two video evaluators, or the on-site evaluator. Chi square and Kappa tests were used for analysis, and unadjusted odds ratios and 95% confidence intervals are reported. Results: Skill retention assessments were completed on 29 (81%) CC-CPR and 26 (68%) CPR trainees. Subjects were elderly (71.5±6.69 years), and had a high rate of previous CPR training (58.0%). Groups were similar in demographic characteristics. After training, participants exhibited high rates of perceived competence (86.4%), although the overall 3 months skill retention was low (43.6%). CC-CPR training resulted in equivalent skill retention rates as compared with traditional CPR training (51.7 vs. 44.4%; P =0.586). No participant factors were associated with skill retention, including age, previous CPR training, education level, medical history, or perceived physical ability to perform. Conclusion: We identified low rates of CPR skill retention in this elderly population. CC-CPR instruction was associated with equivalent skill retention rates compared with traditional CPR instruction. No demographic factors were associated with successful skill retention.

Objective To prospectively examine the diagnostic accuracy of two-dimensional transthoracic echocardiography (2-D echo) in emergency department (ED) patients being evaluated for acute pulmonary embolism (PE). Methods This was a 14-month prospective observational trial of a convenience sample of ED patients undergoing evaluation for suspected PE at a suburban teaching hospital. The 2-D echo was defined as positive if any two of the following were noted: right ventricular dilation, abnormal septal motion, loss of right ventricular contractility, elevated pulmonary artery or right ventricular pressures, moderate to severe tricuspid regurgitation, or visualization of a clot seen in the right ventricle or pulmonary artery. The patient was considered to have a PE if one of the following was positive: a pulmonary angiogram, contrast helical computed tomography, a magnetic resonance angiogram, a high-probability ventilation/perfusion (V/Q) scan without contradictory evidence, or an intermediate-probability V/Q scan with ultrasonic evidence of deep venous thrombosis. Results Of 225 cases identified, 39 met the defined criteria for PE (17%). A 2-D echo was performed on 124 patients (55%), of whom 27 (22%) had PE. In 20 patients the 2-D echo had at least two indicators of right ventricular strain; however, only 11 of these patients had confirmed pulmonary embolus. The 2-D echo had a sensitivity of 0.41 (95% CI = 0.32 to 0.49) and a specificity of 0.91 (95% CI = 0.86 to 0.96). The likelihood ratio positive was a moderately strong 4.4, with a weak likelihood ratio negative of 0.6. Conclusions Bedside 2-D echo is not a sensitive test for the diagnosis of PE in ED patients. Positive findings moderately increase the suspicion for PE but are not diagnostic.

Objective: To assess whether advanced age is an independent predictor of survival to hospital discharge in community-dwelling adult patients who sustained an out-of-hospital cardiac arrest in a suburban county. Methods: A prospective cohort study was conducted in a suburban county emergency medical services system of community-dwelling adults who had an arrest from a presumed cardiac cause and who received out-of-hospital resuscitative efforts from July 1989 to December 1993. The cohorts were defined by grouping ages by decade: 19-39, 40-49, 50-59, 60-69, 70-79, and 80 or more. The variables measured included age, gender, witnessed arrest, response intervals, location of arrest, documented by-stander cardiopulmonary resuscitation, and initial rhythms. The primary outcome was survival to hospital discharge. Results are reported using analysis of variance, chi square, and adjusted odds ratios from a logistic regression model. Age group 50-59 served as the reference group for the regression model. Results: Of the 2,608 total presumed cardiac arrests, the overall survival rate to hospital discharge was 7.25%. Patients in age groups 40-49 and 50-59 experienced the best rate of successful resuscitation (10%). Each subsequent decade had a steady decline in successful outcome: 8.1% for ages 60-69; 7.1% for ages 70-79; and 3.3% for age 80+. In a post-hoc analysis, further seperation of the older age group revealed a successful outcome in 3.9% of patients ages 80-89 and 1% in patients 90 and older. Patients aged 80 years or more were more likely to arrest at home, were more likely to have an initial bradyasystolic rhythm, yet had a similar rate of resuscitation to hospital admission. In the regression model, age 80 or older was associated with a significantly worse survival to hospital discharge (OR = 0.4, 95% CI = 0.20 to 0.82). Conclusions: There was a twofold decrease in survival following out-of-hospital cardiac arrest to discharge in patients aged 80 or more when compared with the reference group in this suburban county setting. However, resuscitation for community-dwelling elders aged 65-89 is not futile. These data support that out-of-hospital resuscitation of elders up to age 90 years is not associated with a universal dismal outcome.

Methods to characterize the interval between a collapse from cardiac arrest until a 911 call is made have not yet been developed.To determine the concordance of cardiac arrest data obtained by two methods: an immediate nurse interview of out-of-hospital cardiac arrest (OHCA) witnesses, and a follow-up phone interview performed two weeks later.This was a prospective study of OHCA witnesses dating from January 1997 to May 1998. Witnesses were briefly interviewed at the time of emergency department presentation, and two weeks later a more lengthy structured phone interview was performed. The authors identified key data elements: 1) was the arrest witnessed? (Wit); 2) was CPR administered prior to EMS arrival? (BCPR); 3) was the first call placed to 911? (c911); and 4) was the estimated collapse to call interval4 minutes? (ECCI). The analysis utilized Cohen's kappa statistic and Spearman's correlation coefficient.A convenience sample of 42 matched pairs of OHCA cases was analyzed. Kappa statistics for agreement between methods were: 1) Wit(kappa = 0.750), 2) BCPR(kappa = 0.892), 3) c911 (kappa = 0.892), and 4) ECCI(kappa = 0.571, Spearman's 0.528).There is good to excellent agreement between immediate and phone interview data retrieval methods. Phone interviews appear to yield data comparable to that with the more difficult and expensive, direct interview method.

To determine whether race, when controlled for income, is an independent predictor of survival to hospital discharge after out-of-hospital cardiac arrest (OHCA).Prospective OHCA data were collected over 4 years (1991-1994) from a convenience sample of OHCA patients transported to nine hospitals in three suburban counties. Race was determined from hospital and vital statistics records. The average household income was identified from ZIP codes and used as a marker of socioeconomic status. Demographic data and known predictors of survival were compared between blacks and whites. A logistic regression analysis was used to assess the association between race, income, and survival.Of the 1,690 patients, 223 (13%) were blacks and 1,467 (87%) were whites. Average household income was less for blacks than for whites ($40,225 versus $46,193; P.001), but both populations were affluent by national standards (national percentile ranks were 73% and 88%, respectively). The populations were no different in percentage of witnessed arrests (57% versus 61%; P = .465). Blacks were younger (mean +/- SD, 62 +/- 16 versus 68 +/- 15 years; P.001); less frequently received bystander CPR (11% versus 20%; P = .002); less often had ventricular tachycardia or ventricular fibrillation (37% versus 50%; P.001); and had a shorter advanced life support call-response interval (median, 4 versus 6 minutes; P.001). The odds ratio for survival (white/black) was .931 (95% confidence interval, .446 to 1.945).Race was not found to predict adverse OHCA outcomes in this affluent population.

Objective: To identify characteristics associated with provision of bystander CPR in witnessed out-of-hospital cardiac arrest cases. Methods: An observational, prospective, cohort study was performed using cardiac arrest cases as identified by emergency medical services (EMS) agencies in Oakland County, MI, from July 1, 1989, to December 31, 1993. All patients who sustained a witnessed arrest prior to arrival of EMS personnel were reviewed. Results: Of the 927 patients meeting entry criteria, the 229 patients receiving bystander CPR were younger: 60.9 ± 14.7 vs 67.9 ± 14.7 years (p < 0.01). Most (76.6%) cardiac arrests occurred in the home. In a multivariate logistic model, only the location of arrest outside the home was a significant predictor of receiving bystander CPR [odds ratio (OR) 3.8; 99% CI 2.5, 5.9]. Arrests outside the home were associated with significantly improved outcome, with 18.2% of out-of-home and 8.2% of in-home victims discharged from the hospital alive (OR 2.5; 99% CI 1.4, 4.4). Conclusion: Patients who have had witnessed cardiac arrests outside the home are nearly 4 times more likely to receive bystander CPR, and are twice as likely to survive. This observation emphasizes the need for CPR training of family members in the authors' locale. This phenomenon may also represent a significant con-founder in studies of out-of-hospital cardiac arrest and resuscitation.

Study objective: To develop criteria that optimize clinical decisionmaking in the use of radiography after isolated knee trauma in adults. Design: A prospective survey of emergency department patients over a 7-month period. Standardized data forms were completed by emergency physicians, residents, and certified physician assistants. Setting: A large suburban community teaching hospital. Participants: Two hundred forty-two patients older than 17 years with isolated knee injuries sustained less than 24 hours previously. Results: We constructed a clinical decision model, calculating sensitivity, specificity, and odds ratios. Twenty-eight patients (11.6%) had fractures, with the patella the most commonly fractured osseous structure. Patients able to walk without limping had not experienced a fracture, nor had patients with twist injuries without effusion. Sensitivity of this model for detecting fracture was 1.0 (99% confidence interval, .97 to 1.0), and specificity was .337 (99% confidence interval, .26 to .42). Conclusion: Clinical decision rules are effective in detecting knee fractures with 100% sensitivity and with sufficient specificity to eliminate 29% of knee radiographs in the ED. These findings require prospective validation. [Weber JE, Jackson RE, Peacock WF, Swor RA, Carley R, Larkin GL: Clinical decision rules discriminate between fractures and nonfractures in acute isolated knee trauma. Ann Emerg Med October 1995;26:429-433.]

Objectives: To assess whether outcome and first–monitored rhythm for patients who sustain a witnessed, nonmonitored, out–of–hospital cardiac arrest are associated with on–scene CPR provider group. Methods: A retrospective, cohort analysis was conducted in a suburban, heterogeneous EMS system. Patients studied were ± 19 years of age, had had an arrest of presumed cardiac origin between July 1989 and January 1993, had gone into cardiac arrest prior to ALS arrival, and had received CPR on collapse. First–monitored rhythms and survival rates were compared for two patient groups who on collapse either: 1) had received CPR by nonprofessional bystanders (BCPR) or 2) had received CPR by on–scene EMS system first responders (FRCPR). Results: Of 217 cardiac arrest victims, 153 (71%) had received BCPR and 64 (29%) had received FRCPR. The BCPR patients were slightly younger (62. 4 vs 68. 4 years, p = 0. 01) and had slightly shorter ALS response intervals (6. 4 vs 7. 7 minutes, p = 0. 02). There was no difference in BLS response time intervals or automatic external defibrillator (AED) use rates. The percentage of patients with a first–monitored rhythm of pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) and the percentage of patients grouped by CPR provider who survived to hospital admission or to hospital discharge were: Controlling for age, the odds ratio for VT/VF with BCPR was 5. 45 (95% CI 2. 8, 10. 3). Conclusion: Patients who receive BCPR more often have a first–monitored rhythm of VT/VF than do FRCPR patients, despite both CPR–provider groups' initiating CPR essentially immediately after patient collapse. Hence, BCPR and FRCPR groups have different first–monitored arrest rhythms, which may affect survival rate. These patient populations should not be considered to be homogeneous groups in CPR research.

To assess whether bystander CPR (BCPR) on collapse affects initial rhythm and outcome in patients with witnessed, unmonitored out-of-hospital cardiac arrest (OHCA).Prospective cohort study. Student's t test, the chi 2 test, and logistic regression were used for analysis.Suburban emergency medical service (EMS) system.Patients 19 years or older with witnessed OHCA of presumed cardiac origin who experienced cardiac arrest before EMS arrival between July 1989 and July 1993.Of 722 patients who met the entry criteria, 153 received BCPR. Patients who received BCPR were younger than those who did not: 62.5 +/- 15.4 years versus 66.8 +/- 15.1 years (P.01). We found no differences in basic or advanced life support response intervals or in frequency of AED use. More patients initially had ventricular fibrillation (VF) in the BCPR group: 80.9% versus 61.4% (P.01). The interval to definitive care for ventricular tachycardia (VT)/VF was longer for the BCPR group (8.59 +/- 5.3 versus 7.45 +/- 4.7 minutes; P.05). The percentage of patients discharged alive who were initially in VT/VF was higher in the BCPR group: 18.3% versus 8.4% (P.001). In a multivariate model, BCPR is a significant predictor for VT/VF and live discharge with adjusted ORs of 2.7 (95% CI, 1.7 to 4.4) and 2.4 (95% CI, 1.5 to 4.0), respectively. For those patients in VT/VF, BCPR predicted live discharge from hospital with an adjusted OR of 2.1 (95% CI, 1.2 to 3.6).Patients who receive BCPR are more often found in VT/VF and have an increased rate of live discharge, with controls for age and response and definitive care intervals. For VT/VF patients, BCPR is associated with an increased rate of live discharge.