The American Journal of Emergency Medicine Contents VOLUME 25 • NUMBER 9 • NOVEMBER 2007

ORIGINAL CONTRIBUTIONS Acute Epidural Hematoma of the Posterior Fossa—Cases of Acute Clinical Deterioration 989 Toshiaki Hayashi, Motonobu Kameyama, Shigeki Imaizumi, Hideyuki Kamii, and Takehide Onuma Patient Sex and Quality of ED Care for Patients With Myocardial Infarction David R. Vinson, 996 David J. Magid, David W. Brand, Frederick A. Masoudi, P. Michael Ho, Ella E. Lyons, Laurie Crounse, Theresa M. van der Vlugt, Thomas G. Padgett, Albert J. Tricomi, Alan S. Go, and John S. Rumsfeld Comparing Different Patterns for Managing Febrile Children in the ED Between Emergency and 1004 Pediatric Physicians: Impact on Patient Outcome Vei-Ken Seow, Aming Chor-Ming Lin, I-Yin Lin, Cien-Chih Chen, Kuo-Chih Chen, Tzong-Luen Wang, and Chee-Fah Chong Risk Factors and Prognostic Predictors of Unexpected Intensive Care Unit Admission Within 1009 3 Days After ED Discharge Ju-Sing Fan, Wei-Fong Kao, David Hung-Tsang Yen, Lee-Ming Wang, Chung-I Huang, and Chen-Hsen Lee Application of the TIMI Risk Score in ED Patients With Cocaine-Associated Chest Pain 1015 Maureen Chase, Aaron M. Brown, Jennifer L. Robey, Kara E. Zogby, Frances S. Shofer, Lauren Chmielewski, and Judd E. Hollander Terrorism: Can Emergency Medicine Physicians Identify Terrorism Syndromes? Joseph Lester, 1019 Steve Christos, Mary Frances Kordick, and Shu B. Chan Characteristics of Cardiac Arrest and Resuscitation by Age Group: An Analysis From the Swedish 1025 Cardiac Arrest Registry Johan Herlitz, Leif Svensson, Johan Engdahl, Jan Gelberg, Johan Silfverstolpe, Aase Wisten, Karl-Axel Ängquist, and Stig Holmberg Combination of Cardiac Pacing and Epinephrine Does Not Always Improve Outcome of 1032 Cardiopulmonary Resuscitation Meng-Hua Chen, Tang-Wei Liu, Zhi-Yu Zeng, Lu Xie, Feng-Qing Song, Tao He, and Shu-Rong Mo Radiologic Diagnoses of Patients Who Received Imaging for Venous Thromboembolism Despite 1040 Negative D-Dimer Tests Kristen E. Nordenholz, Michael Zieske, Debra S. Dyer, James A. Hanson, and Kennon Heard BRIEF REPORTS Does Sex Matter? Effect of Screener Sex in Intimate Partner Violence Screening 1047 Lauren B. Gerlach, Elizabeth M. Datner, Judd E. Hollander, Kara E. Zogby, Jennifer L. Robey, and Douglas J. Wiebe Left Brachiocephalic Vein Perforation: Computed Tomographic Features and Treatment 1051 Considerations Sheung-Fat Ko, Shu-Hang Ng, Fu-Ming Fang, Yung-Liang Wan, Ming-Jang Hsieh, Po-Ping Liu, Chia-Te Kung, and Ber-Ming Liu DIAGNOSTICS Whole-Body Multislice Computed Tomography as the Primary and Sole Diagnostic Tool in 1057 Patients With Blunt Trauma: Searching for Its Appropriate Indication Thomas Erik Wurmb, Peter Frühwald, Wittiko Hopfner, Norbert Roewer, and Jörg Brederlau

(Continued on next page) Contents continued Early Detection and Diagnosis of Acute Myocardial Infarction: The Potential for Improved Care 1063 With Next-Generation, User-Friendly Electrocardiographic Body Surface Mapping Cedric Lefebvre and James Hoekstra EDITORIAL The Earth is Flat! The Electrocardiogram has 12 Leads! The Electrocardiogram in the Patient With 1073 ACS: Looking Beyond the 12-Lead Electrocardiogram William J. Brady CORRESPONDENCE Littmann Sign in Hyperkalemia: Double Counting of Heart Rate János Tomcsányi, 1077 Vince Wágner, and Béla Bózsik Hypothermia for Out-of-Hospital Cardiac Arrest Survivors: A Single-Center Experience 1078 Sebastiaan C.A.M. Bekkers, Bob J.W. Eikemans, Robert Tieleman, Simon H.J.G. Braat, Willem Dassen, Jean Partouns, Chris de Zwaan, Harry J.G.M. Crijns, and Marc C.T.F.M de Krom Shaken Baby Syndrome vs Inflicted Brain Injury Steven Bellemare 1080 ERRATUM 1081

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CASE REPORTS Acute Toxic Hepatitis After Amiodarone Intravenous Loading Emanuela Rizzioli, 1082 Elena Incasa, Susanna Gamberini, Sandra Savelli, Arnaldo Zangirolami, Marilena Tampieri, and Roberto Manfredini Electrocardiographic Myocardial Infarction Without Structural Lesion in the Setting of Acute 1082 Hymenoptera Envenomation Michael A. Valkanas, Scott Bowman, and Michael W. Dailey McKittrick-Wheelock Syndrome: A Cause of Severe Hydro-Electrolyte Disorders in ED 1083 Herlon Saraiva Martins, Rodrigo Antônio Brandão-Neto, André Laranjeira de Carvalho, Alfredo Nicodemo Cruz Santana, Francisco José Bueno Aguiar, Augusto Scalabrini-Neto, and Irineu Tadeu Velasco Tongue Viability After Snakebite—An Unusual Occupational Hazard Ta-Lun Kao 1083 and Chi-Wen Juan Laryngotracheal Disruption After Blunt Neck Trauma Rony Aouad, Homere Moutran, 1084 and Simon Rassi Titanium Alloy Ring Crush Injury Martins Kapickis and Joseph E. Kutz 1084 Use of Recombinant Activated Factor VII in a Jehovah’s Witness Patient Albert Hsieh 1085 and Izham Cheong Ectopic Ovarian Pregnancy in a Second-Trimester Patient Kevin J. Corrigan 1085 and Daniel R. Kowalzyk Massive Pulmonary Embolism Masquerading as Pulmonary Edema Giuseppe Famularo, 1086 Giovanni Minisola, Giulio Cesare Nicotra, and Claudio De Simone Spontaneous Splenic Rupture Associated With Listeria Endocarditis Nadia Llanwarne, 1086 Bogdan Badic, Véronique Delugeau, and Serge Landen An Unusual Presentation of an Unusual Injury: Atraumatic Avulsion of the Achilles Tendon 1087 Laurence Dodd, Alistair Tindall, Richard Hargrove, Andrew Crockett, and Ananthram Shetty INDEX TO VOLUME 25 1088 The American Journal of Emergency Medicine

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Elsevier, John F. Kennedy Blvd, Philadelphia, PA 19103-2899. Director, Journals Production Production Editor Michael T. Miller Karen Stover Executive Publisher Publisher Christine Rullo Theresa Monturano The American Journal of Emergency Medicine

EDITOR J. Douglas White, MD, MPH, MBA

EDITORIAL BOARD William J. Brady, MD, University of Virginia, Richard M. Nowak, MD, MBA, Henry Ford Hospital, Charlottesville Detroit Neal E. Flomenbaum, MD, Cornell Medical Center, New York Jonathan Olshaker, MD, Boston University, Boston Glenn C. Hamilton, MD, Wright State University, Joseph P. Ornato, MD, Medical College of Virginia, Dayton Richmond Gabor D. Kelen, MD, Johns Hopkins University, Baltimore Norman A. Paradis, MD, University of Colorado, Denver Toby L. Litovitz, MD, Georgetown University, Howard A. Werman, MD, Ohio State University, Columbus Washington, DC Charles J. McCabe, MD, Massachusetts General Loren Yamamoto, MD, MPH, MBA, University of Hawaii, Hospital, Boston Honolulu

EDITORIAL CONSULTANTS 2006 Neal Abarbanell, MD Michael Heller, MD Patrick Ray, MD David Amponsah, MD Johan Herlitz, MD, PhD Philip Rice, MD Joel Bartfield, MD C. James Holliman, MD Alfred Sacchetti, MD Steven L. Bernstein, MD James F. Holmes, MD, MPH Philip Salen, MD Paul Biddinger, MD Stephen Huff, MD David M. Schreck, MD, MS Polly Bijur, MD Fredric Husty, MD William Scruggs, MD Michael Blaivas, MD Ken Iserson, MD Donna Seeger, MD Judith Brillman, MD Jeanne Jacoby, MD Philip Shayne, MD Sean Bush, MD Gary Josephsen, MD Ronald Sing, MD Christopher R. Carpenter, MD Marshall Kapp, MD Adam Singer, MD Jeffrey Caterino, MD Lawrence Edward Kass, MD David E. Slattery, MD William Chiang, MD Ijaz Khan, MD Corey M. Slovis, MD Richard Christensen, MD, MA Bruce Klein, MD Richard Sobel, MD William Cordell, MD Wendy Klein-Schwartz, PharmD Matthew Spencer, MD Frank Counselman, MD Michael Kontos, MD Tom Stair, MD Cameron Crandall, MD John G. Laffey, MD LG Stead, MD Sandra J. Cunningham, MD Jerroid Leikin, MD Milton Tenenbein, MD Daniel Davis, MD Philip D. Levy, MD Kevin M. Terrell, DO, MS Robert Derlet, MD Siu Fai Li, MD Stephen Thomas, MD Deborah Dierecks, MD Joseph Losek, MD Joseph Varon, MD Charles Emerman, MD Frank Lovecchio, MD Arvind Venkat, MD Amy Ernst, MD Michael Lyons, MD Gary Michael Vilke, MD Lorrie Garces, MD Scott Melanson, MD Rade Vukmir, MD, JD Leslie A. Geddes, ME, PhD James R. Miner, MD Terry Walman, MD Nina Gentile, MD Antonio Muniz, MD Daniel Walsh, MD Louis Graff, MD Kristen E. Nordenholz, MD Richard Wersman, MD Colin Graham, MD David Overton, MD Howard Werman, MD Steven Green, MD Manish Patel, MD Michael D. Witting, MD Eric A. Gross, MD W. Frank Peacock, MD Tim Wolfe, MD Blaine Hannafin, MD Andrew Perron, MD Allan B. Wolfson, MD Raymond G. Hart, MD, MPH Michael Phelan, MD Keith Wrenn, MD Mark Hauswald, MD Jesse M. Pines, MD, MBA Huiyun Xiang, MD Kennon Heard, MD Rumen D. Powers, MD Leslie Zun, MD Manuscript Submission and Editorial Review Policy

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Original Contribution Acute epidural hematoma of the posterior fossa—cases of acute clinical deterioration

Toshiaki Hayashi MD*, Motonobu Kameyama MD, Shigeki Imaizumi MD, Hideyuki Kamii MD, Takehide Onuma MD

Department of Neurosurgery, Sendai City Hospital, Sendai 984-8501, Japan

Received 10 November 2006; revised 16 February 2007; accepted 22 February 2007

Keywords: Abstract Acute deterioration; Purpose: Posterior fossa epidural hematoma (PFEDH) is an uncommon complication of head injury, Epidural hematoma; which is sometimes associated with acute clinical deterioration (ACD) without significant warning Posterior fossa; symptoms and may results in death. We investigated clinical characteristics of PFEDH with ACD to Venous sinus identify the process of ACD. Methods: A retrospective case-control review of all patients admitted with a diagnosis of PFEDH between September 1989 and February 1999 was performed. Results: Twenty-one patients (14 men and 7 women) were admitted for PFEDH to Sendai City Hospital. Four patients suffered ACD. All patients had struck their occipital region and had occipital fracture. Patients were treated conservatively on admission because computed tomography (CT) showed no significant findings in 2 patients and PFEDH with minimal symptoms in the others. All patients suffered acute deterioration of consciousness after vomiting. Follow-up CTshowed large PFEDH with severe mass effect. Emergency surgery was performed and identified the bleeding point as the venous sinus. The presence of nausea/vomiting was significant risk factor of ACD (Fisher exact test: P = .021). Of the 4 patients, 2 achieved excellent recovery without deficit, 1 was moderately disabled, and 1 died. The outcome of patients with ACD was worse compared to those without ACD (Fisher exact test: P = .046). Conclusions: We should note that vomiting itself could be a significant risk factor of ACD for occipital head trauma. The patients with occipital fracture and vomiting must be observed closely and followed up by CT, even if the initial CT is negative. CT performed shortly after the trauma may reveal no evidence of PFEDH but cannot exclude the development of delayed hematoma. D 2007 Elsevier Inc. All rights reserved.

1. Introduction carried a poor prognosis. Clinical symptoms contributed little to identifying the site of the hematoma, and the Posterior fossa epidural hematoma (PFEDH) is an diagnosis after the onset of medullary complications was too uncommon complication of head injury. Before the intro- late for effective treatment, and the outcome was usually duction of cerebral computed tomography (CT), PFEDH death. Computed tomography has allowed a real revolution in the diagnosis and early treatment of hematoma. However, * Corresponding author. Tel.: +81 22 266 7111; fax: +81 22 211 8972. PFEDH is not always easy to identify before manifesting as E-mail address: [email protected] (T. Hayashi). brainstem symptoms. Furthermore, patients with PFEDH

Table 1 Summary of patients with PFEDH Table 1 (continued) Patients Patients Statistical Patients Patients Statistical without with ACD difference without with ACD difference A.CD A.CD No. of patients 17 4 PVS 0 0 (F, 6; M, 11) (F, 1; M, 3) D01 Median age (y) 16.0 44.0 Unpaired t test: F, female; M, male; GOS, Glasgow Outcome Scale; SAH, subarachnoid P = .056 hemorrhage; SDH, subdural hematoma; GR, good recovery; MD, Cause of injury moderate disability; SD, severe disability; PVS, persistent vegetative Traffic accident 14 1 state; D, died. Fall 3 3 a Statistically significant. b Interval between injury and admission Fractures were all confirmed by CT. c 0-2 h 12 2 Fractures were all confirmed by CT but one which was confirmed 6h 2 1 only at operative findings. 12 h 0 1 24 h 2 0 N24 h 1 0 (median) (2.0 h) (1.65 h) Unpaired t test: sometimes suffer acute clinical deterioration (ACD) without P = .70 significant warning symptoms, even after hospitalization Consciousness loss at injury and CT, and may consequently die. Yes 6 2 The present study describes the clinical and radiological No 11 2 findings of patients with PFEDH who suffered ACD to GCS score on admission identify the process of ACD. 13-15 14 4 9-12 1 0 3-8 2 0 Symptoms on admission 2. Patients and methods Headache 12 4 Fisher exact test: P = .53 A retrospective case-control review of all patients Nausea/vomiting 5 4 Fisher exact test: admitted with a diagnosis of PFEDH between September P = .021a 1989 and February 1999 was performed. A control group of Focal 3 2 Fisher exact test: PFEDH without ACD was statistically compared with the neurological P = .23 patients with ACD with respect to symptom, radiological signs findings, and operative findings. Statistical significance was Hit point established at the probability level of .05 by using Fisher Occipital 14 4 exact test and unpaired t test. Occipitoparietal 3 0 The Glasgow Coma Scale (GCS) was used on admission Skull fracture to assess the level of consciousness. ACD was defined as a Yes 17b 4c change of GCS within a few minutes. Routine CT in all No 0 0 Associated patients confirmed the diagnoses of PFEDH and skull lesion on CT fracture. Computed tomography was performed for all the SAH 4 1 patients with symptomatic head trauma transferred to our SDH 3 0 department. Computed tomographic scans were performed Contusion 9 1 (coup 1) for the patients with epidural hematoma on admission and (coup 3, three and 24 h post admission routinely. Computed contre-coup 6) tomography was also performed in patients who suffered Shearing injury 2 2 clinical deterioration. Hematoma aggravation on CT Yes 5 4 No 12 0 Treatment 3. Results Surgical 3 4 Conservative 14 0 3.1. Patient characteristics GOS Twenty-one patients (14 men and 7 women) were GR 16 2 Fisher’s exact test: P = .046a admitted for PFEDH among 251 patients with epidural MD 1 1 (GR vs. not GR) hematoma (8.4%) admitted to Sendai City Hospital. The SD 0 0 clinical presentations of the 21 patients with PFEDH are described in Table 1. The patients with PFEDH were 4 to 68 Acute epidural hematoma of the posterior fossa 991 years of age (mean, 25.6 F 19.0; median 19.0 years). Four 3.4. Management patients suffered ACD (1 female and 3 males) and were 11 to 68 years of age (mean, 41.8 F 28.1; median, 44.0 years), All 4 patients with ACD underwent emergency surgery whereas the 17 patients without ACD were 4 to 51 years of immediately after the onset of clinical deterioration, and 3 of age (mean, 21.7 F 14.9; median, 16.0 years). Unpaired t the 17 patients without ACD underwent surgery because of test showed no significant difference between the 2 values enlargement of the PFEDH on follow-up CT. The other 2 ( P = .056). patients without ACD who showed enlargement of PFEDH All cases of PFEDH were of traumatic origin, including were conservatively treated because of the minimal symp- 15 cases of traffic accidents: 3 car drivers, 4 motorcyclists, 2 toms. The typical surgical approach was a suboccipital cyclists, and 5 pedestrians. Five cases were due to falls craniotomy with or without resection of the posterior arch of (Table 1). The interval between injury and admission of the C-1 for relief of medullary decompression. In 1 case, burr patients with ACD ranged from 30 minutes to 9 hours hole craniotomy was performed before suboccipital crani- (median, 1.65 hours), which was almost same as that of otomy to reduce the mass effect as early as possible. A patients without ACD (median, 2.00 hours) (unpaired t test: combined suprainfratentorial approach was used for hema- P = .70). tomas expanding to the supratentorial region. The source of the bleeding was the transverse sinus in 3 patients and the 3.2. Clinical symptoms occipital sinus in 1 patient with ACD, and injured dural arteries in 2 patients and transverse sinus in 1 patient Two of the 4 patients with ACD and 6 of the 17 patients without ACD. without ACD lost consciousness at the time of injury (Table 1). All 4 patients with ACD had an initial GCS score 3.5. Outcome of 13 to 15. Two patients were initially conscious and deteriorated after hospitalization. The other 2 patients had a The quality of survival was assessed with the Glasgow lucid interval. Two patients with ACD had focal neurolog- Outcome Scale at discharge. Of the 4 patients with ACD, 2 ical signs at admission. All the patients with ACD showed showed good recovery, 1 was moderately disabled, and 1 the symptoms of headache, nausea, and vomiting. On the died (Table 2). The patient who died had suffered large other hand, 5 of 17 patients without ACD showed the cerebral contusion (Contrecoup injury) with intracranial symptoms of nausea, and 12 of 17 patients showed the hematoma. The patient with moderate disability had cerebral symptoms of headache. Nausea and vomiting were a contusion in the occipital lobe that manifested as hemi- significant risk factor of ACD (Fisher exact test: P = anopsia at discharge. Of the 17 patients without ACD, 16 .021). Headache and focal neurologic sign were not showed good recovery, and 1 had moderate disability significant risk factors of ACD (Fisher exact test: P = .53 associated with bilateral frontal lobe contusions (Table 1). and 0.23 respectively). All 4 patients vomited repeatedly Defining the good outcome as good recovery, outcome of just before ACD. The interval between injury and ACD the patients with ACD was considerably worse than that of ranged from 2 to 15.5 hours (mean, 6.4 hours) (Table 2). the patients without ACD (Fisher exact test: P = .046).

3.3. Radiological findings 3.6. Illustrative case reports All the 21 patients had occipital fractures. The 1 patient 3.6.1. Case 2 in whom a fracture could not be seen on initial CT had it A 25-year-old man struck his occipital region after demonstrated at surgery. Computed tomography performed falling from a motorcycle. He was taken to hospital 30 on admission showed PFEDH in 19 of the 21 patients. minutes after the accident. On admission, he was conscious Initial CT showed no significant findings in 2 of the 4 (GCS score 14) with no focal neurological deficits. He patients with ACD. Serial CT detected enlargement of the complained of nausea and headache. Cerebral CT showed a PFEDH in 9 of the 21 patients. Of these 9 patients, 4 had skull fracture in the occipital region and a small PFEDH ACD. Routine follow-up CT confirmed enlargement of the with minimal mass effect (Fig. 1 upper). The patient was hematoma in the other 5 patients. Of the 5 patients without admitted to our neurosurgical service for neurologic and ACD, 1 showed continuous hematoma expansion associated radiological investigation. Two hours after the accident, his with tendency to bleeding due to lack of von Willebrand level of consciousness declined (GCS score, 9) with factor. The other 4 patients were all admitted to our hospital repeated severe vomiting with raised blood pressure. Repeat within 2 hours of onset, and second CT confirmed CT showed enlargement of the PFEDH with aggravation of aggravation of hematoma. The PFEDH was confined to the mass effect and enlargement of the ventricles (Fig. 1 the posterior fossa in 12 patients and extended to the lower). The operative findings showed that the vertical supratentorial region in 9 patients. Of the 4 patients with occipital fracture had caused laceration of the occipital sinus ACD, 3 showed supratentorial expansion. Associated leading to hematoma expansion. Postoperative course was lesions were present in 2 patients with ACD and 9 patients uneventful. He was discharged 2 weeks after injury, without without ACD (Tables 1 and 2). significant neurologic deficits. 992 T. Hayashi et al.

Table 2 Summary of patients with acute clinical deterioration Case No. Age/sex on Cause of injury Period from onset GCS on Symptoms on Fracture On CT admission to admission admission admission 1 11/M Falla 9 h 15 H, V Occipital

2 25/M Traffic accidentb 0.5 h 14 H, V Occipital

3 63/F Fall downc 1 h 15 H, V Not significant 4 68/M Falld 2.5 h 13 H, V, facial palsy Occipital

H, headache; C, cerebellar sign; t-SAH, traumatic subarachnoid hemorrhage; cons dist, consciousness disturbance. a Fall from 1-m height. b Fall down from motor cycle. c Slip and fall down to frozen road. d Fall from 1.5 m height.

3.6.2. Case 3 severe headache and nausea. She was taken to hospital 1 A 63-year-old woman struck her occipital region when hour after the accident. On admission, she was conscious she slipped and fell on a frozen road. She complained of (GCS score 15) with no neurologic deficits. Cerebral CT

Fig. 1 Case 2. Upper, CT scans performed 0.5 hours after injury showing PFEDH. Middle, CT scans performed 2 h after injury at the time of clinical deterioration showing enlargement of the PFEDH. The fourth ventricle was not visible. The inferior horns of the lateral ventricles were enlarged. Lower, Bone image of CT scans showed skull fracture in right occipital region (arrow head). Acute epidural hematoma of the posterior fossa 993

Intracranial CT Period from Symptoms at ACD CT findings at ACD Treatment Origin of bleeding Result on admission onset to ACD (GCS score) PFEDH 15.5 h Vomiting cons dist (9) PFEDH enlarged, Surgery Transverse sinus GR ventricle enlarged PFEDH, frontal 2 h Vomiting cons dist (9) PFEDH enlarged, Surgery Occipital sinus GR contusion ventricle enlarged none 3 h Vomiting cons dist (5) PFEDH developed Surgery Transverse sinus MD PFEDH, gliding 5 h Vomiting Cons dist (8) PFEDH developed, Surgery Transverse sinus D contusion, t-SAH frontal contusion

showed no significant lesion. (Fig. 2 upper). The patient was of blood in the infratentorial fossa and obstruction of observed at outpatients ward because of nausea. Three hours cerebrospinal fluid (CSF) circulation at the aqueduct and after the accident, her level of consciousness declined (GCS fourth ventricle are considered to be responsible for the score 5) with repeated vomiting with raised blood pressure. increased intracranial pressure. Acute hydrocephalus sec- Repeat CT showed a large PFEDH with severe mass effect ondary to obstruction of the CSF pathway may be a cause of (Fig. 2 lower). The operative findings showed that the clinical deterioration. PFEDH results in greatly reduced vertical occipital fracture crossing the transverse sinus was posterior fossa space, so a slight increase in the hematoma seen in occipital region when craniotomy was achieved, could easily cause obstruction of the CSF pathway. A sudden which caused laceration of the sinus leading to hematoma appearance or increase in the hematoma after hospitalization expansion. Postoperative course was uneventful. She was can cause extensive mass effect. Therefore, the cause of discharged 3 weeks after injury with hemianopsia due to left enlargement of the PFEDH is essential to identify. parietooccipital contusion. All our patients with ACD had clinical symptoms of nausea and vomiting, even the patient without PFEDH at initial CT, and the source of bleeding was a venous sinus, in 4. Discussion which the pressure is not so high compared to the intracranial pressure. Therefore, the symptoms of nausea and vomiting Posterior fossa epidural hematoma accounted for 3.4% to could have caused episodic hematoma expansion by raising 15% of reported epidural hematomas [1-5] and 8.4% of our the venous pressure. Although the precise mechanism of series. Of our 21 patients, 18 (85.7%) achieved excellent posttraumatic vomiting is unknown, stimulation of the recovery without deficit, whereas 2 were moderately disabled vomiting center in the reticular formation of the lateral and 1 died (mortality 4.8%). This result was good compared medulla due to the impact may be the cause [12]. to previous series, which showed the mortality rate of 30% to The possible course of events in our patients with ACD is 50% [1,3,4,6-10], probably because we had only 1 patient as follows. First, the trauma resulted in a fracture crossing with low GCS score on admission, and the patients were the transverse sinus or the torcula, which caused tearing of admitted directly to our emergency facility soon after injury. the venous sinus with subsequent venous bleeding. Because Enlargement of the lesion was seen in 20% to 50% of of low venous pressure, the PFEDH probably developed previous patients with PFEDH [2,4,8,11] and 42.9% (9/21) very slowly. Acute increases in venous pressure caused by of our patients. Acute clinical deterioration was seen in vomiting aggravated the venous bleeding and resulted in 44.4% (4/9) of our patients who showed enlargement of rapid hematoma expansion. PFEDH. Two patients with ACD showed excellent recov- Concurrent systemic traumatic lesions leading to a ery, 1 had moderate disability, and 1 died. As 16 of the 17 hypotensive state and/or intracranial traumatic lesions with patients without ACD showed excellent recovery, the associated increase of intracranial pressure have been outcomes of patients with ACD was considerably worse. classically identified as bprotective mechanismQ responsible Low level of consciousness immediately before surgery is a for the delayed onset of epidural hematoma [13]. But our factor indicating poor prognosis [3,4,8], so ACD is likely to patients did not show such conditions. Arterial bleeding was be the cause of poor outcome. However, removal of identified in 2 of our 7 surgical patients with aggravation of hematoma is not always possible before brainstem symp- hematoma on follow-up CT but no ACD. All these patients toms appear [3]. had a short interval between injury and initial CT or tendency The mechanism by which PFEDH causes a rapidly of bleeding. Therefore, arterial bleeding could cause contin- increasing mass effect is not well understood. Accumulation uous hematoma expansion but not ACD. However, tearing of 994 T. Hayashi et al.

Fig. 2 Case 3. Upper, CT scans performed 1 hour after injury showing no significant findings. Middle, CT scans 3 hours after injury at the time of clinical deterioration showing a large PFEDH with supratentorial extension. Marked brainstem compression was revealed. Lower, Bone image of CT scans did not show skull fracture. the large artery could cause rapid growth of PFEDH 5. Conclusion associated with a lucid interval. In such a case, expansion of hematoma is expected to occur soon after the injury and We should note that vomiting itself could be a significant should be detected by serial CT. risk factor of ACD for occipital head trauma. The patients It is reported that posttraumatic vomiting is associated with occipital fracture and vomiting must be observed with a fourfold increase in the relative risk of skull fracture closely and followed up by CT, even if the initial CT is [12]. In this situation, some arterial tearing could occur negative. Computed tomography performed shortly after the concomitant with widening of the detachment of the dura trauma may reveal no evidence of PFEDH but cannot and, so, promote hematoma expansion. Slight bleeding is exclude the development of delayed hematoma. often observed from the surface of the dura even in patients with bleeding considered to originate from the dural sinus. The fractured skull could also be a source of bleeding. References Detachment of the venous sinus is another possible cause of [1] Dirim BV, Oruk C, Erdogan N, et al. Traumatic posterior fossa bleeding, as no fracture and no tearing of the sinus were hamatomas. Neuroradiology 2005;11:14-8. found even at autopsy in some cases [3,8,14,15]. [2] Mckenzie KG. Extracranial haemorrhage. Br J Surg 1938;26:346-65. Acute epidural hematoma of the posterior fossa 995

[3] Neubauer UJ. Extradural haematoma of the posterior fossa. Twelve [10] Zuccarello M, Pardatscher K, Andrioli GC, et al. Epidural hematomas years experiences with CT-scan. Acta Neurochir (Wien) 1987;87: of the posterior cranial fossa. Neurosurgery 1981;8:434-7. 105-11. [11] Pozzati E, Tognetti F, Cavallo M, et al. Extradural hematomas of the [4] Onuma T, Shimizu Y, Shimosegawa Y, et al. Acute epidural posterior cranial fossa. Observations on a series of 32 consecutive hematoma of the posterior fossa. Clinical study of 30 cases. cases treated after the introduction of computed tomography scanning. Neurotraumatology 1990;13:57-62. Surg Neurol 1989;32:300-3. [5] Tsai FY, Teal JS, Itabashi HH, et al. Computed tomography of [12] Nee PA, Hadfield JM, Faragher EB. Significance of vomiting after posterior fossa trauma. J Comput Assist Tomogr 1980;4:291-305. head injury. J Neurol Neurosurg Psychiatry 1999;66:470-3. [6] Garza-Mercado R. Extradural hematoma of the posterior cranial fossa: [13] Riesgo P, Piquer J, Botella C, et al. Delayed extradural hematoma after report of seven cases with survival. J Neurosurg 1983;59:664-72. mild head injury: report of three cases. Surg Neurol 1997;48:226-31. [7] Kosary IZ, Goldhammer Y, Lerner MB. Acute extradural hematoma [14] Brambilla G, Rainoldi F, Gipponi D, et al. Extradural haematoma of of the posterior fossa. J Neurosurg 1966;24:1007-12. the posterior fossa: a report of eight cases and a review of the [8] Roda JM, Gimenez D, Perez-Higueras A, et al. Posterior fossa epidural literature. Acta Neurochir (Wien) 1986;80:24-9. hematomas: a review and synthesis. Surg Neurol 1983;19:419-24. [15] Yilmazlar S, Kocaeli H, Dogan S, et al. Traumatic epidural [9] Stone LJ, Schaffer L, Ramsey RG, et al. Epidural hematomas of the hematomas of nonarterial origin: analysis of 30 consecutive cases. posterior fossa. Surg Neurol 1979;11:419-24. Acta Neurochir (Wien) 2005;147:1241-8. American Journal of Emergency Medicine (2007) 25, 996–1003

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Original Contribution Patient sex and quality of ED care for patients with myocardial infarctionB

David R. Vinson MDa,*, David J. Magid MD, MPHb,c,d, David W. Brand MSPHb, Frederick A. Masoudi MD, MSPHe,h, P. Michael Ho MD, PhDe,g, Ella E. Lyons MSb, Laurie Crounse MPHb, Theresa M. van der Vlugt MDa, Thomas G. Padgett MDa, Albert J. Tricomi MDe, Alan S. Go MDf, John S. Rumsfeld MD, PhDe,g aPermanente Medical Group, Sacramento, CA, USA bThe Kaiser Permanente Clinical Research Unit, Denver, CO, USA cDepartment of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, CO, USA dDivision of Emergency Medicine, University of Colorado Health Sciences Center, Denver, CO, USA eDepartment of Medicine, University of Colorado Health Sciences Center, Denver, CO, USA fDivision of Research, Kaiser Permanente of Northern California, Oakland, CA, USA gDenver VA Medical Center, Denver, CO, USA hDepartment of Medicine, Denver Health Medical Center, Denver, CO, USA

Received 8 July 2006; revised 13 February 2007; accepted 23 February 2007

Abstract Objective: The aim of the study was to assess the quality of care between male and female emergency department (ED) patients with acute myocardial infarction (AMI). Methods: A 2-year retrospective cohort study of 2215 patients with AMI presenting immediately to 5 EDs from July 1, 2000, through June 30, 2002 was conducted. Data on patient characteristics, clinical presentation, and ED processes of care were obtained from chart and electrocardiogram reviews. Multivariable regression models were used to assess the independent association between sex and the ED administration of aspirin, b-blockers, and reperfusion therapy to eligible patients with AMI. Results: There were 849 women and 1366 men in the study. Female patients were older than male patients (74.3 years for women vs 66.8 years for men, P b.001). Among ideal patients, women were less likely than men to receive aspirin (76.3% of women vs 81.3% of men, P b .01), b-blockers (51.7% of women vs 61.4% of men, P b.01), and reperfusion therapy (64.0% of women vs 72.8% of men, P b.05). However, after adjustment for age, there was no longer a significant relationship between sex and the use of aspirin (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.95-1.03), b-blockers (OR, 0.94; 95% CI, 0.82-1.04), or reperfusion therapy (OR, 1.01; 95% CI, 0.89-1.09). In models adjusting for

Presented at the American College of Emergency Physicians’ Scientific Assembly, October 2004, San Francisco, Calif. B This project was funded by a grant from the Garfield Memorial Fund. Dr Masoudi is supported by the National Institute on Aging NIH Research Career Award K08-AG01011. Dr Rumsfeld is supported by the VA Health Services Advanced Research Career Development Award RCD-98-341-2. * Corresponding author. 1600 Eureka Rd, Kaiser Permanente Medical Centers, Department of Emergency Medicine, Roseville, CA 95661, USA.

0735-6757/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2007.02.049 Patient sex and quality of ED care for patients with myocardial infarction 997 additional demographic, clinical, and hospital characteristics, there remained no association between sex and the processes of care. Conclusion: Women with AMI treated in the ED have a lower likelihood of receiving aspirin, b-blocker, and reperfusion therapy. However, this association appears to be explained by the age difference between men and women with AMI. Although there are no apparent sex disparities in care, ED AMI management remains suboptimal for both sexes. D 2007 Elsevier Inc. All rights reserved.

1. Introduction Ninth Revision, Clinical Modification (code 410.X) [13]. All patients with a hospital discharge diagnosis of AMI More than 1 million acute myocardial infarctions during the study period were identified. These charts were (AMIs) occur in the United States each year [1]. Multiple reviewed to determine which patients had presented studies have found that women with AMI are less likely to immediately to the ED and had elevated cardiac markers receive treatment with aspirin, heparin, and b-blockers, and within the specified time frame. All these eligible patients are less likely to receive coronary revascularization were included in the cohort. compared to men [2-12]. In some studies, adjustment for Elevated cardiac markers diagnostic for AMI were age and other patient characteristics attenuates these defined as either (1) elevations of total creatine kinase or differences, but other studies have found a persistent sex creatine kinase–MB that was 2 or more times the upper limit association despite risk adjustment. For example, a recent of the reference range or (2) elevations in troponin that study of acute coronary syndrome (ACS) care from a large exceeded the normal and indeterminate range. We excluded national registry found an independent association between patients with AMI who were directly admitted to the female sex and lower rates of guideline-indicated ACS inpatient setting without being cared for in the ED, medical therapies and procedures [12]. Thus, significant transferred patients who received their initial ED care at concern remains about potential sex bias in the provision of another institution, and patients whose diagnostic cardiac AMI care. marker elevations occurred more than 24 hours after ED Although most hospital-based AMI management arrival. In addition, to be conservative in judging the quality commences in the emergency department (ED), little of emergency care, patients with electrocardiographic attention has been paid to possible sex-related disparities (ECG) changes alone, without elevated cardiac markers of care in the ED. To address this issue, we compared rates diagnostic for AMI in the ED or within 24 hours of ED of administration of aspirin, b-blocker, and reperfusion arrival, were not included in the study. therapy among male and female ED patients with AMI who were ideal candidates for these treatments. We 2.3. Methods of measurement hypothesized that women with AMI would be less likely to receive these therapies compared to their male counter- Data on the processes of ED care were obtained through parts, independent of demographic, medical history, and review of ED records by 4 physician investigators (DRV, clinical presentation characteristics. TMV, TGP, AJT) using a computerized data abstraction tool. All abstractors received training on the content and coding of each data element, data handling and data 2. Methods transmission procedures, and protocols to handle possible questions or problems during the study. During the training 2.1. Study design and setting period, abstractors also coded 10 practice charts. Although the abstractors were aware that the overall objective of the The Emergency Department Quality in Myocardial Emergency Department Quality in Myocardial Infarction Infarction (EDQMI) project was a 2-year retrospective project was to assess the quality of ED AMI care, they were cohort study focusing on the quality of care for patients not aware at the time of the chart review of the specific with AMI presenting immediately to the ED. The study was hypotheses evaluated in this analysis. conducted at 5 community EDs in California and Colorado Multiple processes were instituted to enhance the from July 1, 2000, through June 30, 2002. accuracy and reliability of the data abstraction process. A 2.2. Selection of participants data manager monitored day-to-day data collection activities, answered coding or eligibility questions, and main- Patients were included in the study if they (1) presented tained a log of all coding decisions made subsequent to the acutely to the ED, (2) had elevated cardiac markers start of the project. After the abstraction was complete and diagnostic for AMI in the ED or within 24 hours of ED the data were entered, the data manager verified case arrival, and (3) had hospital discharge diagnosis of AMI eligibility, confirmed the validity of the responses, and according to the International Classification of Diseases, attempted to locate any missing data. 998 D.R. Vinson et al.

To assess interrater reliability, a random sample of AMI within 24 hours of ED arrival. Patients also were 30 charts was coded by all abstractors and the results of eligible for aspirin if they presented to the ED with these abstractions were compared to a criterion standard discomfort or pressure in the chest, arm, neck, or jaw, and abstraction. Good-to-excellent agreement was found be- had an ED ECG demonstrating new ST-segment depres- tween the abstractions conducted by the physician study sion or T-wave inversion and had elevated cardiac markers abstractors and the criterion standard abstraction for each of diagnostic for AMI within 24 hours of ED arrival. Finally, the key outcome variables: ED administration of aspirin patients were also eligible for aspirin if they had an (j ranged from 0.46 to 0.63), ED administration of admission diagnosis of unstable angina or brule-outQ b-blockers (j ranged from 0.80 to 0.90), and ED admin- myocardial infarction and had elevated cardiac markers istration of reperfusion therapy (j = 1.0 for all abstractors). diagnostic for AMI within 24 hours of ED arrival. Electrocardiogram reviews were conducted by 3 board- Contraindications to aspirin therapy included active bleed- certified cardiologists (FAM, PMH, JSR). The purpose of ing on or before ED arrival, aspirin allergy or hypersen- the ECG review was to provide an objective assessment of sitivity, an international normalized ratio of 3.5 or higher, the electrocardiographic data available to emergency pro- or other reasons documented by the ED provider (eg, viders at the time of the ED encounter. The ECG reviewers anemia, a low platelet count, a history of peptic ulcer were blinded to patient treatment. disease, liver disease, a bleeding disorder, recent intracra- Additional data on select patient characteristics, namely, nial hemorrhage or gastrointestinal bleeding, or patient patient medical history, excluding asthma, were obtained refusal) [15,16]. Patients were counted as having received from chart reviews conducted as part of the National aspirin therapy if they had taken an aspirin or other Registry of Myocardial Infarction, a prospective, observa- antiplatelet agent (ie, ticlopidine or clopidogrel) in the ED tional registry of patients admitted with AMI throughout the or in the 24 hours before ED arrival, including docu- United States. Characteristics of the National Registry of mented administration by prehospital personnel. This Myocardial Infarction, data gathering procedures, and practice is consistent with national guidelines and practice reliability have been previously described [14]. measures and reflects how quality of AMI care is currently being assessed [16,17]. We chose this broader categoriza- 2.4. Variables tion of aspirin administration (ie, documented as having been taken within 24 hours) to give the treating physicians The primary independent, or predictor, variable of interest as much credit as possible for working within the national was patient sex. Other independent variables assessed recommendations. Moreover, given that this study com- included demographics (age and race); medical history pares AMI treatment between the sexes, changing the (diabetes, hypertension, hypercholesterolemia, smoking, chronological parameters of antiplatelet administration asthma, chronic obstructive pulmonary disease [COPD], would not affect the overall outcome measures. peripheral vascular disease, stroke, congestive heart failure, Patients were eligible for b-blocker therapy if they had a previous myocardial infarction, previous angioplasty, and confirmed MI in the ED as evidenced by positive cardiac previous coronary bypass surgery); clinical factors (time of markers in the ED or had an ED ECG demonstrating new ED arrival, mode of transport to the ED, presence of chest ST-segment elevation. Contraindication to b-blocker thera- pain, initial ED pulse rate and blood pressure, and Killip py included heart rate of less than 60 beats per minute; class); and ECG findings (new ST-segment elevation defined systolic blood pressure less than 100 mm Hg; ECG as z1 mm of elevation in at least 2 contiguous electrocar- demonstrating second- or third-degree heart block; heart diographic leads, new ST-segment depression defined as failure or pulmonary edema documented on physical z0.5 mm depression in at least 2 contiguous leads, new examination or chest x-ray; a history of asthma; and known T-wave inversion defined as z1.0 mm in at least 2 contiguous allergy to b-blockers, or any other reason documented by leads, and/or new left bundle-branch block). the ED provider (eg, COPD or patient refusal) [15,16]. 2.5. Outcome measures Patients were eligible for reperfusion therapy (thrombolytic therapy or primary percutaneous coronary intervention) The outcome, or dependent, variables were the ED if they presented to the ED within 12 hours of AMI administration of aspirin, b-blockers, and reperfusion symptom onset and had an ED ECG demonstrating ST- therapy for patients who were ideal candidates for these segment elevation or left bundle-branch block that was not therapies. Patients were considered ideal candidates for a known to be old. Contraindications to reperfusion therapy therapy if they were eligible for and had no contraindication included cardiac arrest with cardiopulmonary resuscitation to that therapy based on current American College of or other traumatic resuscitation; a noncompressible vascular Cardiology/American Heart Association guidelines [15,16]. puncture, aortic dissection, or other active bleeding process; Patients eligible for aspirin therapy had a confirmed MI refractory hypertension (systolic blood pressure N180 mm in the ED as evidenced by positive cardiac markers in the Hg or diastolic blood pressure N100 mm Hg); an acute ED or had an ED ECG demonstrating new ST-segment stroke or a history of hemorrhagic stroke, ischemic stroke, elevation and had elevated cardiac markers diagnostic for transient ischemic attack, central nervous system neoplasms, Patient sex and quality of ED care for patients with myocardial infarction 999

Table 1 Demographic, medical history, clinical, treatment, and hospital factors by reperfusion strategy by sex Characteristic Sex Male (n = 1366) Female (n = 849) P Demographic factors Mean age (y) F SD 66.8 F 13.6 74.3 F 11.9 b.01 b60 32.0 13.2 b.01 60-69 19.2 14.8 70-79 27.9 33.7 80+ 20.9 38.3 Race (%) White 67.3 68.3 b.01 Black 3.9 6.8 Other 28.8 24.9

Medical history Diabetes (%) 26.5 26.5 .978 Hypertension (%) 51.2 64.2 b.01 Hypercholesterolemia (%) 48.1 38.8 b.01 Current smoker (%) 23.1 15.9 b.01 Asthma (%) 4.7 7.4 .015 COPD (%) 12.5 15.7 .032 Peripheral vascular disease (%) 6.4 8.1 .115 Prior stroke (%) 7.8 11.0 .015 Prior congestive heart failure (%) 12.5 16.3 .013 Prior myocardial infarction (%) 30.1 25.7 .023 Prior angioplasty (%) 10.8 6.7 b.01 Prior bypass surgery (%) 13.0 8.2 b.01 Cardiac markers positive for AMI within 24 h post-ED arrival 60.1 63.3 .030

Clinical factors Time of day, hospital arrival (%) Day (8:00 am-4:00 pm) 50.5 50.8 .995 Evening (4:00 pm- midnight) 23.6 23.4 Night (midnight-8:00 am) 25.9 25.8 Arrival by ambulance (%) 42.0 55.8 b.01 Chest pain at presentation (%) 83.4 67.8 b.01 Pulse z100 beats/min (%) 21.9 24.1 .048 Systolic blood pressure (%) b90 mm Hg 2.7 4.3 b.01 90-120 mm Hg 21.0 16.4 N120 mm Hg 76.3 79.3 Killip class (%) I (no heart failure) 79.8 69.9 b.01 II (heart failure) 14.7 19.0 III (pulmonary edema) 5.0 10.2 IV (cardiogenic shock) 0.5 1.0 Initial ECG finding ST-segment elevation (%) 27.3 24.5 .336 ST-segment depression (%) 41.2 43.2 .681 T-wave inversion (%) 23.8 29.9 b.01 Left bundle-branch block (%) 3.6 7.3 b.01 Because of rounding, percentages may not all total 100. The proportions reported for each variable reflect nonmissing data. Complete data were available in more than 98% of cases for all candidate covariates.

or other central nervous system lesion; recent major trauma; intestinal bleeding or other internal bleeding within the last a history of surgery or head injury within the preceding month, pregnancy or ED arrival within 1 week postpartum; 2 months; a known bleeding disorder; a history of gastro- or chronic liver disease, infective endocarditis, active peptic 1000 D.R. Vinson et al.

the Kaiser Foundation Research Institute, Oakland, CA, which waived the requirement for written informed consent.

3. Results 3.1. Baseline characteristics The baseline characteristics of the 849 women and 1366 men in the study population are shown in Table 1. Female patients were older than male patients (74.3 years for women vs 66.8 years for men, P b .001). Women more often had a history of hypertension, congestive heart failure, and COPD, and less often had a history of smoking, Fig. 1 Percentage of treatment-eligible patients receiving aspi- hyperlipidemia, and prior cardiac disease. rin, b-blocker, and reperfusion therapy by sex. The lighter gray bars represent males and the darker gray bars represent females for 3.2. Relationship between sex and use of aspirin each of the 3 types of treatment. Overall, 2036 of 2215 patients were ideal candidates for ulcer, oral anticoagulant therapy, or any other reason the administration of aspirin in the ED (92.9% of men, documented by the ED provider (eg, patient refusal) [15,16]. 90.3% of women). Of the 2036 ideal patients, 1639 (80.5%) received aspirin or another antiplatelet agent in the ED or in 2.6. Data analysis the 24 hours before ED arrival. Compared to men, women were less likely to be administered aspirin (76.3% of women We first assessed the administration of aspirin, b-blocker, vs 81.3% of men, P b .01) (Fig. 1). However, after and reperfusion therapy for ideal male and female patients adjustment for age, female sex was no longer associated using bivariate comparison. Multivariable regression models with a lower likelihood of receiving aspirin (OR, 0.99; 95% adjusting for site were then developed to assess the confidence interval [CI], 0.95-1.03) (Fig. 2). No significant relationship between sex and treatment rates independent relationship between sex and aspirin treatment rates was of other demographic, medical history, and clinical charac- found in subgroup analyses by site as well as in additional teristics [18]. Separate models were constructed for each of models that also adjusted for demographic, clinical, and the 3 outcome variables (aspirin, b-blockers, and reperfu- hospital characteristics. The interaction term between sex sion therapy). In secondary analyses, the relationship and race was not significant. between sex and treatment rates was also assessed by subgroups defined by site. We also evaluated for a first- 3.3. Relationship between sex and use order interaction in the multivariable models between sex of b-blockers and race. To maximally control for potential confounding, the Overall, 916 of 2215 patients were ideal candidates for demographic, medical history, and clinical characteristics the administration of a b-blocker in the ED (42.6% of men, listed in Table 1 were considered as candidate covariates in the regression models. Complete data were available in more than 98% of cases for all candidate covariates. To address the potential issue of overfitting in the development of the reperfusion therapy model (given the significantly fewer eligible patients for this outcome measure), we limited the set of possible predictors to the 10 variables that were included in the final aspirin or b-blocker models. Primary logistic regression models were developed adjusting for the variables listed in Table 1 to maximally control for confounding. In secondary analyses, we applied backward selection to the variables in Table 1 ( P b .05 to remain in model) to evaluate the association between sex Fig. 2 Percentage of eligible patients with AMI receiving and the outcome measures, adjusting for statistically specific treatment by age and sex. From left to right, the white significant covariates. The results of the secondary analyses bar represents men younger than 61 years, and the gray bar, were similar to the primary analyses, and therefore, only the females younger than 61 years; the white bar, males 61 to 75 years primary model results are presented here. All analyses were of age, and the gray bar, females 61 to 75 years of age; the white performed using SAS version 8.2 (SAS Institute, Cary, NC). bar, males 76 years and older, and the gray bar, females 76 years The study was approved by the institutional review board of and older, repeated for each of the 3 types of treatment. Patient sex and quality of ED care for patients with myocardial infarction 1001

39.3% of women). Of the 916 ideal patients, 552 (60.3%) to receive heparin, to undergo cardiac catheterization, and received a b-blocker in the ED. Compared to men, women to be prescribed aspirin, angiotensin-converting enzyme were less likely to be administered b-blockers (51.7% of inhibitors, and statins at discharge, even after risk women vs 61.4% of men, P b .01) (Fig. 1). However, after adjustment [12]. adjustment for age, female sex was no longer associated An important factor that differentiates this study from with a lower likelihood of receiving b-blockers (OR, 0.94; previous studies is the focus on ED care. To our knowledge, 95% CI, 0.82-1.04) (Fig. 2). No significant relationship this is the first study to ascertain the degree to which ED between sex and b-blocker treatment rates was found in processes of care for AMI are influenced by patient sex. subgroup analyses by site as well as in additional models In general, studies of this topic have been unable to that also adjusted for demographic, clinical, and hospital distinguish care rendered in the ED from that provided characteristics. The interaction term between sex and race during the subsequent hospitalization [2,4-12]. Even studies was not significant. that have targeted the ED population have not restricted their outcome measures to the care delivered in the ED [19]. 3.4. Relationship between sex and use of It is therefore possible that sex disparities in AMI care reperfusion therapy may result from differential care provided during the remainder of hospitalization after ED care. If so, the results Overall, 460 of 2215 patients were ideal candidates for of this study are complimentary to the previous literature reperfusion therapy in the ED (22.9% of men, 17.3% of and suggest that efforts aimed at reducing potential sex women). Of the 460 ideal patients, 358 (77.8%) received bias may be best focused on care rendered after initial ED reperfusion therapy. Compared to men, women were less AMI treatment. likely to be administered reperfusion therapy (64.0% of Although this study does not support a sex-specific women vs 72.8% of men, P b .05) (Fig. 1). However, after influence on ED AMI care, the results further underscore the adjustment for age, female sex was no longer associated importance of age-related disparities. In our study, women with a lower likelihood of receiving reperfusion therapy were, on average, more than 7 years older than men (OR, 1.01; 95% CI, 0.89-1.09) (Fig. 2). No significant presenting with AMI, an age difference consistent with the relationship between sex and reperfusion treatment rates literature as a whole [4,6-9,11,12]. With this age difference, was found in subgroup analyses by site as well as in more women were ineligible for ED AMI therapies. additional models that also adjusted for demographic, However, differences in eligibility were small (3%-6%), clinical, and hospital characteristics. The interaction term and among ideal candidates, adjustment for age obviated between sex and race was not significant. any sex differences in treatment. The results of this study are consistent with previous studies demonstrating that older patients with AMI who are ideal treatment candidates do 4. Discussion not receive indicated therapies as often as younger patients with AMI, both within the ED and through AMI hospital- This cohort study of ED patients diagnosed with AMI ization [20-24]. examined the association between sex and guideline- An important aspect of the results of this study is the indicated therapies among ideal treatment candidates. We overall gap in ED AMI care. Among ideal treatment found that women were less likely to be treated with candidates in this cohort, 19.5% did not get aspirin, 39.7% aspirin, b-blockers, and coronary reperfusion therapy. did not get b-blockers, and 22.2% did not get reperfusion However, with adjustment for age, these sex-related therapy. To the extent that prompt treatment of AMI results differences in treatment disappeared. Thus, the results in better patient outcomes, addressing these missed of this study suggest that patient sex itself is not opportunities remains an important goal [15,16].The independently associated with the quality of ED AMI results of this study, placed in the context of the broader care and that women are less likely to receive indicated literature on quality of care, suggest the importance of the therapies primarily because of older age at presentation development and implementation of quality interventions with AMI. to maximize delivery of guideline-indicated therapies to all The results of this study stand in apparent contrast to ED patients with AMI who are ideal treatment candidates, previous studies that have evaluated the association irrespective of age and sex [25,26]. For example, this may between sex and AMI care, which have found lower rates include implementation of bcritical pathwaysQ for patients of evidence-based therapy in women with ACS compared with potentially cardiac symptoms to ensure early recog- to men [2,4-12]. Whereas some of these studies corrobo- nition of cardiac ischemia (eg, ECG within 10 minutes of rate our finding that the association between sex and arrival and timely return of cardiac marker results) and treatment is attenuated with adjustment for age [4-10], delivery of guideline-indicated AMI therapies unless others have found persistent sex differences in AMI contraindications are present. Ultimately, changes in treatment [5,6,10,11]. A recent study from a large systems of care are most likely to maximize delivery of national ACS registry found that women were less likely indicated therapies and are in keeping with the Institute of 1002 D.R. Vinson et al.

Medicine’s call to improve the quality of health care the age difference between men and women with AMI delivery in the United States [27]. presenting to the ED. Although there are no apparent sex disparities in care, AMI management remains suboptimal for both sexes. 5. Limitations

Although this is the first study, to our knowledge, that specifically investigates sex differences in the care References provided for patients with AMI in the ED, certain issues should be considered in the interpretation of the results. [1] American Heart Association. Heart attack and angina statistics. American Heart Association Web site. Available at: http://www.amer- First, this retrospective study relied on data available from icanheart.org/presenter.jhtml?identifier=4591 Accessed April 8, 2007. chart review. Our findings are therefore subject to potential [2] Chandra NC, Ziegelstein RC, Rogers WJ, et al. Observations of the bias from missing data on both eligibility and contra- treatment of women in the United States with myocardial infarction: indications to therapy. Second, this study was conducted in a report from the National Registry of Myocardial Infarction-I. 5 US community hospital EDs, which may limit the Arch Intern Med 1998;158:981-8. [3] Rathore SS, Wang Y, Radford MJ, et al. Sex differences in cardiac generalizability of our results. Most multicenter studies of catheterization after acute myocardial infarction: the role of procedure sex differences in ACS management have failed to stratify appropriateness. Ann Intern Med 2002;137:487-93. their results according to the teaching status of the treating [4] Jelinski SE, Ghali WA, Parsons GA, et al. Absence of sex differences facility [2,3,6,8,9]. The studies that have controlled for this in pharmacotherapy for acute myocardial infarction. Can J Cardiol variable have found no difference in treatments or out- 2004;20:899-905. [5] Harrold LR, Lessard D, Yarzebski J, et al. Age and sex differences in comes between academic and nonacademic hospitals the treatment of patients with initial acute myocardial infarction: a [10,12]. community-wide perspective. Cardiology 2003;99:39-46. Third, we were unable to adjust for other sociodemo- [6] Heer T, Schiele R, Schneider S, et al. Gender differences in acute graphic patient factors such as income, education, myocardial infarction in the era of reperfusion (the MITRA registry). employment, or primary language spoken, which may Am J Cardiol 2002;89:511-7. [7] Mahon NG, McKenna CJ, Codd MB, et al. Gender differences in the vary by sex and may be related to differences in delivery management and outcome of acute myocardial infarction in unselected of care. Fourth, this study was designed to assess the patients in the thrombolytic era. Am J Cardiol 2000;85:921-6. degree of underuse of appropriate therapies in patients [8] Hanratty B, Lawlor DA, Robinson MB, et al. Sex differences in risk with AMI. This study cannot address the possible overuse factors, treatment and mortality after acute myocardial infarction: an of these therapies in patients without AMI, which may be observational study. J Epidemiol Community Health 2000;54:912-6. [9] Oka RK, Fortmann SP, Varady AN. Differences in treatment of acute most important for reperfusion therapy. Fifth, we did not myocardial infarction by sex, age, and other factors (the Stanford include patients with ECG changes alone but who did not Five-City Project). Am J Cardiol 1996;78:861-5. have elevated cardiac markers diagnostic for AMI in the [10] McLaughlin TJ, Soumerai SB, Willison DJ, et al. Adherence to ED or within 24 hours of ED arrival. We did so to be national guidelines for drug treatment of suspected acute myocardial conservative in judging the quality of emergency care, infarction: evidence for undertreatment in women and the elderly. Arch Intern Med 1996;156:799-805 [Erratum in: Arch Intern Med. and this group represents a very small proportion of 156 (1996) 1920]. patients with AMI presenting immediately to the ED. [11] Clarke KW, Gray D, Keating NA, et al. Do women with acute Finally, we cannot exclude the possibility that some myocardial infarction receive the same treatment as men? BMJ patients categorized as not receiving aspirin in the ED 1994;309:563-6. who were transported by emergency medical services [12] Blomkalns AL, Chen AY, Hochman JS, et al. Gender disparities in the diagnosis and treatment of non–ST-segment elevation acute coronary (EMS) may have received aspirin en route to the hospital. syndromes. J Am Coll Cardiol 2005;45:832-7. However, patients were categorized as those receiving [13] Centers for Disease Control and Prevention. International classifica- aspirin if it was documented in either the nursing or the tion of diseases, ninth revision, clinical modification (code10.X). ED record that aspirin was administered by EMS Centers for Disease Control and Prevention Web site. Available at personnel, and we abstracted EMS records when they http://www.cdc.gov/nchs/icd9.htm#RTF Accessed April 8, 2007. [14] Every NR, Frederick PD, Robinson M, et al. A comparison of the were available. Furthermore, the findings were similar in National Registry of Myocardial Infarction 2 with the Cooperative patient subgroups that were and were not transported Cardiovascular Project. J Am Coll Cardiol 1999;33:1886-94. by EMS. [15] Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American 6. Conclusions Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Women who receive AMI treatment in community EDs Cardiol 2002;40:1366-74. [16] Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines have a lower likelihood of receiving aspirin, b-blocker, and for the management of patients with ST-elevation myocardial reperfusion therapy when indicated than their male counter- infarction: a report of the American College of Cardiology/American parts. However, this association appears to be explained by Heart Association Task Force on Practice Guidelines (Committee to Patient sex and quality of ED care for patients with myocardial infarction 1003

Revise the 1999 Guidelines for the Management of Patients with Acute [22] Krumholz HM, Radford MJ, Wang Y, et al. Early beta-blocker therapy Myocardial Infarction). Circulation 2004;110:e82-e292 [Erratum in: for acute myocardial infarction in elderly patients. Ann Intern Med Circulation. 2005;111:2013-4]. 1999;131:648-54. [17] Krumholz HM, Anderson JL, Brooks NH, et al. American College of [23] Krumholz HM, Murillo JE, Chen J, et al. Thrombolytic therapy for Cardiology/American Heart Association Task Force on Performance eligible elderly patients with acute myocardial infarction. JAMA Measures; Writing Committee to Develop Performance Measures on 1997;277:1683-8. ST-Elevation and Non–ST-Elevation Myocardial Infarction. Circula- [24] Regueiro CR, Gill N, Hart A, et al. Primary angioplasty in acute tion 2006;113:732-61. myocardial infarction: does age or race matter? J Thromb Thrombol- [18] Goldstein H. Multilevel Statistical Models, second edition. London: ysis 2003;15:119-23. Edward Arnold; New York: Wiley & Sons. 1995. [25] Majumdar SR, McAlister FA, Furberg CD. From knowledge to [19] Roger VL, Farkouh ME, Weston SA, et al. Sex differences in evaluation practice in chronic cardiovascular disease: a long and winding road. and outcome of unstable angina. JAMA 2000;283:646-52. J Am Coll Cardiol 2004;43:1738-42. [20] Magid DJ, Masoudi FA, Vinson DR, et al. Older emergency [26] Pelliccia F, Cartoni D, Verde M, et al. Critical pathways in the department patients with acute myocardial infarction receive lower emergency department improve treatment modalities for patients quality of care than younger patients. Ann Emerg Med with ST-elevation myocardial infarction in a European hospital. 2005;46:14-21. Clin Cardiol 2004;27:698-700. [21] Rathore SS, Mehta RH, Wang Y, et al. Effects of age on the quality [27] Institute of Medicine (U.S.) Committee on Quality of Health Care in of care provided to older patients with acute myocardial infarction. America. Crossing the quality chasm: a new health system for the 21st Am J Med 2003;114:307-15. century. Washington (DC)7 National Academy Press; 2001. American Journal of Emergency Medicine (2007) 25, 1004–1008

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Original Contribution Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome

Vei-Ken Seow MDa, Aming Chor-Ming Lin MDa, I-Yin Lin MDa, Cien-Chih Chen MDa, Kuo-Chih Chen MDa,b, Tzong-Luen Wang MD, PhDa,b, Chee-Fah Chong MS, MDa,b,* aEmergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan bSchool of Medicine, Fu Jen Catholic University, Taipei 242, Taiwan

Received 13 February 2007; accepted 1 March 2007

Abstract Objective: The management of children with fever of indefinite source still remains controversial. This study aimed to compare different practice patterns between pediatric physicians (PPs) and emergency physicians (EPs) in the management of pediatric fever in the emergency department (ED) and correlate them to existing practice guidelines. Their impact on patient outcomes was also discussed. Methods: Medical records of patients 3 to 36 months of age who presented to the ED with fever of indefinite source from June 1 to December 31, 2006, were retrospectively reviewed on day 5 after the patient’s first visit. At the same time, telephone follow-up was carried out to determine whether the patient had been visiting or being admitted to another clinic or hospital after discharge. Variation in practice patterns were compared for the number of laboratory tests, ED length of stay (LOS), and the rate of immediate admission. Patient outcomes were measured as the rate of unscheduled revisit within 72 hours and the rate of subsequent admission. Compliance with existing practice guidelines between PPs and EPs were evaluated by dividing all eligible patients into 3 groups: (1) toxic appearing patients (group A), (2) nontoxic patients with body temperature (BT) R398C (group B), and (3) nontoxic patients with BT below 398C (group C). Results: A total of 345 patients who met the inclusion and exclusion criteria were enrolled into this study. Pediatric physicians and EPs treated 163 and 182 febrile children, respectively. In group A, PPs admitted more patients than EPs (41% vs 12 %), whereas more unscheduled revisits were seen in EP-treated patients (44% vs 10%). In group B, PPs ordered more laboratory tests than EPs (2.3 vs 0.7 tests per patient), and their patients also had a longer ED LOS (3.4 F 3.2 vs 1.5 F 1.1 hours). However, no difference was found in their rates of immediate admission and unscheduled revisit. In group C, PPs admitted more patients (15% vs 0%) and ordered more laboratory tests (2.0 vs

* Corresponding author. Emergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan, ROC. Tel.: +886 2 28332211; fax: +886 2 28353547. E-mail address: [email protected] (C.-F. Chong).

0.5 tests/patient) than EPs. Longer ED LOS (3.3 F 3.9 vs 1.0 F 1.4 hours) was also noted among PP-treated patients. However, no difference was noted in their rates of unscheduled revisit. In all groups, the rates of subsequent admission were similar. Conclusion: Compliance with existing practice guidelines (admit the toxic cases and work up those with BT R398C) was higher among PPs, which resulted in a lower rate of unscheduled revisit, but no significant difference was found in the rate of subsequent admission. D 2007 Elsevier Inc. All rights reserved.

1. Introduction rate of immediate admission. Patient outcomes were measured as the rate of unscheduled revisit within 72 hours Fever, usually defined as temperature of 388C or greater, and the rate of subsequent admission. Finally, compliance is one of the most common chief complaints of children with existing practice guidelines between PPs and EPs were visiting the emergency department (ED) [1,2]. Although evaluated by dividing all eligible patients into 3 groups: (1) practice guidelines were introduced for managing fever toxic appearing patients (group A), (2) nontoxic patients without source in children [3,4], considerable variation in with body temperature (BT) R398C (group B), and (3) management remains obvious among physicians, as found nontoxic patients with BT below 398C (group C). in several previous studies [5-9]. Comparisons between the study groups were done using Our primary objective was to compare different practice t tests for continuous data and v2 or Fisher exact tests for patterns for managing febrile children between pediatric categorical data. All analyses were carried out with SPSS physicians (PPs) and emergency physicians (EPs). Their for Windows (version 12.0, SPSS, Chicago, Ill). Statistical adherence to existing practice guidelines was also com- significance was set at P b .05 (2-tailed). pared. Our secondary objective was to determine whether the differences in fever management have an impact on patient outcomes. To our knowledge, this is the first full 3. Results article in the English literature that aims to evaluate patient outcomes stem from different patterns for managing febrile During the study period, 1391 children presented to the children in the ED between PPs and EPs. ED with fever; 818 patients were excluded because they were less than 3 months or more than 3 years of age; 2. Methods

This is a retrospective study conducted in the ED of a Table 1 Exclusion criteria teaching hospital, which provides urban tertiary care in Taipei city, Taiwan. This ED has an annual census of 75000 Exclusion criteria visits, 20% of which are children. Up to 99% of the Age b3 months or N3 years population carried the National Health Insurance. Children With definite focal bacterial infection on presentation presented to the ED were managed on by PPs and EPs on an Pneumonia alternating monthly basis. Acute bronchitis or bronchiolitis From June 1 to December 31, 2006, all children 3 to Urinary tract infection Acute otitis media 36 months of age presenting to the ED with fever of Acute gastroenteritis indefinite source were enrolled into this study. Fever was Acute tonsillitis or pharyngitis defined as a triage tympanic temperature of 38.08C Meningitis (100.48F) or greater. All medical records of the enrolled Cellulitis patients were retrospectively reviewed on day 5 after the Bone or joint infections patient’s first visit. At the same time, telephone follow-up Others was also carried out to determine whether the patient had History of immunodeficiency been visiting or being admitted to another clinic or hospital HIV infection after discharge. Patients were excluded if they had a definite Diabetes mellitus focal bacterial infection on presentation, history of immu- Under chemotherapy nodeficiency, or chronic diseases. Those who visited Chronic disease Cancer such as anemia another clinic or hospital within 3 days and those who Steroid-dependent asthma received antibiotics in the past 72 hours were also left out Others (Table 1). Visited another clinic or hospital in the past 72 hours Variation in practice patterns were compared for the Antibiotic use in the past 72 hours number of laboratory tests, ED length of stay (LOS), and the 1006 V.-K. Seow et al.

Fig. 1 Flow diagram depicting the process of inclusion and exclusion.

228 patients were subsequently excluded based on the 3.2. Group B (fever >=398C and nontoxic) exclusion criteria listed in Table 1. Finally, 345 patients who met the inclusion and exclusion criteria were enrolled into In this group, the guidelines suggest septic workup such this study, in which PPs and EPs treated 163 and 182 febrile as complete blood count (CBC), urinalysis, chest radio- children, respectively. All eligible patients were carrying the graphs, and others. Pediatric physicians ordered more National Health Insurance of Taiwan. Fig. 1 represents a CBCs, biochemistries, blood cultures, and urinalysis than flow diagram that illustrates the process of patient inclusion EPs (2.3 vs 0.7 tests per patient). Patients treated by PP also F F and exclusion in this study. No differences in sex, age, body had a longer ED LOS (3.4 3.2 vs 1.5 1.1 hours). weight, presenting temperature, and toxic appearance were However, no difference was found in their rates of noted between the 2 groups (Table 2). All children would be immediate admission and unscheduled revisit. admitted if parenteral antibiotic treatment was considered 3.3. Group C (fever bb398C and nontoxic) necessary. Practice patterns, adherence to existing guidelines, and patient outcomes between PP- and EP-treated No solid guidelines exist for the management of children patients were compared (Tables 3 and 4), in reference to the in this group. Physicians may only give antipyretics and following subgroups of patients: follow up these patients in the next 24 hours. However, PPs 3.1. Group A (fever with toxic appearance) Table 2 Demographics According to existing guidelines, all patients in this group should be admitted for septic workup or treatment. Characteristic PP (n = 163) EP (n = 182) P However, adherence to this recommendation was poor in Male (%) 45 49 .39 our study, with only 41% admission rate among PPs and Age (y) 1.64 F 0.79 1.71 F 0.80 .40 12% among EPs. Although there was no significant Body Weight (kg) 12.9 F 4.7 13.2 F 4.3 .52 F F difference in the number of laboratory tests ordered by Temperature (8C) 37.9 1.2 38.1 1.1 .11 PPs and EPs, patients treated by EPs had a significant longer Patients with temperature 21 23 .71 R39.08C (%) period of stay in the ED. In terms of outcome, although Patients with toxic 18 19 .83 unscheduled revisits (within 72 hours) were more common appearance (%) in patients treated by EPs (44% vs 10%), the rates of Significance defined as P b .05. subsequent admission were similar between PPs and EPs. Different practice patterns for managing febrile children 1007

Table 3 Table comparing practice patterns between pediatric physicians (PP) and emergency physicians (EP) Toxic patients Nontoxic patients (n = 282) Group A (n = 63) BT R388C Group B (n = 38) BT R398C Group C (n = 244) BT b398C PP (29) EP (34) P PP (18) EP (20) P PP (116) EP (128) P Laboratory tests Urinalysis 17 22 NS 9 2 .01* 28 12 b.01* Urine culture 2 3 NS 1 0 NS 3 1 NS CBC 15 18 NS 7 1 .02* 50 6 b.01* Blood culture 15 17 NS 7 1 .02* 45 6 b.01* Biochemistry 13 16 NS 7 1 .02* 50 6 b.01* Chest radiograph 24 24 NS 5 6 NS 30 21 NS KUB film 1 2 NS 2 1 NS 11 13 NS Throat culture 1 2 NS 2 1 NS 2 0 NS ABGs 14 15 NS 1 0 NS 13 1 b.01* No. of test per patient 3.0 3.5 2.3 0.7 2.0 0.5 ED Length of stay (hr) 3.9 F 3.1 7.4 F 4.3 b.01* 3.4 F 3.2 1.5 F 1.1 .02* 3.3 F 3.9 1.0 F 1.4 b.01* Immediate admission 12 4 b.01* 2 0 NS 17 0 b.01* ABG, arterial blood gas; NS, not significant. * Significant at P b .05. still admitted more patients (15% vs 0%) and ordered more Our results showed that PPs had a higher compliance CBCs, biochemistries, arterial blood gasses, blood cultures, with the existing practice guidelines than EPs for managing and urinalysis than EPs (2.0 vs 0.5 tests per patient). children with fever of indefinite focus. Pediatric physicians Longer ED LOS (3.3 F 3.9 vs 1.0 F 1.4 hours) was also tended to admit more patients and ordered more laboratory noted among PP-treated patients. Yet, no difference was tests than EPs regardless of their triage temperature or noted in the rates of unscheduled revisit and the rates of toxicity. These differences in practice patterns may be the subsequent admission. reason of a lower rate of unscheduled revisit among patients treated by PPs. However, no significant difference was found on the rates of subsequent admission. 4. Discussion Isaacman et al showed that PPs more frequently ordered CBCs, blood culture, and urine cultures than did EPs and Pediatric patients in Taiwan are seen by PPs in one ED were less likely to order chest radiographs and perform and by EPs in another ED. Alternating PP and EP visiting lumbar punctures than EPs [5]. In our study, EPs did less schedules in the ED also exist, as presented in this study. blood tests and urinalysis, as compared with PPs. There may bFever phobiaQ commonly exists among parents who lack be several reasons for this occurrence. First, most tertiary knowledge in managing febrile children [10-13]. Under the EDs in Taiwan are overcrowded. Emergency physicians are system of Taiwan’s National Health Insurance, parents are required to treat both adult and pediatric patients. On the free to bring their febrile children to the ED if a high other hand, PPs treat infants or children only. Complete temperature was noted. Unscheduled revisits for children evaluation of fever can be time-consuming. Emergency within 48 to 72 hours of an initial ED visit were around 3% physicians confront with the pressure of overwhelming in published literature [14,15]. Remarkably higher rates of patient load and may inadvertently discharge seemingly well unscheduled revisit were found in our study, 40% (72/182) patients without time-consuming fever workup. Second, for EPs and 28% (45/163) for PPs. The increased comprehensive assessment of fever in children tends to be unscheduled pediatric revisits and overcrowding of adult invasive. Procedures such as blood draws, urinary catheter- patients in the ED might have worsened EPs’ performance izations, and lumbar taps need experienced skill for success. in the management of pediatric patients. Emergency physicians may be less skillful and lack

Table 4 Table comparing outcomes between patients treated by PPs and EPs Group A (n = 63) Group B (n = 38) Group C (n = 244) PP (29) EP (34) P PP (18) EP (20) P value PP (116) EP (128) P Unscheduled Revisit (%) 3 (10) 15 (44) b.05* 3 (17) 8 (40) NS 39 (34) 47 (37) NS Subsequent Admission (%) 1 (4) 2 (6) NS 1 (6) 1 (5) NS 5 (4) 4 (3) NS * Significant at P b .05. 1008 V.-K. Seow et al. confidence for such procedures. This may be one of the References reasons why EPs ordered less laboratory tests than PPs. Another difference in practice between PPs and EPs is [1] Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of the length of stay (LOS) of their patients in the ED. Patients pediatric illness presenting to a general community hospital emergen- who appeared toxic had a shorter ED LOS when they were cy department. Pediatrics 1992;90:5-10. [2] Krauss BS, Harakal T, Fleisher GR. The spectrum and frequency of treated by PPs but longer if they were treated by EPs. This illness presenting to a pediatric emergency department. Pediatr Emerg may be due to a lower threshold for admitting toxic patients Care 1991;7:67-71. by PPs as reflected by their higher admission rate. Patients [3] Baraff LJ. Management of fever without source in infants and seen by EPs, on the other hand, would stay longer in the ED children. Ann Emerg Med 2000;36(6):602-14. [4] Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the before they were admitted because some laboratory studies management of infants and children 0 to 36 months of age with fever and formal consultations with attending pediatricians were without source. Pediatrics 1993;92:1-12 Ann Emerg Med 1993;22: necessary before admission. 1198-210. Conversely, nontoxic patients treated by PPs had a [5] Isaacman DJ, Kaminer K, Veligeti H, et al. Comparative practice longer ED LOS, which may be due to more laboratory tests patterns of emergency medicine physicians and pediatric emergency medicine physicians managing fever in young children. Pediatrics being ordered. Although, the shorter LOS of EP-treated 2001;108:354-8. children may be due to a faster discharge of patients by EPs [6] Schweich P, Smith K, Dowd D, Walkley E. Pediatric emergency because of heavy patient load. This would help to explain medicine practice patterns: a comparison of pediatric and general the higher rate of unscheduled revisits among patients emergency physicians. Pediatr Emerg care 1998;14:89-94. [7] Baraff LJ. Management of the febrile child: a survey of pediatric and treated by EPs. emergency medicine residency directors. Pediatr Infect Dis J 1991;10: Currently, no consensus has been reached for evaluation 795-800. and management of fever without focus of infection in [8] Wittler RR, Cain K, Bass JW. A survey about management of febrile children, although practice guidelines had been introduced children without source by primary care physicians. Pediatr Infect Dis by Baraff [3,4]. Compliance with the practice guidelines J 1998;17:271-7. [9] Leduc DG, Pless IB. Pediatricians and general practitioners: a seems to be unsatisfied [16-18]. No single laboratory test comparison of the management of children with febrile illness. has been shown to reliably identify children at high risk for Pediatrics 1982;70:511-5. having serious bacterial infection [19]. Thus, more pro- [10] Taveras EM, Durousseau S, Flores G. Parents’ beliefs and practices spective studies should be carried out in the future, regarding childhood fever: a study of a multiethnic and socioeco- assessing whether more laboratory tests and increased nomically diverse sample of parents. Pediatr Emerg Care 2004;20(9): 579-87. adherence with practice guidelines would be helpful in [11] Walsh A, Edwards H. Management of childhood fever by parents: improving patient outcome. Unnecessary laboratory tests literature review. J Adv Nurs 2006;54(2):217-27. may bring unreliable confidence to both clinicians and [12] Schmitt BD. Fever phobia: misconceptions of parents about fevers. parents but suffering to children. Am J Dis Child 1980;134:176-81. d T This study has some limitations. First, the quality of data [13] Betz MG, Grunfeld AF. Fever phobia in the emergency department: a survey of children’s caregivers. Eur J Emerg Med 2006;13(3):129-33. obtained in a retrospective study is only as accurate as that [14] Alessandrini EA, Lavelle JM, Grenfell SM, et al. Return visits to a which was recorded and stored. Second, the structure of pediatric emergency department. Pediatr Emerg Care 2004;20(3): Taiwan’s National Health Insurance provides a great 166-71. influence on physicians’ practice patterns, for instance, all [15] Zimmerman DR, McCarten-Gibbs KA, DeNoble DH, et al. Repeat children would be admitted if parenteral antibiotics were pediatric visits to a general emergency department. Ann Emerg Med 1996;28(5):467-73. considered. A large-scale, multicenter, prospective study [16] Kramer MS. Management of the young febrile child: a commentary should be undertaken to confirm our findings. on recent practice guidelines. Pediatrics 1997;100:128-34. In conclusion, our study shows that PPs in a tertiary ED [17] Schringer DL. Clinical guidelines in the setting of incomplete have higher agreement with current practice guidelines for evidence. Pediatrics 1997;100:136. managing febrile children (admit the toxic cases and work [18] Bauchner H, Pelton SI. Management of the young febrile child: a R continuing controversy. Pediatrics 1997;100:128-34. up those with BT 398C). Such adherence to guidelines [19] Hsiao AL, Baker MD. Fever in the new millennium: a review of might result in a lower rate of unscheduled revisit but has no recent studies of markers of serious bacterial infection in febrile significant impact on the rate subsequent admission. children. Curr Opin Pediatr 2005;17(1):56-61. American Journal of Emergency Medicine (2007) 25, 1009–1014

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Original Contribution Risk factors and prognostic predictors of unexpected intensive care unit admission within 3 days after ED discharge

Ju-Sing Fan MDa, Wei-Fong Kao MDa,b, David Hung-Tsang Yen MD, PhDa,c,*, Lee-Ming Wang MDa, Chung-I Huang MDa,b, Chen-Hsen Lee MDa,c aDepartment of Emergency Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan, ROC bDepartment of Emergency Medicine, School of Medicine, National Yang Ming University, Taipei 112, Taiwan, ROC cInstitute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming University, Taipei 112, Taiwan, ROC

Received 11 January 2007; revised 2 March 2007; accepted 2 March 2007

Abstract Objective: Our objective was to investigate the risk factors and prognostic predictors of unexpected intensive care unit (ICU) admission within 3 days after emergency department (ED) discharge. Methods: From January 1, 2001, through December 31, 2005, patients admitted to the ICU unexpectedly within 3 days after being discharged from the ED were enrolled. Medical records of these patients were retrospectively reviewed. We categorized each patient’s characteristics into dichotomous groups and used the v2 test to identify risk factors for unexpected ICU admission within 3 days after ED discharge. A multiple logistic regression was applied to examine possible independent predictors of poor prognoses. Results: During the study period, 365321 patients visited our ED; 241(0.07%) were unexpectedly admitted to the ICU within 3 days after being discharged from the ED. Mean patient age was 74.2 F 16.4 years. The rate of ICU admissions caused by medical error was 0.019% F 0.004% of all visits and 29.0% F 5.7% of all unexpected ICU admissions. The overall mortality rate was 19.9% (48/241). Risk factors for unexpected ICU admission within 3 days after discharge from the ED were age of 65 years or older (odds ratio [OR], 5.4; 95% confidence interval [CI], 4.0-7.4), ambulance transport (OR, 5.1; 95% CI, 3.9-6.5), no accompanying family (OR, 3.5; 95% CI, 2.7-4.5), nonambulatory status (OR, 4.2; 95% CI, 2.9-5.0), not living at home (OR, 2.5; 95% CI, 1.9-3.3), Medicaid insurance (OR, 3.6; 95% CI, 2.8-4.7), and emergency stay of more than 24 hours (OR, 4.4; 95% CI, 3.4-5.7). The independent predictors of mortality were age of 65 years or older (OR, 2.4; 95% CI, 1.7-3.6), multiple comorbidities (OR, 4.0; 95% CI, 1.8-8.5), medical error leading to ICU admission (OR, 3.9; 95% CI, 1.8-8.3), and Acute Physiology and Chronic Health Evaluation II score of 20 or higher (OR, 2.9; 95% CI, 1.1-7.8).

* Corresponding author. Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan, ROC. Tel.: +886 2 28757377; fax: +886 2 28757842. E-mail address: [email protected] (D.-H.T. Yen).

Conclusions: In our study, the risk factors and prognostic predictors of unexpected ICU admission within 3 days after ED discharge were identified. Based on these risk and prognostic prediction factors, further strategies for decreasing the incidence of serious adverse events of ED-discharged patients can be implemented. D 2007 Elsevier Inc. All rights reserved.

1. Introduction admitted to the ICU within 3 days after being discharged from the ED. Candidates included patients with or without In recent years, adverse events in medical care have trauma and pediatric patients. Patients were enrolled if they become a great threat to patients’ safety in emergency had not been treated in a ward, outpatient department, or ED departments (EDs) [1-5]. In the Harvard Medical Practice of another hospital during the time between their initial visit Study report, although only 1.5% to 3% of all adverse and their ICU admission. This study was approved by the events developed in the ED, 25% of those ED adverse institutional review committee of Taipei Veterans General events led to death or permanent disability. Of these serious Hospital, Taipei, Taiwan. or fatal events, 70% were attributed to medical error [1].To help improve the quality of medical care and patient safety 2.2. Data collection and analysis in the ED, additional attention should be paid to discover the We collected data from the patients’ medical records and risk factors for those adverse events, especially factors included demographic data, physicians’ records, nurses’ resulting in serious consequences [1-5]. records, and records of laboratory and imaging studies. To Large retrospective studies such as the Harvard Medical determine the cause of the unexpected ICU admission, we Practice Study and the Colorado-Utah study have given defined medical-error causes for ICU admission as inap- some indications of the nature of errors that have caused propriate care occurring during emergency care, which was adverse events in the ED, but these reports only considered the main reason for unexpected deterioration in the errors associated with patients admitted from the ED [1,3-5]. patient’s condition and for resultant admission to the Most patients seen in the ED, those that were discharged, ICU. Using this definition, 2 experienced emergency were not included [1,4,5]. Although the literature discussing physicians independently determined whether the patient’s ED revisits has mentioned unexpected consequences in ED- situation resulted from medical error by reviewing the discharged patients [6-11], no report has focused on events medical records and by consulting the initial treating in which patients rapidly deteriorated after being discharged physician if available. The reviewers’ supervisor made the and then unexpectedly died or were admitted to intensive final decision in each case. Besides being an experienced care units (ICU) on return visits, which characterizes the emergency physician, the supervisor also had considerable most serious adverse events involving ED-discharged experience in determining medical error. To further analyze patients [1,6-11]. Indeed, to our knowledge, studies focus- the relationship between prognosis and the type of medical ing on this type of serious adverse event in ED-discharged error, we clinically classified medical error as being either patients are rare [5]. diagnosis-related or nondiagnosis-related. The aim of this study was to elucidate the incidence, risk factors, and prognostic predictors for unexpected ICU 2.3. Statistical analysis admission within 3 days after ED discharge. We also classified causes of these unexpected ICU admissions, To identify risk factors for unexpected ICU admission, we including medical-error and non–medical-error causes, and categorized each patient’s characteristics into dichotomous tried to construct a preventive strategy. The ultimate goal groups based on the risk factors for 72-hour ED return visit was to provide reference standards for improving patient or readmission. These factors had been identified in previous safety in the ED. studies [6-11] and were used to statistically analyze patients’ relative risk. Patient characteristics analyzed included age (z65 or b65 years), sex (male or female), means of transportation (ambulance or other), presence of accompa- 2. Methods nying family members (yes or no), ambulatory status (yes or 2.1. Patients no), residency (home or other place such as nursing home), insurance (Medicaid or other), ED triage grade (emergency This study was conducted in the ED of a tertiary referral or nonemergency), type of illness on first visit (trauma or medical center, where 73064 F 5123 (mean F SD) patients other), and duration of ED stay (z24 or b24 hours). Because were treated each year in the past decade. The study period all the ED patients (including the study cases) were treated was from January 1, 2001, to December 31, 2005. Each by physicians of the same grade (board-certificated emer- month, we used the emergency quality-assurance computer gency physician) in our ED, the factor of treating physician’s program of our hospital to screen patients who were grade was not put into the statistic analysis. Unexpected admission to intensive care unit 1011

We statistically analyzed the clinical factors possibly initial visit and their ICU admission. Mean patient age was related to the prognoses to identify independent predictors 74.2 F 16.4 years. of poor prognoses. The selected predictors for analysis had Seventy ICU admissions were due to medical error, as primarily been documented to be related to the prognoses determined by the reviewers’ supervisor. Therefore, the rate of critically ill patients [12,13], including age of 65 years or of ICU admissions caused by medical error was 0.019% F older, male sex, multiple comorbidities, emergency triage 0.004%, or 29.0% F 5.7% of all unexpected ICU grade on first visit to the ED, ED stay of 24 hours or admissions. For this determination, j was 0.72, indicating longer, no inpatient specialist consultation on the first visit , consistency higher than that of previous studies on surgical intervention on return visit, use of inotropic agents inpatients (j = 0.20-0.40) [1-4,14]. Diagnosis-related on return visit, intubation on return visit, return visit with medical error occurred in 24 of 70 patients; 14 (58.3%) of ICU admission within 24 hours after ED discharge, and the 24 patients died. Nondiagnosis-related medical error Acute Physiology and Chronic Health Evaluation II affected 46 patients; 10 (21.7%) of these patients died. The (APACHE II) score of 20 points or higher. Poor prognoses difference between diagnosis- and nondiagnosis-related were considered to be death (including deaths in the medical error was significant among patients who died hospital and deaths of terminally ill patients who dis- (mortality rate, 58.3% F 19.6% and 21.7% F 11.8%, charged themselves and died during follow-up), prolonged respectively; P = .003). admission (hospital stay z4 weeks), being able to walk before admission but not after discharge, and readmission within 3 months after being discharged from wards. During Table 1 Characteristics of patients discharged from the the period of data collection, 1 patient was still hospitalized ED and their odds ratios for unexpected ICU admission within at last follow-up, and the final prognosis could not be 3 days determined. Walking ability was confirmed by telephone in Characteristic ED patients Unexpected ICU all but 2 patients. These 3 patients with missing data were (N = 365321) admissions not included in calculations related to prognosis; however, No. Odds ratioa we assumed that this small omission would not affect the (N = 241) final results. Age (y) In addition, poor prognoses were analyzed according to z65b 146487 189 5.4 (4.0-7.4) different diagnostic categories. Diagnoses were grouped into b65 218834 52 categories using the following diagnostic codes from the Sex International Classification of Diseases, Ninth Revision, Male 216776 151 1.2 (0.9-1.5) Clinical Modification: 290-319, mental disorders; 390-459, Female 148545 90 circulatory system disorders; 460-519, respiratory system Transportation Ambulanceb 67547 129 5.1 (3.9-6.5) disorders; 520-579, digestive system disorders; and all other Other 297774 112 codes for other diagnoses. Companion Statistical analysis was performed using software (SPSS, Family 254429 96 version 13.0; SPSS, Chicago, Ill). Cohen n values were used None or otherb 110892 145 3.5 (2.7-4.5) to examine the consistency of decisions regarding deterio- Ambulatory ration in the patient’s condition caused by medical error. The Yes 157219 37 cross-table method was used to calculate the relative risks of Nob 208012 204 4.2 (2.9-5.0) unexpected ICU admission in patients with different Residence characteristics. A multiple logistic regression was used to Home 292809 148 b examine possible independent factors that might have been Other place 72512 93 2.5 (1.9-3.3) related to the patient’s prognosis. P b .05 indicated a Insurance Medicaidb 127230 159 3.6 (2.8-4.7) statistically significant difference. Other 238091 82 Initial triage grade Emergency 34283 23 1.0 (0.7-1.6) 3. Results Nonemergency 331038 218 Type of illness In this 5-year study, 365321 patients were treated in Trauma 81633 47 0.8 (0.6-1.2) the ED of our hospital, and 246 were admitted to the ICU Other 283688 194 within 3 days after being discharged from the ED. All Emergency stay (h) patients were admitted to the ICU by revisiting the ED, and b24 304440 128 z b 241 patients fulfilled the study criteria, resulting in a rate of 24 60881 113 4.4 (3.4-5.7) 0.07% F 0.008%. Among the 5 excluded patients, 3 had a Data in parentheses are 95% confidence intervals. b been hospitalized, and the remainder had been treated in Significantly associated with an increased risk of unexpected ICU admission within 3 days. the EDs of other hospitals during the time between their 1012 J.-S. Fan et al.

Table 2 Predictors of poor prognoses in patients admitted to the ICU unexpectedly within 3 days after discharge from ED Predictor Odds ratioa Death after Prolonged Nonambulatory status Readmission ICU admission admission after discharge within 3 mo Patient characteristics Age z65 y 2.4 (1.7-3.6)* 4.9 (1.6-15.4)* 3.2 (1.2-8.1)* 2.6 (1.8-4.0)* Male sex 0.7 (0.3-1.5) 1.5 (0.7-3.3) 1.1 (0.5-2.2) 0.5 (0.2-1.1) Multiple comorbiditiesb 4.0 (1.8-8.5)* 7.2 (3.3-15.5)* 0.9 (0.4-1.8) 3.6 (2.2-5.6)* On first visit First triage grade 0.5 (0.1-2.5) 1.5 (0.1-2.3) 1.3 (0.3-4.7) 0.9 (0.2-4.2) Emergency stay z24 h 1.9 (0.4-8.1) 1.3 (0.3-5.3) 0.7 (0.2-2.3) 0.8 (0.2-3.0) No consultation 0.8 (0.3-1.7) 1.6 (0.7-3.4) 0.5 (0.3-1.2) 1.1 (0.5-2.5) On return visit Surgical intervention 0.9 (0.4-2.1) 0.6 (0.3-1.3) 1.2 (0.5-2.4) 0.8 (0.4-1.8) Use of inotropics 0.9 (0.2-3.7) 0.6 (0.2-2.6) 0.4 (0.1-1.6) 0.5 (0.1-2.3) Intubation 2.7 (0.5-15.0) 2.0 (0.4-11.2) 3.1 (2.7-5.5)* 2.1 (0.1-1.1) Medical error 3.9 (1.8-8.3)* 0.6 (0.3-1.4) 1.1 (0.5-2.1) 0.4 (0.4-11.8) Return within 24 h 0.9 (0.4-2.1) 0.9 (0.4-1.9) 0.8 (0.4-1.7) 1.1 (0.5-2.3) APACHE II score z20 2.9 (1.1-7.8)* 0.8 (0.4-2.0) 3.0 (2.2-4.4)* 0.7 (0.3-1.6) a Data in parentheses are 95% confidence intervals of the odds ratio. b Multiple comorbidities was defined as more than 3 of the following comorbidities: liver cirrhosis, hypertension, diabetes, old stroke, congestive heart failure, chronic obstructive pulmonary disease, chronic renal insufficiency, coronary artery disease, and malignancy. * P b .05, statistically significant.

The risk of unexpected ICU admission within 3 days the inability of a previously ambulatory patient to walk on significantly increased for patients 65 years or older, those discharge were age of 65 years or older, intubation, and an brought in by ambulance, those not accompanied by family, APACHE II score of 20 points or higher. Predictors of those nonambulatory, those not living at home, those with readmission within 3 months after discharge were age of Medicaid insurance, and those who stayed in the ED for 65 years or older and multiple comorbidities. 24 hours or longer (Table 1). Respiratory system disorders resulted in the most With regard to prognoses, among 165 patients who had unexpected ICU admissions, followed by circulatory sys- an APACHE II score of 20 or higher, 41 (24.8%) died; tem, digestive, and mental disorders (Table 3). Rates of among 76 patients with an APACHE II score of less than 20, nonambulatory status after discharge were significantly seven (9.2%) died, and 48 had prolonged admission. different among diagnostic categories (higher in mental Among all patients in the study, 75 (including mortality disorders, P b .001), but the rate of death ( P = .76), cases) were unable to walk on discharge, and 23 were prolonged admission ( P = .07), and readmission within readmitted to the hospital within 3 months. Table 2 lists the 3 months ( P = .19) were not. factors possibly related to a poor prognosis. Independent predictors of death were age of 65 years or older, multiple comorbidities, ICU admission caused by medical error, and 4. Discussion an APACHE II score of 20 points or higher. In survivors, independent predictors for prolonged admission were age of Unexpected early ICU admission of an ED-discharged 65 years or older and multiple comorbidities. Predictors for patient is a serious adverse event of ED management.

Table 3 Comparisons of prognoses for different diagnostic categories Diagnostic category (N = 241) No. of patientsa Death Prolonged admission Nonambulatory after dischargeb Readmission within 3 mo Respiratory (n = 96) 22 (22.9) 15 (15.6) 26 (27.1) 6 (6.3) Circulatory (n = 55) 11 (20.0) 10 (18.2) 14 (25.5) 8 (14.5) Digestive (n = 45) 6 (13.3) 8 (17.8) 8 (17.8) 2 (4.4) Mental (n = 27) 5 (18.5) 11 (40.7) 21 (77.8) 4 (14.9) Other (n = 18) 4 (22.2) 4 (28.6) 6 (33.3) 3 (16.7) a Data in parentheses are percentages. b Significant difference for each diagnostic category. Unexpected admission to intensive care unit 1013

Understanding why such serious adverse events happen to was well familiar with the disease. It also suggested that find ways to prevent them may be the most important topic establishing a mechanism to prevent errors in managing in studies related to patient safety [1,2]. In this study, we patients of these disease categories is imperative to reduce investigated the risk factors, causes, and prognostic factors the number of unexpected ICU admissions. of patients unexpectedly admitted to the ICU. Because In terms of the predictors of the poor prognoses, we found patient characteristics and criteria for ICU admission differ that old age and multiple comorbidities were predictors of in various EDs, the incidences of unexpected ICU admis- many unfavorable outcomes. These predictors are known sions may also differ. To our knowledge, no previous study from the time of the patient’s initial visit. If a patient has has focused on these incidences; hence, we were unable to either advanced age or multiple comorbidities, appropriate judge the approximate incidence range. However, in an ED care should be taken in his or her treatment. Extending revisit study conducted in another medical center in Taiwan, observation and treatment times, requesting a supervisor to the rate of unexpected ICU admission within 3 days was verify the suitability of management, and even lowering the 0.04%. This rate was lower than ours (0.07%) partly threshold for admission may be necessary. If the decision is because our admissions included a greater number of single made to discharge the patient, a good discharge plan is also elderly patients [8,9]. In terms of ICU care for these patients required. Researchers have suggested that, when these admitted to the ICU unexpectedly within 3 days after being patients are discharged from emergency care, a specialized, discharged from our ED, 7 (9.2%) of 76 patients with an multidisciplinary consulting team should be assembled to APACHE II score of 10 to 19 points died, and 41 (24.8%) of design a subsequent treatment and follow-up plan [15]. 165 patients with an APACHE II score of 20 points or Chern et al [16] suggested implementing a telephone follow- higher died. These rates were lower than the respective rates up program to decrease the incidence of severe adverse of 12% to 22% (score of 10-19) and 40% (score z20) that events. If patients with unexpected ICU admission have any Knaus et al [13] reported. of the poor prognostic factors, we should make a greater Risk factors for unexpected ICU admission were also the effort in caring for these patients to improve their prognoses. risk factors for other kinds of adverse events. McCusker et al Of note, if the situation evolves into a medical dispute, the [10] reported that living alone and additional functional decision to take legal action and the final verdict are both problems were significantly associated with repeated visits closely related to the patient’s outcome [17]. to the ED. Martin-Gill and Reiser [11] described a significant Factors other than medical error accounted for approx- difference in the risk of 72-hour return and admission in imately two thirds of all unexpected ICU admissions. different types of insurance and initial diagnostic categories. Patients in this situation had an unexpected deterioration Furthermore, multiple studies have mentioned that the in their condition after receiving appropriate care. Their elderly are predisposed to have several kinds of adverse readmission demonstrates the uncertainty and unpredictabil- events because of their poor functional reserve, atypical ity of medical outcomes [18]. Room for improvement in this presentation, highly complex diseases, and poor compliance setting is relatively limited. In the converse, medical error in therapy after they leave the hospital [6-11,15]. represents avoidable human error, and, in this study, ICU As previous studies have shown, the reliability of judging admissions caused by medical error or inappropriate care whether an adverse event was caused by medical error has were associated with a worsened prognosis. Previous always been unsatisfactory [1-4,14]. However, the consis- authors have also mentioned that medical error was related tency of judging in our study was statistically significant, not only to poor prognoses but also to medical disputes, with high j values. The reason for past difficulties was indicating the urgency of improvements in this aspect possibly because the reviewers (nurses, physicians, or [1-5,12-17,19]. Diagnosis- and nondiagnosis-related medi- surgeons) had to make judgments across all medical cal error was examined because errors emerging from the specialties. Because it is impossible for any reviewer to be diagnostic process usually cause more catastrophic results an expert in all fields, previous study designs enhanced [5,20]. In our study, diagnostic error was significantly differences in how situations are interpreted and in their associated with an increased mortality rate. This finding judgments of causality [1-4,14]. In our study, all reviewers once again indicated that the diagnosis is a pivotal part of were experienced emergency physicians with identical the clinical process in the ED. professional training, the topic to be judged was in their professional field, and the initial attending physician was 4.1. Prevention consulted when available to clear up ambiguities. Therefore, we observed a corresponding increase in consistency. As a general measure, a protective mechanism to prevent Diagnoses in 223 (92.5%) of 241 patients fell into 4 unexpected ICU admission should be constructed and diagnostic categories commonly noted among ED patients: applied in the treatment of patients with risk factors. Besides respiratory system disorders, circulatory system disorders, assembling a multidisciplinary consulting team to care for digestive system disorders, and mental disorders. This elderly patients and telephone follow-up for high-risk distribution demonstrated that the patient’s condition could patients, some authors advocate designing a computerized unexpectedly deteriorate even if the emergency physician warning system for high-risk patients to prevent adverse 1014 J.-S. Fan et al. events because this method is more efficient and less labor- References intensive than others [21]. As a specific measure, detailed discussion may be [1] Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events implemented in each unexpected ICU admission caused and negligence in hospitalized patients. Results of the Harvard by medical error to determine the factors contributing to the Medical Practice Study I. N Engl J Med 1991;324(7):370-6. [2] Nguyen TV, Hillman KM, Buist MD. Adverse events in British error [1-5,22,23]. Contributing factors can be found using hospitals. Preventive strategies, not epidemiological studies, are the framework provided by Vincent et al [22]. They divided needed. BMJ 2001;322:1425. these factors into 7 categories: institutional context, organi- [3] Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in zational and management factors, work environment, team hospitalized patients. Results of the Harvard Medical Practice Study factors, individual factors, task, and patient factors. A II. N Engl J Med 1991;324:377-84. [4] Thomas EJ, Studdert DM, Bustin HR, et al. Incidence and types of category-by-category analysis based on this framework adverse events and negligent care in Utah and Colorado. Med Care can be done to accurately pinpoint the source of the 2000;38:261-71. problem, which may then be resolved. Most researchers [5] Hobgood C, Croskerry P, Wears RL, et al. Patient safety in emergency recommend this systematic method, wherein the mistake is medicine. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. found by looking at the institution, the work environment, Emergency medicine: A comprehensive study guide. 6th ed. New York7 McGraw-Hill; 2004. p. 1912-8. the protective mechanism, the physician, and the patient. [6] Keith KD, Bocka JJ, Kobernick MS, et al. Emergency department Solely examining the physician’s mistakes is no longer revisits. Ann Emerg Med 1989;18:964-8. recommended [1-5,14,19-24]. [7] Pierce JM, Kellerman AL, Oster C. dBouncesT: an analysis of short- term revisits to a public hospital emergency department. Ann Emerg Med 1990;19:752-7. [8] Hu CH. Analysis of patient revisits to emergency department. Am J 5. Limitations Emerg Med 1992;10:366-70. [9] Liaw SJ, Bullard MJ, Hu PM, et al. Rates and causes of emergency This study had some limitations. First, the interactions department revisits within 72 hours. J Formos Med Assoc 1999;98: between risk factors for unexpected ICU admissions could 422-5. not be taken into account. The factors could only be related [10] McCusker J, Healey E, Bellavance F, et al. Predictors of repeat to an increase in the incidence and not identified as emergency department visits by elders. Acad Emerg Med 1997;4: independent risk factors. Second, although the prognostic 581-8. [11] Martin-Gill C, Reiser RC. Risk factors for 72-hour admission to the factors calculated in the regression model were independent ED. Am J Emerg Med 2004;22:448-53. predictors, the sample size might have slightly reduced the [12] Olsson T, Terent A, Lind L. Rapid Emergency Medicine Score can statistical power. Third, this study was retrospective, and predict long-term mortality in nonsurgical emergency department incomplete data were difficult to avoid. However, the patients. Acad Emerg Med 2004;11:1008-13. emergency and inpatient data we collected were the most [13] Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818-29. basic information required to complete a case history. [14] Thomas EJ, Lipsitz SR, Studdert DM, et al. The reliability of medical Therefore, the effect of incomplete data was reduced to be record review for estimating adverse event rates. Ann Intern Med minimal. Fourth, we did not recruit the patients who were 2002;136:812-6. admitted to the ICU of other hospitals, those who were [15] Caplan GA, Williams AJ, Daly B, et al. A randomized, controlled trial admitted after 3 days of ED discharge, and those who died of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department: the before return visit, which might underestimate the overall DEED II study. J Am Geriatr Soc 2004;52:1417-23. incidence of serious adverse events of ED management. [16] Chern CH, How CK, Wang LM, et al. Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes. Ann Emerg Med 2005;45:15-23. [17] Brennan TA, Sox CM, Burstin HR. Relation between negligent 6. Conclusions adverse events and the outcomes of medical-malpractice litigation. N Engl J Med 1996;335:1963-7. Early unexpected ICU admission after ED discharge, [18] Scheidt S, Wenger N, Weber M. Uncertainty in medicine: still very especially admission related to medical error, is an much with us in 2004. Am J Geriatr Cardiol 2004;13:9-10. important patient safety topic for which improved under- [19] Vincent CA. Research into medical accidents: a case of negligence? standing and prevention are urgently needed. Our study BMJ 1989;299:1150-3. elucidated patient characteristics related to an increased [20] Kuhn GJ. Diagnostic errors. Acad Emerg Med 2002;9:740-50. [21] Kawamoto K, Houlihan CA, Balas EA, et al. Improving clinical incidence of unexpected ICU admissions within 3 days after practice using clinical decision support systems: a systematic ED discharge and yielded poor prognostic predictors. A review of trials to identify features critical to success. BMJ 2005; protective mechanism should be constructed to help prevent 330:765-8. errors in the care of patients with risk factors, and additional [22] Vincent C, Taylor-Adams S, Stanhope N. Framework for analyzing effort should be made to improve the clinical outcomes of risk and safety in clinical medicine. BMJ 1998;316:1154-7. [23] Adams JG, Bohan JS. System contributions to error. Acad Emerg Med patients with poor prognostic factors. In addition, the errors 2000;7:1189-93. contributing to each unexpected ICU admission should be [24] Reason J. Human error: models and management. BMJ 2000; identified using a system analysis method. 320:768-70. American Journal of Emergency Medicine (2007) 25, 1015–1018

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Original Contribution Application of the TIMI risk score in ED patients with cocaine-associated chest pain

Maureen Chase MD*, Aaron M. Brown BS, Jennifer L. Robey RN, Kara E. Zogby RN, Frances S. Shofer PhD, Lauren Chmielewski BS, Judd E. Hollander MD

Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA

Received 6 January 2007; revised 26 February 2007; accepted 2 March 2007

Abstract Objective: The TIMI risk score has been validated as a risk stratification tool in emergency department (ED) patients with potential acute coronary syndrome. The goal of this study was to assess its ability to predict adverse cardiovascular outcomes in cocaine-associated chest pain. Methods: This was a prospective cohort study of ED patients with chest pain with cocaine use. Data included demographics, medical history, and TIMI risk score. The main outcomes were acute myocardial infarction, revascularization, or death within 30 days of ED presentation. Results: There were 261 patient visits. Patients were 43.2+8 years old, 73% male, 92% black, and 75% smokers. There were 33 patients with the composite outcome. The incidence of 30-day outcomes according to TIMI score is as follows: TIMI 0, 3.7% (95% CI, 0.1-8.3); TIMI 1, 13.2% (5.7-20.7); TIMI 2, 17.1% (4.3-29.8); TIMI 3, 21.4% (4.4-38.4); TIMI 4, 20.0% (0.1-43.6); TIMI 5/6, 50.0% (0.1-100). Conclusions: The TIMI risk score has no clinically useful predictive value in patients with cocaine- associated chest pain. D 2007 Elsevier Inc. All rights reserved.

1. Introduction Cocaine increases the baseline risk of acute myocardial infarction (AMI) by 24 times in the first hour after use [4], and Recent reports from the Substance Abuse and Mental 1 of every 4 nonfatal myocardial infarctions (MIs) in patients Health Services Administration estimate that there are more aged 18 to 45 is related to frequent cocaine use [5]. than 2 million people who have used cocaine in the past Approximately 6% of patients with cocaine-associated chest month [1]. As a consequence, cocaine accounts for 1 of every pain sustain an AMI [6,7]. 5 drug-related emergency department (ED) visits, generating Identification and risk stratification of patients with approximately 250000 visits each year for complaints related potential acute coronary syndrome (ACS) is difficult in to its use [2]. Chest pain is the most frequently encountered the best of circumstances. One method used to risk-stratify symptom among cocaine users presenting to the ED [3]. patients with potential ACS in terms of potential adverse cardiovascular outcomes is the TIMI risk score. Derived and validated to predict 14-day outcomes in trials of patients * Corresponding author. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA. Tel.: +1 617 with unstable angina and non–ST-segment elevation MI 781 2298; fax: +1 617 754 2350. [8-12], the tool uses 7 variables to risk-stratify patients with E-mail address: [email protected] (M. Chase). respect to outcomes. The TIMI score has been proven a

0735-6757/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2007.03.004 1016 M. Chase et al. reliable and valid means for risk-stratifying ED patients with using the European Society of Cardiology/American Col- chest pain of all causes [2,13] as well as helping to guide lege of Cardiology criteria and included AMI during the treatment of those patients with readily identified ACS initial hospitalization as well as within 30 days [15]. This is [9,10]. The TIMI risk score predicts AMI, revascularization, consistent with prior studies on the TIMI risk score in ED and death within 30 days, even when applied at the time of patients [2,13]. Data recorded on hospitalized patients ED presentation [2,13]. However, cocaine users were either included any cardiovascular complications, serial cardiac not addressed or specifically excluded in these previous analyses, and there are no published risk stratification schemes for patients with cocaine-associated chest pain. Table 1 Baseline characteristics of study population The goal of this study was to evaluate the ability of TIMI Patient characteristics n (%) risk score to predict the composite outcome of 30-day AMI, Age (y) 43.2 F 8 revascularization, or death in patients who presented to the Female sex 70 (27) ED with cocaine-associated chest pain. Male sex 191 (73) Race African American 241 (92) Caucasian 15 (6) 2. Materials and methods Asian 2 (b1) This was a prospective observational cohort study of Hispanic 3 (1) Chest pain onset (minutes) 240 (IQR 60-960) consecutively enrolled patients who presented to the ED Chest pain duration (minutes) 180 (IQR 30-720) with chest pain in the setting of cocaine use. The goal of this Cardiac Risk Factors study was to assess the predictive value of the TIMI risk Hypertension 114 (44) score on adverse outcomes in this patient population. The Diabetes 37 (14) study protocol was approved by the institutional committee Elevated cholesterol 28 (11) on research involving human subjects at our institution. Family history of CAD 53 (20) This study was conducted at the Hospital of the University Tobacco use 196 (75) of Pennsylvania. The ED served an urban population with Past Medical History approximately 52000 adult patient visits per year during the Coronary artery disease 55 (21) study period. Trained research assistants were available to Congestive heart failure 33 (13) enroll study participants 16 hours a day, 7 days a week. Angina 47 (18) Myocardial infarction 56 (22) Patients 18 years or older who presented to the ED with Undiagnosed chest pain 27 (10) chest pain and received an electrocardiogram (ECG) were TIMI Risk Factors enrolled. Eligible patients were identified by either a self- Age z65 4 (2) reported history of cocaine use within the prior 7 days or the Known coronary stenosis 44 (17) results of a urine toxicology test revealing cocaine Cardiac risk factors z3 61 (23) metabolites. All treatment decisions, including toxicologic Aspirin use in prior 7 days 54 (21) urine testing, were at the discretion of the treating physician Anginal events z2 over past 24 hours 83 (32) and independent of study enrollment. ST segment deviation 39 (15) All core criteria in the standardized reporting guidelines Elevated cardiac markers 54 (21) [14] were collected, including demographic characteristics, Initial ECG impression medical and cardiac history, characteristics of chest pain and Normal 97 (37) Nonspecific 46 (17) related symptoms, presenting ECG interpretation, and Early repolarization 19 (7) treatment. Treating physicians calculated the TIMI risk Abnormal, not diagnostic 76 (29) N score for each patient. Each positive variable (age 65 years, Ischemia, known to be old 8 (3) 2 or more risk factors for coronary artery disease, known Ischemia, not known to be old 9 (3) coronary artery stenosis, ST-segment deviation on present- Suggestive of MI 6 (2) ing ECG, 2 or more anginal events in prior 24 hours, use of Other ECG findings aspirin in prior 7 days, and elevated serum cardiac markers) ST segment elevation z1 mm 41 (16) received a single point, and each point was added to Q waves 17 (6) determine the total TIMI risk score. If data were missing or Left bundle branch block 1 (b1) b not obtained, a score of zero was assigned for that variable, Right bundle branch block 1 ( 1) in keeping with clinical practice. Cardiac enzymes Ordered 241 (92) Investigators followed the hospital course of admitted Elevated 54 (22) patients daily. Primary outcomes were all-cause mortality, AMI, or revascularization via percutaneous coronary inter- All values are reported as absolute number and percent vention or coronary artery bypass surgery within 30 days of frequency occurrence unless otherwise noted. IQR = interquartile range. ED presentation. The diagnosis of AMI was determined TIMI risk score in cocaine-associated chest pain 1017

Table 2 Relative risk of composite outcome for each TIMI risk score component TIMI variable Outcomes, n (%) Relative risk 95% CI Age z65 y 0 (0) – – Prior CAD 9 (20.4) 1.8 0.91-3.56 z3 Cardiac risk factors 7 (11.5) 0.9 0.40-1.86 ST-segment deviation 9 (23.1) 2.1 0.97-4.12 Aspirin use 9 (16.7) 1.4 0.71-2.81 z2 Anginal events in 24 h 10 (12.0) 0.9 0.47-1.82 Elevated cardiac biomarkers 23 (42.6) 8.8 4.51-17.21 marker results, cardiac diagnostic testing, and final diagno- day follow-up, there were 27 patients who were rehospi- sis. Follow-up was conducted at 30 days from initial talized, and 2 had AMI. There were no additional deaths or presentation for each patient via direct telephone contact revascularization procedures at 30 days. with patients or their health care proxies. The incidence of each TIMI variable in our study cohort Continuous data are presented as either means with SDs was as follows; older than 65 years, 1.5%; known coronary or medians with interquartile ranges based upon the stenosis, 16.9%; 3 or more cardiac risk factors, 23.4%; aspirin distribution of the data. Categorical data are presented as use in the prior 7 days, 20.7%, 2 or more anginal events over the percentage of frequency of occurrence. The relationship 24 hours, 31.8%; ST-segment deviation on presenting ECG, between the TIMI risk score and the composite outcome 14.9%; positive cardiac markers, 20.7%. The only variable was analyzed using v2 testing and the Cochran-Armitage found to have a significant relationship with the composite trend test. Because troponin has been found to be a more outcome was elevated cardiac markers (Table 2). specific marker for myocardial ischemia than creatine The incidence of 30-day death, AMI, and revasculariza- kinase–MB (CK-MB) in patients with cocaine-associated tion according to TIMI score is as follows: TIMI 0, 3.7% chest pain [16], subanalysis was also performed excluding (95% CI, 0.1-8.3); TIMI 1, 13.2% (5.7-20.7); TIMI 2, 17.1% patients diagnosed with an AMI by elevated CK-MB level (4.3-29.8); TIMI 3, 21.4% (4.4-38.4); TIMI 4, 20.0% (0.1- in the absence of elevated troponin I level. All analyses were 43.6); TIMI 5/6, 50.0% (0.1-100). A significant relationship performed using SAS statistical software (Version 9.1; SAS (v2 = 0.02) was observed between TIMI risk score and Institute, Cary, NC). adverse outcomes, but the TIMI score failed to categorize patients into discrete strata of risk (Fig. 1). Most adverse outcomes occurred in patients with low TIMI risk scores. 3. Results Exclusion of patients with AMI with elevated CK-MB level without elevated troponin I level did not significantly During the study period, there were 261 qualifying alter this relationship. The incidence of adverse outcomes in patient visits. The mean patient age was 43.2 F 8 years, and relation to TIMI risk score in this subset of patients is as the study population was 73% male, 92% black, and 6% follows: TIMI 0, 1.2% (95% CI, 0.1-4.2); TIMI 1, 3.3% white. Other patient characteristics at the time of presenta- (0.1-7.5); TIMI 2, 9.8% (0.1-20.1); TIMI 3, 17.9% (1.9- tion are presented in Table 1. 33.8); TIMI 4, 6.7% (0.1-22.6); TIMI z5, 25% (0.1-79.9). There were 213 patients who reported cocaine use in the preceding 7 days. Of the 118 patients who had toxicologic screening, 113 were found to have cocaine metabolites in their urine. There were 204 patients admitted to the hospital; 1 (0.4%) patient had immediate cardiac catheterization, 31 (12%) patients were admitted to the intensive care unit, 161 (62%) patients were monitored in telemetry floor beds, 10 (4%) patients were admitted to an unmonitored floor bed, and 1 (0.4%) patient was transferred to another facility. There were 53 (20%) patients who were discharged from the ED, and 4 (1%) patients left against medical advice. Thirty-day follow-up was completed on 238 (91%) patients. In total, there were 33 patient encounters resulting in one or more of the events in our composite outcome. During index hospitalization, 29 patients had an AMI, and 4 underwent revascularization via percutaneous coronary intervention. There were no coronary artery bypass surgeries Fig. 1 Study population according to TIMI risk score and during initial hospitalization. Two patients died. Upon 30- composite outcome. 1018 M. Chase et al.

4. Discussion References

Based on reports of accelerated atherosclerosis in [1] Wright D, Sathe N. Department of Health and Human Services. State patients with cocaine abuse, it is not unreasonable to Estimates of Subtance Use from the 2003-2004 National Surveys on assume that the same factors that predispose patients with Drug Use and Health. Substance Abuse and Mental Health Services traditional chest pain to adverse cardiac events would Administration, Office of Applied Studies; 2004. [2] Pollack Jr CV, Sites FD, Shofer FS, et al. Application of the TIMI risk contribute to higher risk for patients with cocaine-associ- score for unstable angina and non–ST elevation acute coronary ated chest pain. The TIMI risk score stratification has syndrome to an unselected emergency department chest pain proven reliable in patients with actual and potential ACS population. Acad Emerg Med 2005;13(1):13-8. [2,8,10-13]. However, the results of our study do not [3] Brody SL, Slovis CM, Wrenn KD. Cocaine-related medical problems: support its use for risk stratification in patients with consecutive series of 233 patients. Am J Med 1990;88(4):325-31. [4] Mittleman MA, Mintzer D, Maclure M, et al. Triggering of cocaine-associated chest pain. Although we did observe a myocardial infarction by cocaine. Circulation 1999;99(21):2737-41. relationship between TIMI risk score and rate of adverse [5] Qureshi AI, Suri MF, Guterman LR, et al. Cocaine use and the outcomes, almost half of the observed events occurred in likelihood of nonfatal myocardial infarction and stroke: data from the patients with a TIMI risk score V1. Patients with a TIMI Third National Health and Nutrition Examination Survey. Circulation risk score of zero had a 3.7% incidence of adverse 2001;103(4):502-6. [6] Weber JE, Chudnofsky CR, Boczar M, et al. Cocaine-associated chest outcomes, which is more than twice that reported in pain: how common is myocardial infarction? Acad Emerg Med patients with chest pain unrelated to cocaine use who have 2000;7(8):873-7. a TIMI risk score of zero [13]. [7] Hollander JE, Hoffman RS, Gennis P, et al. Prospective multicenter The overall outcome rate in this study was 12.6% and evaluation of cocaine-associated chest pain. Cocaine Associated Chest includes 31 AMIs. The incidence of AMI in this study is Pain (COCHPA) Study Group. Acad Emerg Med 1994;1(4):330-9. [8] Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for twice that reported in 2 previous studies [6,7]. These unstable angina/non–ST elevation MI: a method for prognostication unpredictable and disparate rates of cardiovascular out- and therapeutic decision making. JAMA 2000;284(7):835-42. comes in cocaine users highlights the challenge of identi- [9] Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of fying those with cocaine-associated chest pain who are at early invasive and conservative strategies in patients with unstable risk. The overall TIMI risk score failed to stratify our study coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344(25):1879-87. population, and we found only a single variable in the TIMI [10] Morrow DA, Antman EM, Snapinn SM, et al. An integrated clinical risk score, elevated cardiac markers, to be independently approach to predicting the benefit of tirofiban in non–ST elevation associated with adverse outcomes. This strong association acute coronary syndromes. Application of the TIMI risk score for UA/ was also noted in previous studies [2,12,13]. NSTEMI in PRISM-PLUS. Eur J Heart 2002;23(3):223-9. There are several potential limitations of our study design [11] Scirica BM, Cannon CP, Antman EM, et al. Validation of the thrombolysis in myocardial infarction (TIMI) risk score for unstable that merit discussion. First, the study cohort was limited in angina pectoris and non–ST-elevation myocardial infarction in the size. Our study population was primarily younger, male, TIMI III registry. Am J Cardiol 2002;90(3):303-5. tobacco smoking, and black. Although these same patient [12] Bartholomew BA, Sheps DS, Monroe S, et al. A population-based demographics are consistent with previous cocaine chest evaluation of the thrombolysis in myocardial infarction risk score for pain reports, our results may not be easily generalized to unstable angina and non–ST elevation myocardial infarction. Clin Cardiol 2004;27(2):74-8. other patient populations who use cocaine. [13] Chase M, Robey JM, Zogby KE, Sease KL, Shofer FS, Hollander JE. Also, 9% of our study cohort was lost to follow-up. These Prospective validation of the TIMI risk score in the emergency patients had similar distribution of demographic character- department chest pain population. Ann Emerg Med 2006;48(3):252-9. istics and TIMI risk scores as compared with our study [14] Hollander JE, Blomkalns AL, Brogan GX, et al. Standardized cohort. Therefore, it is unlikely that additional events in reporting guidelines for studies evaluating risk stratification of emergency department patients with potential acute coronary syn- patients lost to follow-up would have changed the observed dromes. Ann Emerg Med 2004;44(6):589-98. findings in this study. [15] Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction We conclude that all but one of the TIMI variables and redefined—a consensus document of The Joint European Society of the overall TIMI risk score cannot be used to adequately Cardiology/American College of Cardiology Committee for the predict all-cause mortality, MI, or urgent revascularization redefinition of myocardial infarction. J Am Coll Cardiol 2000; 36(3):959-69. by 30 days in patients with cocaine-associated chest pain. [16] Hollander JE, Levitt MA, Young GP, et al. Effect of recent cocaine use This is in contrast to patients with chest pain unrelated to on the specificity of cardiac markers for diagnosis of acute myocardial cocaine use. infarction. Am Heart J 1998;135(2 Pt 1):245-52. American Journal of Emergency Medicine (2007) 25, 1019–1024

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Original Contribution Terrorism: can emergency medicine physicians identify terrorism syndromes?

Joseph Lester MMS, MD, Steve Christos DO, MS, Mary Frances Kordick MBA, MS, PhD, RN*, Shu B. Chan MD, MS

Emergency Medicine Residency Program, Resurrection Medical Center, Chicago, IL 60631, USA

Received 9 February 2007; revised 2 March 2007; accepted 2 March 2007

1. Introduction terrorism syndromes and to identify any educational deficiencies. Terrorism agents include biologic, chemical, or nuclear The lack of prompt recognition a chemical or biologic weapons used to create casualties and psychologic stress terrorist act can quickly lead to disaster. Thus, an accurate among a targeted populace and can result in significant assessment of the ability of emergency physicians to social and economic disruption. The United States is a identify terrorism syndromes, the physical signs and known terrorist target as evidenced most recently by the symptoms of chemical and biologic mass destruction attacks of September 11, 2001, and the use of anthrax as agents, is crucial to national security [1-11]. Letters a weapon against the United States later that same year. containing anthrax sent to health clinics and business This study was designed to assess the knowledge base of offices in Indiana, Kentucky, and Tennessee [12], and emergency medicine (EM) physicians concerning terror- events such as the sarin gas release in the subways of ism syndromes, acting on the premise that EM physicians Tokyo [7] show that terrorism using biologic or chemical would not be able to differentiate between common weapons is a plausible threat. The failure of medical biologic and chemical syndromes [1]. If gaps are found personnel to diagnose a smallpox epidemic was docu- in the collective knowledge base of EM physicians mented in the former Yugoslavia [7], and the failure was so regarding terrorism syndromes, future researchers and profound that it caused that country to close its borders. educators can develop tools to close those gaps and The United States observed repeated failures to diagnose decrease the likelihood that a potential epidemic will go epidemics, as evidenced by a representative botulism unnoticed. Terrorism is a clear threat to the health of the outbreak in Texas between 1994 and 2003 [13]. Adding American public; it is critical that front-line personnel to the risk of terrorism is the unknown location of many such as EM physicians be able to effectively recognize elements of the biologic and chemical arsenal of the former and treat the manifestations of terrorism agents [1-11]. Soviet Union [7]. The literature indicates that biologic and This examination allowed the investigators to assess the chemical weapons are a threat to the American public and knowledge of EM physicians in visually differentiating that the ability of emergency physicians to visually identify terrorism syndromes is of the utmost importance [1-11]. Only education will accomplish this task. Emergency * Corresponding author. Tel.: +1 773 594 7817; fax: +1 773 594 medicine education must formally prepare residents and 7805. attending physicians to recognize and clinically manage E-mail address: [email protected] (M.F. Kordick). chemical and biologic terrorism agents [1].

2. Methods removed, resulting in 73 analyzed participant responses. These 73 usable responses were received from 37 resident 2.1. Study design EM physicians and 36 self-identified attending EM physicians for an 83% response rate (75/90). Thirty-seven The study instrument was a self-developed 17-picture (50.7%) were EM residents, and 36 (49.3%) were EM examination containing descriptions of 11 chemical or biologic attendings. Of the participants, 90.4% practice in the urban terrorism syndromes, none of which involved mass casualty setting, 78.1% are affiliated with a community hospital, and events, which was offered anonymously through the Internet 21.9% are affiliated with a university academic medical and in person. Pictures were taken from public, free-access- center. Of the 37 residents, 13 were post graduate year and-use websites on chemical and biologic weapons of mass (PGY) 1, 13 were PGY2, 10 were PGY3, and 1 was PGY4 destruction. The instrument was tested with 2 experts in the (perhaps an EM fellow). local public health department’s toxicology section and was Table 1 displays demographic information of the popula- found to accurately depict the physical signs and symptoms of tion in relation to scores on the examination. The mean the declared chemical and biologic agents. Victim scenarios difference between attendings’ and residents’ scores was 7.8% were offered with each picture, which contained written (95% CI, 1.04-14.5; P = .024) on the Student t test. Age is not descriptions of different terrorism syndromes (see Appendix). significant for the level of correct responses (F =10,P = Residency training in EM, current practice of EM, and 1,178 .323). The level of training, place of the ED (rural, urban, ability to access the Internet comprised inclusionary criteria. suburban), type of affiliation (community hospital, University - 2.2. Subjects affiliated medical center), and sex of the physician did not affect the level of correct responses. All did equally poorly. Subjects included attending, resident, and intern physi- Table 2 displays stratified results based on level of cians associated with EM residency programs in Illinois and education and type of agent for the 17 questions. Note the were associated with academic, community, or urban low values of the correct responses in each group and the emergency departments (EDs). nonsignificance between them. Overall, the mean score was 42.5% (SD, 14.9). Attending physicians performed better than 2.3. Method residents (46.6% vs 38.8%). On the individual questions, The examination was distributed to volunteers on the scores ranged from a high of 86.3% on one anthrax question to Internet through Formsite.com and in paper format if a low of 17.8%% on one tularemia question. Attending requested. All physicians took the same examination. physicians scored higher than residents on most of the Demographic information was obtained including age, level individual questions. Less than 47% (46.8%) of the biologic of training, sex, and type of ED. agent questions were answered correctly, whereas only 32.6% of the chemical agent questions were answered correctly. 2.4. Data analysis Examination scores were compared between different types 4. Discussion of EDs and between levels of EM physicians. Descriptive and correlation analyses, v2 procedures, and t test analyses were Terrorism is an increasing concern for the American among the statistical tests performed in SPSS 11.5.1 (SPSS, public, and EM physicians are likely to be called upon to Inc, Chicago, Ill). Institutional review board approval was recognize the medical syndromes that accompany terrorism obtained for this study, and informed consent was obtained agents. This knowledge is vitally important to our ability to with the submission of each completed study instrument. respond to such an incident, and a failure to identify terrorism syndromes could have catastrophic consequences for the American people. Although the study does not 3. Results address mass casualty events, the beginnings of such events may become more quickly recognized by astute observers. Seventy-five participants responded to this online survey. Previous studies indicate a potential deficiency in the One medical student and one unidentified person were education of EM residents in identifying terrorism syn-

Table 1 Mean correct scores by level of training, age, and sex Type of Participant n Age (SD), y % Males Mean score (SD) Range EM attendings 36 39.14 (7.3) 72.2 46.6% (15.7) 24%-82% EM residents 37 28.6 (4.1) 54.1 38.8% (13.1) 18%-71% Statistical variance 73 t = 7.594, 71 v2 = NS t = 2.301, 71 – P b .000 P = .024 NS indicates not significant. The biological/chemical terrorism 1021

Table 2 Results on individual questions Type of agent Correct responses Odds ratio 95% CI Attendings Residents All (n=36) (n=37) (N=73) Anthrax Painless necrotic eschar 77.78% 94.59% 86.3% .822* .679-.995 Hyperdense lymph nodes (noncontrast CT) 88.9% 94.6% 91.8% .800* 1.4-1.65 Chest x-ray (widened mediastinum) 69.4% 43.2% 56.2% 1.606* 2.464-1.047 Plague Painful lymph nodes 41.7% 56.8% 49.3% .734 1.184-0.455 Acral necrosis 41.7% 29.7% 35.6% 1.402 2.627-0.748 Hemoptysis 25.0% 16.2% 20.5% 1.542 3.890-0.611 Tularemia Swollen lymph node, 36.1% 51.4% 43.8% .703 1.202-0.411 fever with relative bradycardia Local ulceration with raised edges 16.7% 18.9% 17.8% .881 2.369-0.328 Infiltrates (normal mediastinum) 22.2% 18.9% 20.5% 1.175 2.903-.475 Smallpox Synchronous rash 91.7% 78.4% 84.9% 1.170 1.423-.962 Viral hemorrhagic fever Ecchymosis, bleeding 58.3% 59.5% 58.9% .981 1.439-0.669 Mycotoxins Blisters hours after exposure 58.3% 40.5% 49.3% 1.439 2.321-0.892 Mustard Blisters, delayed pain 55.6% 40.5% 47.9% 1.370 2.231-.0842 Lewisite Blisters, immediate pain 33.3% 27.0% 30.1% 1.233 2.490-0.611 Chlorine Immediate pulmonary symptoms/ 47.2% 24.3% 35.6% 1.941* 3.775-0.998 noncardiogenic pulmonary edema Phosgene Delayed pulmonary symptoms/ 25.0% 13.5% 19.2% 1.850 4.990-.686 noncardiogenic pulmonary edema VX gas Cholinergic excess 41.7% 18.9% 30.1% 2.202* 4.761-1.019 CT indicates computed tomography. * Significant at P V .05 on independent samples test. dromes. This study suggests that emergency physicians at December 2003, President Bush, through the Department of all levels struggle with identifying terrorism syndromes. Health and Human Services, asked health care workers to Emergency medicine physicians are more readily able to volunteer for routine smallpox vaccination and to form identify biologic agents than chemical agents, and the level volunteer smallpox response teams to assist homeland of training of the emergency physician is important. The security efforts [14]. ability of an EM physician to identify both biologic and This study is limited by a suboptimal sample size, a chemical terrorism syndromes increases with each year of nonvalidated study instrument, and a nonstandardized residency and is at its highest when the emergency environment for physicians to take the examination, but physician is at the attending physician level. This study the study has provided valuable information concerning the suggests that attending EM physicians have a greater ability ability of EM physicians to identify terrorism syndromes. to identify terrorism syndromes as compared with resident Future studies might use a larger sample size and EM physicians, but the overall mean score of the 2 groups standardize the environment to achieve even greater indicated significant educational gaps for both groups of clinical relevance. emergency physicians. Higher scores are noted for both groups of physicians in this study with regard to the small pox and anthrax agents as 5. Conclusions observed on Table 2. We believe this is due to wider public awareness of these agents through the media, the 2001 Our study illustrates some significant deficiencies in anthrax attacks, and rising smallpox awareness. As early as the ability of EM physicians to differentiate between 1022 J. Lester et al. descriptions of biologic and chemical terrorism syndromes. These deficiencies, if present in the reality of the ED, could delay the response to plausible terrorist acts. These conclusions suggest a need to increase terrorism education for EM residents and attendings to augment our defense against potential biologic and chemical terrorism events.

Appendix A. Addendum Scenario 5: Presence of enlarged hyperdense nodes depicted on a noncontrast CT. Cases for study (Bold = correct response) Scenario 1: A 25-year-old male presents to the emergency department complaining of a black area on his arm. Inspection of the arm reveals a painless black necrotic eschar with painful lymphadenopathy.

Scenario 6: A 34-year-old female presents to the emergency department with the onset of burning skin pain, erythema, blistering, tenderness, and progression to skin necrosis with blackening and sloughing of skin surfaces Scenario 2: A 48-year-old male presents to the emergen- within hours of exposure to an unknown substance. What is cy department complaining of erythematous, warm, very the agent? painful swollen lymph nodes with surrounding edema.

Scenario 7: A 26-year-old male presents with painful Scenario 3: A 56-year-old female presents to the erythema reminiscent of sunburn with small vesicles around emergency department complaining of fever, chills and the erythema that began 6 hours after exposure to an rigors. She also has lower back myalgia with weakness, and unknown substance. 6 hours after the erythema appears, has a heart rate of 45 beats per minute. dome-shaped thin-walled translucent yellow blisters appear. What is the agent?

Scenario 4: A 27 year old male presents to the emergency department with the immediate onset of burning and watering of the eyes, coughing, choking, dyspnea, chest tightness, noncardiogenic pulmonary edema and respiratory failure after being exposed to an unknown substance. The biological/chemical terrorism 1023

Scenario 8: A 46-year-old female presents with myalgias, Scenario 12: A 50-year-old male presents from a storage fatigue, non-productive cough, dyspnea, chest pain, head- facility with excessive salivation, lacrimation, and diarrhea ache, and abdominal pain. after being exposed to an unknown amber liquid. What is What is the agent? the agent?

Frequency Percent A) Phosgene 32 43.8 B) Chlorine 0 0 C) Mustard 17 23.3 D) VX 22 30.1 E) Cyanide 1 1.4 Total 73 100.0

Scenario 9: A 22-year-old male presents with acral Scenario 13: A 27 year old male presents to the emergency necrosis of fingers and toes and his entire body was black a department with the onset of burning and watering of the few days ago. What is the agent? eyes, coughing, choking, dyspnea, chest tightness, noncardiogenic pulmonary edema and respiratory failure 6 hours after being exposed to an unknown substance. What is the agent?

Scenario 10: A child presents with abrupt onset of cough, malaise, fever, chills, myalgias, nausea, and vomiting and back pain. What is the agent?

Scenario 14: A 17-year-old female presents with flushing of her face, conjunctival injection, periorbital edema, hypotension, malaise, myalgias, headache, vomiting, and diarrhea. After a few days, she developed petechiae, ecchymosis, and bleeding from her gums. What is the agent?

Scenario 11: A 40-year-old female presents with an erythematous, tender papule that becomes pustular and ulcerates within a few days. It has a depressed center and may become covered by a black eschar. She has tender Scenario 15: A 34-year-old male presents with fever, lymphadenopathy that progresses to suppurating buboes. cough, chest pain, dyspnea, hemoptysis, abdominal pain, nausea, vomiting, and diarrhea. What is the agent? 1024 J. Lester et al.

Scenario 16: A 26-year-old male presents with painful [2] Inglesby TV, O’Toole T, Henderson DA, Bartlett JG, Ascher MS, erythema reminiscent of sunburn with small vesicles around Eitzen E, et al. Anthrax as a biological weapon, 2002: updated the erythema that began immediately after exposure to an recommendations for management. JAMA 2002;287(17):2236-52. [3] Henderson DA, Inglesby TV, Bartlett JG, Ascher MS, Eitzen E, unknown substance. 6 hours after the erythema appears, Jahrling PB, et al. Smallpox as a biological weapon: medical and dome-shaped thin-walled translucent yellow blisters appear. public health management. Working Group on Civilian Biodefense. What is the agent? JAMA 1999;281(22):2127-37. [4] Borio L, Inglesby T, Peters CJ, Schmaljohn AL, Hughes JM, Jahrling PB, et al. Hemorrhagic fever viruses as biological weapons: medical and public health management. JAMA 2002;287(18): 2391-405. [5] Richards CF, Burstein JL, Waeckerle JF, Hutson HR. Emergency physicians and biological terrorism. Ann Emerg Med 1999;34(2): 183-90. [6] McGovern TW, Christopher GW, Eitzen EM. Cutaneous manifestations of biological warfare and related threat agents. Arch Dermatol 1999;135(3):311-22. [7] Inglesby TV, O’Toole T, Henderson DA. Preventing the use of biological weapons: improving response should prevention fail. Clin Scenario 17: A 35-year-old male presents with fever, Infect Dis 2000;30(6):926-9. chills, and malaise, and then later develops pleuritic chest [8] Keim M, Kaufmann AF. Principles for emergency response to bioterrorism. Ann Emerg Med 1999;34(2):177-82. pain, dyspnea, and a non-productive cough. [9] Shapiro RL, Swerdlow DL. Botulism: keys to prompt recognition and What is the agent? therapy. Consultant 1999;1021-7. [10] Slater MS, Trunkey DD. Terrorism in America. An evolving threat. Arch Surg 1997;132(10):1059-66. [11] Brennan RJ, Waeckerle JF, Sharp TW, Lillibridge SR. Chemical warfare agents: emergency medical and emergency public health issues. Ann Emerg Med 1999;34(2):191-204. [12] Bioterrorism alleging use of anthrax and interim guidelines for management—United States, 1998. MMWR Morb Mortal Wkly Rep 1999;48(4):69-74. [13] Kalluri P, Crowe C, Reller M, Gaul L, Hayslett J, Barth S, et al. An outbreak of foodborne botulism associated with food sold at a salvage store in Texas. Clin Infect Dis 2003;37(11):1490-5. [14] Protecting Americans: Smallpox Vaccination Program. Centers for Disease Control and Prevention. 12-13-2002. 2-23-2007.

References

[1] Pesik N, Keim M, Sampson TR. Do US emergency medicine residency programs provide adequate training for bioterrorism? Ann Emerg Med 1999;34(2):173-6. American Journal of Emergency Medicine (2007) 25, 1025–1031

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Original Contribution Characteristics of cardiac arrest and resuscitation by age group: an analysis from the Swedish Cardiac Arrest RegistryB

Johan Herlitz MD, PhDa,*, Leif Svensson MD, PhDb, Johan Engdahl MD, PhDa, Jan Gelberg MDc, Johan Silfverstolpe MDd, Aase Wisten MDe, Karl-Axel A¨ ngquist MD,PhDf, Stig Holmberg MD, PhDa aDepartment of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, SE-413 45 Go¨teborg, Sweden bDivision of Cardiology, South Hospital, 118 83 Stockholm, Sweden cDivision of Anesthesiology, Lund University Hospital, 221 85 Lund, Sweden dEmergency Medical Services, KAMBER, Regionhuset 222 40 Lund, Sweden eDepartment of Internal Medicine, Sunderby Hospital, 971 80 Lulea˚, Sweden fSurgical Department, Norrland’s University Hospital, 901 85 Umea˚, Sweden

Received 13 February 2007; revised 5 March 2007; accepted 5 March 2007

Abstract Aim: The objective of this study was to describe patients who experienced an out-of-hospital cardiac arrest (OHCA) by age group. Methods: All patients who suffered from an OHCA between 1990 and 2005 and are included in the Swedish Cardiac Arrest Registry (n = 40,503) were classified into the following age groups: neonates, younger than 1 year; young children, between 1 and 4 years; older children, between 5 and 12 years; adolescents, between 13 and 17 years; young adults, between 18 and 35 years; adults not retired, between 36 and 64 years; adults retired, between 65 and 79 years; and older adults, 80 years or older. Results: Ventricular fibrillation was lowest in young children (3%) and highest in adults (35%). Survival to 1 month was lowest in neonates (2.6%) and highest in older children (7.8%). Children (b18 years), young adults (18-35 years), and adults (N35 years) survived to 1 month 24.5%, 21.2%, and 13.6% of cases, respectively (P = .0003 for trend) when found in a shockable rhythm. The corresponding figures for nonshockable rhythms were 3.8%, 3.2%, and 1.6%, respectively (P b .0001 for trend). Conclusions: There is a large variability in characteristics and outcome among patients in various age groups who experienced an OHCA. Among the large age groups, there was a successive decline in survival with increasing age in shockable and nonshockable rhythms. D 2007 Elsevier Inc. All rights reserved.

B This study was supported by grants from the Swedish National Board of Health and Welfare (Stockholm, Sweden). * Corresponding author. Tel.: +46 31 342 1000; fax: +46 31 827375. E-mail address: [email protected] (J. Herlitz).

1. Introduction tion (CPR) was attempted. Thus, there are currently approximately 4000 annual OHCAs of which nearly 3000 A number of studies have shown that the etiologies are reported to the registry. behind cardiac arrest in children and young adults differ from those in adults [1-8]. 2.3. Study design However, as far as we know, there are only few previous reports in which patients in various age groups were For each case of OHCA, an ambulance crew (mostly compared within the same database with regard to character- composed of 2 persons, 1 of whom is usually a nurse) istics and outcome when the full spectrum of ages was completed a form with information such as age, location of included in the analyses [9]. cardiac arrest, probable background to the arrest, and a So far, it has been difficult to compare survival between standardized description of the resuscitation procedure, children and young adults, simply because the number of including intervention times and interventions such as patients younger than 35 years who experience a cardiac bystander CPR (a bystander is defined as someone starting arrest is so limited compared with that of patients aged 35 CPR before the arrival of the first ambulance, regardless of years or older. The study by Engdahl et al [9] should profession). therefore be regarded as a pilot study for this first large-scale In ambulances with manual defibrillators, the first study ever to be performed that attempted to determine recorded rhythm was defined as ventricular fibrillation, survival after out-of-hospital cardiac arrest (OHCA) in pulseless electric activity, or asystole. For automated relation to the full spectrum of age groups. external defibrillators, the rhythm was defined as shockable This survey aimed to describe characteristics and or nonshockable. In this study, ventricular fibrillation relates outcome by age group among patients who experienced to patients with pulseless ventricular tachycardia. Over an OHCA when the whole spectrum of ages was included in years, an increasing proportion of ambulances had used an the analyses. We previously reported from this database automated external defibrillator. Today, nearly 100% use using the following age groups: younger than 65 years; such a device. between 65 and 75 years; and older than 75 years [10]. To establish the time of cardiac arrest in witnessed Whereas that survey focused on survival among elderly cases, as instructed, the ambulance crew interviewed patients as compared with patients younger than 65 years, bystanders about the delay from arrest to call. The this survey focused on children and young adults as ambulance crew also classified the etiology of the arrest compared with adults in total and when various subgroups in 9 diagnostic categories (heart disease, lung disease, according to age were included in the analyses. trauma, drug overdose, suicide, drowning, suffocation, sudden infant death syndrome, and other) based on clinical assessments and bystander information. Their diagnosis was accepted for this study, and no further control was 2. Patients and methods made among initial survivors during hospitalization. The 2.1. Patients form was completed during and immediately after the acute event. Each form was sent to the medical director, and a Patients who experienced a cardiac arrest for which an copy was sent to the central registry in Gfteborg. Another ambulance was called were included in the Swedish Cardiac copy was subsequently sent with additional information Arrest Registry, with the exception of patients who had about whether the patient died or survived after 1 month. If obviously been dead for a long time and whose bodies were there was uncertainty about survival, it was checked therefore not taken to the hospital by the ambulance crew. according to the National Registry of Deaths. All the data For all other patients, a standardized form was completed by were computerized in a database in Gfteborg. the ambulance crew. 2.4. Description by age 2.2. Registry Patients were divided into the following age groups This study was based on material collected by the (Tables 1-3): neonates, younger than 1 year (n = 276); Swedish Cardiac Arrest Registry, which is a joint venture young children, between 1 and 4 years (n = 136); older between the Federation of Leaders in Swedish Ambulance children, between 5 and 12 years (n = 142); adolescents, and Emergency Services and the Swedish Council on between 13 and 17 years (n = 148); young adults, between Cardiopulmonary Resuscitation. Since 1993, the registry 18 and 35 years (n = 1235); adults not retired, between 36 has been funded by the Swedish National Board of Health and 64 years (n = 10,742); adults retired, between 65 and and Welfare. The registry, which is a voluntary organization, 79 years (n = 17,071); and older adults, 80 years or older started in 1990 with a few ambulance services. It has been (n = 9095). successively joined by others; today, the registry covers Patients were also divided into 3 main age groups: approximately 70% of all patients in Sweden who experi- children, between 0 and 17 years; young adults, between 18 enced an OHCA and in whom cardiopulmonary resuscita- and 35 years; and adults, older than 35 years. Outcome after cardiac arrest in versus age groups 1027

Table 1 Characteristics of the patients by age group Characteristic* Age group P b1y 1-4 y 5-12 y 13-17 y 18-35 y 36-64 y 65-79 y z80 y (n = 276) (n = 136) (n = 142) (n = 148) (n = 1235) (n = 10,742) (n = 17,071) (n = 9095) Sex (4) Female 40 33 40 42 29 25 28 40 b.0001 Witnessed status (8) Crew witnessed 4 4 10 13 9 13 14 20 b.0001 Bystander witnessed 22 30 46 38 41 54 57 53 b.0001 Nonwitnessed 74 66 45 49 51 33 29 28 b.0001 Initial rhythm (8) Ventricular fibrillation 8 3 11 23 17 35 35 26 b.0001 Bystander CPR (4)y 63 66 78 68 54 47 34 26 b.0001 Time intervals (min, median) (17) Call for to arrival 77876 7 6 6b.0001 of ambulance Collapse to call 54524 4 4 4NS for ambulancez Collapse to arrival 12 12 13 10 11 12 11 10 b.0001 of ambulancez Values are presented as percentages. NS indicates not significant. * Percentages of patients with missing information are provided in parentheses. y Crew-witnessed cases were excluded. z Only bystander-witnessed cases were included.

2.5. Statistical methods significant. In the analyses of trends, we used Pitman’s nonparametric test. 2.5.1. Descriptive statistics The distribution of variables is given as percentage, 2.5.3. Multivariate statistical analyses mean F SD, or median. Results are also presented as odds Stepwise logistic regression was used to select inde- ratios and 95% confidence intervals. Missing information pendent associations with dichotomous dependent varia- was given as the percentage of all patients. To compare with bles (ie, alive at 1 month after cardiac arrest). The previous surveys and to limit the number of statistical variables (all suitable variables in Tables 1-3) that were analyses, we compared all children (b18 years old) with entered into the model were a priori sex (women vs men), young adults (18-35 years old) and adults (N35 years old). etiology (cardiac vs noncardiac), first documented rhythm (shockable rhythm vs nonshockable rhythm), witnessed 2.5.2. Statistical analyses status (witnessed vs nonwitnessed), CPR initiated by In the evaluation of the association between age and bystander (yes vs no), location of cardiac arrest (not at dichotomous as well as continuous variables, we used the home vs at home), age (continuous variable), and interval Wilcoxon and Spearman tests, respectively. Two-tailed tests between call for and arrival of ambulance (continuous were applied. A P value lower than .01 was regarded as variable; logarithmic scale).

Table 2 Location of arrest among the patients by age group Location* Age group P b1y 1-4 y 5-12 y 13-17 y 18-35 y 36-64 y 65-79 y z80 y (n = 276) (n = 136) (n = 142) (n = 148) (n = 1235) (n = 10,742) (n = 17,071) (n = 9095) At home 84 63 41 47 52 61 67 64 b.0001 Nursing home 25544 2 3 10b.0001 In an ambulance 0.4 2242 5 5 7b.0001 On the street 5 6 18 17 14 11 11 9 b.0003 At work 0 0 0 0.7 4 5 0.5 0.1 b.0001 In another place 9 24 34 27 24 16 13 9 b.0001 Values are presented as percentages. * Missing information in 1% of the cases. 1028 J. Herlitz et al.

Table 3 Etiology of cardiac arrest among the patients by age group Etiology* Age group P b1y 1-4 y 5-12 y 13-17 y 18-35 y 36-64 y 65-79 y z80 y (n = 276) (n = 136) (n = 142) (n = 148) (n = 1235) (n = 10,742) (n = 17,071) (n = 9095) Heart 11 13 14 20 15 61 79 79 b.0001 Drug overdose 0 0 0 8 21 3 0.2 0.1 b.0001 Accident 3 7 24 13 13 2 0.8 0.7 b.0001 Lung disease 4 5 5 11 5 7 7 6 NS Suffocation 2 13 8 1 4 2 1 1 b.0001 Suicide 0 0 2 10 11 2 0.3 0.2 b.0001 Sudden infant 70 10 0 0 0 0 0 0 b.0001 death syndrome Drowning 0.8 20 17 11 3 0.9 0.3 0.1 b.0001 Other 11 35 33 28 31 25 14 15 b.0001 Values are presented as percentages. * Missing information in 7% of the cases.

In the multivariate analyses, crew-witnessed cases were excluded because the influence of bystander CPR on outcome cannot be evaluated in these patients. The percentage of patients for whom complete data were Table 4 Survival to 1 mo available (crew-witnessed cases excluded) was 68% of all Patients P* Patients P* Patients N35 non–crew-witnessed cases. b18 18-35 years old years old years old (n = 36,908) (n = 702) (n = 1235) 3. Results All patients 5.6 6.8 .024 5.5 Sex Between January 1, 1990, and December 31, 2005, there Female 3.6 .004 8.4 .006 5.0 were 49,815 patients in the registry. Of these patients, 9312 Male 6.8 6.4 5.7 (19%) did not receive CPR. Among the remaining 40,503 Witnessed status patients, information on age was missing in 1658 (4%). This Crew witnessed 13.9 13.7 14.3 survey deals with the remaining 38,845 patients. Bystander 7.6 11.6 b.0001 5.5 witnessed 3.1. Characteristics Nonwitnessed 3.8 2.7 .031 1.6 Cardiac etiology The percentage of females differed in various age groups Yes 9.3 15.1 b.0001 6.3 and was highest among neonates, older children, adoles- No 5.1 5.3 .004 3.5 cents, and older adults (Table 1). Bystander CPR The percentage of nonwitnessed cases and that of Yes 6.1 8.8 .043 6.8 patients who received bystander CPR decreased with No 3.6 3.4 2.4 increasing age. Ventricular The percentage of patients found in a shockable rhythm fibrillation increased with increasing age. Yes 24.5 21.2 .003 13.6 The interval between collapse and call for an ambulance No 3.8 3.2 b.0001 1.6 as well as that between collapse and arrival of an ambulance Cardiac arrest appeared to be somewhat shorter in the older age groups. outside home Yes 9.5 9.2 9.8 3.2. Location of cardiac arrest No 3.4 4.8 .016 3.1 Interval between There was variability in the location of cardiac arrest in call for and the various age groups. A cardiac arrest occurred most arrival of frequently at home among neonates. A cardiac arrest ambulance (min) occurred in a nursing home and in an ambulance most Median or less 8.2 8.3 .030 6.2 b frequently among the older adults. A cardiac arrest occurred Greater 2.6 4.4 .0001 1.7 than median most frequently on the street among young children and adolescents, and it occurred most frequently at work among Values are presented as percentages. * P values refer to a comparison between the various age groups. young adults and adults not retired (Table 2). Outcome after cardiac arrest in versus age groups 1029

3.3. Etiology There was variability in the judged etiology when the various age groups were compared. Cardiac etiology increased with increasing age (Table 3). Drug overdose as the cause of cardiac arrest was most common in young adults. An accident as the cause of cardiac arrest was most common in older children. A lung disease was most common as the cause of cardiac arrest in adolescents. Suffocation was most common among young children. Suicide was most common among adolescents and young adults. Finally, drowning was most common among young and older children. Drug overdose, accident, suffocation, suicide, and drowning all tended to be found less frequently in the youngest and oldest age groups. Fig. 2 Survival to 1 month in children, young adults, and adults 3.4. Survival found in a shockable rhythm and a nonshockable rhythm. 3.4.1. Univariate analysis Information on survival to 1 month was missing in less 3.4.2. Multivariate analysis than 1% of the patients (Table 4; Figs. 1 and 2). Table 5 shows the independent influence of 8 factors of The rate of survival was lowest in neonates (2.6%), importance for outcome in CPR within each of the 3 main second lowest among older adults (3.4%), and highest in age groups. Only 1 of those was independently associated older children (7.8%) (Fig. 1). In analyzing the 3 main age with an increased chance of survival in all 3 age groups (ie, groups (0-17, 18-35, and N35 years), we found no marked decreasing interval between call for ambulance and arrival difference in survival between them (Table 4). of the rescue team). Among the bystander-witnessed cases, the rate of Whereas female sex was associated with an increased survival was highest among young adults and lowest among chance of survival among young adults and adults, the adults. A similar pattern was found among patients who opposite was found for children. experienced a cardiac arrest with a cardiac etiology. Among young adults, ventricular fibrillation and receipt Among patients found in a shockable rhythm, the rate of of bystander CPR were independently associated with survival was highest among patients younger than 18 years, an increased chance of survival, whereas in adults, all intermediate in young adults, and lowest in adults ( P = the listed factors with the exception of cardiac etiology .0003 for trend). A similar pattern was found among were independently associated with an increased chance patients found in a nonshockable rhythm ( P b .0001 for of survival. trend) (Fig. 2).

4. Discussion

This study gives an overall perspective of characteristics and outcome in OHCA when all age groups are considered. Because such an analysis on such a large sample size has not been done before, most of the data presented are new.

4.1. Variations in sex distribution, location of cardiac arrest, witnessed arrest, and bystander CPR Although sex distribution differed significantly between age groups, there is no clear pathophysiologic explanation for this observation. Fig. 1 Survival to 1 month in neonates (b1 year old), young In all the age groups, it was shown that most cardiac children (1-4 years old), older children (5-12 years old), arrests occurred at home. In 2 groups (5-12 and 13-17 adolescents (13-17 years old), young adults (18-35 years old), years), the proportion was less than 50%, however. This is adults not retired (36-64 years old), adults retired (65-79 years old), somewhat surprising. We have no pathophysiologic expla- and older adults (z80 years old). nation for this finding. 1030 J. Herlitz et al.

Table 5 Independent predictors of survival to 1 mo Patients b18 years old Patients 18-35 years old Patients N35 years old (n = 359) (n = 718) (n = 21,525) Initial rhythm Ventricular fibrillation 3.92 (0.93-16.55) 5.72 (2.67-12.24) 5.04 (4.22-6.01) Delay to treatment (min; continuous variable; logarithmic scale) Call for to arrival of ambulance 0.21 (0.08-0.56) 0.36 (0.19-0.71) 0.32 (0.28-0.37) Witnessed status Bystander witnessed 1.24 (0.36-4.32) 1.32 (0.59-2.96) 1.97 (1.61-2.42) Location Outside home 4.20 (1.28-13.78) 1.71 (0.83-3.55) 2.17 (1.86-2.53) Etiology Cardiac 0.91 (1.19-4.39) 1.46 (0.67-3.18) 1.09 (0.90-1.32) Treatment before arrival of ambulance Bystander CPR 2.40 (0.70-8.24) 2.74 (1.25-5.98) 2.22 (1.91-2.60) Sex (female vs male) 0.16 (0.03-0.74) 2.27 (1.12-4.58) 1.26 (1.06-1.49) Age (y; continuous variable) 1.02 (0.93-1.12) 0.98 (0.92-1.04) 0.98 (0.98-0.99) Values are presented as odds ratios and 95% confidence intervals.

4.2. Variations in witnessed arrest and This observation is most probably linked to the increase bystander CPR in cardiac etiology with increasing age and the relatively high rate of primary respiratory arrest cases in the youngest We found that the percentage of patients who received age groups. CPR before the arrival of the rescue team decreased with increasing age. This is in agreement with previous reports 4.4. Variations in survival [9]. This observation should be related to the fact that The overall survival to 1 month was low in all age groups. witnessed cardiac arrest cases increased with increasing age. This is disappointing. However, subsets with a much higher Our results thus suggest that when witnessed cases go up, survival rate were defined in all 3 main age groups. Patients bystander CPR goes down. One might argue how this found in a shockable rhythm appeared to have a 4- to 5-fold relates to the training of the likely observers, location of the increase in the chance of survival in all 3 main age groups. arrest, and so on. Reported survival rates after OHCAvary a great deal. In the Regardless of training and location of arrests, our data United States, survival rates of 30% to 35% have been reported indicate that the activity of bystanders in terms of initiating for patients with ventricular fibrillation as the first recorded CPR appears to be much higher in the younger age groups. rhythm [14], but lower survival rates are also presented [15]. One reason for the low rate of nonwitnessed cardiac The rate of survival was nearly twice as high among patients arrest cases in adults could be reluctance even on the part of younger than 18 years found in ventricular fibrillation as that the ambulance crew to start CPR in adult patients among adults. One of the reasons for the relatively high experiencing an OHCA that was not witnessed, resulting survival rate among patients younger than 18 years found in in a relative increase in witnessed cardiac arrest cases in this ventricular fibrillation might be that a large percentage were subset. It is however a little surprising that the percentage of grown-up children with a better physiologic capacity to witnessed cardiac arrests was lower in young adults than in survive. However, others have reported on lower survival adults because the latter individuals are supposed more rates among children found in ventricular fibrillation [16]. frequently to live alone, be a widow or widower, and so on. In all 3 older age groups, a strong inverse relation between 4.3. Variations in etiology and heart rhythm ambulance response time and outcome was confirmed. This highlights the importance of early treatment. Cardiac etiology increased with increasing age. However, Among patients with a bystander-witnessed cardiac arrest the percentage with a cardiac background is probably and those with a cardiac etiology, the highest survival rate underestimated, especially in persons younger than 35 was found among young adults. This is in agreement with years. Sudden death from cardiac causes in young adults the findings of a previous report [9]. commonly occurs without any previous knowledge of heart The initiation of CPR before the arrival of the rescue disease [11] Moreover, an unknown fraction of those with team (bystander CPR) was only independently associated sudden infant death syndrome are considered to have a with survival among adults and young adults. However, the cardiovascular background [12,13]. Despite the fact that odds ratio for an increased chance of survival if bystander bystander CPR cases decreased with increasing age, CPR was performed vs that when no bystander CPR ventricular fibrillation increased with increasing age. occurred was equally high in children; hence, with a larger Outcome after cardiac arrest in versus age groups 1031 sample size, bystander CPR will hopefully be shown to be 5. Conclusions associated with increased survival rates even in younger age groups. A further contributory factor explaining why In analyzing patients who have experienced an OHCA in bystander CPR was not an independent predictor of survival various age groups, there is a large variability in terms of in the youngest age group might be the high rate of sudden etiology, patient characteristics, and patient outcome. infant death for which the prognosis is extremely poor Moreover, among patients younger than 18 years, different regardless of bystander CPR. age groups with various outlooks can be defined. However, We found that sex appears to influence survival in a in comparing patients younger than 18 years, those aged different way among the various age groups. Among between 18 and 35 years, and those older than 35 years, patients younger than 18 years, male sex was independently there is a successive decline in survival among patients associated with an increased chance of survival, whereas found in shockable and nonshockable rhythms. among young adults and adults, female sex was associated with an increased chance of survival. These data are new. We are not aware of any other medical condition in which References sex appears to influence outcomes differently in various age groups. It is only possible to speculate that a different [1] Eisenberg M, Bergner L, Hallstrom A. Epidemiology of cardiac arrest etiology behind cardiac arrest in different age groups might and resuscitation in children. Ann Emerg Med 1983;12:672-4. influence the impact of sex on the prognosis. [2] Kuisma M, Suominen P, Korpela R. Paediatric out-of-hospital cardiac arrests—epidemiology and outcome. Resuscitation 1995; We have previously reported on an increased chance of 30:141-50. survival among female adults and young adults [17], and [3] Hickey RW, Cohen DM, Strausbaugh S, et al. Pediatric patients similar findings have been reported by others, at least with requiring CPR in the prehospital setting. Ann Emerg Med regard to early survival [18,19]. 1995;25:495-501. We have no clear explanation for the varying levels of [4] Herlitz J, Engdahl J, Svensson L, et al. Characteristics and outcome among children suffering from out of hospital cardiac arrest in influence of sex on survival after OHCA among children, Sweden. Resuscitation 2005;64:37-40. young adults, and adults. [5] Raymond JR, van den Berg EK, Knapp MJ. Nontraumatic prehospital The change from manual to automatic defibrillators might sudden death in young adults. Arch Intern Med 1988;148(2):303-8. have influenced survival over time. However, because other [6] Safranek DJ, Eisenberg MS, Larsen MP. The epidemiology of cardiac changes have taken place as well, it is not possible to define arrest in young adults. Ann Emerg Med 1992;21(9):1102-6. [7] Liberthson R. Sudden death from cardiac causes in children and the influence of a change in the type of defibrillators used. young adults. N Engl J Med 1996;334:1039-44. [8] Donoghue AJ, Nadkarni V, Berg RA, et al. Out-of-hospital pediatric 4.5. Limitations cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med 2005;46:512-22. 1. Information (inherent to registry reporting) was [9] Engdahl J, Axelsson 2,B3ng A, et al. The epidemiology of cardiac missing for a certain percentage of patients for most arrest in children and young adults. Resuscitation 2003;58:131-8. of the variables that were studied. [10] Herlitz J, Eek M, Engdahl J, et al. Factors at resuscitation and outcome among patients suffering from out of hospital cardiac arrest in relation 2. There was no information about cerebral function to age. Resuscitation 2003;58:309-17. and quality of life among survivors. [11] Wisten A, Forsberg H, Krantz P, et al. Sudden cardiac death in 15-35 3. So far, there has been no validation of data by year olds in Sweden 1992-1999. J Int Med 2002;252:529-36. periodic independent abstraction. [12] Rasten-Almqvist P, Eksborg S, Rajs J. Myocarditis and sudden infant 4. The clinically evident cause of death is often difficult death syndrome. APMIS 2002;110:469-80. [13] Schwartz PJ. Stillbirths, sudden infant deaths, and long-QT syndrome. to determine. Because of the lack of autopsies, we Circulation 2004;109:2930-2. were not able to assess the causality of death and can [14] Valenzuela T, Roe D, Cretin S, et al. Estimating effectiveness of only give a clinical suggestion as to causality. cardiac arrest interventions: a logistic regression survival model. 5. Not having data on those who died without Circulation 1997;96:3308-13. ambulance surveys limits the epidemiological scope [15] Becker LB, Ostrander MP, Barrett J, et al. Outcome of CPR in a large metropolitan area: where are the survivors? Ann Emerg Med of the work. 1991;20:355-61. [16] Young KD, Gausche-Hill M, McClung CD, et al. A prospective, 4.6. Implications population-based study of the epidemiology and outcome of out- of-hospital pediatric cardiopulmonary arrest. Pediatrics 2004; Our results do not suggest that any age group has such a 114:157-64. low survival rate that CPR should be considered meaning- [17] Herlitz J, Engdahl J, Svensson L, et al. Is female sex associated with less. Overall, although a shockable rhythm is less frequent increased survival after out-of-hospital cardiac arrest? Resuscitation in children, the chance of survival is highest in children and 2004;60:197-203. lowest in adults when specifically analyzing patients with [18] Pell JP, Sirel J, Marsden AK, et al. Sex differences in outcome following community-based cardiopulmonary arrest. Eur Heart J and those without a shockable rhythm. Finally, we need to 2000;21:239-44. further explore the mechanisms through which sex influen- [19] Kim C, Fahrenbruch CE, Cobb LA, et al. Out-of-hospital cardiac ces outcomes differently in adults and children. arrest in men and women. Circulation 2001;104:2699-703. American Journal of Emergency Medicine (2007) 25, 1032–1039

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Original Contribution Combination of cardiac pacing and epinephrine does not always improve outcome of cardiopulmonary resuscitationB

Meng-Hua Chen MDa,*, Tang-Wei Liu MDa, Zhi-Yu Zeng MDa, Lu Xie DPharmb, Feng-Qing Song MDa, Tao He MDa, Shu-Rong Mo MDb aInstitute of Cardiovascular Diseases, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China bDepartment of Physiology, School of Pre-Clinical Sciences, Guangxi Medical University, Nanning 530027, China

Received 13 November 2006; revised 27 January 2007; accepted 8 March 2007

Abstract We hypothesized that the combination of cardiac pacing and epinephrine would yield a better efficacy for cardiopulmonary resuscitation (CPR) and the combination of 2 therapies at different opportunity would achieve the same results of CPR. Cardiac arrest was induced by clamping the tracheal tubes in 60 Sprague-Dawley rats. At 10 minutes of asphyxia, the animals were prospectively randomized into 5 groups (n = 12/group), and received saline (Sal-gro, 1 mL, intravenous [IV]), epinephrine (Epi-gro, 0.4 mg/kg, IV), pacing (Pac-gro, transesophageal cardiac pacing combined with saline 1 mL, IV), pacing + epinephrine group 1 (PE-gro1, transesophageal cardiac pacing combined with epinephrine 0.4 mg/kg, IV), or pacing + epinephrine group 2 (PE-gro2, transesophageal cardiac pacing combined with epinephrine 0.4 mg/kg, IV, 4 minutes after the transesophageal cardiac pacing initiating and failing to resuscitate the animals), followed by initiation of CPR. Restoration of spontaneous circulation in Sal-gro was lower than in Epi-gro, Pac-gro, PE-gro1, and PE- gro2 (16.67% vs 66.67%, 66.67%, 100%, and 100%; P b .05 or P b .001, respectively). The proportions of withdrawing ventilator and 2-hour survival proportions in Pac-gro and PE-gro2 were higher than in Epi-gro and PE-gro1 (8/8, 10/12 vs 1/8, 2/12, respectively, P b .01, and 7/8, 8/12 vs 1/8, 2/12, respectively, P b .05 or P b .01). Mean survival time in Pac-gro and PE-gro2 were longer than in Epi-gro and PE-gro1 ( P b .05 or P b .01). Therefore, the combination of 2 therapies does not always improve outcome of CPR. It is obvious that the combination of transesophageal cardiac pacing with delayed administration of epinephrine yields a better outcome compared to the combination of 2 therapies at the same time during CPR in a rat asphyxia cardiac arrest model. D 2007 Elsevier Inc. All rights reserved.

B This study received support from Guangxi Department of Education and Guangxi Natural Science Foundation of China (no. 0135038). * Corresponding author. Tel.: +86 771 5356536; fax: +86 771 5350031. E-mail address: [email protected] (M.-H. Chen).

1. Introduction 2. Material and methods

Although epinephrine has been the preferred adrenergic This study was approved by the animal investigation amine for the treatment of human cardiac arrest (CA) for committee of our university, and was performed in more than 40 years, its effectiveness is not optimized. The accordance with National Institutes of Health guidelines search for better therapies in CA and optimal cardiopulmo- for ethical animal research. nary resuscitation (CPR) strategies remains a big challenge. The use of external pacing as an alternative for CPR was 2.1. Animal preparation first described by Zoll [1] in 1952. This technique increased Sprague-Dawley rats of both sexes, weighing 180 to the chances of reviving patients with acute and chronic 220 g, were fasted overnight but were allowed free access to complete heart block as well as some cases of bventricular water. The animals were anesthetized via an intraperitoneal standstillQ [2,3]. injection of 1 g/kg urethane and placed in a supine position On one hand, transcutaneous cardiac pacing produces on a surgical board, and then their extremities were the same hemodynamic effectiveness as conventional immobilized. The proximal trachea was surgically exposed transvenous pacing [4], offers many advantages over in the animals and a 14-gauge cannula was inserted through temporary transvenous pacing, avoids some common a tracheostomy 10 mm caudal to the larynx. The cannula complications of the invasive transvenous technique was advanced for a distance of 1 cm into the trachea and [5,6], and achieves many positive results during CPR secured by ligature, which was also anchored to the skin. [7-11]. On the other hand, transcutaneous cardiac pacing Through the right external jugular vein, an 18-gauge also shows several disadvantages: pain associated with polyethylene catheter (Intramedic PE 50; Becton Dickinson, stimulation of skin and skeletal muscle, electrically Sparks, MD) was advanced through the superior vena cava induced myocardial damage, and difficulty in recognition into the right atrium. Right atrial pressure was measured of cardiac responses [12-14]. Furthermore, many nonef- with reference to the midchest with a high-sensitivity fective results of cardiac pacing during CPR have been pressure transducer. Another 18-gauge polyethylene cathe- reported [15-18]. ter was advanced from the left carotid artery into the These conflicting reports provoked suspicions over the thoracic aorta for measurement of aortic pressure with the effect of cardiac pacing in CPR. The enthusiasm for the use high sensitivity pressure transducer (YH-4, Chengdu Tech- of cardiac pacing in CPR has rapidly decreased and nology & Market Co Ltd, Chengdu, China). The void space literature pertinent to the subject has nearly disappeared of the catheters was filled with a physiologic salt solution recently. An advantage of using animal models in CPR containing 5 IU/mL of bovine heparin. The core temperature research is the ability to control differing variables that may was measured via a rectal temperature probe. Conventional be impossible to standardize in clinical trials. Trans- lead II electrocardiograms (ECG) were recorded with esophageal cardiac pacing is a form of noninvasive cardiac subcutaneous needles. pacing [19] that has fewer side effects and higher pacing The ECG (lead II), aortic, and right atrial pressures were efficacy compared to transcutaneous cardiac pacing. We continuously recorded on a desktop computer via 4-channel were prompted to investigate the effectiveness of the physiologic recorder (BL-420 E Bio-systems, Chengdu technique in an animal model of cardiac arrest. In our Technology & Market Co Ltd) for subsequent analyses. previous study, we found that transesophageal cardiac The coronary perfusion pressure (CPP) was calculated as the pacing could increase the rate of survival in asphyxia rat difference between the diastolic aortic and right atrial model compared to the control group [20]. We also pressures measured simultaneously [22]. observed that transesophageal cardiac pacing had better effectiveness than epinephrine during CPR under the same 2.2. Experimental protocol experimental condition [21]. However, whether the combination of transesophageal cardiac pacing and epinephrine After a 10- to 15-minute postsurgery equilibration period, was further beneficial to the outcome of CPR and whether 10 minutes of asphyxial CA was induced by clamping the the different time points of the combination of 2 therapies tracheal tubes. Cardiac arrest was determined by loss of previously described influences the outcome of CPR aortic pulsations and mean aortic pressure (MAP) of less remained unclear. The purpose of this study, therefore, than 10 mm Hg together with asystole or pulseless electrical was to evaluate the efficacy of combination of trans- activity [23]. Before CPR, 60 Sprague-Dawley rats of both esophageal cardiac pacing and epinephrine, and determine sexes were randomized into 5 groups (n = 12/group): Sal-gro the optimum timing of the combination of 2 therapies (saline group), treated with normal saline (1 mL, IV); Epi- during CPR in a 10-minute asphyxia rat model. The gro (epinephrine group), treated with epinephrine (0.4 mg/ hypothesis was that the combination of the 2 therapies kg, IV); Pac-gro (pacing group), treated with transesopha- would yield better efficacy for CPR and the different time geal cardiac pacing combined with normal saline (1 mL, IV) points of combination of the both would not influence the at the same time; PE-gro1 (pacing + epinephrine group 1, outcome of CPR. drug was used at the same time), treated with trans- 1034 M.-H. Chen et al. esophageal cardiac pacing combined with administration of Failure to restore spontaneous circulation resulted in epinephrine (0.4 mg/kg, IV) at the same time; PE-gro2 discontinuation of resuscitation efforts after 10 minutes. (pacing + epinephrine group 2, drug was used and delayed 4 minutes if necessary) treated with transesophageal cardiac 2.3. Transesophageal cardiac pacing protocol pacing combined with delayed administration of epinephrine (0.4 mg/kg, IV) 4 minutes after the transesophageal cardiac A 5F pacing catheter with two 1-mm ring electrodes pacing was initiated and failed to restore spontaneous (interelectrode distance, 5 mm) was inserted orally into the circulation (if the animal was successfully resuscitated esophagus of animals in 5 groups before CPR at a depth of within 4 minutes, epinephrine was not be administered). about 7 cm. The pacing catheter was connected to a cardiac After 10 minutes of asphyxia, CPR was applied. Each electrophysiologic stimulus apparatus (DF-5A, Suzhou drug was administered and transesophageal cardiac pacing DongFang Electric Apparatus Factory, Suzhou, China). In was initiated in Pac-gro, PE-gro1, and PE-gro2 at the same addition to transmitting electric stimuli, the stimulus time. The drug was administered only once at this point in apparatus can emit acoustical audio tones at a frequency all groups, except for PE-gro2 (epinephrine was delayed or of 180 per minute to guide the investigator in performing not administered in PE-gro2, depending on the resuscitation consistent chest compressions for the rats in all groups. Only of the animal). Ventilation was performed by a volume- animals in the pacing group, pacing + epinephrine group 1 controlled small animal ventilator (DH-150, the medical and pacing + epinephrine group 2 received pacing stimuli instrument of Zhejiang University, Hangzhou, China), with (in other words, saline and epinephrine groups had only a room air at 70 breaths per minute, and tidal volume was sham catheter placed for pacing). Cardiac pacing was adjusted to 6 mL/kg. Ventilation was maintained until performed using 2 poles on the pacing catheter (stimulus spontaneous breathing started, or until 1 hour after duration width, 10 milliseconds and 25 V). Stimulation at a restoration of spontaneous circulation (ROSC). This imitat- rate of 180 stimuli per minutes was performed continuously ed the scenario of no available oxygen in some circum- in early CPR. With the ROSC of the rats, the pacing stances. Manual chest compression at a rate of 180 frequency was altered to a rate of 20-30/min higher than the compressions per minute with equal compression-relaxation rate of intrinsic rhythm of the rats correspondingly and the duration was always performed by the same investigator. left atrium was stimulated intermittently (20 seconds for This investigator was excluded from the hemodynamic stimulation and 10 seconds for pause alternately) for 30 monitor tracings and guided only by acoustical audio tones minutes so as to quicken the heart rate (HR) and improve the emitted from the cardiac electrophysiologic stimulus appa- cardiac output of the resuscitated animal. ratus, which would ensure that the chest compression 2.4. Postresuscitation care quality was consistent for all animals. Compression depth was approximately 30% the anterioposterior chest diameter Hemodynamics and HR monitoring were continued for at maximal compression. Restoration of spontaneous 1 hour. Mechanical ventilation was continued for 1 hour or circulation was defined as an unassisted pulse (ECG showed less after a successful resuscitation depending on the condition the return of supraventricular rhythm) with a mean arterial of the animal’s respiration. The appearance of spontaneous pressure of 20 mm Hg or higher for 5 min or more [23]. breathing (AOSB)—defined as the return of spontaneous

Table 1 Variables at baseline Item Statistic Sal-gro (n = 12) Epi-gro (n = 12) Pac-gro (n = 12) PE-gro1 (n = 12) PE-gro1 (n = 12) Weight (g) Mean (SD) 195.00 (12.43) 195.00 (9.05) 189.17 (12.4) 195.17 (12.37) 195.83 (12.4) 95% CI 187.96 to 202.04 189.89 to 200.12 182.15 to 196.19 188.17 to 202.17 188.81 to 202.85 HR (beats/min) Mean (SD) 412.67 (26.86) 417.67 (43.89) 386.08 (31.53) 387.25 (36.88) 394.42 (43.03) 95% CI 397.48 to 427.86 392.84 to 442.50 368.24 to 403.92 366.38 to 408.12 370.08 to 418.76 Systolic blood Mean (SD) 142.92 (8.31) 137.33 (13.01) 137.33 (13.61) 138.25 (15.07) 136.25 (13.15) pressure 95% CI 138.22 to 147.62 129.96 to 144.70 129.62 to 145.03 129.72 to 146.78 128.80 to 143.70 (mm Hg) Diastolic blood Mean (SD) 93.25 (11.95) 87.5 (8.85) 86.83 (16.21) 99.08 (17.48) 85.25 (11.73) pressure 95% CI 86.49 to 100.01 82.50 to 92.50 77.66 to 96.00 89.18 to 108.98 78.61 to 91.89 (mm Hg) MAP (mm Hg) Mean (SD) 114.83 (10.93) 108.25 (8.96) 108.58 (15.93) 117.67 (15.39) 104.67 (13.05) 95% CI 108.75 to 120.91 103.17 to 113.33 99.56 to 117.60 108.97 to 126.37 97.28 to 112.06 Center venous Mean (SD) 3.24 (1.19) 0.56 (1.08) 0.56 (1.51) 3.24 (1.19) 3.52 (1.56) pressure 95% CI 3.91 to 2.56 1.12 to 0.09 1.42 to 0.29 3.91 to 2.56 4.40 to 2.63 (mm Hg) There were no differences in any variables at baseline between the groups. Combination of cardiac pacing and epinephrine 1035

2.5. Statistical analysis Data were presented as mean F SD (95% confidence interval [CI]) for approximately normally distributed variables and otherwise as median (25th, 75th percentiles). One- way analysis of variance was used to determine the statistical significance among the 5 groups. Mann-Whitney U test was used to determine differences for variables that were not normally distributed between groups. Using Fisher exact test, discrete variables such as ROSC, survival proportion, and proportions of ventilator withdrawal were tested. A 2-tailed value of P b .05 was considered statistically significant.

Fig. 1 Changes in CPP during the earliest 10 minutes of 3. Results resuscitation after 10 minutes of untreated asphyxia. Variables are presented as mean F SEM. Coronary perfusion pressure in PE- Before asphyxia, no significant differences were ob- gro1, Pac-gro, PE-gro2, and Epi-gro was higher than that in Sal- served among the 5 groups in regard to body weight, HR, gro ( P b .05 or P b .01, respectively). The lowest CPP in Sal-gro systolic blood pressure, diastolic blood pressure, MAP, resulted in the lowest proportion of ROSC during the first 10 center venous pressure, and body temperature ( P =NS minutes of the resuscitation phase. between groups, Table 1). There was no significant difference in the time from initiation of asphyxia to CA breathing with more than 5 breaths per minute under the among the 5 groups (ranging between 4 and 5 minutes in all circumstances of mechanical ventilation—in the animals was groups; P = NS between groups). Time from initiation of closely observed and immediately recorded. If spontaneous asphyxia to termination of spontaneous breathing was also breathing presented with at least 40 breaths per minute for not significantly different among the 5 groups (ranging 5 minutes or more within 1 hour after ROSC, and blood between 0.8 and 1.1 minutes in all groups; P = NS between pressure remained stable or increased gradually, mechanical groups). Pulseless electrical activity occurred in all animals ventilation could be withdrawn. After 1 hour of intensified during the subsequent 5 to 6 minutes of nonintervention CA observation, all catheters were removed with tracheal tube left interval. No ventricular fibrillation was observed until CPR in place. The wound was sutured. The animals were then was started. Cardiac rhythms in 52 of 60 animals returned to their cages and allowed to recover without further subsequently resulted in asystole, whereas 8 of 60 animals interventions. The investigators observed the animals until remained in pulseless electrical activity until initiation of their spontaneous breathing stopped. The survival time was CPR ( P = NS between groups). defined as the time from ROSC to the cessation of During CPR, ventricular tachycardia and ventricular spontaneous breathing. (But under the circumstances of fibrillation repeatedly occurred only in 4 animals of PE- mechanical ventilation, survival time was defined as the time gro1 and terminated spontaneously without electric shock. from ROSC to the time that MAP decreases to b20 mm Hg.) Coronary perfusion pressure in Epi-gro, Pac-gro, PE-gro1, Necropsy was routinely performed after the death of and PE-gro2 were significantly higher than in Sal-gro ( P b animals, both resuscitated and unresuscitated ones. Thoracic .05 or P b .01, respectively) during the first 10 minutes of and abdominal organs were examined for gross evidence of the resuscitated phase (Fig. 1). traumatic injures that associated with surgery and CPR The proportion of ROSC in Sal-gro was significantly procedure. The position of catheters was documented. lower than those in Epi-gro, Pac-gro, PE-gro1, and PE-gro2

Table 2 Comparison of ROSC and time from CPR to ROSC among 5 groups Groups Rats Rats (%) of ROSC Time from CPR to ROSC (s) Sal-gro 12 2 (16.67) 142 (60, 153) Epi-gro 12 8 (66.67)* 47 (33, 119)y Pac-gro 12 8 (66.67)* 105 (60, 201) PE-gro1 12 12 (100)** 50 (44, 165)y PE-gro2 12 12 (100)** 160 (63, 381) Time from CPR to ROSC was presented as median (25th, 75th percentiles). * P b .05 vs Sal-gro. ** P b .001 vs Sal-gro. y P b .05 vs, PE-gro2. 1036 M.-H. Chen et al.

Table 3 Comparison of changes in respiration within 60 minutes after ROSC among 4 groups Groups ROSC (n) Rats (%) Rats (%) of Time from CPR Time of ventilator of AOSB ventilator withdrawal to AOSB (min) withdrawal (min) Epi-gro 8 5 (62.5) 1 (12.5) 14 (5) (10.64, 18.36) 50 Pac-gro 8 8 (100)* 8 (100)** 14 (6) (10.00, 18.50) 33 (12) (24.65, 41.10) PE-gro1 12 6 (50.0) 2 (16.67) 21 (7) (15.53, 26.47) 50 (7) (52.94, 61.34) PE-gro2 12 10 (83.3) 10 (83.3)** 20 (12) (12.57, 26.83) 41 (11) (35.96, 52.22) Data are presented as mean F SD (95% CI) in time from CPR to AOSB and time of ventilator withdrawal. Time from CPR to AOSB was not different among the 4 groups. Time of ventilator withdrawal was not different among Pac-gro, PE-gro1, and PE-gro2. Sal-gro data were excluded because of the low survival proportion. * P b .05 vs PE-gro1. ** P b .01 vs Epi-gro and vs PE-gro1.

( P = .036, P = .036, P = .000, and P = .000, respectively), showed a decreasing tendency 15 minutes later. Changes in but no differences were noted among Epi-gro, Pac-gro, PE- HR in PE-gro2 shared the similarity between Epi-gro and gro1, and PE-gro2. Time from CPR to ROSC in PE-gro2 Pac-gro (Fig. 3). was longer than those in Epi-gro ( P = .02) and in PE-gro1 Necropsy results confirmed the correct placement of ( P = .014), but no differences were noted among Sal-gro, catheters in all animals. No adverse side effects of invasive Epi-gro, Pac-gro, and Pac-gro1 (Table 2). procedures or other traumatic injures were documented. Only 4 of 12 animals in PE-gro2 needed administration of epinephrine in addition to transesophageal cardiac pacing to restore spontaneous circulation. Appearance of sponta- 4. Discussion neous breathing was observed in Epi-gro, Pac-gro, PE-gro1, and PE-gro2, but the proportions of ventilator withdrawal In the present study, transesophageal cardiac pacing within 60 minutes after resuscitation in Pac-gro and PE-gro2 combined with delayed administration of epinephrine (if were much higher than those in Epi-gro and PE-gro1 ( P = necessary) could improve the outcome of CPR in the rat .001 and P = .005, respectively) (Table 3). asphyxia model. Although transesophageal cardiac pacing The 1-hour survival proportion in PE-gro1 was signifi- combined with administration of epinephrine at the same cantly lower than in Epi-gro, Pac-gro, and PE-gro2 ( P b .05 time during CPR could increase the proportion of ROSC, it or P b .01, respectively). The 2-hour survival proportions in also resulted in a shorter survival time. These data show that Pac-gro and PE-gro2 were significantly higher than in Epi- the combination of transesophageal cardiac pacing and gro and PE-gro1 ( P b .05 or P b .01, respectively). Mean epinephrine does not always produce beneficial effects, and survival time was longer in Pac-gro and PE-gro2 than in different opportunities of combining 2 therapies may yield Epi-gro and PE-gro1 after resuscitation ( P b .05 or P b .01, different outcomes of CPR. respectively) (Table 4). Because high doses of epinephrine enhanced myocardial Mean aortic pressure in Pac-gro remained stable, in perfusion pressure and myocardial blood flow, leading to contrast to Epi-gro and PE-gro1, which indicated a falling improved proportions of ROSC [24,25] without increased tendency during the 60-minute monitoring phase after CPR. direct complications in the CA population, compared to Changes in MAP in PE-gro2 shared the similarity between standard dose epinephrine [26], we chose a relatively high Epi-gro and Pac-gro (Fig. 2). dose of epinephrine in the present study. Although no Among 4 groups, HR in PE-gro1 was highest at 5 and 10 difference was noted in the proportion of ROSC between minutes during the 60-minute monitoring phase after CPR. Epi-gro and Pac-gro, shorter survival time and worse Heart rate in Pac-gro was higher than in Epi-gro and respiration situation after ROSC was observed in the Epi- remained stable; alternately, HR in the Epi-gro and PE-gro1 gro than in the Pac-gro. It was suggested that transesophageal

Table 4 Comparison of survival time after resuscitation among the 4 groups Groups ROSC (n) 1 h survival, n (%) 2 h survival, n (%) Longest survival time (h) Median survival time (h) Epi-gro 8 8 (100)* 1 (12.5) 9 1 (1, 1) Pac-gro 8 8 (100)* 7 (87.5)**,y 24 3.5 (2, 18.3)**,y PE-gro1 12 5 (41.7) 2 (16.7) 2 1 (0.8, 1) PE-gro2 12 12 (100)** 8 (66.7)*,y 22 3 (1, 5)** Mean survival time was presented as median (25th, 75th percentiles). * P b .05 vs PE-gro1. ** P b .01 vs PE-gro1. y P b .05 vs Epi-gro. Combination of cardiac pacing and epinephrine 1037

mias [28], and causing myocardial dysfunction in the postresuscitation phase [29], probably due to its b-receptor agonistic effect. Although the combination of the 2 therapies at the same time enhances the efficacy of increasing CPP and proportion of ROSC, the adverse effect of epinephrine was strengthened synchronously as well. Consequently, the situation of postresuscitation in the animals of PE-gro1 was significantly worsened in comparison to that in Epi-gro and Pac-gro. By contrast, transesophageal cardiac pacing combined with delayed administration of epinephrine could yield a better outcome of CPR. The decision to apply a delayed administration of epinephrine was based on the following: according to our preliminary study, nearly all animals treated with cardiac pacing alone returned to spontaneous circulation within 4 minutes after CPR, and no animal was Fig. 2 Changes in MAP during the 60-minute monitoring phase resuscitated beyond 4 minutes by transesophageal cardiac after CPR (mean F SEM). *PE-gro1: n = 12 (before 35 minutes), pacing alone. We hypothesized that a delayed administration n = 11 (35-45 minutes), n = 9 (50 minutes), n = 8 (55 minutes), n = of epinephrine might increase the possibility of ROSC and 7 (60 minutes). Mean aortic pressure in Epi-gro and PE-gro1 was reduce the adverse effects of epinephrine. That assumption significantly higher than in Pac-gro and PE-gro2 at 5 and was validated by the present study as well. The resuscitation 10 minutes during the 60-minute monitoring phase after CPR proportion in PE-gro2 increased to 100% from 66.67% ( P b .05 or b .01, respectively). Thirty-five minutes later, MAP in PE-gro1 was significantly lower than in Epi-gro, PE-gro2, and Pac- owing to administration of epinephrine 4 minutes after gro ( P b .05 or P b .01, respectively). In Pac-gro, MAP remained transesophageal cardiac pacing was initiated and there was a stable 15 minutes later. In PE-gro1 and Epi-gro, in contrast, MAP failure to resuscitate the animal. In PE-gro2, only 8 of 12 showed a rapidly falling tendency and had much lower value from animals were successfully resuscitated by transesophageal 25 and 35 minutes, respectively, to 60 minutes, compared with that cardiac pacing alone, whereas 4 of 12 animals needed at 15 minutes ( P b .05 or P b .01, respectively). Changes in MAP in PE-gro2 shared the similarity between Epi-gro and Pac-gro. Sal- gro data were excluded because of the low survival proportion. cardiac pacing alone offers a better outcome of CPR than epinephrine alone in the rat asphyxia model. The reason for this phenomenon may be related to the beneficial effect of transesophageal cardiac pacing [20,21] and the adverse side effect of epinephrine [27-29] during and after CPR. Considering that transesophageal cardiac pacing may possibly influence the neurohumoral regulation of the animal and cause endogenic vasoconstrictive substances to be released, which may result in contractive reaction of systemic vessel, increase in CPP, and improvement in resuscitation [21], it is very likely that the combination of transesophageal cardiac pacing with epinephrine enhanced CPP during CPR and improved the proportion of ROSC. This assumption was validated in the present study. The Fig. 3 Changes in HR during the 60-minute monitoring phase proportion of ROSC in PE-gro1 and PE-gro2 was 100%. after CPR (mean F SEM). *PE-gro1: n = 12 (before 35 minutes), Ventricular fibrillation occurred only in animals of PE- n = 11 (35-45 minutes), n = 9 (50 minutes), n = 8 (55 minutes), n = gro1 during CPR in the present study. The proportion of 7 (60 minutes). Heart rate in PE-gro1 was significantly higher than AOSB and the proportion of ventilator withdrawal after in Epi-gro, Pac-gro, and PE-gro at 5 and 10 minutes during the 60- b b ROSC were also lower in PE-gro1. Furthermore, survival minute monitoring phase after CPR ( P .05 or P .01, respectively). However, at 15 minutes and beyond, HR in Pac- time was shortest in PE-gro1 among groups. These data gro was higher than in Epi-gro ( P b .05) and remained stable. In indicated that the combination of 2 therapies at the same contrast, HR in Epi-gro and PE-gro1 showed a falling tendency, time during CPR did not yield a better outcome in rat and a lower HR was noted from 30 to 60 minutes compared with asphyxia model. The familiar side effects of epinephrine that at 15 minutes ( P b .05 or P b .01, respectively). Changes in include increasing myocardial oxygen consumption during HR in PE-gro2 shared the similarity between Epi-gro and Pac-gro. ventricular fibrillation [27], inducing ventricular arrhyth- Sal-gro data were excluded because of the low survival proportion. 1038 M.-H. Chen et al. administration of epinephrine in addition to cardiac pacing a consequence of shunt caused by high-dose epinephrine to return spontaneous circulation. That is why the time from [29] in this experiment, and this would influence survival CPR to ROSC in PE-gro2 was longer than that in Epi-gro, and weaning time in the Epi-gro and PE-gro1. Perhaps these and why the resuscitated animals in the PE-gro2 shared are also the reasons why Epi-gro and PE-grop1 were similar characteristics between Epi-gro and Pac-gro in associated with worse outcome when compared to Pac-gro regard to changes in respiratory efficiency, survival time, and PE-gro2. However, the optimum dose of epinephrine MAP, and HR after ROSC. during CPR in rat asphyxia model remains to be established. There have been considerable professional debate on the Third, there were no parameters to evaluate postre- effect of cardiac pacing during CPR, and many clinical suscitation myocardial function. There were no blood gas investigations have differed in their conclusion in this regard results, and not even end tidal carbon dioxide (ETCO2) [7-11,15-18]. Unfortunately, little attention has been paid to monitoring to support the benefits of transesophageal cardiac the optimum timing of cardiac pacing combined with pacing on respiration. Lack of presentation of key data might epinephrine during CPR in the clinical settings. This may result in less objective conclusions. be 1 of the reasons why there are so many discrepancies Finally, most animals in PE-gro2 were treated only by about the effect of cardiac pacing on the outcome of CPR in cardiac pacing without administration of epinephrine. clinical investigations. Consequently, our findings may Therefore, PE-gro2 actually included some cardiac pacing provide some implications for the improvement of applica- alone data, which make the data a little confusing. However, tion of cardiac pacing and epinephrine during CPR in the this type of grouping was designed to clarify whether clinical setting. There is no doubt that choosing a well-timed delayed administration of epinephrine could increase occasion for a combination of cardiac pacing with epineph- survival proportion when transesophageal cardiac pacing rine is essential to increase the efficacy of cardiac pacing alone failed to restore spontaneous circulation, and deter- and avoid the disadvantages of 2 therapies during CPR. mine the optimum timing of the combination of trans- We did not stop the pacing when ROSC was attained, esophageal cardiac pacing with epinephrine during CPR. because we thought that continuing transesophageal cardiac Furthermore, no better grouping was considered eligible for pacing for 20 to 30 minutes after ROSC might help to quicken this research design. Consequently, notwithstanding its HR or induce increase in HR in the resuscitated animals. limitation, this study does suggest that different opportuni- White et al [30] reported that the use of external pacing ties of combination of cardiac pacing with epinephrine may increased the proportion of pulseless idioventricular rhythm influence the outcome of CPR. and profound bradycardias even without evidence of electrical capture. The rate gradually slowed again after discontinuation of pacing, and increased with reinstitution of 5. Conclusion pacing. This always occurred in the absence of any sign of electrical capture and was not temporally related to the Although the different opportunities of combination of administration of medications or to the changes in CPR. It is transesophageal cardiac pacing with epinephrine make no possible that external electrical stimulation of the heart, even difference in regard to the increase in the proportion of in the absence of electrical capture, can induce myocardium ROSC, changes in respiration, MAP, HR, and survival time to become more responsive to exogenous catecholamines. after ROSC vary significantly between groups. Therefore, we These authors believed that the application of rhythmic conclude that combination of cardiac pacing and epinephrine electrical stimulation in the area of the thoracic ganglia could does not always improve outcome of CPR. It is obvious that produce sympathetic stimulation of the cardiac plexus. In the the combination of transesophageal cardiac pacing with present study, cardiac output was not measured because of the delayed administration of epinephrine yields a better outcome difficulty in the procedure of advancing the catheter to the left when compared with the combination of 2 therapies at the ventricular cavity without damnification of the heart during same time during CPR in a rat asphyxia CA model. CPR. Theoretically speaking, a slightly faster HR could enhance the cardiac output, improve perfusion pressure of vital organs, and rectify metabolic turbulence of the animals. Acknowledgments Some limitations should be noted in the present study. First, the asphyxial cardiac arrest rat model is an unusual The authors express their gratitude to the staff of the model. Only a few of incidences of cardiac arrest are caused department of physiology for excellent technical help and by asphyxia. Therefore, our results would not apply to most constructive criticism. cardiac arrest victims. Second, administration of high dose of epinephrine in this study was contradictive with some of the recent findings References that high-dose epinephrine resulted in higher mortality immediately after resuscitation and did not improve survival [1] Zoll PM. Resuscitation of the heart in ventricular standstill by external time. It is possible that lung oxygen transfer was reduced as electric stimulation. N Eng J Med 1952;247(20):768-71. Combination of cardiac pacing and epinephrine 1039

[2] Zoll PM, Linenthal AJ, Norman LR. Treatment of Stokes-Adams [18] Cummins RO, Graves JR, Larsen MP, Hallstrom AP, Hearne TR, disease by external electric stimulation of the heart. Circulation Ciliberti J, et al. Out-of-hospital transcutaneous pacing by emergency 1954;9(4):482-93. medical technicians in patients with asystolic cardiac arrest. N Engl J [3] Zoll PM, Linenthal AJ, Norman LR, Paul MH, Gibson W. Treatment Med 1993;328(19):1377-82. of the unexpected cardiac arrest by external electric stimulation of the [19] Hartley JM. Transoesophageal cardiac pacing. Anaesthesia heart. N Eng J Med 1956;254(12):541-6. 1982;37(2):192-4. [4] Syverud SA, Hedges JR, Dalsey WC, Gabel M, Thomson DP, Engel [20] Song FQ, Xie L, Chen MH. Transoesophageal cardiac pacing is PJ. Hemodynamics of transcutaneous cardiac pacing. Am J Emerg effective for cardiopulmonary resuscitation in a rat of asphyxial Med 1986;4(1):17-20. model. Resuscitation 2006;69(2):263-8. 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Original Contribution Radiologic diagnoses of patients who received imaging for venous thromboembolism despite negative D-dimer testsB,BB

Kristen E. Nordenholz MDa,*, Michael Zieske BSb, Debra S. Dyer MDc, James A. Hanson BSb, Kennon Heard MDa aDivision of Emergency Medicine, Department of Surgery, University of Colorado School of Medicine, Colorado Emergency Medicine Research Center, Denver, Colorado 80262, USA bUniversity of Colorado School of Medicine, Denver, Colorado 80262, USA cDepartment of Radiology, University of Colorado School of Medicine, Denver, Colorado 80262, USA

Received 26 February 2007; accepted 10 March 2007

Abstract Objective: The literature supports a negative D-dimer (ÀDD) excluding venous thromboembolic disease (VTE) in low-risk patients. We determined the radiologic diagnoses in patients where imaging was ordered despite a ÀDD. Methods: This is a retrospective chart review of patients with a ÀDD (Tinaquant; Roche Diagnostics, Mannheim, Germany) and a radiologic study within 48 hours, sought to determine radiologic diagnosis (primary outcome), treatment of VTE, and consensus diagnosis of acute VTE. Results: Among 3462 DD tests, 1678 met the inclusion criteria. Of 1362 patients with DD values of 350 ng/mL or less, 166 (12.2%) had radiologic studies: 93.4% of the final radiologic diagnoses were negative for VTE, 3.6% were indeterminate, and 3.0% (1.0%-6.9%) were positive; 1.8% ultimately had a consensus diagnosis of acute VTE. In 316 patients with DD values between 351 and 500 ng/mL, 88 (27.8%) had radiologic studies: 95.5% were negative, 1.1% were indeterminate, and 3.4% (0.7%-9.6%) were positive. Conclusions: Of patients who receive radiologic studies despite ÀDD tests, 3.0% have positive radiologic diagnoses for acute VTE; only 1.8% had acute VTE after the review of their hospital course. D 2007 Elsevier Inc. All rights reserved.

These data were presented in a oral presentation at the 2005 Society for Academic Emergency Medicine Annual Meeting in New York, NY, in May 2005. B This study was funded by an internal research grant with the Department of Surgery at the University of Colorado. BB KN and DD conceived the study. KN obtained research funding. KN, DD, MZ, JH, and KH designed the trial. MZ and JH performed data collection. KH supervised the conduction of the trial, provided advice on study design, and performed data analysis and statistics. KN drafted the manuscript, and all authors contributed substantially to its revision. KN takes responsibility for the article as a whole. * Corresponding author. Division of Emergency Medicine, University of Colorado Health Sciences Center, PO Box B215 Denver, CO 80262, USA. Tel.: +1 303 372 5500; fax: +1 303 372 5528. E-mail address: [email protected] (K.E. Nordenholz).

1. Introduction This algorithm recommends no further evaluation for patients who are clinically at low risk of VTE and have a Venous thromboembolic disease (VTE), which includes D-dimer of 350 ng/mL or less. Previous studies have shown deep vein thrombosis (DVT) and pulmonary embolism (PE), that gestalt impression of clinician risk stratification is is challenging to diagnose because of its nonspecific clinical similar to formal assessment [14]. We believe that patients presentation. Both over- and underdiagnosis of VTE are who go on to receive imaging despite a negative D-dimer associated with risk. The diagnostic challenges of VTE have represent a group who the clinicians feel have a higher risk led to the development of clinical algorithms and noninvasive of VTE. tests that can safely rule out VTE in most symptomatic The objective of this study is to determine the number of patients [1-4]. Many clinical algorithms incorporate D-dimer, patients who had positive radiologic imaging for VTE which is a plasmin-derived fibrin breakdown product with despite negative D-dimer tests and to examine the character- high sensitivity but low specificity for VTE. It is well istics of this population including which patients were established that this test performs well as a negative predictor treated with anticoagulation and those ultimately felt, using in the population at low risk for VTE [5-12]. However, the chart review, to have true acute VTE disease. literature does not clarify how the D-dimer performs in patients at higher risk [13]. The usefulness of the D-dimer in these patients remains in question. 2. Methods Our hospital system has an established, hospital-wide algorithm for the diagnosis of VTE that helps guide clinical This was a retrospective case series of patients who decision-making in the workup of possible VTE (Fig. 1). received a D-dimer between February 1, 2002, and Febru-

Fig. 1 PE/DVT imaging algorithm. 1042 K.E. Nordenholz et al. ary 1, 2003. Our institutional review board approved the examination result might be reclassified as positive or study; because it did not involve interventions or sensitive negative examination result. If multiple studies were information, informed consent was waived. It was per- performed on a patient, the radiologists reviewed all formed at an urban, academic, 300-bed tertiary care center examination images and assigned a consensus diagnostic and its associated satellite clinics. code of N, I, or P. The laboratory uses a Tinaquant D-dimer (Roche Two senior radiologists then reviewed the original Diagnostics, Mannheim, Germany) assay, which is an images for a random subset of patients with negative immunoturbidimetric assay with a sensitivity of 99% (97- imaging studies. These physicians were blinded to the initial 100), specificity of 41% (36-47), negative predictive value results and to each other. Finally, 2 attending emergency of 98% (95-100), and positive predictive value of 76% physicians (KN, KH) independently reviewed the hospital (68%-84%) [15]. All patients in our hospital system charts of those patients with either positive or indeterminate (emergency department [ED], inpatient services, and out- radiologic imaging to further characterize these patients and patient clinics) who received a D-dimer were included to determine which patients received anticoagulation. through a search of the clinical laboratory database. There Treatment for acute VTE was determined by review of the were no prespecified exclusion criteria. patient’s discharge summary. Administration of heparin, D-dimer assays were ordered at the discretion of the low-molecular-weight heparin, or warfarin was considered treating attending clinicians. For patients with D-dimer treatment of VTE. A consensus diagnosis was then results of 350 ng/mL or less, the algorithm (Fig. 1) directs determined by review of all radiologic studies, the inpatient providers to consult with the chest or body imaging clinical course, and the discharge diagnoses. radiologist if clinical suspicion remains high. The popula- Means with ranges were determined for continuous tion of interest were patients who had a negative D-dimer variables using SAS V8 (SAS, Cary, NC). Proportions with test, defined as 350 ng/mL or less, and a radiologic study to 95% confidence intervals were determined for categorical rule out VTE within 48 hours. We also analyzed patients variables using GraphPad 3.0 (InStat, San Diego, Calif). with an intermediate D-dimer result between 351 and 500 ng/mL who met the same radiologic study criteria. The radiologic studies were defined as V/Q scanning, computed 3. Results tomography pulmonary angiogram (CTPA), extremity venous ultrasound, or conventional pulmonary arteriogram. Of 3462 D-dimer tests performed in the clinical V/Q scans were performed using a Picker AXIS camera. laboratory during the study year, 1678 had a D-dimer value Computed tomography pulmonary angiogram was per- of 500 ng/mL or less. We examined 2 groups within this formed on the GE CTI single-slice helical scanner until population, patients with D-dimer values of 350 ng/mL or b Q January 2003 when the Siemens Sensation 10-slice CT less ( 350 group) and patients with values between 351 and b Q scanner became available. Extremity ultrasound with 500 ng/mL ( 500 group). We did not perform a combined venous compression and Doppler interrogation was per- analysis of the 2 groups because we believe there are formed using a Toshiba or Acuson machine. Ultrasound studies performed by the vascular laboratory used an ATL HDI Ultramark 9 machine. The D-dimer test results were separated into the following groups: negative (V350 ng/mL), intermediate (351-500 ng/mL), and positive (N500 ng/mL). The electronic chart of each patient with a D-dimer value of 500 ng/mL or less was then independently reviewed by 1 of 2 trained reviewers (MZ, JH) for age, sex, and the presence of an imaging study for VTE within 48 hours. Imaging results from the bImpressionQ section of the bRadiological ReportQ in the electronic chart were classified into 1 of 4 groups: negative (N) for no PE or DVT or low- probability V/Q scans; indeterminate (I) for intermediate probability or indeterminate V/Q scans and all other ambiguous interpretations (ie, acute vs chronic clot, suboptimal scan, nondiagnostic examinations, catheter- associated thrombus, etc); positive (P) for unequivocal embolism or thrombus; or multiple (M). The original images that were coded as I or P were reread by a senior chest radiologist or a senior ultrasonographer to confirm Fig. 2 The b350Q group—radiologic results for patients with positive results or to determine if any indeterminate D-dimer test results of 350 ng/mL or less. Radiologic diagnoses of patients who received imaging for VTE 1043

Table 1 The b350Q group—characteristics of patients with D-dimer test results of 350 ng/mL or less and positive or indeterminate radiologic studies Age Sex Medical history Taking INR D-dimer Previous Radiologic Anticoagulation Consensus Acute anticoagulant VTE? diagnosis started after diagnosis VTE at presentation? imaging? after chart diagnosis? review 23 Male Cystic fibrosis No n/a 324 No Right brachial No Chronic No vein clot right brachial vein clot 42 Male Testicular Yes, warfarin 1.0 240 PE PE Yes Intravascular No cancer tumor 75 Male Atrial Yes, 1.7 346 No DVT Yes Positive Yes fibrillation enoxaparin DVT and warfarin 37 Female None No n/a 235 DVT Acute on Yes Chronic No chronic DVT DVT 51 Female Breast cancer Yes, n/a 138 No PE Yes Positive PE Yes with metastases dalteparin 49 Male Asthma No n/a b150 No PE on No Reactive No suboptimal airway scan disease 29 Female Antithrombin Yes, 0.96 155 PE PE—small Yes Chronic PE No III deficiency warfarin subsegmental in left lower lobe 72 Female Atrial Yes, 1.65 248 No Indeterminate Yes Atrial No fibrillation and warfarin scan limited fibrillation mitral valve by motion repair 38 Female Lupus and Yes, 0.96 b150 PE DVT—acute Yes Acute vs Yes pregnancy warfarin and on chronic chronic— Greenfield unclear filter 35 Female Obesity and No n/a 189 No Suboptimal No Negative No diabetes scan for VTE 56 Female Atrial Yes, 0.94 283 PE Indeterminate No Negative No fibrillation and warfarin scan for VTE pulmonary hypertension INR indicates international normalized ratio; n/a, not applicable. inherent differences between them. The agreement between anticoagulants at the time of VTE diagnosis. After review of radiologists for the random subset of negative V/Q and CT the available data, 3 (1.8%) were assigned a consensus acute studies was 96% (27/28; 95% confidence interval [CI], VTE diagnosis. 81%-99%). A smaller group (n = 316) of study subjects had D- Most (n = 1362) of the test results were 350 ng/mL or dimer test results between 351 and 500 ng/mL (b500Q less (b350Q group). The mean age of the patients in this group). The mean age among this group was 53 years (16- group was 48 years (10-96 years); 61% were female. Most 85 years); 68% were female. The ED staff again ordered (71%) of these D-dimer requests were ordered by the ED most (60%) of these tests. Fewer (16%) came from staff, 12% came from inpatient floors, and 17% came from inpatient floors and clinics (24%). Among these patients, outpatient clinics. Among these patients, 166 had a single or 88 had a single or multiple radiologic studies within 48 multiple radiologic studies within 48 hours (Fig. 2). Five hours (Fig. 3). Three (3.4%; 95% CI, 0.7%-9.6%) patients (3.0%; 95% CI, 1.0%-6.9%) patients had positive imaging had positive imaging for acute VTE. One (1.1%; 95% CI, for acute VTE. Six (3.6%; 95% CI, 1.3%-7.7%) had 0.0%-6.2%) had an indeterminate study (complete images indeterminate studies and 155 (93.4%; 95% CI, 88.5%- not obtained) and 84 (95.5%; 95% CI, 88.8%-98.8%) had 96.7%) had negative imaging. The characteristics of the 11 negative imaging. The characteristics of the 4 patients with patients with positive or indeterminate studies are shown in positive or indeterminate studies are shown in Table 2. Table 1. Seven of these patients were concurrently taking None of these patients were concurrently taking anti- 1044 K.E. Nordenholz et al.

these studies should have been repeated or not considered in the clinical evaluation. We reported these data to ensure that we were not underrepresenting potentially positive studies. Third, all of the studies coded as I, M, or P were re-reviewed by the radiologists and only a small portion of the negative studies were re-reviewed. It is possible that a number of negative studies may have been reclassified but were not investigated further. This could bias our results toward fewer positive and indeterminate studies; however, our interrater agreement for the reviewed negative studies was high. Next, the clinical applicability of our study is limited by the lack of a systematic evaluation of pretest probability. It is possible that patients who underwent imaging studies despite a D-dimer of 350 ng/mL or less would have been classified as having lower risk if a rigorous stratification system had been used. However, this would have resulted in more low-risk patients being imaged in our study and therefore should have biased our results toward a lower Fig. 3 The b500Q group—radiologic results for patients with percentage of patients having VTE. Finally, the accuracy of D-dimer test results between 351 and 500 ng/mL. the radiologic diagnoses in this study was also limited by the use of a single-slice helical CT until January 2003. This coagulants at the time of VTE diagnosis. After review of single-slice CT scanner has limitations, which are recog- the available data, 3 (3.4%) were assigned a consensus nized in the literature as potentially missing subsegmental acute VTE diagnosis. clot [16-18]. Although this may result in fewer positive radiologic studies, one could argue that we would see a larger number of indeterminate studies as well. In January 4. Limitations 2003, our institution acquired a 10-slice multidetector CT scanner, which is more sensitive and is supported by the There are several limitations to the validity of this study. literature as having fewer false-negative and false-positive First, as a retrospective case series, the laboratory database scans [19,20]. or electronic medical record may be missing data that were contained in the hospital paper chart. This could result in missed cases of positive or negative VTE; however, there is 5. Discussion no reason to suspect that this would result in systematic error. Second, we considered low-probability V/Q scans as We found that 3% of patients who received a radiologic negative for VTE unless other imaging was obtained. This study despite a D-dimer of 350 ng/mL or less had a positive may have resulted in misclassification. Also, many of the study for acute VTE reported to the clinician at the time of indeterminate studies were actually nondiagnostic because initial patient evaluation. However, only 3 of these patients of motion artifact or other technical limitations. Ideally, were ultimately assigned an acute VTE diagnosis. This

Table 2 The b500Q group—characteristics of patients with D-dimer test results between 351 and 500 ng/mL and positive or indeterminate radiologic studies Age Sex Medical Taking INR D-dimer Previous Radiologic Anticoagulation Consensus Acute VTE history anticoagulant VTE? diagnosis started after diagnosis diagnosis? at presentation? imaging? after chart review 59 Female Lupus No n/a 410 PE PE Yes PE Yes 56 Male None No n/a 498 PE DVT Yes DVT Yes 41 Male Rheumatoid No n/a 365 No PE Yes PE Yes arthritis 64 Male COPD and No n/a 375 No Inadequate No Negative No recent long study for VTE haul flight Radiologic diagnoses of patients who received imaging for VTE 1045 suggests that the rate of acute VTE in patients with a concurrently taking anticoagulants at the time of diagnosis. D-dimer of 350 ng/mL or less is less than 2% in a group Kline et al [22] suggested that concurrent warfarin therapy judged to be at higher clinical risk for VTE. in a patient presenting with signs and symptoms of VTE More concerning to us were the 3 patients with a might result in false-negative D-dimer values. Kraaijenha- D-dimer value between 351 and 500 ng/mL who were found gen et al [23] showed that patients on low-molecular-weight to have acute VTE during their evaluation. In our institution, heparin might have a false-negative D-dimer, and other a negative D-dimer cutoff value of 350 ng/mL or less is used studies outside the emergency medicine literature also in screening for VTE. Patients with test results between highlight a similar phenomenon [24-26]. It is important to 351 and 500 ng/mL may go on to receive imaging regard- note that patients taking anticoagulants were excluded from less of risk assessment; hence, some patients judged as the original studies of Wells et al [27]. As patients on having clinically low risk still go on to imaging. This should anticoagulants have potentially high risk, this study suggests result in a lower incidence of acute VTE among this that the effect of anticoagulation on the D-dimer warrants population; however, this group had a 3.4% risk of acute further investigation. VTE in our study. Historically, most clinicians have accepted a blow- Hammond and Hassan [21] recently showed that no probability V/Q scanQ as excluding PE. Considering the patient with a D-dimer of less than 275 ng/mL was incidence of PE in low pretest probability, patients with low diagnosed with a PE birrespective of clinical probability.Q probability V/Q scans was 4% in the Prospective Investi- One patient (D-dimer reported as 138) in our study had a gation of Pulmonary Embolism Diagnosis study [28],a3% consensus diagnosis of acute VTE. At our institution, all D- bmiss rateQ of the D-dimer is actually an improvement over dimer values of greater than 149 ng/mL are quantified, the standard use of V/Q scanning. Furthermore, a recent whereas levels less than 150 are reported as bb150 ng/mL.Q BMJ systematic review [29] cites a posttest probability of The value of 138 ng/mL was reviewed with the laboratory 5% as safe for excluding VTE, based on work done by supervisor, but we could not determine why this particular Kearon [30]. To avoid excessive risk, Kline et al [31] reason value was reported quantitatively rather than as b150 ng/ that a posttest probability of 2%, preferably 1%, is safe mL. Therefore, it is possible that one of the positive cases based on work by Gossellin et al [32]. We feel that our may have been due to laboratory error. consensus acute VTE diagnosis rate of 1.8% in patients The patients in both the b350Q and b500Q groups who with D-dimer values of 350 ng/mL or less is well within were diagnosed with VTE had complicated medical these boundaries. histories (Tables 1 and 2). In some cases, these medical conditions may have resulted in false-positive radiologic studies. For example, a 42-year-old man was initially 6. Conclusions diagnosed with acute VTE; however, he had no response to anticoagulation and was ultimately diagnosed with In a real-time practice, working environment, 3% of intravascular tumor. patients who received imaging despite a negative Tinaquant Before we began this investigation we recognized the D-dimer had a positive radiologic imaging study for VTE. issue of distinguishing acute from chronic thrombus. However, only 1.8% had a consensus diagnosis of acute Therefore, examinations were scrutinized in an effort to VTE after review of the entire medical record. The D-dimer differentiate between the acutely positive radiologic studies appears to be a reliable tool in screening patients for for VTE and studies positive for chronic VTE. For acute VTE in presumed non–low pretest probability example, the CT findings of acute PE include expanded patients. Our consensus review suggests that patients with vessels with central filling defects, whereas chronic PE is negative D-dimer values and positive radiologic imaging represented by mural thrombus and eccentric intravascular may ultimately have nonacute VTE or have other diagnoses filling defects. With V/Q scans, acute vs chronic PE is to explain their radiologic findings. Studies that have used recognized by the persistence of ventilation and perfusion single radiologic imaging as the gold standard for acute mismatch on subsequent scans. Unfortunately, it is there- VTE may have misclassified those patients. We also fore difficult to differentiate acute vs chronic PE on a single recommend further research with regard to the D-dimer in V/Q scan. Acute vs chronic DVT is differentiated by the anticoagulated patients, particularly those receiving low- presence of collateral vessels in chronic DVT. It is possible dose or subtherapeutic warfarin. that we have erred on the side of interpreting chronic clot as acute, in favor of missing an acute thrombus and overestimating the strength of the D-dimer. In an attempt to Acknowledgment address the validity of the radiologic diagnosis, we used clinician consensus on review of the medical record to We acknowledge Dr Steven Lowenstein from Emergency verify the radiologic impression. Medicine for his rigorous critique of the study design, and An interesting finding from our study is that many of the Dr David Lynch, Julia Drose, and Phyllis Siracusano from patients with apparently false-negative D-dimer values were the Department of Radiology for their assistance. 1046 K.E. Nordenholz et al.

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Effect of low-dose warfarin on pulmonary embolism. Ann Emerg Med 2000;35:168-80. D-dimer levels during sickle cell vaso-occlusive crisis: a brief report. [9] Brown MD, Rowe BH, Reeves MJ, et al. The accuracy of the enzyme- Eur J Haematol 2004;72:213-6. linked immunosorbent assay D-dimer test in the diagnosis of [25] Kim SB, Lee SK, Park JS, et al. Effects of fixed low-dose warfarin on pulmonary embolism: a meta-analysis. Ann Emerg Med 2002;40: hemostatic factors in continuous ambulatory peritoneal dialysis 133-44. patients. Am J Kidney Dis 2001;37:343-7. [10] Leclercq MG, Lutisan JG, van Marwijk Kooy M, et al. Ruling out [26] Jafri SM, Mammen EF, Masura J, et al. Effects of warfarin on markers clinically suspected pulmonary embolism by assessment of clinical of hypercoagulability in patients with heart failure. Am Heart J 1997; probability and D-dimer levels: a management study. Thromb 134:27-36. Haemost 2003;89:97-103. [27] Wells PS, Ginsberg JS, Anderson DR, et al. 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Brief Report

Does sex matter? Effect of screener sex in intimate partner violence screeningB Lauren B. Gerlach BSa,⁎, Elizabeth M. Datner MDa, Judd E. Hollander MDa, Kara E. Zogby RNa, Jennifer L. Robey RNa, Douglas J. Wiebe PhDb aDepartment of Emergency Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA bDepartment of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA

Received 3 May 2007; accepted 13 June 2007

Abstract Study Hypothesis: The sex of the individual performing screening affects the willingness of adult male and female ED patients to disclose incidents of intimate partner violence (IPV). Methods: We performed a prospective cross-sectional survey at an urban academic medical center. A consecutive sample of adults who presented to the ED from 7:00 AM to 00:00 AM, 7 days/wk, over an 8-week period, were screened for IPV by 26 trained research assistants (42.3% female; mean age 23 years; 3.8% African American, 53.8% white). Intimate partner violence was detected using a 4-item tool to measure both physical and psychological abuse within the past 6 months. Comparison of medical history and disposition was performed using χ2 tests and t tests. Regression analysis was performed to determine the association of sex and screening outcomes, controlling for patient and screener age and race. Results: A total of 2853 patients participated (63.0% female; mean age, 36 years; 67.5% African American, 22.9% white). During the study 48 female patients (2.7%) and 21 male patients (2.0%) reported incidents of IPV within the past 6 months. The sex of the screener was not associated with the screening outcomes for male (odds ratio, 0.98; CI, 0.35-2.72) or female patients (odds ratio, 0.90; CI, 0.45-1.82). Conclusions: Sex of the screener does not appear to affect disclosure of IPV. These results support the continuation of existing screening practices and call for IPV detection at multiple stages throughout patient care. © 2007 Published by Elsevier Inc.

Poster presented at the 2006 American College of Emergency Physicians (ACEP) National Research Forum in New Orleans, La 1. Introduction (10/2006). ☆ Research supported by a grant from the Leonard Davis Institute of Current estimates suggest that over 250,000 patients are Health Economics at the University of Pennsylvania. treated annually within the ED for IPV-related injuries ⁎ Corresponding author. 1631 Mankato Ct, Claremont, CA 91711, USA. Tel.: +1 330 608 8527; fax: +1 215 823 4123. nationally [1]. Previous studies have shown that 12% to 54% E-mail addresses: [email protected], [email protected] of women and 8% to 16% of men within the ED report (L.B. Gerlach). current or previous abuse by their spouse or intimate partner

[2,3]. The high prevalence of IPV among ED patients 2.4. Data collection and processing therefore presents an opportunity to victims, whether they are presenting for an acute IPV-related injury or illness or they Intimate partner violence was detected using a 4-item are in an abusive relationship but are presenting for a questionnaire adapted from the Abuse Assessment Scale to condition not related to IPV [4]. measure both physical and psychological abuse over the past Few hospitals, however, have mandatory screening 6 months [10,11]. An indication of being hit, kicked, practices in place, and adherence to existing protocols is punched, or threatened by an intimate partner either recently relatively low [5,6]. Yet a positive screen for IPV is or at any time in the past 6 months was considered a predictive of future violence: female ED patients who “positive” IPV screen. All positive screens were reported to report IPV are an estimated 11.3 times more likely to the attending physician caring for the patient. experience physical violence in the future [7]. With the risk of revictimization so high, it is important to 2.5. Primary data analysis identify factors that may affect patients' likelihood to report IPV. Comparison of baseline demographic variables, health Although many studies have assessed the validity of status, medical history, and disposition was performed using existing screening measures, few studies have investigated χ2 tests and t tests. A crude determination of whether the the potential impact of sex of the screener on patient comfort screening outcome varied by screener sex was assessed using with discussing issues of IPV [8]. This study sought to χ2 tests. An adjusted test for a screener sex effect was determine whether the sex of the screener influences conducted using logistic regression with adjustment for both patients' self-reports of IPV. The findings should have patient and screener age and race and nonindependence implications for the design and performance of IPV screen- among screening staff. The fit of the models was evaluated ing measures. using conventional techniques [12]. All statistical measures were analyzed using the statistical software package Stata (version 9.0, StataCorp LP, College Station, Tex). 2. Methods

2.1. Study design 3. Results

We performed a cross-sectional survey to investigate 3.1. Characteristics of study subjects whether the sex of the screener affects the willingness of adult ED patients to disclose being the victim of IPV. This study A total of 2853 patients (63% female; mean age, 36 years; was approved by the university institutional review board. 67.5% African American, 22.9% white) completed IPV screening. Male and female patients did not differ signifi- 2.2. Setting cantly with respect to demographic information, chief complaint, or disposition (Table 1). Injury was the most The study was conducted at an urban ED with a level I common chief complaint among patients reporting either trauma center. This hospital is an academic and teaching recent or past IPV, for women and men alike. The types of facility that evaluates a census of 52,000 patients annually injuries that these patients presented with differed by sex, within the ED. with a greater number of female patients (53%) presenting for an assault as compared to males (37%). Chief complaints 2.3. Selection of participants of pain were also more common among those patients

We enrolled a consecutive sample (N = 2853) of all adult men and women (aged 18 to 64) who presented to Table 1 Baseline characteristics of the study group the ED from 7:00 AM to 00:00 AM. Data collection Demographic n (%) occurred 7 days/wk over an 8-week period in 2006. characteristics Female Male Screening was performed by academic associates, individuals trained in recruiting patients for clinical studies and Sex 1795 (62.9) 1058 (37.1) aware of the sensitive nature of IPV screening [9]. Prior to Age (median) 36 40 Race the administration of the screening questionnaire, verbal African American 1311 (73.2) 636 (60.3) consent was obtained in private examination rooms. American Indian 5 (0.3) 6 (0.6) Patients were considered ineligible if they were unable to Asian 31 (1.7) 11 (1.0) answer questions or were unable to provide consent due to White 316 (17.6) 310 (29.4) a language barrier (ie, non-English speaking), medical Other 128 (7.2) 92 (8.7) instability, or psychiatric disturbance. Does sex matter? Effect of screener sex in intimate partner violence screening 1049

signs of IPV within the ED, to the best of our knowledge, this Table 2 Baseline characteristics of screeners is the only study investigating the potential effect of screener Demographic characteristics n (%) sex on IPV screening outcomes in an urban ED. The results Women Men lend support for the continuation of mandatory screening Sex 11 (42.3) 15 (57.7) measures within the ED and further investigation into other Age (median) 23 23 factors that can potentially bias patient self-report of IPV. Race The prevalence of IPV within this study population was African American 0 1 (6.7) considerably lower than reported national averages as well as American Indian 0 0 previous studies published through this ED [2,6]. This Asian 4 (36.4) 5 (33.3) finding may be indicative of false-negative screens, White 7 (63.6) 7 (46.7) suggesting that the prevalence of IPV within this population Other 0 2 (13.3) was underestimated. A study limitation, then, is that if this Mean number of subjects 114 (49-165) 103 (44-151) potential misclassification of patients varies by the sex of the enrolled (range) screener, the relationship between screener sex and willingness to disclose IPV may be different than was reported here (ie, null). This finding suggests a need for a two-stage screening positive for IPV, whereas complaints of cardio- screening process, with the second stage conducted by pulmonary problems were negatively correlated with IPV. clinicians over the course of the interaction with the patient, Intimate partner violence screeners consisted of 26 aca- to try to capture a greater number of victims of IPV. Although demic associates (42.3% women; mean age, 23; 3.8% the current (screener only) method may be beneficial in African American, 53.8% white). Each screener enrolled on identifying a subset of victims, clinicians should conduct average 109 subjects (mean enrollment: female screeners, their own screening to identify a broader range of patients 114 subjects; male screeners, 103 subjects) throughout the currently undergoing abuse. duration of the study (Table 2). Recent studies have suggested that face-to-face screening Over the study period, the average weekly census methods may not be the most effective method to capture (24 hours/d inclusive) was 1066 patients (range, 986- information regarding sensitive topics such as IPV. Such 1123 per week). Of these visits, 80.1% of the visits occurred studies report that other methods such as a computer-based or between 7:00 AM and 00:00 AM. Comparing patients seen written self-completed questionnaire are preferred by during and not during the hours where screeners were patients over traditional face-to-face methods [13]. Although present, these two groups did not differ in terms of mean such methods may be preferred, IPV detection and age (39.8 vs 39.8 years, respectively, P = .97). The groups prevalence do not appear to be affected by the type of differed in a statistical sense, but not to a meaningful degree screening measure used. From a cost-effectiveness and substantively, when comparing by race (P = .06) (screening feasibility standpoint, face-to-face screening still remains an hours: 64.9% African American; 24.7% white; nonscreening inexpensive and easily implemented screening method. hours: 67.3% African American; 23.7% white) and by chief Further limitations arise in the unknown nature of the complaint (P = .03) (most common chief complaints among relationship of the victim-aggressor pair, which was not screening hours vs nonscreening hours: cardiopulmonary, assessed here. Studies suggest that same sex violence occurs 16.5% vs 17.1%; injury, 15.6% vs 14.8%). at levels equal to or potentially greater than heterosexual couples [14]. Given the possibility that the effects of screener 3.2. Main results sex on IPV disclosure may have differed among heterosexual

Intimate partner violence in the past 6 months (ie, a positive screen) was reported by 48 female patients (2.7 %) Table 3 Effect of sex on patient willingness to disclose and 21 male patients (2.0%). The sex of the screener was not incidents of IPV significantly associated with the screening outcomes for male (odds ratio, 0.98; CI, 0.35-2.72) or female patients Sex of patient Female Male (odds ratio, 0.90; CI 0.45-1.82; Table 3). (n = 1795) (n, %) (n = 1058) (n, %) Sex of screener Women Men Women Men Positive domestic 20 28 10 11 4. Discussion violence screen (2.5) (2.8) (2.1) (1.9) Negative domestic 782 965 467 570 violence screen (97.5) (97.2) (97.2) (98.1) The results of this study suggest that sex of the screener Pearson χ2 χ2 = 0.18, P = .67 χ2 = 0.06, P = .81 does not affect the IPV screening outcome for men or Logistic regression Odds ratio = 0.90 Odds ratio = 0.98 women. Despite the importance of adhering to and [0.45-1.82] [0.35-2.72] evaluating a consistent screening protocol to recognize the 1050 L.B. Gerlach et al. and homosexual relationships, control for and stratifying by Survey. Washington (DC): Department of Justice (US). [Publication this factor in future studies may produce results that inform No. NCJ 181867]. [4] Kothari CL, Rhodes KV. Missed opportunities: emergency depart- this issue. ment visits by police-identified victims of intimate partner violence. In summary, we have demonstrated that screener sex Ann Emerg Med 2006;47:190-9. does not appear to impact IPV screening outcomes for men [5] Ernst AA. Intimate partner violence: steps for future generations. or women within an urban ED setting. These results support Ann Emerg Med 2006;47:200-2. the continuation of existing screening practices and call [6] Datner EM, O'Malley M, Schears RM, et al. Universal screening for interpersonal violence: inability to prove universal screening improves for IPV detection at multiple stages throughout patient provision of services. Eur J Emerg Med 2004;11:35-8. care. In addition, these results highlight the importance of [7] Houry D, Feldhaus K, Perry B, et al. A positive domestic violence recognizing the signs of IPV and thoroughly screening screen predicts future domestic violence. J Interpers Violence 2004;19: patients presenting with a chief complaint of injury. 955-66. Although screener sex did not influence screening outcomes, [8] Shakil A, Donald S, Sinacore JM, et al. Validation of the HITS domestic violence screening tool with males. Fam Med 2005;37: it is possible that other characteristics may have a more 193-8. substantial effect. Future studies should therefore be aimed [9] Hollander JE, Valentine SM, Brogan GX. Academic associate at determining other factors that can potentially bias patient program: integrating clinical emergency medicine research with self-report of IPV such as race, ethnicity, and age of undergraduate education. Acad Emerg Med 1997;4:225-30. the screener. [10] Feldhaus KM, Zoziol-McLain J, Amsbury HL, et al. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61. [11] Reichenheim ME, Moraes CL. Comparison between the abuse References assessment screen and the revised conflict tactics for measuring physical violence during pregnancy. J Epidemiol Community Health [1] Greenfield LA, Rand MR, Craven D, et al. Violence by intimates: 2004;58:523-7. analysis of data on crimes by current or former spouses, boyfriends, [12] Hosmer DW, Taber S, Lemeshow S. The importance of assessing the and girlfriends. Washington (DC): Department of Justice (US); 1998 fit of logistic regression models: a case study. Am J Public Health [Publication No. NCJ 167237]. 1991;81:1630-5. [2] Abbott J, Johnson R, Koziol-McLain J, et al. Domestic violence [13] MacMillan HL, Wathen CN, Jamieson E, et al. Approaches to against women: incidence and prevalence in an emergency department screening for intimate partner violence in health care settings. JAMA population. JAMA 1995;273:1763-7. 2006;296:530-6. [3] Tjaden P, Thoennes N. Extent, nature, and consequences of intimate [14] Peterman L, Dixon C. Domestic violence between same-sex partners: partner violence: findings from the National Violence Against Women implications for counseling. J Couns Dev 2003;81:40-7. American Journal of Emergency Medicine (2007) 25, 1051–1056

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Brief Report

Left brachiocephalic vein perforation: computed tomographic features and treatment considerations Sheung-Fat Ko MDa,⁎, Shu-Hang Ng MDa, Fu-Ming Fang MDa, Yung-Liang Wan MDa, Ming-Jang Hsieh MDb, Po-Ping Liu MDc, Chia-Te Kung MDd, Ber-Ming Liu MDd aDepartment of Radiology, College of Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University, Kaohsiung 833, Taiwan bDepartment of Cardiovascular and Thoracic Surgery, College of Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University, Kaohsiung 833, Taiwan cDepartment of Traumatology, College of Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University, Kaohsiung 833, Taiwan dDepartment of Emergency Medicine, College of Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University, Kaohsiung 833, Taiwan

Received 22 May 2007; revised 11 June 2007; accepted 13 June 2007

Abstract Objective: To report the clinical and computed tomographic findings of 5 cases of left brachiocephalic vein perforation (LBCVP). Methods: The clinical and imaging features of 5 patients with LBCVP (1 woman, 4 men; mean age, 57.6 years) encountered over the last 2 decades were reviewed. Results: Etiologies included left jugular central catheter penetration in 2 patients, blunt trauma in 2, and idiopathic in 1. All patients manifested acute chest pain with a widened mediastinum on chest radiographs. Characteristic computed tomographic features included a cord-like hematoma along the course of the left brachiocephalic vein associated with a left upper anterior mediastinal hematoma (AMH). Three clinically stable patients with AMH smaller than 5 cm convalesced after conservative treatment and 2 clinically unstable patients with AMH bigger than 7 cm recovered well after surgery. Conclusions: Computed tomography is helpful in diagnosing LBCVP. Under close surveillance, patients with stable LBCVP with AMH smaller than 5 cm may be managed conservatively. However, emergency surgery is warranted if there are any signs of instability. © 2007 Elsevier Inc. All rights reserved.

1. Introduction

Percutaneous central venous catheter placement for administration of drugs or parenteral nutrition, monitoring ⁎ Corresponding author. of central venous or pulmonary arterial pressure, and short- E-mail addresses: [email protected], [email protected] term dialysis is more and more common in medical practice. (S.-F. Ko). However, owing to the angulation between the left internal

Table 1 Summary of clinical and CT features of 5 patients with left brachiocephalic vein perforation Case No. Age/sex Clinical features Blood pressure/ CT Findings Treatment Follow-up hemoglobin 1 60 y/F Acute sharp chest pain 100/76 mm Hg/ Cord-like hematoma along LBCV, Medical 1 y, A after left jugular central 9.3 g% left AMH (5 × 2 cm) with catheter insertion lower AM extension 2 53 y/M Acute sharp chest pain 110/70 mm Hg/ Cord-like hematoma along LBCV, Medical 3 y, A after left jugular central 9.8 g% left AMH (4 × 2 cm) with catheter insertion lower AM extension 3 57 y/M Sharp chest pain after 106/65 mm Hg/ Cord-like hematoma encasing LBCV Medical 6Y, A MVA 9.1 g% with subtle contrast agent leakage, left AMH (5 × 3 cm) with lower AM extension 4 60 y/M Sharp chest pain after 86/48 mm Hg/ Cord-like hematoma along LBCV, Left BCV 10 y, A MVA 7.6 g% left AMH (10 × 8 cm) with fluid-fluid ligation level and lower AM extension 5 58 y/M Acute sharp chest pain 98/66 mm Hg/ Cord-like hematoma along LBCV, Venoplasty 14 y, A 8.7 g% left AMH (7 × 5 cm) with lower AM extension, aortic arch saccular aneurysm (5 × 3 cm) A indicates alive; AM, anterior mediastinal, M, male; F, female; MVA, motor-vehicle accident.

jugular and left brachiocephalic vein (LBCV), an inadver- underwent conservative treatment after the diagnosis was tently torqued catheter over this angulation may lead to established based on the clinical and CT findings, and a catastrophic vascular injury [1-3]. Blunt chest trauma may follow-up CT was performed 1 month after discharge. A injure intrathoracic vessels and usually affects the aorta, 3-month follow-up CT was also performed for patient 3. The arch vessels, and small mediastinal veins [4-9].Left remaining 2 patients underwent emergency surgery. brachiocephalic vein perforation (LBCVP) caused by chest trauma is rare [9]. Spontaneous brachiocephalic vein rupture is extremely unusual, and, to our knowledge, only 1 case of 3. Results simultaneous rupture of the subclavian artery and brachiocephalic vein, in a 25-year-old man with Ehlers-Danlos The clinical and CT findings of the patients are syndrome, has been documented [10]. The objective of this summarized in Table 1. study was to present our experience of 5 unusual cases of LBCVP with an emphasis on computed tomographic features and treatment implications. 3.1. Clinical findings

The patients included 1 woman and 4 men (age range, 53-60 years; mean, 57.6 years). None had prior history of 2. Methods vascular or connective tissue disease, but patients 1 and 5 had a history of hypertension for more than 10 years. Patient 1 From July 1986 through March 2007, of approximately was a 60-year-old woman with dyspnea and was referred to 1.3 million ED visits (approximately 60000-65000 visits our ED by a community hospital owing to acute sharp chest each year), a total of 5 cases of LBCVP were found after a pain after a central catheter was inserted via the left jugular retrospective investigation of the hospital database. The vein. Patient 2 was admitted for lumbar spine surgery but medical records of these patients were reviewed for clinical experienced sharp chest pain after a central catheter was presentation, known prior diseases, pertinent laboratory data, inserted via the left jugular vein. Because of chest pain and and outcomes. All patients had chest radiographs for poor venous return, the catheters were subsequently evaluation. The chest radiographs of 2 patients were obtained removed. Patients 3 and 4 presented with chest pain 1 to after central venous catheter removal, whereas the radio- 2 hours after blunt chest trauma in motor vehicle accidents. graphs of the other 3 patients were taken within 15 minutes Patient 5 presented with acute sharp chest pain without after arrival at the ED. Three patients had noncontrast radiation to the back and there was no operation history or computed tomography (CT; patients 1, 2, and 4 in Table 1) recent trauma. This patient was a retired soldier and had a and 2 patients (patients 3 and 5 in Table 1) had both history of blunt chest and abdominal trauma due to an noncontrast and contrast CT for analysis. Three patients explosive injury, in which he recovered after conservative Left brachiocephalic vein perforation: CT 1053

Fig. 2 Case 3. A, Noncontrast CTrevealing a cord-like hyperdense hematoma (small white arrows) along the course of the LBCV and a left upper AMH (big white arrow). B, Computed tomography revealing subtle extravasation (open arrows) of the contrast agent from the LBCV that is encased by a cord-like hematoma.

treatment, 10 years before this admission. All patients experienced a decline in both blood pressure and hemoglobin levels. Otherwise, physical and laboratory examination results were unremarkable.

3.2. Imaging features

On chest radiographs, a widened mediastinum (Fig. 1A) was demonstrated in all 5 patients but there was no pneumomediastinum. For patients 1 and 2, noncontrast CT

Fig. 1 Case 1. A, Chest radiograph revealing widening of the mediastinum. B, Noncontrast CT revealing a cord-like hyperdense hematoma (small black and white arrows) along the anterior border of the LBCV (open arrows) and a left upper AMH (big white arrow). C, Computed tomography showing a left AMH (big white arrow) and caudal extension of the hematoma (small black and white arrows) into the lower anterior mediastinal fat. 1054 S.-F. Ko et al.

hematoma (Fig. 4A and B) and a saccular aortic aneurysm with mural thrombus.

3.3. Surgical findings, treatment outcome, and follow-up

Patients 1, 2, and 3 were hemodynamically stable and were treated conservatively. Complete resolution of the cord-like perivenous hematoma and AMH in patients 1 and 2 was demonstrated on the 1-month follow-up CT. For patient 3, total regression of the lesions was shown on the 3-month follow-up CT. Patients 4 and 5 underwent emergency surgery owing to rapidly deteriorating hemodynamic status under the initial impressions of AMH with

Fig. 3 Case 4. A, Noncontrast CT revealing a large left upper AMH (big white arrows) with intralesional fluid-fluid level (open arrows) and a cord-like hyperdense hematoma (small white arrows) along the course of the LBCV. B, Computed tomography revealing caudal extension of the hematoma (black and white arrows) anterior to the parietal pericardium.

revealed a cord-like hyperdense hematoma along the anterior border of the LBCV, the presence of left upper anterior mediastinal hematoma (AMH), and caudal extension of the hematomas into the lower anterior mediastinum anterior to the parietal pericardium (Fig. 1B and C). For patient 3, in addition to a left AMH, contrast CT revealed subtle leakage of the contrast agent from the LBCV, which was encased by a perivenous cord-like hematoma (Fig. 2). For patient 4, noncontrast CT clearly depicted a cord-like hematoma along the course of the LBCV, a large left AMH with intralesional fluid-fluid level, which was suggestive of Fig. 4 Case 5. A, Contrast CT showing a cord-like hematoma active bleeding, and caudal extension of the hematoma (small black and white arrows) along the course of the LBCV and a into the lower anterior mediastinum (Fig. 3A and B). For left AMH (large arrow). Note the saccular aortic arch aneurysm patient 5, besides a characteristic cord-like hematoma, (open arrow). B, Computed tomography revealing caudal extension there was also a left AMH with caudal extension of the of the hematoma (arrows) anterior to the parietal pericardium. Left brachiocephalic vein perforation: CT 1055 active bleeding and suspected rupture of aortic aneurysm, eventually turn out to be normal [12,14]. As in our cases, the respectively. For patient 4, a large AMH due to a 2-cm LBCV lesion could hardly be disclosed, even if emergency laceration in the anterior wall of the LBCV at the left thoracic arteriograms had been performed. parasternal level was found during surgery, and the Computed tomography has been reported to be useful LBCV beyond the laceration was collapsed and partially in evaluating traumatic and nontraumatic causes of a encased by some perivenous blood clots. The lacerated widened mediastinum [1,4,5,7,11,12]. In the present study, part was ligated. For patient 5, the surgeons found an AMH CT was useful for confirming the presence of mediastinal due to a 1-cm laceration in the anterior wall of the LBCV at hematoma in all of our cases. However, mediastinal the left parasternal level and the LBCV beyond the hematomas may not necessarily be associated with aortic laceration was encased by a perivenous hematoma. The rupture. Nonaortic sources include mediastinal small veins; laceration was managed with venoplasty. In addition, an arch or thoracic cage vessels; fractures of the sternum, ribs, aortic aneurysm was noted but there was no evidence of and spine; and, rarely, as in our cases, injury to the LBCV aneurysmal rupture. Histopathologic examination of the [1,7-9,12]. Wicky et al [1] reviewed the clinical and brachiocephalic vein wall specimens showed no underlying imaging features of 11 cases of severe vascular complica- vascular lesions. All patients recovered without recurrence tions after central venous catheter misplacement. Among of LBCV lesions during follow-up (range, 1-14 years; them, 3 had LBCVP due to misplacement of a dialysis mean, 5.6 years). catheter through the left jugular vein. From an anatomical viewpoint, central catheter insertion via the left internal jugular vein is a potential site of perforation due to the sharp angulation (106° ± 9°) of the LBCV as it drapes over 4. Discussion the aorta or arch vessels. A central catheter inadvertently torqued at this angulation may make direct contact with the Acute chest pain is a commonly encountered problem vessel wall and even cause perforation [2,15]. Computed in the ED. It may occur in a variety of disease processes tomography allows definitive diagnosis when the distal tip involving the cardiovascular system, respiratory system, of the catheter has coursed outside the vascular structures. gastrointestinal tract, and/or musculoskeletal system. A Furthermore, other findings, such as pneumothorax, thorough history and physical examination are the first hemopericardium, and even life-threatening arterial injury, steps in evaluating such patients [5,6,11]. Among our cases, can be demonstrated [1]. Three-dimensional CT demonstra- a pertinent clinical history of acute chest patient after catheter tion of a case of LBCVP by a pacemaker lead with its tip insertion via the left jugular vein was highly suggestive of positioned in between the mediastinal pleura and the catheter-induced vascular injury in patients 1 and 2. Patients parietal pericardium has recently been described [3]. 3 and 4 were victims of motor vehicle accidents, and thoracic In patients 1 and 2, CT was performed after the catheter injury with traumatic aortic rupture was initially suspected. was removed and the exact perforation site, presumably at For patient 5, acute aortic syndrome or coronary arterial the sharp angulation of the LBCV as it drapes over the disease was probable in this elderly man with a long history aorta, could not be demonstrated. Nevertheless, CT clearly of hypertension. depicted the medial spread of hemorrhage via the anterior Chest radiography has traditionally been the primary wall of the LBCV, accumulation of blood at the angulation screening method for chest pain [5,11]. For patients 1 and 2, site forming a left AMH, and subsequent caudal extension a widened mediastinum on the chest radiographs was of the hematoma into the mediastinal fat anterior to the suggestive of vascular complications, probably involving parietal pericardium. the LBCV, due to advertent central catheter penetration. For a widened mediastinum caused by trauma, a Further confirmation and assessment of the site of catheter- negative chest CT offers an approximately 100% negative induced venous or arterial injury, and lesion extent are predictive rate of aortic injury [4,5,12]. In contrast, using important for treatment decision making [1-5]. For patients hemomediastinum as the sole CT criterion for predicting 3, 4, and 5, a widened mediastinum was evocative of aortic injury, the positive predictive value varies from 50% traumatic aortic rupture in patients 3 and 4, and acute aortic to 90% for small traumatic pseudoaneurysms that may be lesion in patient 5. However, improper radiographic overlooked and mediastinal hemorrhage that may be the technique, multiple injuries, and/or altered mental status of result of leakage from a small artery or vein [4,12]. In our the patient may lead to a false-positive finding [5,12,13].In series, CT did not show any abnormal density around the addition, patients with paraspinal hemorrhage, paramediast- aorta or the major arteries but it depicted a cord-like inal lung contusion, a tortuous aorta, or mediastinal perivenous hematoma along the course of the LBCV, a left lipomatosis may also exhibit a widened mediastinum upper AMH and caudal extension of the hematoma into the [6,7,12,13]. Immediate thoracic angiography based solely lower anterior mediastinal fat in front of the parietal on abnormality found on a chest radiograph may reveal only pericardium. Computed tomography demonstration of 10% to 20% of cases that actually have aortic injury, whereas subtle leakage of contrast agent from the LBCV further a substantial number of such angiographic examinations added weight to the diagnosis of patient 3. For patient 4, 1056 S.-F. Ko et al. consistent with the rapid deterioration in hemodynamic References status, the presence of a large left AMH with fluid-fluid level was highly suggestive of active bleeding. For patient [1] Wicky S, Meuwly JY, Doenz F, et al. Life-threatening vascular 5 with clinical presentations mimicking acute aortic complications after central venous catheter placement. Eur Radiol syndrome, the direct or immediate cause of LBCVP 2002;12:901-7. could not definitively be identified. There was no history [2] Senderoff E, Lutchman G, Shevde K. Catheter-induced innominate vein perforation: anatomical considerations. J Cardiothorac Anesth of thoracic surgery, recent trauma, or underlying connective 1987;1:57-8. tissue disease. However, in this retired soldier, we postulate [3] Igawa O, Adachi M, Yano A, et al. Brachiocephalic vein perforation on that prior explosive injury with blunt chest trauma might three-dimensional computed tomography. Europace 2007;9:74-5. plausibly induce vascular insult, which might be a [4] Mirvis SE, Shanmuganathan K, Miller BH, et al. Traumatic aortic predisposing factor of LBCVP. injury: diagnosis with contrast-enhanced thoracic CT-five-year experience at a major trauma center. Radiology 1996;200:413-22. Surgical intervention for large mediastinal hematomas is [5] Wilson D, Voystock JF, Sariego J, et al. Role of computed tomography recommended in patients with rapid clinical deterioration scan in evaluating the widened mediastinum. Am Surg 1994;60:421-3. that may be unexpectedly fatal [1,4-8,12,13]. Patients 1, 2, [6] Geusens E, Pans S, Prinsloo J, et al. The widened mediastinum in and 3 had a stable clinical status and AMH of less than trauma patients. Eur J Emerg Med 2005;12:179-84. 5 cm in size, and they were successfully managed with [7] Braatz T, Mirvis SE, Killeen K, et al. CT diagnosis of internal mammary artery injury caused by blunt trauma. Clin Radiol 2001;56: conservative treatment. However, close surveillance is 120-3. important in such patients and surgery is warranted if [8] Sloan TJ, Burch BH. Large mediastinal hematomas not associated with there are any signs of hemodynamic instability. The other aortic rupture. Case presentations and surgical approach. Chest 1983; 2 patients had rapid clinical deterioration and AMH of 83:109-11. greater than 7 cm in size, as measured on CT. Such CT [9] Graham JM, Feliciano DV, Mattox KL, et al. Innominate vascular injury. J Trauma 1982;22:647-55. findings, especially for patient 4 with fluid-fluid level [10] Dalton ML, Bricker DL, Nannini L. Spontaneous rupture of the within the AMH, might be suggestive of large vascular subclavian artery and innominate vein. Arch Surg 1974;109:552-4. damage and, thus, spontaneous regression is arduous. [11] Bonomo L, Di Fabio F, Rita Larici A, Merlino B, Luigia Storto M. Fortunately, both patients underwent emergency surgery Non-traumatic thoracic emergencies: acute chest pain: diagnostic and recovered well. strategies. Eur Radiol 2002;12:1872-85. [12] Wong YC, Wang LJ, Lim KE, et al. Periaortic hematoma on helical CT In summary, this case series highlights that CT is helpful of the chest: a criterion for predicting blunt traumatic aortic rupture. in diagnosing LBCVP with characteristic features including AJR Am J Roentgenol 1998;170:1523-5. a cord-like hematoma along the course of the LBCV [13] Attar S, Ayella RJ, McLaughlin JS. The widened mediastinum in associated with a left upper AMH and variable degrees of trauma. Ann Thorac Surg 1972;13:435-49. caudal anterior mediastinal extension of the hematoma. [14] Mirvis SE, Bidwell JK, Buddemeyer EU, et al. Value of chest radiography in excluding traumatic aortic rupture. Radiology 1987; Under close surveillance, stable patients with LBCVP and 163:487-93. AMH b5 cm in size may be managed conservatively. [15] Salik E, Daftary A, Tal MG. Three-dimensional anatomy of the left However, emergency surgery is warranted if there are any central veins: implications for dialysis catheter placement. J Vasc signs of instability. Interv Radiol 2007;18:361-4. American Journal of Emergency Medicine (2007) 25, 1057–1062

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Diagnostics Whole-body multislice computed tomography as the primary and sole diagnostic tool in patients with blunt trauma: searching for its appropriate indication

Thomas Erik Wurmb MDa,*, Peter Fru¨hwald MDb, Wittiko Hopfner Cand Medc, Norbert Roewer MDa,Jo¨rg Brederlau MDa aKlinik und Poliklinik fu¨r Ana¨sthesiologie der Universita¨t Wu¨rzburg, 97080 Wu¨rzburg, Germany bInstitut fu¨r Radiologie, Heinrich-Braun-Krankenhaus Zwickau, 08060 Zwickau, Germany cUniversta¨t Wu¨rzburg, Medizinische Fakulta¨t, 97080 Wu¨rzburg, Germany

Received 30 November 2006; revised 8 January 2007; accepted 18 March 2007

Abstract In our hospital, whole-body multislice computed tomography is used as the primary diagnostic tool in patients with suspected multiple trauma. A triage rule is used for its indication. We have retrospectively analyzed data of sedated, intubated and ventilated patients consecutively admitted to our trauma center to assess whether the triage rule can help identify patients with severe trauma (injury severity score z16). We have found that overtriage (injury severity score b16) occurs in 30%, and undertriage occurs in 6% of patients. Although we have found the triage rule to be highly sensitive, this results in a high rate of overtriage. Until we know more about the most relevant and independent predictive factors, sole reliance upon multislice computed tomography in triaging suspected polytrauma victims will imply the risk to overscan many patients. D 2007 Elsevier Inc. All rights reserved.

1. Introduction [1-6]. Especially, the development of multislice spiral computed tomography (MSCT) has led to substantial The initial diagnostic workup, including a fast and refinement in the diagnostic workup [4,5,7]. One of the priority-based physical examination of trauma patients, is most important technical improvements is time gain by a very important element of a well-defined trauma using predefined scan protocols and standardized scan management. Traditionally, conventional radiography and parameters. Whole-body MSCT can rapidly reveal all ultrasound is completed by organ focused computed injuries [2,5,7-10] resulting in an immediate treatment plan. tomography (CT) [1,2]. In the last years, CT has gained Whether whole-body MSCT or conventional radiography importance in the early diagnostic phase of trauma care combined with ultrasound and organ-focused CT scans should be used as the primary diagnostic tool remains a subject of an ongoing discussion [2,4,5,11]. The use of * Corresponding author. Tel.: +49 931 20130043; fax: +49 931 201. MSCT depends on the hospitals’ financial resources and its E-mail addresses: [email protected] (T.E. Wurmb)8 [email protected] (P. Fru¨hwald)8 [email protected] availability nearby or directly in the resuscitation room. If (W. Hopfner)8 [email protected] (N. Roewer)8 whole-body MSCT is used for initial diagnostic workup in [email protected] (J. Brederlau). trauma patients, it is mandatory to identify patients with

Table 1 Multiple trauma triage scheme Category I, mechanism of trauma Category II, vital signs Category III, clinical apparent injuries Falls N5 m Blood pressure b80 mm Hg Flail chest Traffic accident Respiratory rate b10; others, N29 Open chest wound 1. High-speed crash 2. Crash against a truck 3. Pedestrian thrown or run over Auto crash Pulse oxymetry b90% Open abdominal wound 1. Patient trapped in the car 2. Roll over 3. Head-on collision 4. Ejection from auto 5. Death in same passenger compartment Explosion, buried person Intubated patient with an Unstable pelvis initial GCS b9 on scene z2 Proximal long-bone fractures Amputation proximal to wrist or ankle GCS, Glasgow Coma Scale. suspected serious injuries to justify the higher radiation patients with severe trauma (ISS z16) and thereby dose. Another important aspect is to treat life-threatening justifying whole-body MSCT. conditions before starting whole-body MSCT. Therefore, implementation of a CT diagnostic phase in a priority-based trauma algorithm seems to be reasonable [1,6,12]. In our 2. Protocols and clinical experience level 1 trauma center, the indication for whole-body MSCT is set by using a systematic triage rule. It is based on a triage Trauma patients, who were admitted to the trauma suite system that was published in 1994 by Nast-Kolb et al [13]. of Wuerzburg University Hospital, have been studied. Data We assumed that trauma screening with whole-body MSCT of 126 traumatized, sedated, endotrachealy intubated or is justified in patients with an injury severity score (ISS) of ventilated patients who had consecutively been delivered to 16 or greater. Objective of this retrospective data analysis the trauma suite over a period of 6 months have been was to assess whether the triage rule helped identifying retrospectively analyzed (data of patients with localized

Fig. 1 Trauma resuscitation room with MSCT bsliding gantry.Q The flash assigns the direction of the moving gantry. Screening trauma patients with MSCT 1059

Table 2 Predefined scan protocol of the whole-body MSCT Series 1 (head and cervical spine) Series 2 (thorax and abdomen) Series 3 (thorax and abdomen) (early) (late) Slice thickness 2 mm 3 mm 5 mm Collimation 16 Â 0.75 16 Â 0.75 16 Â 0.75 Contrast media – + + Contrast media flow – 3 mL/s 3 mL/s Total contrast media – 150 mL points of impact, which required a localized workup, were trauma protocol including conventional plain film radiog- not included in the analysis). raphy of the cervical spine, the chest, the pelvis, and According to our standardized trauma concept, all ultrasound of the abdomen is initiated. If the conventional patients have initial resuscitation and are then sub- trauma protocol is inconclusive or reveals injuries that need jected to a scoring system (triage rule) to decide for to be addressed with CT, an organ-focused CT examination further diagnostics. is performed afterwards. Alternatively, the patients are either diagnosed by whole-body MSCT (CT trauma protocol) or by conven- 2.2. Computed tomographic trauma protocol tional radiological methods including plain film radiogra- Our concept is based on whole-body MSCT as the first- phy, ultrasound, and an organ-focussed CT (conventional line diagnostic tool in trauma patients (CT trauma protocol). trauma protocol). A multislice CT with a 16-row scanner (bsliding gantry,Q 2.1. Triage rule Somatom Sensation 16; Siemens AG Medical Solutions, Forchheim, Germany) is installed directly in the resuscita- According to our trauma protocol, we screen trauma tion room of the trauma suite. Any technical equipment patients in a standardized manner to decide on diagnostic needed for the management of severe traumatized patients is measures. The scheme consists of 3 categories with different available in this room. Once placed on the carbon CT parameters in each category. The triage rule is shown in examining and intervention table, the patient’s position is Table 1. If just 1 parameter in 1 of the 3 categories is not modified. Any life-saving procedures, including airway positive, serious injuries in one or more organ systems are management, emergency laparotomy, or thoracotomy can be suspected [13]. The CT trauma protocol will be initiated. If performed on that table [6]. Before starting the CT scan, a the patient fails to meet one of the criteria, conventional priority-based physical workup is done for an initial assessment and resuscitation. Emergency ultrasound of chest and abdomen (focused assessment with sonography for trauma) is performed in hemodynamically unstable patients. The CT scan starts when life-threatening problems have been resolved. Any device such as respirator tubing, central venous lines, and others can be left unchanged in their position, whereas the mobile sliding CT gantry is moving from toe to head of the patient [6] (Fig. 1). The whole-body MSCT is performed according to a predefined standardized protocol (Table 2). It consists of a scout view (anteroposterior topogram of 150-cm length) (Fig. 2) and 3 series of scans: (1) native scan of the head and

Fig. 2 Scout view showing severe lung contusion. Fig. 3 Results. 1060 T.E. Wurmb et al.

ISS takes values from 0 to 75. If an injury is assigned AIS of Table 3 Radiological findings in patients with overtriage 6, the ISS score is automatically 75 [14]. 9/26 Moderate Serious The results have been analyzed by a 2 Â 2 table. Pulmonary contusion n = 2 n = 5 Sensitivity, specificity, and positive and negative predictive Spine injuries n = 1 values have been calculated to evaluate the quality for the triage rule as a screening test for appropriate whole-body the cervical spine; (2) early bvascular phaseQ with intrave- MSCT indication. nous contrast media of chest, abdomen, and pelvis; and (3) late bparenchymal phaseQ of chest, abdomen, and pelvis. If not yet diagnosed by the clinical evaluation, the scout view 3. Results can visualize life-threatening thoracic injuries (tension One hundred twenty-six traumatized, sedated, endotra- pneumothorax, hematothorax, etc). They are treated imme- chealy intubated and ventilated patients were admitted to diately before starting the scan series. our trauma resuscitation room between March and July 2.3. Injury severity scores 2004. Data from 120 trauma patients were analyzed. Six patients were not included in the evaluation. Four were The ISS is routinely used as value to describe the severity treated simultaneously to other multiple trauma patients of trauma [14]. We assume that patients with an ISS of 16 or occupying the resuscitation room with the CT scanner. Two greater were appropriately matched to the CT trauma patients were dead on arrival in the emergency department. protocol because they are major trauma victims according There were 91 men (72%) and 35 women (28%), with an to the literature [15-18]. Patients who received whole-body average age of 41 years, ranging from 8 to 82 years. The MSCT but had an ISS below 16 retrospectively are defined average ISS was 19 (range, 3-75). Twenty-six patients as overtriaged. (21%) had an ISS of 3; 33 patients (26%), 4 to 15; 65 patients (51%), 16 to 74; and 2 patients (2%), 75. 2.4. Protocol and statistics As judged by the triage result, 85 patients (70%) were In all trauma patients, the ISS was calculated retrospec- assigned to be diagnosed by the CT trauma protocol, and 35 tively and was correlated with the result from the triage patients (30%) were assigned to be diagnosed by the scheme. Overtriage is defined as the use of CT trauma conventional trauma protocol. Six patients were excluded protocol in patients with an ISS below 16. Undertriage is from data analysis. From those patients diagnosed by defined as conventional trauma protocol used in patients conventional trauma protocol (n = 35), 2 patients (6%) with an ISS of 16 or greater. Appropriate indications are had an ISS of 16 or greater retrospectively (undertriage) presumed when patients have an ISS of 16 or greater, and (Fig. 3). They received whole-body MSCT after the whole-body MSCT was used. conventional trauma protocol. Their injuries were more For calculating the ISS, the Abbreviated Injury Scale serious than expected by triage. One patient presented with a (AIS) is determined by a staff medical doctor experienced in short period of unconsciousness after a bike accident (injury trauma care and radiological diagnostic. The AIS is an pattern: subarachnoidal hemorrhage, pulmonary contusion, anatomical scoring system. Injuries are ranked on a scale of rib fracture, and scapula fracture; ISS = 26). The other 1to6,with1beingminorand6representingan patient was hit by a steel plate and presented with fractures unsurvivable injury. The AIS is determined for 6 body of both lower legs (injury pattern: pelvis fracture, disrupture regions (head, face, chest, abdomen, extremities, and of the femoral artery with serious hemorrhage, and bilateral external). For calculating the ISS, the 3 most injured body distal femur fractures; ISS = 33). regions have their AIS squared and are added together. The From those patients (n = 85) diagnosed by CT trauma protocol, 59 (70%) had an ISS of 16 or greater and 26 (30%) had an ISS below 16 (overtriage) (Fig. 3). Nine of them Table 4 Triage criteria in overtriaged patients who had (35%) had significant injuries, whereas the ISS was below significant injuries 16 (Table 3). The triage criteria for these patients are shown Patient Triage criterion in Table 4. 1 Fall N5m 2 High-speed crash Table 5 Two-by-two table P 3 Autocrash against truck Triage with multiple trauma triage scheme 4 Rollover 5 Head-on collision CT trauma Conventional trauma protocol 6 High-speed crash protocol 7 Fall N5m ISS z16 59 2 61 8 Ejection from auto PISS b16 26 33 59 9 Blood pressure b80 mm Hg 85 35 120 Screening trauma patients with MSCT 1061

Table 6 Sensitivity, specificity, positive predictive value, and the negative predictive value Sensitivity Specificity Positive predictive value Negative predictive value Ratio 59/61 33/59 59/85 33/35 96.7% 55.9% 69.4% 94.3%

Patients who were first matched for the conventional deaths in trauma patients [5,23-25]. There is evidence that trauma protocol and received an organ-focused CT scan MSCT is superior to conventional x-ray in the diagnosis of after conventional diagnostics (eg, isolated head trauma) thoracic injuries [2,5,7,25,26], and therefore, whole-body were not classified as undertriage (n = 5; 2%). MSCT in trauma patients might be justified to reveal serious Sensitivity of the triage system was 96.7%; specificity isolated organ injury. was 55.9%. The positive predictive value of the triage One patient diagnosed by the CT trauma protocol with an system was 69.4%; the negative predictive value was 94.3% ISS below 16 had thoracic and lumbal vertebral fractures (Tables 5 and 6). (Th12, L1, L2). Multislice spiral computed tomography is invaluable in the evaluation of the traumtatized spine; it is superior to plain films delineating extension of fracture 4. Discussion fragments into the spine canal [10,27-29]. For clearing the cervical spine, MSCT is superior to plain film radiography The ISS is routinely used to describe the severity of [30-34], especially in intubated patients, where the cranio- trauma. According to the literature, an ISS of 16 is taken as cervical junction and the lower cervical spine is often a cutoff value to define major trauma [15-18]. We assumed difficult to evaluate [34,35].Wintermarketal[36] that trauma screening with whole-body MSCT is justified in conducted a prospective study to determine whether MSCT those patients. can replace conventional radiography and can be performed In the group of overtriaged patients, there were 9 (34%) alone in severe trauma patients for depiction of thoraco- of 26 patients who had relevant findings in the whole-body lumbar spine fractures. They concluded that MSCT can MSCT. Eight of them had pulmonary contusions and one replace plain radiography and can be performed alone in had vertebral fractures (Table 3). patients who have sustained severe trauma. For that reason, Because lung contusions contribute to an increased MSCT seems to be justified in all trauma patients suspicious morbidity and mortality in trauma patients [5,19], those for spine fractures, especially in sedated and intubated injuries should not be missed in the early diagnostic patients. Brown et al [8] adopted spiral CT as the primary workup. The value of the thoracic CT in the assessment of modality for the diagnosis of spine fractures. The authors trauma patients with blunt chest trauma was demonstrated stated that routine plain radiographs of the spine are not by Trupka et al [5]. The authors performed a prospective necessary in the evaluation of blunt trauma patients when study in 103 trauma patients with clinical or radiological spiral computed tomography is used [8]. In a recent meta- signs of chest trauma. Patients were diagnosed by conven- analysis, Holmes and Akkinepalli [9] found no randomized tional chest x-ray and thoracic computed tomography, and controlled trial but ample evidence that CT significantly the results were compared looking at additional findings in outperforms plain radiography as a screening test in patients the CT scan. It was concluded that thoracic CT is highly with high risk of cervical spine injury [9]. sensitive in detecting thoracic injuries after blunt chest The main goal of our protocol using a systematic triage trauma and is superior to routine chest x-ray in visualizing rule was to minimize overtriage to avoid higher radiation lung contusions, pneumothorax, and hematothorax. The dose associated with whole-body MSCT. A comparison of authors reported a significant change in therapeutic man- radiation exposure from whole-body MSCT and conven- agement caused by CT scan results. They recommended tional radiography with organ-specific CT was published by thoracic CT in the initial diagnostic workup of patients with Wedeg7rtner et al [37]. The authors calculated the radiation multiple injuries and with suspected chest trauma. In our dose of 5 different diagnostic procedures. First was whole- patients, there were 8 of 26 with an ISS below 16, who had body MSCT. Second was conventional plain film radiogra- significant thoracic injuries diagnosed by whole-body phy including chest; cervical, thoracic, and lumbar spine in MSCT. Although an ISS below 16 indicates that those two views; as well as pelvis. Third was conventional patients did not match for the diagnosis multiple trauma, radiography, as described above, in combination with application of whole-body MSCT seemed to be justified organ-specific CT. The CT examination included head with retrospectively because not detecting those injuries might cervical spine (combination a), head with cervical spine, and have had a negative impact on the patients’ outcome. It is chest (combination b) or head with cervical spine and well known that most injuries missed in the early phase of abdomen (combination c). The effective doses were 20 mSv trauma management are abdominal or thoracic in origin for whole-body MSCT, 2 mSv for conventional radiogra- [20-22], representing the leading causes for preventable phy, 6.8 mSv for combination a, 10.3 mSv for combination 1062 T.E. Wurmb et al. b, and 18 mSv for combination c. The authors concluded [15] Copes WS, Champion HR, Sacco WJ, et al. The injury severity score that whole-body MSCT in multiple trauma patients com- revisited. J Trauma 1988;28:69-77. pared to conventional radiography with organ-specific CT [16] Esposito TJ, Offner PJ, Jurkovich GJ, et al. Do prehospital trauma center triage criteria identify major trauma victims? Arch Surg 1995; induces a 3-fold increased dose in unfavorable situations 130:171-6. and no increased dose in favorable situations [37]. [17] Stalp M, Koch C, Ruchholtz S, et al. Standardized outcome evaluation As the superiority of MSCT is widely accepted for organ- after blunt multiple injuries by scoring systems: a clinical follow-up focused diagnostics after trauma, its appropriate indication investigation 2 years after injury. J Trauma 2002;52:1160-8. as a sole and primary diagnostic tool remains unclear, [18] Stewart TC, Lane PL, Stefanits T. An evaluation of patient outcomes before and after trauma center designation using trauma and injury especially in those patients with only suspected major severity score analysis. J Trauma 1995;39:1036-40. trauma. Although using a highly sensitive triage rule, we [19] van Olden GD, Meeuwis JD, Bolhuis HW, et al. Clinical impact of found overtriage in 30% of our patients. Therefore, the advanced trauma life support. Am J Emerg Med 2004;22:522-5. triage rule needs to be reevaluated. Further studies are [20] Hirshberg A, Wall Jr MJ, Allen MK, et al. Causes and patterns of required to elucidate the most relevant and independent missed injuries in trauma. Am J Surg 1994;168:299-303. [21] Ledgerwood AM, Lucas CE. Postoperative complications of abdom- predictive factors for the need of a whole-body MSCT in inal trauma. Surg Clin North Am 1990;70:715-31. early trauma care. The risk of overscanning the patient must [22] Nast-Kolb D, Waydhas C, Kastl S, et al. The role of an abdominal be carefully weighted against the risk of missing pertinent injury in follow-up of polytrauma patients. Chirurg 1993;64:552-9. injuries in patient with severe trauma. [23] Johnson JA, Cogbill TH, Winga ER. Determinants of outcome after pulmonary contusion. J Trauma 1986;26:695-7. [24] Obertacke U, Neudeck F, Majetschak M, et al. Local and systemic reactions after lung contusion: an experimental study in the pig. Shock References 1998;10:7-12. [25] Rieger M, Sparr H, Esterhammer R, et al. Modern CT diagnosis [1] Boehm T, Alkadhi H, Schertler T, et al. Application of multislice of acute thoracic and abdominal trauma. Anaesthesist 2002;51: spiral CT (MSCT) in multiple injured patients and its effect on 835-42. diagnostic and therapeutic algorithms. Rofo 2004;176:1734-42. [26] Exadaktylos AK, Sclabas G, Schmid SW, et al. Do we really need [2] Low R, Duber C, Schweden F, et al. Whole body spiral CT in primary routine computed tomographic scanning in the primary evaluation of diagnosis of patients with multiple trauma in emergency situations. blunt chest trauma in patients with bnormalQ chest radiograph? Rofo 1997;166:382-8. J Trauma 2001;51:1173-6. [3] Kuhnigk H, Steinhubel B, Keil T, et al. The bWurzburg T.Q A concept [27] Gestring ML, Gracias VH, Feliciano MA, et al. Evaluation of the for optimization of early multiple trauma care in the emergency lower spine after blunt trauma using abdominal computed tomograph- department. Anaesthesist 2004;53:645-50. ic scanning supplemented with lateral scanograms. J Trauma 2002;53: [4] Okamoto K, Norio H, Kaneko N, et al. Use of early-phase dynamic 9-14. spiral computed tomography for the primary screening of multiple [28] Ghoshhajra K, Rao KC. CT in spinal trauma. J Comput Tomogr 1980; trauma. Am J Emerg Med 2002;20:528-34. 4:309-18. [5] Trupka A, Waydhas C, Hallfeldt KK, et al. Value of thoracic [29] Wilson BP, Finlay D. Computerized tomography of injury to the computed tomography in the first assessment of severely injured thoracolumbar spine. Injury 1987;18:185-9. patients with blunt chest trauma: results of a prospective study. [30] Barba CA, Taggert J, Morgan AS, et al. A new cervical spine J Trauma 1997;43:405-11. clearance protocol using computed tomography. J Trauma 2001;51: [6] Wurmb T, Fruhwald P, Brederlau J, et al. The Wurzburg polytrauma 652-6. algorithm. Concept and first results of a sliding-gantry-based computer [31] Berne JD, Velmahos GC, El Tawil Q, et al. Value of complete cervical tomography diagnostic system. Anaesthesist 2005;54:763-8. helical computed tomographic scanning in identifying cervical spine [7] Philipp MO, Kubin K, Hormann M, et al. Radiological emergency injury in the unevaluable blunt trauma patient with multiple injuries: a room management with emphasis on multidetector-row CT. Eur J prospective study. J Trauma 1999;47:896-902. Radiol 2003;48:2-4. [32] Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance [8] Brown CV, Antevil JL, Sise MJ, et al. Spiral computed tomography of blunt cervical spine injury: plain radiograph or computed for the diagnosis of cervical, thoracic, and lumbar spine fractures: its tomography scan? J Trauma 2003;55:222-6. time has come. J Trauma 2005;58:890-5. [33] Hanson JA, Blackmore CC, Mann FA, et al. Cervical spine injury: a [9] Holmes JF, Akkinepalli R. Computed tomography versus plain clinical decision rule to identify high-risk patients for helical CT radiography to screen for cervical spine injury: a meta-analysis. screening. AJR Am J Roentgenol 2000;174:713-7. J Trauma 2005;58:902-5. [34] Schenarts PJ, Diaz J, Kaiser C, Carrillo Y, et al. Prospective [10] Watura R, Cobby M, Taylor J. Multislice CT in imaging of trauma of comparison of admission computed tomographic scan and plain films the spine, pelvis and complex foot injuries. Br J Radiol 2004;77(Spec of the upper cervical spine in trauma patients with altered mental No 1):S46-63. status. J Trauma 2001;51:663-8. [11] Linsenmaier U. Disputed concept in polytrauma: whole-body spiral [35] Jelly LM, Evans DR, Easty MJ, et al. Radiography versus spiral CT in CT as primary diagnosis. (Comment on: RoFo 1997;166(5):382-8). the evaluation of cervicothoracic junction injuries in polytrauma Rofo 1998;168:306. patients who have undergone intubation. Radiographics 2000;20(Spec [12] Kanz KG, Korner M, Linsenmaier U, et al. Priority-oriented shock No):S251-9. trauma room management with the integration of multiple-view spiral [36] Wintermark M, Mouhsine E, Theumann N, et al. Thoracolumbar spine computed tomography. Unfallchirurg 2004;107:937-44. fractures in patients who have sustained severe trauma: depiction with [13] Nast-Kolb D, Waydhas C, Kanz KG, et al. An algorithm for multi-detector row CT. Radiology 2003;227:681-9. management of shock in polytrauma. Unfallchirurg 1994;97:292-302. [37] Wedegartner U, Lorenzen M, Nagel HD, et al. Diagnostic imaging in [14] Baker SP, O’Neill B, Haddon W, et al. WB. The injury severity score: polytrauma: comparison of radiation exposure from whole-body a method for describing patients with multiple injuries and evaluating MSCT and conventional radiography with organ-specific CT. Rofo emergency care. J Trauma 1974;14:187-96. 2004;176:1039-44. American Journal of Emergency Medicine (2007) 25, 1063–1072

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Diagnostics

Early detection and diagnosis of acute myocardial infarction: the potential for improved care with next-generation, user-friendly electrocardiographic body surface mapping Cedric Lefebvre MD⁎, James Hoekstra MD

Department of Emergency Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA

Received 26 April 2007; revised 18 June 2007; accepted 19 June 2007

Abstract Prompt and accurate identification of patients with acute coronary syndrome (ACS) presenting to the emergency department (ED) is paramount to the success of interventional and therapeutic strategies. Accurate diagnosis of ST-segment elevation myocardial infarction or non–ST-segment elevation myocardial infarction is hindered by atypical presentations and suboptimal diagnostic tools. The current standard of care, 12-lead electrocardiogram, has limited efficacy. It does not allow complete imaging of various anatomic segments of the heart and therefore fails to accurately identify some patients who would benefit from immediate therapy. Body surface mapping (BSM) allows greater spatial representation of cardiac electrical activity than 12-lead electrocardiogram, with a more complete view of cardiac electrophysiology and greater sensitivity for detecting acute myocardial infarction. Recent technological advances have overcome previous limitations of BSM, including the need for extensive training, difficulty interpreting results, and cost. The future of BSM in the ED is not yet known but will be aided by the ongoing large-scale Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction trial (OCCULT-MI) trial, which uses PRIME BSM technology. © 2007 Elsevier Inc. All rights reserved.

1. Introduction become the focus of aggressive diagnostic and treatment algorithms. Yet despite advances in pharmacologic and Cardiovascular disease is a leading cause of morbidity invasive strategies to treat AMI, mortality associated with and mortality in American adults. Within the spectrum of this phenomenon approaches 38% within the first year [2]. acute coronary syndrome (ACS), acute myocardial infarc- This may be due in part to the loss of valuable time from tion (AMI) is a particularly severe health event associated onset of symptoms to treatment, with the rate-limiting with significant death and disability. An estimated 700000 factor in many cases being identification and diagnosis Americans will have an AMI and 500000 will experience of AMI. a recurrent MI each year [1]. For this reason, AMI has Guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) highlight the ⁎ Corresponding author. Tel.: +1 336 716 4629. importance of rapid identification and treatment of AMI, E-mail address: [email protected] (C. Lefebvre). specifically ST-segment elevation myocardial infarction

(STEMI) [3]. Class I recommendations for STEMI include AMI so that treatment of this cardiac event can be initiated acquisition and interpretation of a 12-lead electrocardiogram more quickly. (ECG) within 10 minutes of emergency department (ED) arrival, administration of fibrinolytic therapy within 30 minutes of arrival, and/or percutaneous coronary intervention (PCI) within 90 minutes of arrival [3]. Several clinical 2. Current paradigm of AMI diagnosis trials have shown that early treatment and/or intervention in patients with STEMI affords the maximum benefit [4-9]. Presently, physicians make the diagnosis of AMI by using These data and subsequent ACC/AHA recommendations several diagnostic tools, including the 12-lead ECG, cardiac have driven health systems nationwide to implement guide- biomarkers, and clinical judgment. Fig. 1 depicts the current line-based protocols to rapidly identify and treat AMI. paradigm of AMI diagnosis. Unfortunately, each diagnostic Patients with AMI who are not immediately identified by ST- tool has limitations. Cardiac biomarkers are highly sensitive segment deviation, however, often experience delays to and specific for the detection of myocardial injury but often diagnosis and subsequent pharmacologic intervention and take several hours from onset of injury to become elevated PCI [10]. This delay precludes access to the benefits of early [14-17]. Their sensitivity for AMI in the ED setting treatment, namely, preservation or restoration of Thrombo- approximates only 40% at presentation. This precludes lysis in Myocardial Infarction grade 3 flow in the infarct- their use for directing early pharmacologic and interven- related artery. Studies have shown that refractory/recurrent tional therapies in the setting of AMI. ischemia and delay to reperfusion imparts a negative impact Conversely, a 12-lead ECG can be obtained within on survival in patients with AMI [8,9,11-13]. Therefore, minutes of patient presentation to the ED and is therefore improvements are needed in the techniques used to identify the cornerstone in the initial evaluation for STEMI and

Fig. 1 Current paradigm of AMI diagnosis. TIMI indicates Thrombolysis in Myocardial Infarction. Electrocardiographic body surface mapping 1065 cardiac ischemia. Unfortunately, initial 12-lead ECG is not true in high-risk subgroups, such as patients with diabetes highly sensitive for the detection of these events. Several [35-37]. If less time is allocated to the diagnostic approach studies have shown that the sensitivity of initial ECG of ACS, more time could be allotted to the aggressive (positive identification of AMI) ranges from 34% to 56% treatment of AMI, which would undoubtedly improve when evaluating a patient presenting with ACS symptoms outcomes. Therefore, it is important to use diagnostic [18-21]. In addition, confounding factors such as left bundle- methods with greater sensitivity that can identify patients branch block (LBBB), left ventricular strain, or other baseline with AMI earlier in their course so that they may benefit ECG abnormalities may complicate ECG interpretation, from early therapy. A more accurate method is needed for further diminishing its sensitivity for AMI. This is especially rapid identification of AMI in patients with chest pain evident in patients with bundle-branch blocks (BBBs). presenting to the ED. Despite the development of diagnostic algorithms to improve the diagnostic sensitivity of the ECG in the setting of LBBB (ie, the Sgarbossa criteria), current diagnostic practice remains inadequate in the setting of confounding electro- 3. Consequences of missed AMI by ECG physiologic variables to reliably identify AMI by ECG [22- 26]. Patients with AMI and LBBB generally have a worse Without tools to more accurately and immediately prognosis compared to those without LBBB [27]. These identify AMI in patients with chest pain without ST patients develop more complications such as congestive heart elevation, current practice guidelines rely on risk stratifica- failure and lethal arrhythmias [28]. Go et al demonstrated that tion to direct early treatment. Because the risk of death and AMI patients with BBB patterns, in addition to having more nonfatal cardiac events is highest during initial presentation comorbidities, are less likely to receive thrombolytic therapy. and subsequent hospitalization, ACC/AHA guidelines use This group also carries a higher incidence of in-hospital risk stratification to direct early therapy [38]. Despite these mortality. In fact, AMI patients with LBBB and RBBB recommendations, however, pharmacologic therapy has been patterns had a 22% and 23% risk for in-hospital death, underused. Furthermore, there appears to be a correlation respectively, compared with a mortality rate of 13% for between mortality and lack of adherence to ACC/AHA patients without BBB [29]. Failure of ECG to detect STEMI guidelines in the management of patients with NSTEMI because of confounding BBB patterns further limits the [39-41]. Patients with NSTEMI may carry a higher rate of sensitivity of this diagnostic modality and may diminish the adverse outcomes than their counterparts with ST elevation benefit of early treatment strategies. because of delayed treatment [10]. And despite recent efforts Acquisition of serial ECGs has been proposed to increase to promote the use of upstream pharmacologic therapies, the sensitivity of the ECG in the detection of AMI. The such as glycoprotein IIb/IIIa receptor inhibitors, in high-risk ACC/AHA guidelines include a class I recommendation to patients with NSTEMI, this patient group continues to obtain serial ECGs in a patient with symptoms of ongoing experience delays to treatment [10,42]. Furthermore, there is cardiac ischemia/infarction if the initial ECG does not reveal emerging evidence that high-risk patients with NSTEMI evidence of STEMI [3]. Serial ECGs may improve might benefit from early invasive strategies [43,44].If sensitivity in the detection of AMI as demonstrated by a 12-lead ECG does not identify electrophysiologic patterns of prospective trial by Fesmire et al [19] in which serial 12-lead ischemia or infarction in patients with chest pain, these ECG, obtained about 47 minutes after arrival to the ED, patients may be inaccurately deemed nonspecific chest pain identified injury in an additional 16% of patients with AMI. and may not receive appropriate early therapy. Missed ECG Other studies, however, demonstrated modest benefit from findings result in a loss of valuable time and preclude the serial ECGs in the evaluation of non-STEMI (NSTEMI) and benefit of early treatment. low-to-intermediate risk patients with ACS [30,31]. The In a retrospective analysis, Masoudi et al [45] illustrated combination of serial ECG and serial cardiac biomarkers at the consequences of missed high-risk ECG findings on initial 2-hour intervals may also increase sensitivity for the ECG. Patients with chest pain who were ideal candidates for detection of AMI [32]. Interestingly, when dynamic ECG treatments including aspirin, β-blockers, and reperfusion changes were identified over time, patients with these therapy had higher odds of not receiving these therapies if changes had a significantly greater risk of death compared to initial high-risk ECG findings were overlooked. In-hospital those without such changes [19,30]. These data suggest that mortality was 4.9% among patients without missed high-risk sensitivity of current diagnostic tools improves during ECG findings compared with 7.9% for those with missed recurrent ischemia or during the evolution of infarction. findings [45]. These interesting results suggest that, in Acquisition of serial ECGs and serial biomarkers requires addition to poor sensitivity of 12-lead ECG for capturing the hours of valuable time. As mentioned, rates of adverse data needed to identify AMI, human error in interpreting this cardiac events and mortality increase with time elapsed from data may further diminish our ability to diagnose AMI with onset of symptoms to early therapy. Thus, early treatment initial ECG. The consequence of missing high-risk ECG serves to limit infarct size during AMI, which correlates with findings and/or missing opportunities to treat high-risk improved outcome [33,34]. This appears to be particularly patients with chest pain is costly. This exposes the 1066 C. Lefebvre, J. Hoekstra

Fig. 2 A sample electrocardiograph (A); a picture of the output using PRIME BSM technology (B); and a coronary angiogram (C), all from one patient. Images used courtesy of the Royal Victoria Hospital, Belfast, Northern Ireland. Electrocardiographic body surface mapping 1067

Several clinical trials have shown the efficacy and clinical relevance of a new generation of user-friendly BSM technology in the detection of AMI [52-56]. Body surface mapping has the potential to improve diagnostic evaluation of patients presenting with symptoms of AMI but on whom 12- lead ECG shows only ST depression. Menown et al prospectively evaluated validation-set patients with chest pain whose initial 12-lead ECG showed ST depression only. Investigators studied the ability of BSM to detect STelevation at sites outside the conventional precordial area in which only ST depression was identified. Acute myocardial infarction was defined by the presence of acute chest pain of more than 20 minutes and an elevation of creatine kinase more than twice the upper laboratory reference or creatine kinase–MB of higher than 7%. They demonstrated a sensitivity of 38% and specificity of 81% for AMI in a 12-lead multivariate ECG model vs sensitivity of 88% and specificity of 75% in a BSM model [52]. Body surface mapping might help direct upstream use of aggressive pharmacotherapy and PCI in patients deemed to have NSTEMI by ECG but who have, in fact, STEMI by BSM. If patients with nonspecific changes on 12-lead ECG can be appropriately identified as AMI by BSM, these high-risk patients might incur fewer delays to aggressive pharmacotherapy and PCI, presumably improving outcomes. This has particular relevance to emergency physicians who routinely evaluate patients with chest pain Fig. 2 (continued) and are charged with initiating early therapy. Body surface mapping has also displayed the potential for inadequacy of the current paradigm for identifying AMI and early detection of STEMI in specific regions of the its significant consequences. The implications of inadequate myocardium. In particular, BSM appears to be well suited ECG sensitivity on the initial evaluation of patients with for detecting injury patterns in the RV and posterior regions chest pain translates to missed opportunities to treat high-risk associated with inferior AMI [55]. The addition of right-sided patients who would benefit from aggressive therapy. and posterior leads to conventional 12-lead ECG has been shown to enhance the anatomic description of cardiac involvement and increase sensitivity for involvement of “electrocardiographically silent” regions of the myocardium 4. Body surface mapping and detection of AMI during AMI [57-62].Menownetal[54] have shown that BSM further augments this spatial sampling, which leads to its Body surface mapping (BSM) is an extension of the sensitivity in detecting acute ST-segment elevation in the RV conventional 12-lead ECG concept that may deliver and posterior areas. Analysis of consecutive, biomarker- improvements to the current diagnostic paradigm for AMI. confirmed AMI patients with inferior ST-segment elevation Body surface mapping displays as a topographic map over a revealed a greater sensitivity by regional maps when compared larger area of the thoracic surface, including the right to 12-lead ECG enhanced by RV (V2R, V4R) and posterior ventricular (RV), posterior, and high left lateral regions. With chest leads (V7,V9) for identification of RV and posterior 80 individual leads from which to measure electrocardio- involvement. ST elevation of ≥0.1 mVacross ≥1electrodeon graphic potentials, the BSM technique allows collection and the regional RV map (BSM) was noted among 58% of subjects analysis of data from a broader thoracic area, which allows compared to ST elevation ≥0.1 mV in selected additional RV for greater spatial sampling. The principles of BSM have chest leads among 42% of subjects. More notably, STelevation been well established [46,47]. Until recently, however, its ≥0.1 mV in ≥1 electrode was revealed in 27% of regional cumbersome electrode application and complex analysis of maps compared to STelevation ≥0.1 mV shown in only 2% of simultaneous multichannel ECG data have limited its use to subjects analyzed by additional posterior leads V7 and V9 [54]. the experimental research setting [48,49]. With the emer- The superiority of BSM over 12-lead ECG in its sensitivity gence of more user-friendly computer hardware/software and for the detection of STEMI, particularly posterior AMI, has electrode application, BSM has now become feasible in also been demonstrated by Ornato et al [53]. This multicenter clinical practice for the evaluation of patients with chest trial compared BSM to 12-lead ECG in detecting STEMI pain [48,50,51]. among patients with biomarker-confirmed AMI and a 1068 C. Lefebvre, J. Hoekstra discharge diagnosis of AMI. PRIME showed a greater criteria identified AMI with a sensitivity of 33% (specificity, sensitivity compared to 12-lead ECG (93% vs 57% in 97%; positive predictive value, 86%; negative predictive troponin-positive AMI, P = .008) for identifying ST value, 76%). Patients with abnormal BSM imaging in the elevation. Specificity between the 2 diagnostic modalities presence of LBBB were more likely to have AMI (odds ratio, was comparable (95% by PRIME, 96.5% by ECG) [53]. 4.9; 95% confidence interval, 1.5-6.4, P = .007). Although the These findings suggest that BSM may have a role in sample size was small in this study (N = 56), its findings identifying high-risk patients among AMI populations earlier suggest a role for BSM in the detection of AMI during the and with greater accuracy. By overcoming the anatomic evaluation of chest pain complicated by the presence of LBBB. limitations of 12- and 15-lead ECG, rapid colorimetric body mapping generated by the 80-lead BSM system provides a larger spatial image of the myocardium, including posterior 5. Body surface mapping technology: regions. This allows the clinician to identify STEMI within seconds of initial patient contact. the PRIME ECG system In addition to defining injury patterns in patients with STEMI, BSM may also improve diagnostic sensitivity for One example of BSM technology, the PRIME ECG AMI in the setting of BBB. Maynard et al [56] used an 80-lead System (PRIME Heartscape Technologies, Columbia, MD) BSM device to obtain electropotential data from patients uses a unique 2-piece electrode array (vest) that allows admitted to an acute medical cardiology unit with chest pain placement of 80 leads on the torso, providing a more and LBBB pattern on index ECG. Of the patients with complete view of the electrical activity of the heart. Designed biomarker-confirmed AMI and LBBB, BSM performed with a primarily for ED use, this system provides analysis of the sensitivity of 67% (specificity, 71%; positive predictive value, heart's electrical activity with 360° of spatial resolution, 52%; negative predictive value, 82%) in revealing data which has the potential to detect critical diagnostic informa- suggestive of AMI, whereas 12-lead ECG using Sgarbossa tion not visible with a traditional ECG.

Fig. 3 The OCCULT-MI trial design. *The primary comparison in this study is between time to catheter laboratory (door-to-sheath time) for the patients diagnosed with STEMI by 12-lead ECG and patients diagnosed with STEMI by PRIME technology (56 ECG STEMI vs 22 OCCULT STEMI). CAD indicates coronary artery disease; DM, diabetes mellitus; HTN, hypertension; UA, unstable angina. Electrocardiographic body surface mapping 1069

ST-segment elevation and depression are translated into implications of using BSM technology. It may expedite colors (red = elevation, blue = depression) and displayed disposition in the ED and thereby improve hospital costs at against a 3-dimensional torso image for physician review. presentation, prevent the need for more expensive imaging These images allow for rapid pattern recognition to identify technology, reduce the incidence of rehospitalization, and problem areas that correlate with regions of ischemia or ostensibly reduce the risk of malpractice for improper or infarction. This graphic imaging allows the physician to delayed diagnosis. quickly focus on specific ECG morphology that contains the most valuable diagnostic information without exploring data from each of the 80 leads. The colorimetric body mapping 6. Ongoing trial: the Optimal Cardiovascular provides the clinician with an immediate review of the ST- segment status. A sample ECG is presented in Fig. 2A, and a Diagnostic Evaluation Enabling Faster picture of the output using PRIME BSM technology in the Treatment of Myocardial Infarction trial same patient is shown in Fig. 2B. A coronary angiogram of the same patient is also shown (Fig. 2C). The Optimal Cardiovascular Diagnostic Evaluation In published studies completed over 10 years involving Enabling Faster Treatment of Myocardial Infarction approximately 2500 patients, BSM has been shown to be (OCCULT-MI) trial will measure the impact of a more significantly more sensitive than current standard ECG complete view of the electrical signals of the heart with the testing in the immediate detection of such AMIs [54,63]. PRIME ECG System, compared with the standard ECG, The earlier detection and expanded information provided including time to treatment (cardiac catheterization sheath by the BSM system should provide physicians with greater placement or door-to-sheath time) for patients diagnosed diagnostic insight to assess patient risk and evaluate the using PRIME compared with the time to treatment using the benefits of early intervention, a central factor in reducing standard 12-lead ECG. The study will be an 11-site, adverse outcomes. Body surface mapping has been shown prospective-cohort, blinded observational study of subjects to have superior sensitivity over 12-lead ECG, without a presenting to the ED with symptoms of ACS. The population significant loss of specificity, identifying ST-segment will consist of approximately 1400 male or female patients elevations outside of the 12-lead ECG purview. These olderthan39yearspresentingtotheEDwithACS STEMIs often involve RV, inferior, and posterior infarc- symptoms of 24 hours or less, chest pain, and at least one tions and account for approximately 22% of biomarker- of the following: (a) ECG abnormality; (b) known coronary confirmed acute infarctions, which are otherwise treated as artery disease; or (c) at least 3 coronary risk factors for NSTEMIs and recognized only after serum biomarker coronary artery disease (including family history, current or confirmation [51,64]. Body surface mapping diagnosis of treated hypertension, current or treated hypercholesterole- STEMI in this setting could be the basis for more rapid mia, diabetes, and current smoker). access to PCI and reduced door-to-sheath time, with Because the optimal treatment of AMI depends on rapid resultant improvements in outcomes such as cardiovascular time to reperfusion of the infarct-related artery, the primary mortality, infarct size, new-onset congestive heart failure, end point of this study is door-to-sheath time. The primary and subsequent hospitalizations. objective of this study is to assess door-to-sheath time in The question of whether this technology is both subjects with STEMI on standard ECG and door-to-sheath adequately effective and user-friendly to be incorporated time in subjects with STEMI on PRIME maps but not on into standard practice has yet to be determined. A recent standard ECG (ie, PRIME-only STEMI patients) as a survey study demonstrates a lack of confidence in the 15-lead measure of treatment delay that could be eliminated if the ECG. Emergency physicians were less likely to administer a BSM system was used routinely in chest pain assessment. It is fibrinolytic agent to a hypothetical patient with STEMI noted anticipated that the PRIME-only subjects will have a door-to- only on additional ECG leads [65]. Even with the addition of sheath time that is longer than those of STEMI patients. 3 leads to standard 12-lead ECG, there are regions of the The secondary end point of the trial is to examine the myocardium that are left incompletely imaged. The substan- incidence of all ischemia diagnoses on BSM in subjects with tially increased spatial imaging of the heart by PRIME nondiagnostic standard 12-lead ECGs, and the sensitivity and provides a considerably more thorough imaging of the specificity of such findings for ACS diagnosis, as a measure myocardium. The PRIME system may help overcome the of potential for enhanced triage and therapy decisions in these anatomic limitations of 12- and 15-lead ECGs. This increased subjects if the BSM system was used routinely in chest pain scrutiny of the heart may also translate into an increased rate assessment. Some of the specific key secondary comparisons of STEMI diagnoses, thus improving the ability to provide in this trial will be (a) the comparison of 30-day major adverse appropriate therapy early in the patient's course. cardiac event rates between PRIME-only STEMI patients and This technology may result in not only faster treatment STEMI patients; (b) the sensitivity, specificity, positive but also in a more accurate diagnosis. Physicians may easily predictive value, and negative predictive value for PRIME collect and quickly analyze data from PRIME ECG in real vs 12-lead ECG with respect to MI (adjudicated by troponin [I time, even in an ED setting. There are also financial or T]) stratified by presence/absence of pain at time of PRIME 1070 C. Lefebvre, J. Hoekstra recording; (c) comparison of PRIME-only STEMI and [2] Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke — STEMI subjects in terms of the distributions of coronary statistics 2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation artery stenosis and occlusion by coronary artery location for 2007;115:e69-e171. all subjects undergoing cardiac catheterization; and (d) [3] Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines comparison of PRIME-only STEMIs and STEMIs in terms for the management of patients with ST-elevation myocardial of the rates of revascularization (PCI or coronary artery infarction-executive summary. A report of the American College of bypass graft). The OCCULT-MI trial design is shown in Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the Fig. 3. management of patients with acute myocardial infarction). J Am Coll Although a wealth of data support the benefit of BSM, Cardiol 2004;44:671-719. this trial may prove the advantage of this specific PRIME [4] Fibrinolytic Therapy Trialists Group. Indications for fibrinolytic technology to the degree that it should be incorporated into therapy in suspected acute myocardial infarction: collaborative guidelines and quality of care initiatives in the ED. overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994;343:311-22. [5] Boersma E, Maas AC, Deckers JW, et al. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 7. Conclusion 1996;348:771-5. [6] De Luca G, Suryapranata H, Zijlstra F, et al. 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Relationship of symptom-onset-to-balloon time and door-to-balloon time with mor- lead ECG does not allow for complete imaging of the various tality in patients undergoing angioplasty for acute myocardial anatomic segments of the heart and therefore fails to infarction. JAMA 2000;283:2941-7. accurately identify a number of patients who would benefit [9] Stone GW, Cox D, Garcia E, et al. Normal flow (TIMI-3) before from immediate therapy. Body surface mapping is a useful mechanical reperfusion therapy is an independent determinant of tool in the ED for assessing a patient with possible AMI. Its survival in acute myocardial infarction: analysis from the primary angioplasty in myocardial infarction trials. Circulation 2001;104: value lies in greater spatial representation of cardiac 636-41. electrical activity than 12-lead ECG, thus allowing a more [10] Cox DA, Stone GW, Grines CL, et al. 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Relationship between delay in performing direct coronary angioplasty and early clinical outcome in perhaps dangerous use of thrombolysis in this group. Recent patients with acute myocardial infarction: results from the global use of technological advances have largely overcome the previous strategies to open occluded arteries in Acute Coronary Syndromes limitations of BSM, including the need for extensive (GUSTO-IIb) trial. Circulation 1999;100:14-20. training, difficulty in interpreting the results, and cost issues. [13] McNamara RL, Wang Y, Herrin J, et al. Effect of door-to-balloon time The future of BSM in the ED is not yet known but will be on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2006;47:2180-6. aided by the ongoing large-scale trial OCCULT-MI that uses [14] Collinson PO, Gaze DC, Morris F, et al. Comparison of biomarker the PRIME BSM technology. 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Editorial The Earth is flat! The electrocardiogram has 12 leads! The electrocardiogram in the patient with ACS: looking beyond the 12-lead electrocardiogram

The Earth is flat! The electrocardiogram (ECG) has 12 [that this device] is the most sophisticated scientific leads! Both time-honored statements that were once widely instrument of the century…” accepted as “The Truth.” And now, we know that neither is, Certainly, the earliest clinical applications of the ECG in fact, completely correct. involved rhythm diagnosis. In 1910, Lewis recognized the Let's consider “the Earth is Flat.” Up to the late 15th ECG's clinical potential in the patient with atrial fibrillation century, the western world maintained the belief that the with his description of “circus conduction” within atria in world was flat. Should some uninformed explorer wander the publications “The Mechanism of the Heart Beat” (1911) too far from the known paths of travel, he or she would [1] and “Clinical Electrocardiography” (1913) [2].” Another simply fall off the world. Christopher Columbus, a well- 20 years passed before the clinical use of the ECG in the known explorer, set out from Europe in the early 1490s to differentiation of cardiac and noncardiac chest pain (1930s, uncover a more direct route to the east in an effort to Wood and Wolferth). Up to this point in the ECG's history, unlock the riches of the orient and to avoid the risks of the clinical ECG used only 3 leads, Einthoven's original traversing the southern tip of Africa. Columbus was limb leads. ridiculed by his peers before his journey because of his Twenty-five years later, Wilson introduced the unipolar belief that the world is round. And yet, despite this lengthy “exploring” electrode, which could be placed anywhere on the journey, Columbus and his crew did not fall off the edge of body. Further development of this exploring electrode was the Earth. Although he did not discover a more direct sea standardized by the American Heart Association in 1938 with route to the Orient, he was able to inform his sponsors, the determination of the standard 6 precordial chest leads, V1 King Ferdinand and Queen Isabella, that the Earth is through V6. Several years later, in 1942, Goldberger developed definitely round. the augmented unipolar limb leads (aVr, aVl, and aVf). Thus, Thus, reasoned investigation driven by the spirit of the 12-lead ECG was born—Einthoven's 3 limb leads plus exploration lead the explorers of the 15th century to the Wilson's adapted 6 precordial leads plus Goldberger's 3 correct answer. Let us apply this same approach to the augmented limb leads equals the 12-lead ECG. Despite 12-lead ECG. significant advances in cardiac diagnosis and management, The ECG has had an interesting developmental history, little further development of the 12-lead ECG has occurred starting in the late 19th century. In 1903, Wilhelm Einthoven since 1942 other than the occasional use of the additional leads published recordings of the electrical cardiac cycle using a in association with the 12-lead ECG. This observation is quite new device, the string galvanometer. This instrument shocking when one considers the paramount importance of the provided the basis for the contemporary clinical ECG. The 12-lead ECG in management strategies of the patient with device used the standard frontal-plane limb leads, essentially potential cardiorespiratory ailment. today's limb leads. In this early work, Einthoven defined the The current evaluation strategy in the emergency depart- 5 separate electrical deflections, establishing the PQRST ment (ED) for patients with chest pain suspected of cardiac cycle. He also set the standard for recording rates ACS includes 3 principal tools: the history of the event, and amplitudes. Further developments and refinements of the 12-lead ECG, and cardiac serum markers. Among these the ECG resulted in the award of the Nobel Prize to patients with chest pain, the prompt and accurate detection of Einthoven in 1924. Common medical opinion at that time ACS remains a very significant clinical challenge for the reflected the importance of the ECG with the comment “… emergency physician. Numerous obstacles are present,

0735-6757/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2007.07.025 1074 Editorial including atypical and less-than-classic clinical presenta- significantly more patients with BSM than an additional-lead tions, nondiagnostic ECGs, and false-negative serum marker ECG. These investigators concluded that BSM more directly results. As noted, the ECG has its shortcomings, including a visualized the right ventricle and posterior wall of the left rather low sensitivity of the initial 12-lead ECG for acute ventricle, thus increasing the diagnostic rate of STEMI in myocardial infarction (AMI) diagnosis in the ED. Fesmire these poorly imaged regions of the heart. Ornato et al [9] and Percy [3] noted that the initial 12-lead ECG demon- compared the 12-lead and BSM ECGs in the evaluation of strated a sensitivity of only 55% in patients ultimately patients suspected of AMI. In this multicenter trial, the diagnosed with AMI. Rude and colleagues [4] noted that less authors found that the body surface–mapping ECG was than 50% of patients ultimately diagnosed with AMI more sensitive than 12-lead ECG in detecting STEMI. demonstrated ST-segment elevation on their initial ECG in Body-map ECG undoubtedly provides a more complete the ED. One primary issue responsible for this rather low anatomical description of the heart in patients with ACS. sensitivity is the presence of electrocardiographically “silent” Although a more complete descriptive imaging of the heart is and “near-silent” areas of the heart. valuable, the actual clinical impact of this additional One potential strategy used to overcome this initial poor information remains unknown. Most acute reperfusion trials, sensitivity of the 12-lead ECG and enhanced imaging of including those on fibrinolysis and percutaneous coronary these underimaged areas of the myocardium is the applica- intervention (PCI), however, have focused on STEMI of the tion of additional ECG leads. For example, it has been anterior, inferior, and lateral walls of the left ventricle. suggested that the diagnostic power of the ECG can be Clinicians are now faced with managing patients with ECG increased if additional body surface leads are used in selected ST-segment elevation of the electrocardiographically silent individuals [5]. Body surface mapping (BSM) is simply a and near-silent areas of the myocardium. natural extension of the additional-lead concept with the Perhaps the most robust support from the literature can be application of numerous leads about the torso. found regarding these electrocardiographically silent areas Lefebvre and Hoekstra [6], in this edition of the American and related reperfusion therapy decisions when the clinician Journal of Emergency Medicine, challenge common medical considers the isolated posterior wall myocardial infarction. teaching and traditional clinical practice—in this case, that Contemporary coronary care recommendations state that the 12-lead ECG is adequate and appropriate as the sole ECG fibrinolytic agents are not indicated in patients with ACS- study in patients suspected of ACS. In their review “The related ST-segment depression. In fact, authorities note that early detection and diagnosis of acute myocardial infarction: the mortality rate is actually increased by the use of the potential for improved care with next-generation, user- fibrinolytic agents in this subset of patients with ACS [10-13]. friendly electrocardiographic body surface mapping,” these This group of patients with ACS, those individuals authors describe the current dilemma of ACS diagnosis in the suspected of acute coronary event who present with ECG ST- ED; they suggest that ECG body surface mapping not only segment depression, is actually quite diverse, with multiple can improve the ability to detect certain cases of ST-segment final cardiac diagnoses encountered. For instance, unstable elevation myocardial infarction (STEMI) but also diagnose angina as well as non–ST-segment elevation AMI are seen AMI at an earlier phase in the process. This review is well frequently in these ST-segment depression patient presenta- written and should be considered by all emergency tions. In other words, this large group of patients is quite physicians who manage the patient with chest pain. I agree heterogeneous in underlying pathophysiology. Undoubtedly, with their comments and, more importantly, the existing a portion of these rather diverse patients with ACS are literature supports these thoughts. experiencing an isolated posterior wall myocardial infarc- Body surface mapping can be used in patients with ACS tion. It is important to recall that the posterior wall is a to detect unanticipated STEMI; note that unanticipated segment of the left ventricle. Furthermore, it is known that refers to the imaging capabilities of the 12-lead ECG. the isolated posterior wall AMI is associated with a Menown et al [7] used BSM to further evaluate the patient significant amount of myocardium in jeopardy and the with suspected ACS and ST-segment depression on their potential for significant cardiovascular adverse event—thus, initial 12-lead ECG. In this ECG patient group, the authors an aggressive reperfusion approach to these ECG presenta- noted that numerous patients with serum marker–confirmed tions should be considered [14,15]. AMI demonstrated ST-segment elevation on body-map The literature does not provide an easy, direct answer to regions not imaged by the standard 12-lead ECG, including this clinical dilemma; although this treatment issue has not the inferior, lateral, posterior, and right ventricular regions. been aggressively pursued in the literature, expert opinion, Menown and colleagues [8] investigated the BSM's ability to physician survey results, and extrapolations from existing investigate both posterior and right ventricular wall infarc- data sets have suggested that clinicians should consider tion in patients diagnosed with inferior wall STEMI. The fibrinolysis and/or PCI in the patient with isolated posterior authors compared the BSM with an additional-lead ECG, AMI. The American Heart Association/American College of using V2R,V4R,V7, and V9, in addition to the standard Cardiology notes an exception to the ST-segment depression 12 leads. The authors reported that ST-segment elevation fibrinolysis exclusion when “…marked ST-segment depres- over the right ventricle and posterior wall was detected in sion is confined to leads V1 through V4…,” [11] which is also Editorial 1075 supported in the American College of Emergency Physi- The primary clinical indication for body-map ECG perfor- cian's clinical guidelines in the discussion of ECG indica- mance is the patient with chest pain with an intermediate to tions for fibrinolysis in presumed STEMI [10]. Novak and high clinical suspicion for ACS and a nondiagnostic 12-lead colleagues [16] demonstrated that emergency physicians and ECG; in this instance, the clinician is in search of a STEMI in cardiologists would be more likely to administer fibrinolytic an electrocardiographically silent and near-silent areas— agents if they were provided with evidence suggestive of namely, the far inferior and lateral walls, the posterior wall, posterior STEMI—essentially, ECG ST-segment elevation and the right ventricle. Two important aspects of BSM occurring in an anatomical region. In another survey of suggest significant potential utility in the ED: (1) BSM has emergency physicians managing the isolated posterior wall the potential to immediately alter therapy, namely, by STEMI, we found that the clinician would administer a expanding the use of early reperfusion therapy for AMI; fibrinolytic agent in approximately 60% of such cases; the and (2) the use of BSM entails a mere expansion of the ECG tendency to prescribe fibrinolysis was more often seen in interpretation skills emergency physicians already possess, physicians who requested additional ECG leads imaging the not learning a new system of interpretation nor requiring posterior wall of the left ventricle [17]. unique personnel onsite for review. Electrocardiographic In subset analysis, authorities have noted the considerably body surface mapping clearly has the potential to enhance diverse nature of these ECG ST-segment depression ACS the emergency physician's ability to more completely image presentations; these clinicians suggest that a portion of these the heart and increase the rate of STEMI diagnosis at an heterogeneous patients are, in fact, experiencing a posterior earlier time in the evaluation. wall STEMI rather than anterior wall ischemia. For instance, We know that the world is not flat. We must also now the LATE trial and related commentary reported that a subset consider that contemporary diagnostic and management of patients managed with fibrinolysis and significant ST- strategies in the patient with ACS have outpaced the 12 leads segment depression demonstrated a reduction in mortality; it of the ECG. Perhaps it is time to move beyond the traditional is theorized that this subset of patients were experiencing an 12 leads of the 12-lead ECG and to recognize (and treat) isolated, acute posterior wall myocardial infarction [18,19]. STEMI of these electrocardiographically silent and near- Boden and colleagues [20] investigated patients with isolated silent regions of the myocardium. precordial ST-segment depression, noting that posterior wall myocardial infarction is a not uncommon cause of this ECG 1 finding. They recommended that this subtype of patient with William J. Brady MD ACS be considered for fibrinolytic therapy if AMI is Department of Emergency Medicine suspected based on clinical grounds. Although the evidence University of Virginia is not overwhelming regarding acute reperfusion decisions in Charlottesville VA 22908-0699, USA the patient with suspected isolated posterior wall myocardial E-mail address: [email protected] infarction, it is correct to note that these patients are, in fact, experiencing a STEMI of the left ventricle. Urgent management of this presentation aimed at both the restoration of References adequate coronary perfusion and myocardial salvage is medically correct and appropriate. [1] Lewis T. The mechanism of the heartbeat; with special reference to its Certainly, patients experiencing STEMI of the electro- clinical pathology. London: Shaw Publishing; 1911. cardiographically near-silent areas, namely, the far inferior [2] Lewis T. Clinical electrocardiography. London: Shaw Publishing; and lateral walls, should also be approached aggressively 1913. [3] Fesmire FM, Percy RF. Usefulness of automated serial 12-lead ECG with either fibrinolysis or PCI performed in rapid fashion. In monitoring during the initial emergency department evaluation of the various reports of BSM use in the patient with ACS, patients with chest pain. Ann Emerg Med 1998;31:3-11. STEMI diagnosis is increased 15% to 20% with myocardial [4] Rude RE, Poole WK, Muller JE, et al. Electrocardiographic and infarction of the inferior, lateral, posterior, and anterior walls, clinical criteria for recognition of acute myocardial infarction based on more often seen with this enhanced ECG imaging [7-9].A analysis of 3,697 patients. Am J Cardiol 1983;52:936-42. [5] Melendez LJ, Jones DT, Salcedo JR. Usefulness of three additional diagnostic study capable of detecting these various STEMI electrocardiographic chest leads (V7,V8 and V9) in the diagnosis of syndromes in timely fashion is needed in the ED. Electro- acute myocardial infarction. Can Med Assoc J 1978;119:745-8. cardiographic body mapping is such a technology. [6] Lefebvre CW, Hoekstra JW. The early detection and diagnosis of acute Electrocardiographic body surface mapping is a useful myocardial infarction: the potential for improved care with next- ECG tool in the evaluation of the ED patient with potential generation, user-friendly electrocardiographic body surface mapping. Am J Emerg Med 2007;25:1063-72. ACS. It is important to note that BSM is not designed to replace 12-lead ECG but to augment this traditional diagnostic practice. In fact, the body-map ECG should only be used as a second tier evaluation tool in the 1 William Brady serves as a member of the scientific advisory board of consideration of the patient with intermediate to high clinical Heartscape Technologies, Columbia, MD, a manufacturer of an electro- suspicion for ACS and an unrevealing initial 12-lead ECG. cardiographic body-mapping system. 1076 Editorial

[7] Menown IBA, Allen J, Anderson JM, Adgey AAJ. ST segment unstable angina and non–Q-wave myocardial infarction: results of the depression only on initial 12-lead ECG: early diagnosis of acute TIMI-IIIB trial. Circulation 1994;89:1545. myocardial infarction. Eur Heart J 2001;22:218-27. [14] Zalenski RJ, Cooke D, Rydman R, Sloan EP, Murphy DG. Assessing

[8] Menown IBA, Allen J, Anderson JM, Adgey AA. Early diagnosis of the diagnostic value of an ECG containing leads V4R,V8, and V9: the right ventricular or posterior infarction associated with inferior wall 15-lead ECG. Ann Emerg Med 1993;22:786-93. left ventricular acute myocardial infarction. Am J Cardiol 2000;85: [15] O'Keefe Jr JH, Sayed-Taha K, Gibson W, et al. Do patients with left 934-8. circumflex coronary artery–related acute myocardial infarction with- [9] Ornato JP, Menown IBA, Riddell JW, et al. 80-lead body map detects out ST-segment elevation benefit from reperfusion therapy? Am J acute ST segment elevation myocardial infarction missed by standard Cardiol 1995;75:718-20. 12-lead electrocardiography. J Am Coll Cardiol 2002;39:332. [16] Novak PG, Davies C, Ken GG. Survey of British Columbia cardiologists' [10] Fesmire FM, Brady WJ, Hahn S, et al. American College of and emergency physicians' practice of using nonstandard EKG leads

Emergency Physicians clinical policy: indications for reperfusion (V4R to V6R and V7 to V9) in the diagnosis and treatment of acute therapy in emergency department patients with suspected acute myocardial infarction. Can J Cardiol 1999;15:967-72. myocardial infarction. Ann Emerg Med 2006;48:358-71. [17] Somers MP, Pines JM, Caovan D, Brady WJ. Internet-based survey on [11] Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines the use of additional lead electrocardiograms and fibrinolysis of for the management of patients wit ST-elevation myocardial infarction: posterior and right ventricular acute myocardial infarctions. Am J executive summary: a report of the ACC/AHA Task Force on Practice Emerg Med (accepted for publication/publication pending). Guidelines (Committee to Revise the 1999 Guidelines on the [18] Langer A, Goodman SG, Topol EJ, et al. Late assessment of Management of Patients with Acute Myocardial Infarction). Circula- thrombolytic efficacy (LATE) study: prognosis in patients with non– tion 2004;110:1-49. Q wave myocardial infarction (LATE Study Investigators). J Am Coll [12] Fibrinolytic Therapy Trialist's (FTT) Collaborative Group. Indications Cardiol 1996;27:1327-32. for fibrinolytic therapy in suspected acute myocardial infarction: [19] Braunwald E, Cannon C. Non–Q wave and ST-segment depression collaborative overview of early mortality and major morbidity results myocardial infarction: is there a role for thrombolytic therapy [editorial form all randomized trials of more than 1000 patients. Lancet 1994; comment]. J Am Coll Cardiol 1996;32:1333-4. 343:311-22. [20] Boden WE, Kleiger RE, Gibson RS, et al. Electrocardiographic [13] The TIMI-IIIB Investigators. Effects of tissue plasminogen activator evolution of posterior acute myocardial infarction: importance of early and a comparison of early invasive and conservative strategies in precordial ST-segment depression. Am J Cardiol 1987;59:782. American Journal of Emergency Medicine (2007) 25, 1077–1080

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Correspondence

Littmann sign in hyperkalemia: double counting of rate by electrocardiographic (ECG) interpretation heart rate software. One of the limitations of this discovery was that all incorrect diagnoses were made by a GE-Marquette system To the Editor, (Milwaukee, WI) using the 12SL interpretation software. The aim of this report is to demonstrate that double counting We read with great interest the new finding by Littmann of heart rate in hyperkalemia is not unique to the GE- et al [1] in severe hyperkalemia: double counting of heart Marquette systems.

Fig. 1 Electrocardiogram in severe hyperkalemia recorded and interpreted by a Schiller electrocardiograph system. The computer diagnosis was “atrial fibrillation, ventricular premature complex(es), bigeminy.” The reported heart rate was 71/min, whereas the true heart rate was 35/min. The serum potassium level was 9.2 mmol/L.

An 85-year-old female with a history of diabetes was hypothermia is now recommended by the Advanced Life hospitalized for dizziness. She was bradycardic; otherwise, her Support Task Force of the International Liaisons Committee vital signs were normal. An ECG (Fig. 1) was recorded by a on Resuscitation and incorporated in the American and Schiller system, an electrocardiograph commonly used in European resuscitation guidelines as part of post resuscita- Europe. The interpretation software indicated a heart rate of tion care [3]. 71/min, twice the true heart rate of 35/min. Computer diagnosis We undertook this study to investigate the mortality and was atrial fibrillation, ventricular premature complexes, and neurologic outcome of mild therapeutic hypothermia in bigeminy. The true rhythm, however, was a slightly irregular surviving OHCA patients in a single university hospital in junctional bradycardia. On laboratory testing, the patient's the southern part of the Netherlands with a catchments area serum potassium level was found to be 9.2 mmol/L. After of approximately 200000 inhabitants, with a yearly correcting the drug-induced hyperkalemia elicited by incidence of sudden cardiac arrest of approximately 10 per the coadministration of an angiotensin-converting enzyme– 10000 inhabitants [4]. inhibitor and a potassium-sparing diuretic, the patient became Medical charts of 101 consecutive OHCA patients asymptomatic, and the ECG returned to normal. admitted alive to our intensive coronary care unit were Our case supports the findings by Littmann et al that retrospectively analyzed. Forty-three patients receiving double counting of heart rate by ECG interpretation software hypothermic treatment in 2004 and 2005 (hypothermia may be a sign of severe hyperkalemia. Moreover, it also group) were compared to 58 historical control patients from proves that this ECG sign is not specific to the GE-Marquette 2001 to 2003 not treated with hypothermia (normothermia electrocardiographs and interpretation softwares. In our case group). Data on cardiac arrest were recorded and analyzed with the Schiller system and in several of Dr Littmann's according to the “Utstein Style” recommended guidelines [5]. cases with the GE-Marquette system, the interpretation Differences between groups were analyzed using χ2, Mann- software mistakenly read the tall and peaked T waves as Whitney U, or Students t test. Our hypothermia protocol ventricular bigeminy. Clinicians treating critically ill patients is primarily based upon the inclusion and exclusion criteria need to be educated that whenever the ECG interpretation from 2 recent randomized controlled clinical trials; how- software double counts the heart rate and falsely diagnoses ever, the actual decision of initiation and duration of bigeminy, severe hyperkalemia should be suspected. mild hypothermia was left to the discretion of the treating cardiologist [1,2]. All patients received current standard care including percutaneous coronary intervention; were János Tomcsányi PhD mechanically ventilated; and received intravenous midazo- Vince Wágner MD lam and piritramide for sedation and analgesia, respectively, Béla Bózsik MD and intravenous pancuronium to prevent shivering. Mild Department of Cardiology hypothermia was initiated as soon as possible after admission Hospitaller Brothers of St John of God, Budapest and was induced and maintained at a target temperature of 1023 Árpád fejedelem u.7, Hungary 33°C using a closed-loop endovascular system (Alsius E-mail address: [email protected] CoolGard, Irvine, Calif). Patients were allowed to passively rewarm. The mean arterial pressure was maintained at z90 doi:10.1016/j.ajem.2007.06.009 mmHg with inotropic support when necessary. The institution's ethics committee approved the study. Neurologic death Reference was regarded when patients had absent somatosensory evoked potentials after 72 hours and died after active care [1] Littmann L, Brearley WD, Taylor L, Monroe MH. Double counting of was withdrawn. Cardiac death was regarded as death due to heart rate by interpretation software: a new electrocardiographic sign of persistent cardiogenic shock despite (non)invasive measures. severe hyperkalemia. Am J Emerg Med 2007;25:584-90. Discharged survivors or one of their relatives were contacted by telephone at least 6 months after discharge, and neurologic outcome was evaluated using predefined questionnaires Hypothermia for out-of-hospital cardiac arrest survivors: (Glasgow Outcome Score [GOS] [6]). Unfavorable outcome a single-center experience was defined as death, severe disability, or vegetative state (GOS 1-3). Discharge to home or a rehabilitation facility with GOS z4 was defined as favorable neurologic outcome. To the Editor, Baseline characteristics were comparable between both groups; however, patients in the normothermia group tended Out of hospital cardiac arrest (OHCA) patients have a to be older, were more likely to have bystander cardiopul- poor prognosis, with only 10% of patients surviving. Recent monary resuscitation (CPR), and had shorter arrival of randomized trials have shown that moderate therapeutic paramedics and return of spontaneous circulation (ROSC) hypothermia improves neurologic outcome and survival in times (Table 1). Hypothermia was initiated at a median of selected patients after cardiac arrest [1,2]. Therapeutic 4 hours (1.8-6.4 hours) after ROSC. The target temperature Correspondence 1079

Table 1 Baseline characteristics and outcome differences in the chain of survival concept. Relatively high bystander CPR rates have previously been reported in the Hypothermia Normothermia P Netherlands and may make it more difficult to demonstrate (n = 43) (n = 58) additional improvement in outcome after mild hypothermia Baseline characteristics [7]. Our protocol was frequently violated, and patients Age (y) were cooled more liberally but, on the other hand, more Mean ± SD 56.2 (12.8) 63 (10.9) .12 closely followed the recommended International Liaisons Female sex (%) 14 (33) 18 (31) .87 Committee on Resuscitation guideline indications [3]. Our Initial rhythm VT/VF (%) 37 (86) 54 (93) .24 study partly demonstrates the difficulty in generalizing Asystole (%) 3 (7) 4 (7) randomized trial results to everyday practice. Further PEA (%) 3 (7) 0 research is therefore needed, and prospective randomized Bystander-performed CPR 22 (51) 42 (72) .05 trials should be done to determine the broadest application (%) of moderate therapeutic hypothermia. Time collapse—arrival of 10 (2-25) 8 (1-30) .6 paramedics (min) (median [range]) Sebastiaan C.A.M. Bekkers MD Time to ROSC (min) 27 (11-75) 22 (8-60) .50 Bob J.W. Eikemans MD (median, [range]) Robert Tieleman MD, PhD Simon H.J.G. Braat MD, PhD Outcome Willem Dassen PhD Unfavorable outcome (%) 22 (51) 28 (48) .56 GOS (%) Jean Partouns 1 22 (51) 27 (47) Chris de Zwaan MD, PhD 200 Harry J.G.M. Crijns MD, PhD 301 Department of Cardiology 41112 University Hospital Maastricht 5917 P.O.Box 5800, 6202 AZ Maastricht Lost to follow-up 1 1 The Netherlands PEA indicates pulseless electrical activity; GOS 1, dead; GOS 2, vege- E-mail address: [email protected] tative state; GOS 3, severe disability; GOS 4, moderate disability; GOS 5, good recovery; VT/VF, ventricular tachycardia and ventricular Marc C.T.F.M de Krom MD, PhD fibrillation. Department of Neurology University Hospital Maastricht was reached in all patients at a median of 3 hours (0.1- P.O. Box 5800, 6202 AZ Maastricht, The Netherlands 7 hours) and was maintained for 16.2 ± 6.3 hours. Two patients were lost to follow-up. doi:10.1016/j.ajem.2007.06.008 Twenty-two (51%) of 43 patients treated with hypothermia vs 28 (48%) of 58 normothermic patients had an unfavorable outcome. Mortality was 51% in the hypothermia group vs References 47% in the normothermia group. The cause of death was not significantly different between both groups with all deaths [1] Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose occurring in hospital. Uncomplicated hyperglycemia, which survivors of out-of-hospital cardiac arrest with induced hypothermia. was controllable with insulin, and the need for inotropic N Engl J Med 2002;346:557-63. support were significantly more prevalent in the hypothermia [2] The Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. group. Only 9 (21%) of 43 hypothermic patients completely N Engl J Med 2002;346:549-56. fulfilled our protocol criteria. These patients were compared [3] Nolan JP, Morley PT, Hoek TL, et al. Therapeutic hypothermia after with 8 (14%) of 58 patients from the normothermia group cardiac arrest. An advisory statement by the Advancement Life support who would have been eligible for hypothermia when Task Force of the International Liaison committee on Resuscitation. available at that time. Again, no significant difference in Resuscitation 2003;57:231-5. [4] de Vreede-Swagemakers JJ, Gorgels AP, Dubois-Arbouw WI, et al. mortality was found (66.7% vs. 62.5%). Out-of-hospital cardiac arrest in the 1990's: a population-based study in Thus, we were unable to demonstrate a significant the Maastricht area on incidence, characteristics and survival. J Am Coll benefit of moderate hypothermia for OHCA patients in our Cardiol 1997;30:1500-5. hospital. Physicians should all be aware that the available [5] Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended evidence is based on randomized clinical trials with strict guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals inclusion and exclusion criteria, excluding approximately from a task force of the American Heart Association, the European 92% of patients initially screened. In addition, the variation Resuscitation Council, the Heart and Stroke Foundation of Canada, and in survival rates among communities can be attributed to the Australian Resuscitation Council. Circulation 1991;84:960-75. 1080 Correspondence

[6] Jennett B, Bond M. Assessment of outcome after severe brain damage. evidence of an impact to the head, a feature not seen in Lancet 1975;1:480-4. shaking alone. The retinal hemorrhages, although concern- [7] Waalewijn RA, de Vos R, Koster RW. Out-of-hospital cardiac arrests in ing, are not sufficiently described to allow their attribution Amsterdam and its surrounding areas: results from the Amsterdam resuscitation study (ARREST) in “Utstein” style. Resuscitation solely to shaking, stressing the need to consider other causes, 1998;38:157-67. such as an impact to the head, in the differential diagnosis. In addition, although the absence of ICHs in shaking injuries has been reported in the literature [2,3], such a presentation is Shaken baby syndrome vs inflicted brain injury unusual. Overall, the sum of all of these factors points to an impact to the head as a distinct possibility to account for this child's findings; and although shaking could have occurred To the Editor, in addition to blunt trauma, the term SBS should not have been used in this case. I read with interest the article by Healey and Schrading [1], Inflicted traumatic brain injury is a more generic, less describing an alleged case of shaken baby syndrome (SBS) mechanism-specific term for cases of inflicted head injury. with unilateral retinal hemorrhages and no associated The use of this term reflects a broader, more inclusive intracranial hemorrhage (ICH). It is applaudable that the approach to the diagnosis of abusive head injuries in children authors were alerted to the potential that the child was likely that acknowledges the fact that ITBI and its associated the victim of abuse. The authors' conclusion that the child was findings (retinal hemorrhages, fractures, bruising) may be the a victim of SBS however is not supported by their findings and result of shaking, impact, or both. must be viewed cautiously. Although the issue I raise may be Physicians who face suspected cases of abusive head viewed as semantic, it is crucial that physicians be careful not injuries can best serve their patients by using the term ITBI to make assertions that cannot withstand scrutiny. instead of SBS. Discussions of specific mechanisms of injury The term SBS is often erroneously used synonymously for are best addressed by physicians experienced in neurotrauma inflicted traumatic brain injury (ITBI) in infants. One must or child abuse pediatrics. remember however that shaking is only one of many mechanisms of injury that can lead to brain injury and Steven Bellemare MD retinal hemorrhages. Dalhousie University, Child Protection Team Although I agree that the reported case likely constitutes IWK Health Centre, PO Box 9700, Halifax, Nova Scotia a case of ITBI, it is not necessarily a case of SBS. The Canada B3K-6R8 authors seem to have fallen victim to the use of the term E-mail address: [email protected] SBS as a synonym for child abuse in their efforts to convey that unilateral retinal hemorrhages may point to a doi:10.1016/j.ajem.2007.06.007 diagnosis of SBS even in the absence of ICH. I find it important to point out that the simple presence of retinal hemorrhages in an infant with evidence of brain injury does References not automatically imply a diagnosis of SBS, as seems to be suggested by the authors. The determination of the cause of [1] Healey K, Schrading W. A case of shaken baby syndrome with injury should be based on a more thorough investigation unilateral retinal hemorrhage with no associated intracranial hemor- including skeletal survey, nuclear bone scintigraphy, rhage. Am J Emerg Med 2006;24(5):616-7. elimination of differential diagnostic possibilities, and [2] Morad Y, Avni I, Capra L, et al. Shaken baby syndrome without interprofessional collaboration. intracranial hemorrhage on initial computed tomography. J AAPOS 2004;8(6):521-7. A number of features go against shaking alone as a [3] Morad Y, Avni I, Benton SA, et al. Normal computerized tomography of mechanism of injury in the reported case. The presence of brain in children with shaken baby syndrome. J AAPOS 2004;8(5): bruising on the head of the child represents definitive 445-50. American Journal of Emergency Medicine (2007) 25, 1081

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Erratum

In the article, “A New Full Body Low-Dose X-Ray Technique is an Alternative to Conventional “Shunt Series” in Patients With Ventriculoperitoneal Shunt Dysfunction” in Am J Emerg Med 2007:25:720-1, the order of the authors was incorrect. The correct byline is: Benoit B. Schaller, Robert H. Andres, Harald M. Bonel, Aristomenis K. Exadaktylos

DOI of original article: doi:10.1016/j.ajem.2007.03.009.

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Case Report Acute toxic hepatitis after amiodarone intravenous history included hypertension, previous acute myocardial B loading infarction treated with coronary stenting, atrial fibrillation, severe heart failure (ejection fraction, 25%), type 2 diabetes Intravenous amiodarone is the drug of choice for the mellitus, and chronic obstructive pulmonary disease. Vital management of atrial fibrillation in patients in unstable signs were as follows: blood pressure, 120/80 mm Hg; pulse, condition with known impairment of ventricular function. 100 beats per minute; respiration, 20 breaths per minute; The most important adverse effects are hypotension, axillary temperature, 36.78C (96.48F), pulse oximetry, 94% asystolic/cardiac arrest and/or electromechanical dissocia- on room air. Physical examination revealed arrhythmic heart tion, cardiogenic shock, congestive heart failure, bradycar- beat with no heart murmur, and bilateral basal crepitations. dia, and liver function test abnormalities. We report the case Electrocardiogram showed atrial fibrillation and left bundle of acute toxic hepatitis in a 79-year-old woman with atrial branch block. Chest radiography showed cardiomegaly and fibrillation and severe congestive heart failure that occurred initial signs of interstitium-alveolar stasis. Laboratory data soon after administration of intravenous amiodarone. Even if were as follows: white blood cell count, 13800/mm3 with we have no direct (eg, bioptic or autoptic) features of liver 68% neutrophils; hematocrit, 43.6%; hemoglobin, 13.8 g/ damage, the cause-effect relationship between amiodarone dL; platelets, 319000/mm3; sodium, 141 mEq/L; potassium, infusion and hepatitis seems to be probable (Naranjo adverse 4.47 mEq/L; chloride, 108 mEq/L; creatinine, 1.2 mg/dL; drug reaction probability score, 7). Peculiarity is given by the glucose, 220 mg/dL; aspartate aminotransferase, 15 U/L; very short latency time (6 hours) elapsed between infusion prothrombin time (international normalized ratio), 1.80; and high transaminase elevation (N100-fold). Amiodarone is the drug of choice for the management of fibrinogen, 365 mg/dL; erythrocyte sedimentation rate, atrial fibrillation in patients in unstable condition with known 25 mm; troponin I, 0.19 ng/mL; myoglobin, 128 ng/mL. impairment of ventricular function [1]. However, amiodarone The result of urinalysis was normal. The patient was treated hydrochloride, the intravenous form of amiodarone, shows a with digoxin, nitrates, aspirin, furosemide, and low-molec- considerable interindividual variation in its response. Thus, ular-weight heparin. On the second night, she complained of the recommended starting dose of about 1000 mg over the first severe acute dyspnea. Electrocardiogram showed atrial 24 hours has to be delivered with caution: a rapid infusion of tachyfibrillation (N130 beats per minute). In consideration 150 mg over the first 10 minutes, followed by slow infusion of of the ventricular dilation with severe impairment of systolic 360 mg over the next 6 hours, and a further maintenance contractility, an intravenous loading dose of amiodarone infusion of 540 mg over the remaining 18 hours [2]. The most (Cordarone, Sanofi-Synthelabo, Milan, Italy) was given, important adverse effects are hypotension, asystolic/cardiac starting (3:00 am) with 180 mg over the first 60 minutes, arrest and/or electromechanical dissociation, cardiogenic followed by slow infusion of 360 mg over the next 5 hours. shock, congestive heart failure, bradycardia, and liver function Average heart rate was reduced (100 beats per minute), and test abnormalities. In controlled and uncontrolled clinical dyspnea was reduced. The morning after, laboratory exam- trials, liver function test abnormalities were observed in 3.9% ination revealed an important elevation of transaminases of patients [2]. Acute hepatitis is a rare adverse effect of (Table 1), and amiodarone infusion was promptly stopped treatment with parenteral amiodarone and is usually reversible (9:00 am). Thus, total dose of amiodarone was 540 mg. with discontinuation of the infusion, and maintenance Transaminases had their peak on the successive day, then treatment with oral amiodarone is possible also in patients started a progressive decrease (Fig. 1). However, a severe, who develop liver disease during intravenous loading [3]. worsening congestive heart failure, poorly responsive to 1. Case report medical therapy, lead to death on day 7 from admission.

A 79-year-old woman was admitted to the hospital 2. Discussion complaining of nocturnal shortness of breath. Her medical Many drugs may cause liver injury infrequently, and these B Supported, in part, by a scientific grant (Finanziamento per ricerca reactions are considered idiosyncratic [4]. They occur at locale) from the University of Ferrara, Ferrara, Italy. therapeutic dose in 1 of every 1000 to 100000 patients, are

Table 1 Laboratory examination pattern Day 1, Day 3, 1/28 Day 3, 1/28 Day 4, Day 5, Day 6, Day 7, 1/26 (8:00 am) (3:00 pm) 1/29 1/30 1/31 2/1 AST (5-37 IU/L) 13 1568 3397 4202 2352 1164 581 ALT (5-40 IU/L) 15 1088 2060 3387 2387 1800 1260 Bilirubin, total 1.00 1.76 2.20 1.10 1.90 2.52 2.71 (0.16-1.20 mg/dL) Bilirubin, conjugated 0.45 1.20 1.50 0.80 1.20 1.84 1.90 (0.0-0.5 mg/dL) INR (0.85-1.25) 1.60 1.80 2.40 2.40 2.50 2.10 Creatinine 1.2 1.6 1.8 1.4 1.5 1.3 (0.6-1.4 mg/dL) AST indicates aspartate aminotransferase; ALT, alanine aminotransferase; INR, international normalized ratio. characterized by a variable delay or latency period ranging reversible with discontinuation of the infusion, and mainte- from 5 to 90 days, and often involve damage to hepatocytes nance treatment with oral amiodarone is possible also in throughout the hepatic lobule, with various degrees of patients who developed liver disease during intravenous necrosis [4]. As for other drugs, for example, acetaminophen, loading [3]. Polysorbate 80, an organic surfactant added to the bromfenac, cocaine, phencyclidine, cyclophosphamide, cy- intravenous infusion as a solvent, is a more likely cause of this closporine, methotrexate, niacin, and oral contraceptives, complication because similar reactions have been described amiodarone hepatotoxicity is characterized by dose depen- in neonates receiving an intravenous formulation of vitamin E dency, and amiodarone-induced steatohepatitis is multifacto- [10], and a mediation by immunologic mechanisms has been rial [4]. Studies on isolated rat liver mitochondria showed that suggested [11]. It is proposed that rapid administration of a amiodarone has a dose-dependent toxicity on the respiratory high loading dose of amiodarone can cause acute confluent chain and on beta oxidation, with a significant reduction of necrotic hepatitis, and 2 fatal cases of amiodarone-induced either the respiratory control ratio or oxidation of palmitate acute hepatitis are reported. These patients, aged 28 and 64 [5]. Again, in mice administered amiodarone and examined years, both died of hepatic coma and acute renal failure on for changes in hepatic histology and gene regulation, hepatic 14th and 4th day, respectively. Needle liver biopsy, performed RNA analysis revealed a dose-dependent increase in the immediately after death, revealed lesions of acute drug- expression of several genes critical for fatty acid oxidation, induced hepatitis with confluent and bridging necrosis [12]. lipoprotein assembly, and lipid transport [6]. Liver enzyme More recently, another fatal case occurred in a 64-year-old elevation is commonly observed in patients receiving man admitted as an emergency, with symptomatic uncon- amiodarone [7]. However, there are differences between oral trolled atrial fibrillation [13]. and intravenous amiodarone administration, with the former being safely prescribed also in patients with elevated baseline alanine aminotransferase [8]. Although most hepatic amio- 3. Conclusions darone-associated adverse effects are transient and reversible In our case, the diagnosis is based on drug history, with time, one case of fatal hepatotoxicity associated with temporal relationship, time course of liver dysfunction, chronic use of oral amiodarone has been reported [9]. Acute exclusion of other causes, and rapid improvement after hepatitis may be more frequently observed as an adverse amiodarone withdrawal. Although we have no direct (eg, effect of treatment with parenteral amiodarone. This is usually bioptic or autoptic) features of liver damage, the cause-effect relationship between amiodarone infusion and hepatitis, according to the Naranjo adverse drug reaction probability score [14] (Table 2), is probable. Peculiarity is given by the very short latency time elapsed between infusion and transaminase elevation. Previous reports, in fact, showed intervals of 1 or more days to get significant liver damage, and transaminase elevation was lower [15]. Adverse drug events are common among elderly subjects [16], and elderly women seem to be at particular risk for drug-induced liver injuries [17]. In critically ill elderly patients treated with intravenous amiodarone loading, a high level of alertness should be maintained, and liver function should be moni- Fig. 1 Time course of transaminase levels. tored even during the first hours of infusion. Case Report 1082.e3

Table 2 Evaluation of possible adverse drug reaction: the Naranjo probability score Yes No Do not know Score Are there previous conclusive reports on this reaction? +1 0 0 +1 Did the adverse event appear after the suspected drug was administered? +2 À10 +2 Did the adverse reaction improve when the drug was discontinued or a +1 0 0 +1 specific antagonist was administered? Did the adverse reactions appear when the drug was readmnistered? +2 À10 0 Are there alternative causes (other than the drug) that could, on their own, À1+20 +2 have caused the reaction? Did the reaction reappear when a placebo was given? À1+10 0 Was the drug detected in the blood (or other fluids) in +1 0 0 0 concentrations known to be toxic? Was the reaction more severe when the dose was increased or less severe +1 0 0 0 when the dose was decreased? Did the patient have a similar reaction to the same or similar +1 0 0 0 drugs in any previous exposure? Was the adverse event confirmed by any objective evidence? +1 0 0 +1 Total score +7

Total score Adverse drug reaction probability classification 9 Highly probable 5-8 Probable 1-4 Possible 0 Doubtful

Acknowledgments References

The authors thank Dr Angela Benini, PharmD, from the [1] Connolly SJ. Evidence based analysis of amiodarone efficacy and Pharmacovigilance Unit, Department of Pharmaceutical safety. Circulation 1999;100:2025-34. [2] Physicians’ desk reference, 52nd ed. Montvale (NJ)7 Medical Assistance, Azienda USL, Ferrara, Italy, for her valuable Economics Co Inc; 1998. p. 3027-30. collaboration. [3] Ratz Bravo AE, Drewe J, Schlienger RG, et al. Hepatotoxicity during rapid intravenous loading with amiodarone: description of three cases Emanuela Rizzioli MD and review of the literature. Crit Care Med 2005;33:128-34. Elena Incasa MD [4] Lee WH. Drug-induced hepatotoxicity. N Engl J Med 2003;349: 474-85. Susanna Gamberini MD [5] Waldhauser KM, Torok M, Ha HR, et al. Hepatocellular toxicity and Sandra Savelli MD pharmacological effect of amiodarone and amiodarone derivatives. Arnaldo Zangirolami MD J Pharmacol Exp Ther 2006;319:1413-23. Marilena Tampieri MD [6] McCarthy TC, Pollack PT, Hanniman EA, Sinal CJ. Disruption of Department of Internal Medicine hepatic lipid homeostasis in mice after amiodarone treatment is associated with peroxisome proliferator-activated receptor–alpha Hospital of the Delta target gene activation. J Pharmacol Exp Ther 2004;311:864-73. Lagosanto, Ferrara, Italy [7] Pye M, Northcote RJ, Cobbe SM. Acute hepatitis after parenteral amiodarone administration. Br Heart J 1988;59:690-1. [8] Kum LC, Chan WW, Hui HH, et al. Prevalence of amiodarone-related Roberto Manfredini MD hepatotoxicity in 720 Chinese patients with or without baseline liver Department of Internal Medicine dysfunction. Clin Cardiol 2006;29:295-9. Hospital of the Delta [9] Richer M, Robert S. Fatal hepatotoxicity following oral administration Lagosanto, Ferrara, Italy of amiodarone. Ann Pharmacother 1995;29:582-6. Department of Clinical and Experimental Medicine [10] Rhodes A, Eastwood JB, Smith SA. Early acute hepatitis with parenteral amiodarone: a toxic effect of the vehicle? Gut 1993;34:565-6. Section of Clinica Medica [11] Breuer HW, Bossek W, Haferland C, et al. Amiodarone-induced University of Ferrara severe hepatitis mediated by immunological mechanisms. Int J Clin Ferrara, Italy Pharmacol Ther 1998;36:350-2. E-mail addresses: [email protected] [12] Kalantzis N, Gabriel P, Mouzas J, et al. Acute amiodarone-induced [email protected] hepatitis. Hepatogastroenterology 1991;38:71-4. [13] MacFayden RJ, Palmer TJ, Hisamuddin K. Rapidly fatal acute amiodarone hepatitis occurring in the context of multiple organ doi:10.1016/j.ajem.2007.02.045 failure. Int J Cardiol 2003;91:245-7. 1082.e4 Case Report

[14] Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the [16] Terrel KM, Heard K, Miller KL. Prescribing to older ED patients. probability of adverse drug reactions. Clin Pharmacol Ther 1981;30: Am J Emerg Med 2006;24:468-78. 239-45. [17] Ostapowicz G, Fontana RJ, Schibdt FV, et al. Results of a prospective [15] Gregory SA, Webster JB. Acute hepatitis induced by parenteral study of acute liver failure at 17 tertiary care centers in the United amiodarone. Am J Med 2002;113:254-5. States. Ann Intern Med 2002;137:947-54. American Journal of Emergency Medicine (2007) 25, 1082.e5–1082.e8

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Case Report Electrocardiographic myocardial infarction without involving temporary electrocardiographic (EKG) changes structural lesion in the setting of acute and accompanying myocardial infarctions (MIs). Awareness hymenoptera envenomation of this phenomenon, including prompt recognition and treatment, is essential for optimizing patient outcomes. Most We report a case of a 69-year-old man with electrocardio- patients who present with acute anaphylaxis after a bee sting graphic myocardial infarction after being stung by a bee. The prompt treatment with epinephrine, steroids, and histamine patient had no history of hymenoptera allergy and no blockers. This results in resolution of symptoms with little cutaneous or respiratory evidence of anaphylaxis. At initial sequela. We present the case of a previously healthy presentation to the emergency medical services, the patient 69-year-old man without known coronary artery disease was found obtunded with agonal respiration, a systolic blood who experienced heart block and ST elevation (STE) after pressure of 92 mm Hg, and an electrocardiogram revealing being stung by a bee. second-degree heart block type 2 with a 2:1 conduction, a rate A previously healthy 69-year-old man presented to the of 51 beats per minute, and an ST elevation consistent with an emergency medical services (EMS) after a 911 call was inferolateral myocardial infarction. There were continued placed by the patient’s long-time companion. The com- dynamic changes to the cardiogram en route to the hospital, panion reported that the patient had come in from outside and the patient was taken emergently to cardiac catheteriza- in obvious distress asking for help and stating that a bee tion. He had no acute structural disease. This rare case of had stung him. She further stated that the patient had no direct cardiac toxicity secondary to hymenoptera envenoma- known drug allergies, had no significant past medical tion and the implication for emergency treatment of this history, and took no medications on a regular basis. potentially fatal, albeit rare, event are discussed. Upon arrival of the EMS, the patient was seated upright Anaphylaxis secondary to hymenoptera envenomation is on a chair, obtunded, with his neck hyperextended. His a common cause of morbidity worldwide. Mortality in the airway was patent, and he was making agonal respiratory United States has been variously reported from 29 to effort at a rate of 8 breaths per minute. It was noted that the 50 deaths per year. Rarely reported in the literature are cases patient’s skin was cool, pale, and diaphoretic. No flushing or

Fig. 1 Initial EMS electrocardiogram demonstrating second degree heart block with two to one and variable conduction.

Fig. 2 Initial EMS 12-lead electrocardiogram confirming second degree AV block and further demonstrating ST-elevation. uticaria was noted. The patient was then moved to the floor obtained (Fig. 2). The diagnostic EKG confirmed the and placed in the supine position. A carotid pulse was presence of a second-degree atrioventricular block and palpable, and a blood pressure of 92/40 mm Hg was further showed STE in leads I, II, III, aVF, V3,V4,V5, obtained. His airway was managed with an oropharyngeal and V6. Confirmation was made with the patient’s compan- airway, and ventilatory assistance was maintained via bag ion that epinephrine had not been administered. valve mask ventilations. The patient’s breath sounds were The paramedics then contacted medical control. Given noted to be clear bilaterally with no adventitious sounds. the presence of STE in 2 or more contiguous leads, a The cardiac monitor was then placed on the patient and decision was made to activate the cardiac catheterization revealed a second-degree heart block type 2 with 2:1 team and to take the patient directly to the catheterization conduction and a ventricular rate of 51 beats per minute laboratory. Prehospital treatment included continued fluid (Fig. 1). A thorough secondary survey revealed no obvious resuscitation, diphenhydramine 50 mg IV and methylpred- sting sites; however, the patient’s companion reported that nisone 125 mg IV, as well as postintubation sedation with the patient said his left elbow had been stung. etomidate. En route, a repeat 12-lead EKG was obtained Paramedical personnel initiated bilateral intravenous (Figs. 3 and 4). Interpretation was difficult secondary to lines in the patient’s antecubital fossa, whereas the airway motion artifact; but the heart rate had increased to 120 beats was more definitively protected through nasotracheal per minute, and STE was no longer present, yet ST intubation. Because of the atypical presentation without depression was noted. Upon arrival at the emergency hypotension, regional EMS protocol for the treatment of department, the patient was taken directly to the cardiac anaphylaxis was initially withheld while a 12-lead EKG was catheterization laboratory.

Fig. 3 Serial electrocardiogram showing the evolution of the event. The ST elevations are no longer present but depression can now be seen. Case Report 1082.e7

Fig. 4 Serial electrocardiogram showing the evolution of the event. The ST elevations are no longer present but depression can now be seen.

Initial hospital workup revealed both a complete blood cell of hymenoptera venom that include histamine, serotonin, and comprehensive metabolic profile that were within normal kinin, bradykinin, acetylcholine, phospholipase A and B, and limits. Levels of creatine kinase, creatine kinase–MB, and hyaluronidase may cause endogenous amine release and troponin I were 245 IU/L, 6.6 ng/mL, and 0.01 mg/mL, vasodilation, which then leads to a paradoxical vasoconstric- respectively. An initial portable anterior posterior chest tion. In addition, venom contains epinephrine, dopamine, showed an endotracheal tube above the carina, a normal- leukotriene, and thromboxane, which all cause platelet sized heart, mildly prominent pulmonary vasculature without aggregation and direct vasoconstriction. In fact, animal interstitial edema, and no evidence of pneumothorax. Cardiac studies of bee venom infusion have demonstrated EKG catheterization revealed a 30% to 40% left anterior descend- changes [1-6]. ing coronary artery lesion and a 10% to 20% left circumflex The commonality of exposure to bee stings and the rarity lesion and an ejection fraction of 65%. There was no acute of MI in this setting lead one to hypothesize that other structural lesion. factors may contribute to its occurrence. One theory is the Over the next 24 hours, the patient was successfully presence of underlying endothelial dysfunction predisposing weaned from the ventilator and extubated. He was noted to unfortunate subjects to this occurrence. The mechanism may have a cholesterol level of 201 mg/dL and triglycerides of be secondary to severe yet temporary vasospasm or in situ 227 mg/dL. For this reason, he was started on Lipitor and thrombus secondary to active constituents of hymenoptera aspirin. On hospital day 3, the patient was discharged from venom. Suggestive in this patient’s presentation is undoc- the hospital. He was given a Medrol dosepak and an EpiPen. umented hypotension coupled with nonsignificant coronary He was further instructed to follow up with his primary care artery lesions and potential vasospasm that resulted in provider and be examined by an allergist. No further cardiac temporary STE MI with resolution before sustaining intervention was indicated at the time of discharge. He will myocardial damage. follow up with cardiology in 6 months. This subject had minimal cardiac risk factors, had no Hymenoptera exposure is a common occurrence in both chest pain, experienced only moderate hypotension, and was the United States and worldwide. Less common is anaphy- not administered epinephrine yet demonstrated MI on his laxis secondary to envenomation. Rarely reported is the initial EKG. This should give clinicians pause when treating occurrence of MI after exposure. The mechanism is widely patients after venomous stings. Epinephrine is well known believed to be secondary to either prolonged hypotension or to increase myocardial oxygen demand and worsen tissue the administration of epinephrine in the setting of anaphy- damage in the presence of MI. Obviously, if the patient has laxis. Our case focuses on a patient who demonstrated only respiratory symptoms, epinephrine should not be withheld; minimal coronary artery disease by subsequent percutaneous but in the absence of acute respiratory distress, clinicians transluminal coronary angioplasty yet experienced a STE MI may choose to obtain a 12-lead EKG as part of the initial in the absence of profound hypotension or epinephrine workup for a patient stung by a bee or wasp. administration. The implication for this is great given that Future animal studies may be needed to further elucidate epinephrine is the standard of care for anaphylaxis but is the mechanism of STE MI in the setting of hymenoptera contraindicated in the presence of cardiac ischemia. envenomation and to determine when and if epinephrine A clear relationship between STE MI and bee stings has should be withheld. Currently, one should consider the not been clearly established. It is believed that in the absence efficacy of obtaining 12-lead EKGs on patients felt to be at of hypotension or epinephrine administration, constituents risk even in the absence of chest pain. 1082.e8 Case Report

Michael A. Valkanas MD References Department of Emergency Medicine Albany Medical Center [1] Ceyhun C. Myocardial infarction following a bee sting. Int J Cardiol Albany, NY 12208, USA 2001;80:251-3. [2] Jones E. Acute myocardial infarction after a wasp sting. Br Heart J Scott Bowman BA, EMT-P 1988;59:506-608. [3] Wagdi P. Acute myocardial infarction after wasp stings in a patient with Albany County Sheriff’s Department normal coronary arteries. Am Heart J 1994;128:820-3. Voorheesville, NY 12186, USA [4] Freye H. Acute myocardial infarction following hymenoptera envenomation. Allergic Proc 1989;10:119-26. Michael W. Dailey MD [5] Levine H. Acute myocardial infarction following wasp sting. Am Heart Department of Emergency Medicine J 1976;91:366-74. [6] Armar M. Acute myocardial infarction in a professional diver after Albany Medical Center jellyfish sting. Mayo Clinic Proc 2003;78:1557-60. Albany, NY 12208, USA E-mail address: [email protected] doi:10.1016/j.ajem.2007.02.046 American Journal of Emergency Medicine (2007) 25, 1083.e1–1083.e3

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Case Report McKittrick-Wheelock syndrome: a cause of severe The abnormal findings of laboratory examinations on hydro-electrolyte disorders in EDB admission were severe hyponatremia (117 mmol/L), hypokalemia (2.57 mmol/L), hypochloremia (64 mmol/L), and severe acute renal failure (Table 1). Other laboratory data A 72-year-old woman presented with a history of 1 year of were normal, including thyroid and hepatic function. diarrhea and, in the last 3 weeks, weakness and drowsiness. Colonoscopy revealed a villous, reddish-surfaced, frag- Initial laboratory findings were hyponatremia (sodium, 117 mmol/L), hypokalemia (potassium, 2.57 mmol/L), ile-consistency polyp, 17 cm from the anus (Fig. 2). A secreting villous adenoma structure without malignant areas hypochloremia (64 mmol/L), and azotemia (urea, 434 mg/ was diagnosed on histopathologic examination. dL and creatinine, 4.36 mg/dL). The patient had a full The patient had a full recovery after hydration and recovery after hydration and correction of all electrolyte correction of all electrolyte disorders (Table 1). disorders. In the investigation of the cause of diarrhea, we In the 1950s, McKittrick and Wheelock [2] were the first found a polypoid lesion 17 cm in length, revealing a secretory ones to describe the aggressive villous adenomatous polyp tubulovillous adenoma in the histologic evaluation. Here we of the colorectal area that has a course with dehydration, describe a rare case of the McKittrick-Wheelock syndrome with a dramatic presentation in the emergency department. electrolyte disorders, and acute renal failure. The villous adenomas of the colon cause secretory Adenomatous polyps are neoplasms with malignant po- diarrhea associated with severe electrolyte and fluid tential, located mainly at the level of the sigmoid and rectum. depletion syndrome (McKittrick-Wheelock syndrome). Most patients with colonic adenomatous polyps present with Large rectal villous adenomas (4-10 cm) can cause fluid mild gastrointestinal symptoms or are asymptomatic, colono- depletion of 0.5 to 3 L every 24 hours and hypokalemia scopic exploration being the procedure of choice for the [2]. Prostaglandin E2 has been implicated as a possible diagnosis [1]. In rare cases, patients with villous adenomas secretagogue compound in the pathogenesis of this exhibit secretory diarrhea with considerable loss of fluids and electrolytes. The most dramatic presentation with diarrhea, syndrome, and indomethacin and other prostaglandin inhibitors have been used with apparent benefit in dehydration, acute renal failure, and electrolytic disorders is a controlling the volume of rectal effluent in patients with rare condition known as McKittrick-Wheelock syndrome [2]. secretory villous adenomas [3,4]. Here we describe a case of this rare syndrome with The villous adenomas of the colon decrease the serum presentation in the emergency department (ED). potassium concentration because there is excessive deple- A 72-year-old white woman from Sa˜o Paulo, Brazil, was tion of this ion. The patients can present mainly with brought to the ED with severe watery diarrhea, dehydration, neuromuscular and cardiovascular symptoms, evolving to limb weakness, and sleepiness. The patient had a 1-year history of chronic diarrhea. flaccid quadriplegia, areflexia, respiratory insufficiency, arrhythmias, and sudden cardiac death. On examination, she was sleepy, confused, dehydrated, and The hypokalemia causes an ST-segment depression, with tachypnea. Her temperature was 35.48C, her pulse 134 reduction in T waves, and the presence of U waves in the beats per minute, her respiratory rate was 24 breaths per electrocardiogram (Fig. 1). The treatment is based on oral minute, and her blood pressure 80/50 mm Hg. Her skin was potassium replacement and, in more serious symptomatic cool and clammy, and she appeared ill. Examination of the forms, by parenteral therapy. heart revealed a rapid rhythm; the sounds and point of maximal The possibility of hyponatremia must be considered impulse were normal. The breath sounds and abdomen examination were normal. The rectal examination showed a mass. whenever there is dysfunction of the central nervous system [5]. The main therapy consists in increasing the serum The electrocardiogram on admission showed alterations sodium concentration to correct the neurologic symptoms, suggestive of hypokalemia (ST-segment reduction and U and it must be done supported by insurances formulas and waves) (Fig. 1). by characteristics of infusates (change in serum Na+=infu- sate Na+/total body water+1) not exceeding 1 mEq/h or B 12 mEq/24 h [6]. The presence of symptoms and their This study is supported by the Faculty of Medicine of the University of Sa˜o Paulo, Brazil. severity determine the pace of correction. Nevertheless,

Fig. 1 Electrocardiogram suggests hypokalemia: ST-segment reduction and U waves. correction should be of a sufficient pace and magnitude to The precocious diagnosis of the McKittrick-Wheelock reverse the manifestations of hypotonicity but not be so syndrome is very important for immediate replacement of rapid and large as to pose a risk of the development of fluid and electrolyte. Even so, the surgical removal of the osmotic demyelination [6]. adenoma led to complete recovery of the symptoms. The patient was admitted in the hospital with severe To our knowledge, our case is one of the most striking hyponatremia, hypokalemia, hypochloremia, and uremia. hydro-electrolyte disorders with high levels of creatinine What is impressive in this case are the levels of urea and urea [2,7-13], all this totally reversible. (434 mg/L) and creatinine (4.36 mg/L) on admission; these Although the McKittrick-Wheelock syndrome is a rare values had been normalized after aggressive replacement illness, it is very important to make the diagnosis in of fluid and electrolytes (urea, 23 mg/dL and creatinine, precocious phases, allowing the total reversibility of the 0.73 mg/dL). abnormalities with adequate treatment.

Table 1 Laboratory data on admission and during patient’s hospitalization Variable Reference range Admission 2 d 3 d 4 d 6 d 16 d Sodium (mmol/L) 135-145 117 121 128 133 136 137 Potassium (mmol/L) 3.5-5.0 2.57 2.6 2.6 3.2 4.1 3.9 Calcium, ionic (mg/dL) 4.8-5.16 3.69 3.6 – 4.2 – 4.8 Magnesium (mmol/L) 1.4-2.0 3.24 3.28 – 2.65 1.83 – Chloride (mmol/L) 98-106 64 71 – 92 102 – Urea (mg/dL) 10-30 434 387 353 304 105 23 Creatinine (mg/dL) b1.4 4.36 4.11 3.87 2.59 1.57 0.73 Glucose (mg/dL) 70-100 287 132 88 – – 92 Bicarbonate, arterial (mmol/L) 22-26 31.9 – 27.9 – – 23.9 Case Report 1083.e3

Fig. 2 Rectosigmoidoscopy: villous rectal adenoma. Mucous injury of the villous aspect, sessile with circumferential form, filling the lumen of the rectum.

Herlon Saraiva Martins MD [4] Smelt AH, Meinders AE, Hoelman K, Noort WA, Keirse MJ. Rodrigo Antoˆnio Branda˜o-Neto MD Secretory diarrhea in villous adenoma of rectum: effect of treat- Andre´ Laranjeira de Carvalho MS ment with somatostatin and indomethacin. Prostaglandins 1992;43: 567-72. Alfredo Nicodemo Cruz Santana MD [5] Hans DS, Cho BS. Therapeutic approach to hyponatremia. Nephron Francisco Jose´ Bueno Aguiar MD 2002;92(Suppl. 1):9-13. Augusto Scalabrini-Neto MD, PHD [6] Androgue HJ, Madias NE. Hyponatremia. N Engl J Med 2000;342: Irineu Tadeu Velasco MD, PHD 1581-9. Faculty of Medicine of the University of Sa˜o Paulo [7] Kioer HW. Villous adenomas of the colon and the rectum with electrolyte disturbances. McKittrick-Wheelock’s syndrome. Ugeskr Brazil Laeger 1969;131(39):1646-9. E-mail address: [email protected] [8] Tosi F, Branchini L, Armiraglio L, Scandroglio I, Massazza C. Villous adenoma of the rectum with water-electrolyte imbalance (McKittrick- doi:10.1016/j.ajem.2007.03.002 Wheelock syndrome). Minerva Chir 1987;42(9):793-7. [9] Suarez J. McKittrick and Wheelock syndrome. Clinical case. Rev Med Chil 1994;122(2):198-200. [10] Older J, Older P, Colker J, Brown R. Secretory villous adenomas that References cause depleting syndrome. Arch Intern Med 1999;159:879-80. [11] Helgesen A, Fuglsig S. Villous adenoma of the rectum with electrolyte [1] Bond JH. Polyp guideline: diagnosis, treatment and surveillance imbalance. McKittrick-Wheelock syndrome. Ugeskr Laeger 2000; for patients with colorectal polyps. Am J Gastroenterol 2000;95: 162(32):4272-3. 3053-63. [12] Popescu A, Orban-Schiopu AM, Becheanu G, Diculescu M. [2] McKittrick LS, Wheelock FC. Carcinoma of the colon. 1954. Dis McKittrick-Wheelock syndrome—a rare cause of acute renal failure. Colon Rectum 1997;40(12):1494-5 [discussion 1495-6]. Rom J Gastroenterol 2005;14:63-6. [3] Pugh S, Thomas GA. Patients with adenomatous polyps and [13] Lepur D, Klinar I, Mise B, Himbele J, Vranjican Z, Barsic B. carcinomas have increased colonic mucosal prostaglandin E2. Gut McKittrick-Wheelock syndrome: a rare cause of diarrhea. Eur J 1994;35:675-8. Gastroenterol Hepatol 2006;18(5):557-9. American Journal of Emergency Medicine (2007) 25, 1083.e5–1083.e7

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Case Report Tongue viability after snakebite—an unusual A 49-year-old man, a snake charmer, presented to the occupational hazard emergency department of our hospital with tongue snakebite of 1-hour duration. The snake was identified as Taiwan- Snakebites are encountered worldwide; of the 3000 Chinese cobra (Nnajaatra). This is no ordinary place of species of snake, about 10% to 15% are venomous. Snake- snakebite. He had initially progressive pain and swelling of bites give hemorrhagic toxin predominately; 97% of snake- tongue. No breathing difficulty was noted. On physical bites are on the extremities. The venom-induced necrosis is a examination, he was conscious, oriented, and orthopnoeic, common local debilitating sequela of bites by many vipers, having a respiratory rate of 20 breaths per minute. His pulse frequently resulting in severe permanent scarring and rate was 67 beats per minute; blood pressure was 197/120 mm deformity. Antivenoms are not effective under these circum- Hg. The tongue showed fang-puncture wounds exuding stances unless administered within a few minutes of the bite. bloody fluid, erythematous, ecchymosis, and necrosis To report a snake charmer with an unusual presentation of a (Figs. 1 and 2). The otorhinolaryngologic examination only Taiwan-Chinese cobra (Naja naja atra) snakebite presenting revealed mild vocal cord swelling. The breath sounds were with significant local tissue injury and necrosis of the tongue. normal, and there were no or rhonchi. Laboratory inves- The patient received polyvalent snake anti venom almost tigations revealed a hemoglobin level of 17.7 g/dL, total 1 hour after the bite. At no time did the patient develop leukocyte count of 8100/mm3, platelet count of 229 Â 103/lL, respiratory insufficiency, neurotoxicity, or renal failure. and normal peripheral blood smear results. Coagulation Tongue damage rapidly resolved after early and aggressive profile showed a prothrombin time of 9.2 seconds (control, treatment with polyvalent snake antivenom. The preserved 14 seconds) with an international normalized ratio of 0.88; tongue remained well perfused and viable, and tongue partial thromboplastin time was 30 seconds (control, 36 sec- mobility was good. The tongue possesses rich blood supply onds). All results of biochemical investigations including that provides a resistance to necrosis, allows lacerations to plasma glucose, blood urea, serum creatinine, aspartate heal quickly, and offers these patients the potential for tongue aminotransferase, alanine aminotransferase, and serum elec- preservation. Therefore, tongue snakebite damage rapidly trolyte were within normal limits. His electrocardiogram respond to polyvalent snake antivenom, avoiding tongue showed normal sinus rhythm, and chest x-ray showed mild amputation and dumbness sequelae. pleural effusion on the left side. He was treated with Worldwide, only about 15% of the more than 3000 species polyvalent snake antivenom immediately. Because of the of snakes are considered venomous to humans [1]. The annual report of snakebites is approximately 300 to 600 with mortality of approximately 10% to 20% [2]. In developing countries, snakebite is an occupational hazard for traditional faith healers, snake charmers, and religious men. Males are bitten a little more frequently than females. The dorsum of the foot and the ankle are the most common sites of snakebites. In general, the viperids tend to have venom that is strongly hemotoxic, whereas the elapids tend to have venom that is more strongly neurotoxic. However, elements of both are often found in all snakes as all elapid venoms possess some degree of neurotoxin, which causes paralysis of systemic neuromuscular system, muscle weakness, dizziness, and death due to respiratory paralysis with little reaction at the site of the bite. We report an unusual tongue snakebitebyTaiwan-Chinesecobra(Naja naja atra) belonging to the Elapidae family that produced a distinctive clinical picture characterized by prominent local effect with Fig. 1 Tongue ecchymosis and myonecrosis along with fang few neurotoxicity and quick tongue recovery. marks and scratches on dorsum of the tongue.

ing paralysis and polypeptides that contribute to local tissue damage. However, local tissue necrosis is the main clinical feature of the Taiwan-Chinese cobra bite, aside from neurologic symptoms and sign. According to the 43 patient studies from the Poison Control Center, Taiwan-China, from 1986 to 1998, 94.4% of patients had local swelling, 38.9% had necrosis or wound poor healing, and 19.4% had nonspecific systemic symptoms after a Taiwan-Chinese cobra bite. Both mortality and typical sign of neurotoxicity were absent [8]. The cause of local tissue necrosis can be attributed to direct toxin effect and vascular thrombosis of surrounding tissue. Pressure immobilization is highly effective against neurotoxic venoms such as those of most elapids. Developed by Struan Sutherland in 1978, the object of pressure immobilization is to contain the venom within a bitten limb and prevent it from moving through the lymphatic system to the vital organs in the body core [9]. Fig. 2 Tongue ecchymosis and myonecrosis along with fang The dorsum of the foot and the ankle are the most common marks and scratches on dorsum of the tongue. sites of snakebites and rarely the tongue. Because of the possible airway threat, he was admitted to the intensive care tremendous local tissue destruction, it is usual in severe unit for closed observation. He was given antibiotics and bites for amputation of the affected limb to become relevant supportive therapy. The patient responded well to necessary. However, pressure immobilization and amputa- treatment and repeat oral examination, which showed good tion may not be appropriate for tongue snakebites. tongue perfusion and mobility (Fig. 3). He was discharged Most snakebites are defensive bites, an accidental from the hospital in good health after 5 days. After this, encounter between man and snake, where the victim does the patient was followed up with no sequela. not receive a bite with a full load of venom injected. The The family Viperidae is the largest family of venomous bites generally take on the ankle and rarely on the tongue snakes; and members of this family can be found in Asia, [2]. To the best of our knowledge, there was a death case Africa, Europe, and the Americas. The family Elapidae is the report from snakebite on the tongue that occurred in Russia next largest family of venomous snakes. In North America the in 1971 [10]. Gerkin et al [11] described tongue snakebite venomous species are members of the families Elapidae, and from the rattlesnake with life-threatening obstruction of Viperidae, subfamily Crotalidae. Cobras, mambas, and kraits upper airway secondary to massive edema of the tongue, are also members of the family Elapidae but are not and other soft tissue structures quickly followed enveno- indigenous to the Americas. However, an increasing number mation. Therefore, poisonous snakebites are medical emer- of exotic species are kept by both zoos and private collectors, gencies, and they can be deadly if not treated quickly; making bites by nonindigenous species increasingly common survival of victims depends much on the appropriate first- [3]. In contrast, the tropical Asia is home to more than 150 venomous species, representing 3 snake families: the Viperidae, the Elapidae, and the Colubridae [11]. There are 6 major venomous snakes in Taiwan-China: 4 from the Crotalidae family and 2 from the Elapidae family. The Crotalidae family includes the Taiwan habu (Trimeresurus mucrosquamatus), the green habu or Chinese bamboo pit viper (Trimeresurus stejnegeri or Trimeresurus gramineus), the hundred-space snake or sharp-nosed viper (Deinagkistrodon acutus), and Russell viper (Vipera russellii formosensis) [4]. Except for Russell viper, which produces both hemorrhagic and neurotoxic venom, these snakes produce hemorrhagic venom only. The Elapidae family includes the banded krait (Bungarus multicinctus) and the Taiwan-Chinese cobra (Nnajaatra), both of which produce a neurotoxic venom [5]. More than half the fatalities due to venomous snakebites in Taiwan-China were caused by cobra bites, although viper bites were 3 to 4 times more common [6,7]. Asian cobra is classified as a neurotoxic snake. Its venom Fig. 3 Good viability and mobility after quickly antivenin possesses neurotoxic property that may cause life-threaten- treatment. Case Report 1083.e7 aid measures and immediate transportation to the nearest References health center where the facility to administer antisnake venom and supportive care is available. [1] Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J It is our intention to underline that the tongue is a Med 2002;374:374-456. muscular organ suspended by its intrinsic muscles, which [2] Ong J-R, Ma H-P, Wang T-L, et al. Snake bite. Ann Disaster Med 2004;2:80-7. are attached to the surrounding skull base, mandible, and [3] Britt A, Burkhart K. Naja naja cobra bite. Am J Emerg Med 1997; hyoid bone. The lingual arteries supply its rich blood 15(5):529-31. supply; and the facial, inferior alveolar, and buccal arteries [4] Jih-Chang C, Shiumn-Jen L, Michael J, et al. Treatment of poisonous make only minor contributions. In tongue myonecrosis, snakebites in northern Taiwan. J Formos Med Assoc 2000;9:135-9. preservation of just one of the lingual arteries is sufficient to [5] Pawar DK, Singh H. Elapid snake bites. Br J Anaesth 1987;59:385-7. [6] Anonymous. Snakebites in the tropics. Lancet 1972;785:1016. maintain adequate tongue vascularity from crossover [7] Trishnananda M. Incidence, clinical manifestation and general man- perfusion by the contralateral lingual artery. Therefore, agement of snakebites. Southeast Asian J Trop Med Public Health early and aggressive medical treatment provides it with a 1979;10:248-50. resistance to necrosis and allows lacerations and incisions to [8] Gian-Kaw L, Ming-Ling W, Jou-Fang D, et al. Taiwan cobra (Naja heal quickly [12-14]. naja atra) injury, cases analysis of Poison Control Center. J Emerg Med (ROC) 2000;2:46-58. [9] Sutherland SK, Coulter AR, Harris RD. Rationalization of first-aid Ta-Lun Kao MD measures for elapid snakebite. Lancet 1979;1:183-6. Department of Critical care Medicine [10] Shagylydzhov K, Pepchuk TA. Death from a snake bite on the tongue. Show Chwan Memorial Hospital Sud Med Ekspert 1971;14(2):55-6. Changhua, Taiwan, Republic of China [11] Gerkin R, Sergent K, Curry SC, et al. Life-threatening airway obstruction from rattlesnake bite to the tongue. Ann Emerg Med 1987;16:813-6. Chi-Wen Juan MD [12] Foster PK, Weed DT. Tongue viability after bilateral lingual artery Department of Emergency Medicine ligation and surgery for recurrent tongue-base cancer. Ear Nose Throat Show Chwan Memorial Hospital J 2003;82:720-4. Changhua, Taiwan, Republic of China [13] Thomas A, Smith II TA, Figge HL. Treatment of poisonous snakebite poisoning. Am J Hosp Pharm 1991;48:2190-6. E-mail address: [email protected] [14] Russell FE, Ruzic N, Conzales HC. Effectiveness of antivenom (Crotalidae) polyvalent following injection of crotalus venom. doi:10.1016/j.ajem.2007.02.047 Toxicon 1973;11:461-4. American Journal of Emergency Medicine (2007) 25, 1084.e1–1084.e2

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Case Report Laryngotracheal disruption after blunt neck trauma penetrating wounds or ecchymosis of the skin. When he became stable, a high-resolution computed tomographic Laryngotracheal injuries after motor vehicle accidents are scan revealed complex fractures of the thyroid and cricoid rare. They are mostly confined to the cervical trachea, cartilages, extensive hemorrhage and edema totally obliter- resulting from direct blunt injury to the anterior neck. In ating the airway (Fig. 1) with complete laryngotracheal addition, complete laryngotracheal separation carries a high disruption (Figs. 2 and 3), diffuse subcutaneous emphyse- mortality rate immediately, and its early diagnosis is very ma, right pneumothorax, pneumomediastinum, pneumo- difficult because of nonspecific signs in the settings of acute peritoneum, and right hip fracture. He underwent trauma. We present a case of a 27-year-old man who immediate laryngotracheal reconstruction and insertion of experienced a high-energy blunt trauma to the neck, and we bilateral chest tubes. On regular follow-up, he was discuss the clinical signs and symptoms in laryngotracheal dysphonic, with a slight paresis of both vocal cords. injuries, the importance of imaging features and manage- Airway trauma may be life-threatening, immediately or ment in this kind of injury. in the hours after acute injury. In civilian practice, blunt A 27-year-old male motorcyclist was transferred to the trauma to the airway from motor vehicle accidents used to emergency department after a car hit him. Glasgow score be the most common cause of such injuries [1]. was 3, and he received cardiopulmonary resuscitation Laryngotracheal injuries represent less than 1% of all immediately with orotracheal intubation. Physical examina- trauma injuries and account for more than 75% of tion revealed subcutaneous emphysema from the supra- immediate mortality. Most injuries are confined to the clavicular regions to the angle of the mandible, with slight cervical trachea, resulting from direct blunt trauma, where tenderness when palpating the thyroid cartilage, without any the larynx is compressed against the cervical spine. The thyroid and cricoid cartilages may be fractured and the cricoarytenoid joint dislocated. Separation of the airway may be partial or complete. The points of rupture are most commonly between the cricoid and trachea and in the upper trachea. One or both recurrent laryngeal nerves may be temporarily or permanently

Fig. 1 Axial computed tomographic scan with contrast, at the level of the vocal cords, showing multiple fractures of thyroid (big arrow) and cricoid cartilages. Extensive hemorrhage and edema totally obliterate the airway (double asterisk) around the orotracheal tube. The internal jugular vein (IJV) and the carotid (asterisk) are also shown. Bilateral marked emphysema resulting from the laryngotracheal disruption is also evident. The left thyroid ala is Fig. 2 Computed tomographic scan showing the free space displaced medially against the arytenoid cartilage (small arrow). between the orotracheal tube and the surrounding neotrachea.

findings in laryngeal trauma [4,6,7]: fractures, dislocations, hemorrhage, and laryngotracheal separation. Airway management must be the highest initial priority in the unstable patient. Once stable, the damaged larynx and trachea should be repaired surgically.

Rony Aouad MD Homere Moutran MD Simon Rassi MD Department of Otolaryngology–Head and Neck Surgery Hotel Dieu de France Hospital, Saint Joseph University PO BOX 70-056, Antelias, Beirut, Lebanon E-mail address: [email protected]

doi:10.1016/j.ajem.2007.02.048

Fig. 3 Laryngotracheal disruption is evident, with the cuff of the References orotracheal tube completely filling the space between the neotrachea and the upper end of the distal trachea. [1] Bacha EA, Mathisen DJ, Grillo HC. Airway trauma. In: Westaby S, Odell JA, editors. Cardiothoracic trauma. London7 Arnold; 1999. p. 265-79. damaged [2]. In complete tracheal transection, the surround- [2] Couraud L, Velly JF, Martigne C, et al. Posttraumatic disruption of ing tissues may provide a bneotracheaQ; therefore, intubation the laryngo-tracheal junction. Eur J Cardiothorac Surg 1989;3(5):441-4. is very hazardous because the lower end of the endotracheal [3] Baumgartner FJ, Ayres B, Theuer C. Dangers of false intubation after traumatic transection. Ann Thorac Surg 1997;63(1):227-8. tube may pass into a false track at the site of the tracheal [4] Angood PB, Attia EL, Brown RA, et al. Extrinsic civilian trauma to the separation, and hence, not only obstruct the airway larynx and cervical trachea—important predictors of long-term completely but also exacerbate any mediastinal or pleural morbidity. J Trauma 1986;26(10):869-73. air leak [3]. [5] Chagnon FP, Mulder DS. Laryngotracheal trauma. Chest Surg Clin Clinical signs are nonspecific [4,5], but the diagnosis of North Am 1996;6(4):733-48. [6] Gayler BW, Kashima HK, Martinez CR. Computed tomography of the any laryngeal injury is suspected on the presence of neck. Crit Rev Diagn Imaging 1985;23(4):319-76. subcutaneous emphysema. Computed tomographic scan is [7] Mancuso AA, Hanafee WN. Computed tomography imaging of the the imaging modality of choice in demonstrating the various injured larynx. Radiology 1979;133(1):139-44. American Journal of Emergency Medicine (2007) 25, 1084.e3–1084.e5

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Case Report Titanium alloy ring crush injury last resort always has been the ring cutter. This simple and effective device is the only choice for open finger injuries. Finger rings can cause considerable damage to the finger The advantage of not cutting the ring in closed injuries is an if certain precautions are not observed while working or emotional one, because many of the rings, in the view of participating in sports. Common ring cutters used in patients, are symbols not to be damaged. emergency departments (EDs) appear to be appropriate We present a case report in which conventional means tools for gold, silver, or pure titanium ring removal in acute of ring removal after injury failed because of the cases. Some hardened materials recently introduced for use material characteristics (Ti-6/6/2 alloy) and resulted in in jewelry, such as titanium alloys and tungsten carbide, can iatrogenic injury. pose a considerable risk of secondary damage if no A 27-year-old, right hand–dominant woman, who was appropriate cutting tools are available in the ED. A case breast feeding, injured her left ring finger and small finger of secondary iatrogenic damage to the finger during ring when she tripped and fell. She sustained an open fracture of removal is reported. the proximal phalange of the ring finger and a closed Finger rings have been used as decorations and symbols fracture of the base of the proximal phalange of the small for thousands of years. The first accounts of the use of finger finger (Fig. 1). The patient had been wearing an aerospace- rings date back to the early Bronze Age [1]. Finger rings grade titanium alloy ring on her ring finger. The patient was served not only as a decoration but mostly as a sign of social taken to another regional hospital emergency department status. The use of signet rings to indicate official business (ED). After numbing the ring finger with local anesthetic, dates back at least to Old Testament times (eg, Genesis 41:42 physicians initially attempted to remove the ring using a [circa 1900 bc], Jeremiah 22:24 [circa 600 bc]). Finger standard ring cutter of the type commonly available in EDs. rings have also been used to signify treaties and covenants, These cutters are hand-powered hardened-steel circular including marriage. The choice of materials was dictated by saws. When this attempt was unsuccessful, they called staff availability as well as social perception of the value of the from the technical department for help. Because a hard material used. Jewelry has been made from materials that are substance would be required to cut through titanium, a attractive, soft, and plastic. Gold has been a standard material diamond or other cutter was used to remove the ring. It took to signify, seal, and symbolize status of the wearer. The approximately 3 minutes to remove the ring with the power appearance and malleability of gold and silver have made cutter. In the process, the patient sustained a third-degree them the top choices of jewelers for many applications. In the friction burn to the proximal phalange of the injured ring last century, materials developed for use in other industries, finger (Fig. 2). After the ring was removed, she was referred such as aerospace, have given consumers new choices. to our facility. Jewelers have enthusiastically incorporated new materials To verify that this ring was indeed too hard to cut with a such as titanium, platinum, and tungsten carbide into standard ring cutter, we asked if the patient would allow us bijouterie. As in ancient times, the bearer of the ring to make another cut on the side of the ring (Fig. 3). We had indicates his values by the ring he is wearing. Consequently, to agree that it would not be possible to cut this ring with the some consumers feel that it is not enough to wear a pure conventional cutters in our possession. Closed pinning of titanium ring because this is not the btopQ material. Even the base of the proximal phalange of small finger was jewelry merchants are advertising titanium alloys as being performed, and closed reduction of the ring finger was superior to pure titanium in many aspects, perhaps most achieved. Debridement and full-thickness skin graft of the importantly to provide consumers the feeling of having dorsum of the proximal phalange was done at the end of the aerospace-grade (space shuttle) material on their fingers. third week. The early postoperative period was uneventful, There are many accounts in the literature regarding the and wounds healed without further intervention. complications of wearing a finger ring, the worst being ring Titanium was discovered in 1791 by the Reverend avulsion injury [2]. Any injury to a ring-bearing finger can William Gregor, an English pastor [3]. M. H. Klaproth result in the loss of the digit unless the ring is removed in a rediscovered the element in 1795 and named it after the timely manner using the proper technique. Many removal Titans of Greek mythology, who were very strong. Pure techniques have been advised with closed injuries, but the titanium was first produced by Matthew A. Hunter, an

Fig. 1 Open fracture of the proximal phalange of the ring finger Fig. 3 Titanium alloy ring removed from the patient’s finger. and closed fracture of the base of the proximal phalange of the small finger. choose a titanium band because it is easy to get used to American metallurgist, in 1910, but it was not produced wearing because of its light weight and comfort. commercially until the 1940s. Titanium is the ninth most Unlike gold and silver, titanium cannot be melted and abundant element in the earth’s crust (0.57%). It is as strong molded into designs. Instead, rings must be forged from a as steel but 45% lighter and twice as strong as aluminum but solid block of titanium and, therefore, cannot be resized. only 60% heavier. Titanium is not easily corroded. Titanium Titanium alloys posses even greater strength than the pure alloys are used in the aerospace industry, where strength, low form of the metal but offer little, if any, additional aesthetic weight, and resistance to high temperatures are particularly appearance. Aircraft-grade titanium (grade 5 or Ti/6Al/4V) important. Because titanium does not react within the human is an alloy of 90% titanium, 6% aluminum, and 4% body, it is used to create different biologic implants. vanadium. It has higher tensile strength than grade 2 CP Traditionally reserved for the engineering and aerospace titanium, which is not an alloy but the element in its pure industries, titanium has only recently been applied to jewelry, form. The highest-tensile-strength alloy, Ti-6/6/2 (which and its popularity has grown quickly in recent years. Many consists of 86% titanium, 6% aluminum, 6% vanadium, 2% jewelry shops and Web sites market titanium rings as a sign of tin) is 130% stronger than aircraft-grade titanium alloy. good taste and financial wealth. The metal is roughly one Because many titanium ring customers have expressed third the weight of gold (4.5 g/cm3), and many couples concern that, in the case of a medical emergency, a titanium ring might be impossible to cut off, sellers have incorporated this question into their question and answer sections. They state that if it is made of pure titanium, with no metals added for increased strength, any titanium ring can be cut off if necessary with a standard ring cutter. This is not true, however, with alloys such as aerospace-grade titanium, which have been used to make rings for especially demanding customers. Our experiments with conventional ED ring cutters showed that the time required for a grade 2 titanium ring was approximately 10 minutes per cut, which is about twice the time it took to cut 2 mm of stainless steel. Cutting a Ti-6/6/2 alloy ring yielded far different results. After 5 minutes, we barely penetrated the surface, and the cutter edge showed significant wear. The reality is that any economy-grade ring cutter that is available in most EDs is able to cut pure titanium (grade 2), hardened steel, and any other conventional precious metals such as gold and silver. Even if the ring cutter has to be discarded after removing titanium or hardened steel Fig. 2 Third-degree friction burn to the proximal phalange of the rings, it does not pose any additional danger to a patient. injured ring finger. Extensor tendon has been preserved. The problem arises with modern titanium alloys on which Case Report 1084.e5 a hardened high-grade steel ring cutter has to be used. tissue (eg, digital vein and artery) injury. We do not Some jewelers report that it takes approximately 10 minutes recommend a diamond cutter, but if it is used, irrigation is to cut a 2-mm-thick, 7-mm-wide ring made of aerospace- mandatory because of the high revolutions per minute, grade Ti/6Al/4V and approximately 15 minutes for the which generates excessive heat. Always make 2 opposite same size Ti-6/6/2 ring using a high-grade steel ring cutter cuts, thus splitting the ring into 2 parts. (personal communication with http://www. titaniumstyle. Tungsten carbide rings require special consideration com). Apparently, most of the jewelers affirm that the because they are so hard that no ring cutter can cut them. purer CP2 grade is more than adequate for jewelry Tungsten rings are the most wear-resistant rings available. situations, and its durability far exceeds precious metals. It is about 10 times harder than 18-carat gold, 5 times Aerospace (grade 5) titanium most of the time is used for harder than tool steel, and 4 times harder than titanium. tension-set diamond designs, and it is possible that these These rings can only be removed by cracking them into higher-grade alloys are more of a gimmick and do not pieces with standard, vice grip–style locking pliers. This actually contribute anything (personal communication with removal by cracking is much harder to control and http://www.titaniumstyle.com). consequently much more dangerous. This means that any Although the choice of ring materials is left to the taste ED must have grip-style locking pliers to crack the and common sense of the consumer, we can make some tungsten carbide ring as well. recommendations about that choice. In addition to generally well-known recommendations for ring wearing (eg, take it Martins Kapickis MD off during manual work and sports), we suggest entirely Joseph E. Kutz MD refraining from wearing titanium rings of aerospace grade. Christine M. Kleinert Institute We recommend this because no one can guarantee that a Louisville, KY 40202, USA local ED will possess a hardened steel ring cutter and, E-mail address: [email protected] consequently, a slight injury with marked edema may be disastrous for the survival of a finger. doi:10.1016/j.ajem.2007.03.006 An electric ring cutter is a good option in an emergency setting where speed, safety, and comfort are essential. The chrome blade usually cuts the strongest alloys in less than References 10 seconds, safely, without heat. Unfortunately, it is 30 times more expensive than an economy-grade ring [1] Boardman J, Wilkins RL. Greek gems and finger rings: early bronze cutter. It must be stressed that even with a high-grade steel to late classical, New Expand ed. London7 Thames and Hudson; 2001. manual ring cutter, it takes 10 to 15 minutes to remove a p. 19-66. [2] Tsai TM, et al. Primary microsurgical repair of ring avulsion titanium alloy ring. The time required is of paramount amputation injuries. J Hand Surg [Am] 1984;9A(1):68-72. importance because prolonged wriggling and twitching of [3] Stwertka A. In A guide to the elements. 2nd ed. New York: Oxford the finger during manual removal can inflict additional soft University Press, USA; 2002. p. 81, 238. American Journal of Emergency Medicine (2007) 25, 1085.e1–1085.e2

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Case Report

Use of recombinant activated factor VII in a Jehovah’s was taken to administer recombinant activated factor VIIa Witness patient (NovoSeven, Novo Nordisk, Baulkham Hills, NSW, Aus- tralia). He was given 90 lg/kg of the drug (a total of 4.2 mg) Managing acute hemorrhages in Jehovah’s Witnesses at 5:35 pm, and his bleeding stopped approximately 3 hours who refuse blood (or blood components) transfusions has later. Overnight, his condition remained stable with no been a well-documented clinical challenge for medical further observed episode of per rectum bleeding. His professionals. This article reports the successful use of hemoglobin level the following morning was 54 g/L. He recombinant activated factor VIIa in controlling gastroin- was returned to the general ward the same afternoon and was testinal hemorrhage in a Jehovah’s Witness patient. transferred to a palliative hospital 4 days later. A 77-year-old male Jehovah’s Witness with metastatic Managing acute hemorrhages in Jehovah’s Witnesses who oropharyngeal carcinoma and myelodysplastic syndrome refuse blood (or blood components) transfusions has been a was admitted at the Dubbo Base Hospital with anorexia, well-documented clinical challenge for medical professional severe weight loss, bony tenderness, and constipation. His worldwide [1-8]. Recombinant activated factor VIIa, which initial blood tests showed a hemoglobin level of 92 g/L, could induce local hemostasis via the extrinsic pathway of the platelet count of 186 Â 109, international normalized ratio of coagulation cascade and directly activate coagulation factors 1.8 (not on oral anticoagulant, normal activated partial IX and X, has been approved by the Food and Drug thromboplastin time of 27.2 sec), serum potassium level of Administration to treat hemorrhages and prevent hemor- - 2.5 mmol/L, serum HCO3 level of 39.2 mmol/L, and rhages during invasive procedures in patients with factor VII corrected serum Ca++ level of 4.38 mmol/L. The clinical deficiency and in patients with hemophilia A and B [9]. impression was paraneoplastic hypercalcemic syndrome Moreover, it has been demonstrated to successfully control complicated by dehydration and malnutrition. He was treated severe hemorrhages in other settings [3,4,7,8]. With the large with intravenous fluids and potassium replacement, which number of Jehovah’s Witnesses worldwide, recombinant brought his serum calcium level down to 3.65 mmol/L. activated factor VIIa can potentially be an important On day 2 of his admission, he developed severe fresh per therapeutic option for the management of acute hemorrhages rectum bleeding with clots. His pulse rate increased to in Jehovah’s Witnesses without contradicting their believes. 108 beats per minute, and although his blood pressure remained normal he became disoriented to time and place, Albert Hsieh with his Glasgow Coma Scale score recorded at 14. He Royal Prince Alfred Hospital was resuscitated with intravenous Gelofusine (B. Braun Sydney, Australia Australia Pty Ltd, Bella Vista, NSW), and blood was immediately sent for group and crossmatching. The surgical Izham Cheong team was consulted, but he was deemed unsuitable for Department of Medicine urgent colonoscopy or surgery because of the continuing Dubbo Base Hospital bleeding and because he was a poor candidate for NSW, Australia anesthesia. At this point, the attending medical team Faculty of Medicine was informed of an advanced directive documented in his University of Sydney, Australia previous admission 4 years ago that he is not to receive any E-mail address: [email protected] blood products because of his religious belief. His wish was doi:10.1016/j.ajem.2007.03.007 confirmed by the daughter. The patient and his daughter were informed that the bleeding is severe and he may bleed to death without adequate transfusion. He continued to pass References fresh blood per rectum, and his hemoglobin level fell to 70 g/L. He was given vitamin K and tranexamic acids and was [1] Marsh JCW, Bevan DH. Haematological care of the Jehovah’s Witness patient. [see comment]. Br J Haematol 2002;119:25-37. transferred into the intensive care unit. [2] Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal After an urgent consultation with the hematology unit at hemorrhage in a Jehovah’s Witness: new treatment strategies. [see Royal Prince Alfred Hospital in Sydney, Australia, a decision comment]. Crit Care Med 2002;30:1893-5.

[3] Veneri D, Franchini M. Successful treatment of intestinal hemorrhage [7] Virchis A, Hughes C, Berney S. Severe gastrointestinal haemorrhage in a Jehovah’s Witness patient. Am J Hematol 2005;79:344-5. responding to recombinant factor VIIa in a Jehovah’s Witness with [4] Haan J, Scalea T. A Jehovah’s Witness with complex abdominal trauma refractory immune thrombocytopenia. Hematol J 2004;5:281-2. and coagulopathy: use of factor VII and a review of the literature. Am [8] Tanaka KA, Waly AA, Cooper WA, Levy JH. Treatment of excessive Surg 2005;71:414-5. bleeding in Jehovah’s Witness patients after cardiac surgery [5] Allison G, Feeney C. Successful use of a polymerized hemoglobin with recombinant factor VIIa (NovoSeven). Anesthesiology 2003;98: blood substitute in a critically anemic Jehovah’s Witness. South Med J 1513-5. 2004;97:1257-8. [9] COAGULATION FACTOR VIIA. In Klasco RK, editor. DRUGDEX [6] Gohel MS, Bulbulia RA, Slim FJ, Poskitt KR, Whyman MR. How to System. Greenwood Village, Colorado: Thomson Micromedex. approach major surgery where patients refuse blood transfusion MICROMEDEX (R) Healthcare Series. Retrieved January 9, 2007 (including Jehovah’s Witnesses). Ann R Coll Surg Engl 2005;87:3-14. from http://www.micromedex.com/index.html. American Journal of Emergency Medicine (2007) 25, 1085.e3–1085.e4

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Case Report Ectopic ovarian pregnancy in a second-trimester patient have a right ovarian pregnancy (Table 1), and subsequently underwent a right oophorectomy and salpingectomy. Abdominal pain in the first 20 weeks of pregnancy is a Because ectopic pregnancy is responsible for 10% of frequent complaint in the emergency department (ED). The pregnancy-related deaths and is the leading cause of maternal assessment of a gravid patient with abdominal pain is chal- death in the first trimester, emergency physicians must be lenging with advancing gestational age because the uterus vigilant for this diagnosis [1]. However, ovarian pregnancy can displace intraperitoneal structures. In addition, imaging is provides an additional challenge. Not only is it rare—1:7000 restricted to minimize radiation exposure to the fetus. It is of all deliveries and 1% to 3% of all ectopics—but it may important to remain vigilant for ectopic pregnancy past 7.2 F present later than tubal ectopics [2,3]. Furthermore, initial 2 weeks of gestation. Most ovarian pregnancies present with misdiagnosis leads to hemodynamic instability being more unstable vital signs and hemoperitoneum. When ultrasound common in ovarian ectopics [5,6]. Although ovarian preg- findings are nondiagnostic and hemodynamic compromise nancies usually rupture by the 40th gestational day, there have and pain persist despite initial resuscitative efforts, it is been reports of these progressing into the third trimester and paramount to have early involvement of surgical consultants. even to live births [4]. The risk factors for tubal ectopic A 35-year-old, gravida 3, para 2 woman who was 16 weeks pregnancies do not correspond with the incidence of ovarian 1 day by first trimester ultrasound presented to our emergency pregnancies. Ovarian pregnancy seems to be a random event department (ED) after 7 hours of acute-onset, constant right- with a debatable association with multiparity and intrauterine sided abdominal pain, shortness of breath, and nausea. The device use [2,5,7]. patient went to a neighboring ED 11 days prior for similar The definitive treatment of peritoneal pain of unknown symptoms and was discharged home with diagnoses of etiology and unstable vital signs is a laparoscopy. For ovarian urinary tract and Trichomonas vaginalis infections. She had a pregnancy, it is both diagnostic and therapeutic; and at the time history of placenta previa and anxiety, and felt that it may be of operation, 90% have been found to be ruptured with hemo- anxiety because she had familiar complaints of paresthesias peritoneum secondary to the high ovarian vascularity [2,7]. to her fingers and shortness of breath. Her physical examination was remarkable for right-sided Kevin J. Corrigan DO abdominal pain with light palpation and for a gravid uterus Department of Emergency Medicine that was 1 cm to the right of the midline and 5 cm below the Midwestern University umbilicus. A bedside ultrasound performed by the ED Olympia Fields, IL, USA physician demonstrated fetal heart tones in the 140s with visualization of cardiac activity. Her pelvic examination was Daniel R. Kowalzyk DO most notable for the amount of pain she had when getting Department of Emergency Medicine into the examining position. She had no bleeding, and her St Francis Hospital Blue Island cervical os was closed and nontender. Midwestern University While in the ED, she received 2 L of isotonic sodium St. Francis Hospital chloride solution. Her systolic blood pressure improved, but Blue Island, IL, USA _ her heart rate was persistently 130 to 150. She was still E-mail address: kevincorrigan [email protected] tender, and her laboratory test results indicated a 1.3-g decline in hemoglobin to 7.2 from 11 days prior. The doi:10.1016/j.ajem.2007.03.012 radiologist submitted a preliminary ultrasound report that demonstrated ba 16 and 2/7 week live gestation with a small References subchorionic bleed and ascites around the liver.Q The gallbladder appeared normal and the appendix was not well [1] Ectopic pregnancy—United States, 1990-1992. MMWR Morb Mortal visualized (Fig. 1A and B). It was at that time that the Wkly Rep 1995;44:46. [2] Vasilev S, Sauer M. Diagnosis and modern surgical management of gynecologist and the general surgeon were both consulted, ovarian pregnancy. Surg Gynecol Obstet 1990;170:395-8. and the patient was consented for a blood transfusion and a [3] Gaudoin M, Coulter K, Robins A, et al. Is the incidence of ovarian ectop- laparoscopy. The patient was taken to surgery, was found to ic pregnancy increasing? Eur J Obstet Gynecol Reprod Biol 1996;70:141.

Fig. 1 A and B, These figures reinforce the challenge with diagnosing an ovarian pregnancy and that emergency physicians should not solely rely on laboratory tests or radiographs to make critical therapeutic decisions. Even an experienced radiologist has difficulty noting the location of the pregnancy, as it is a rare occurrence. The question marks on the ultrasound illustrate the confusion to identify landmarks. The bfluidQ demonstrated in the Morrison pouch was misinterpreted as ascites rather than blood.

[4] Evruke C, Ozgunen T, Demir C. Second trimester ovarian pregnancy. Table 1 Diagnostic criteria of ovarian pregnancy described Int J Gynecol Obstet 1996;53:167-9. by Spiegelberg [5] Sidek S, Lai S, Lim-Tan S. Primary ovarian pregnancy: current 1. The fallopian tube on the affected side must be intact. diagnosis and management. Singapore Med J 1994;35:71-3. 2. The gestational sac must occupy the same position as the ovary. [6] Kaplan BC, Dart RG, Moskos M, et al. Ectopic pregnancy: prospective 3. The ovary must be connected to the uterus by the utero-ovarian study with improved diagnostic accuracy. Ann Emerg Med 1996;28:10-7. ligament. [7] Raziel A, Schacter M, Mordechai E, et al. Ovarian pregnancy—a 4. Ovarian tissue must be located in the gestational sac wall. 12-year experience of 19 cases in one institution. Eur J Obstet Gynecol Reprod Biol 2004;114:92-6. American Journal of Emergency Medicine (2007) 25, 1086.e1–1086.e2

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Case Report Massive pulmonary embolism masquerading as results for electrolytes, liver function, and coagulation pulmonary edema indexes were normal. Blood levels of myoglobin and creatine kinase–MB were also normal with levels of We report a patient who presented with typical features troponin T elevated at 1.75 ng/mL (normal, b0.10); D- of cardiogenic pulmonary edema; however, massive pul- dimer level was 3196 ng/mL (normal, b280), arterial pH monary embolism was ultimately diagnosed. Pulmonary was 7.2, bicarbonate level was 16 mEq/L, partial pressures embolism masquerading as acute pulmonary edema has of carbon dioxide and oxygen were 30 mm Hg and 85 mm been rarely reported with parenchymal areas where Hg, respectively, with oxygen saturation at 78% while the pulmonary arteries are patent and more likely involved patient was breathing room air. with alveolar edema than lung segments where arteries are We diagnosed cardiogenic pulmonary edema and treated occluded. Mechanisms of pulmonary edema associated the patient with oxygen supplement, furosemide, nitroglyc- with embolism are unclear; however, mechanical obstruc- erin, and morphine sulfate with no significant improve- tion seems less important than the local release of ment; 2 hours later he was still unstable and breathless proinflammatory cytokines and prostaglandins. Patients in with worsening dyspnea and no change in the results of whom pulmonary embolism mimics the features of physical examination. At this time, a transthoracic cardiac pulmonary edema represent a subset raising strong diag- ultrasonography showed left ventricular hypertrophy and a nostic challenges. greatly enlarged right ventricle with several areas of The hypertensive or volume overload types of pulmonary akinesis and dyskinesis of the free wall; pulmonary artery edema are usually diagnosed upon typical clinical param- pressure was estimated at 70/35 mm Hg, and ejection eters that include elevated blood pressure, dyspnea, orthop- fraction was normal. nea, and bilateral rales heard at both lower and middle lungs We suspected massive pulmonary embolism, and enox- [1]. These features are commonly advocated to rule out at aparin (100 UI/kg twice daily) was added to his regimen. A the bedside of breathless patients the occurrence of computed tomography with contrast medium revealed pulmonary embolism; however, clinical assessment alone massive pulmonary embolism with several filling defects is unreliable for the diagnosis of pulmonary embolism, and in both the main pulmonary arteries and also in several the consequences of misdiagnosis are serious [2].We segmental and subsegmental branches. Locoregional pul- describe a patient in whom massive pulmonary embolism monary thrombolysis with urokinase was immediately presented with clinical features mimicking those of pulmo- started with complete reperfusion achieved on the 4th nary edema. day. Extensive workup did not reveal any cancer nor did A 72-year-old man presented with the sudden onset of we recognize any embolic source such as abdominal or severe dyspnea. His previous history revealed diabetes lower leg venous thrombosis. Result of thrombophilic mellitus, gastroesophageal reflux, hypertension, and chronic screening was negative except for elevated levels of blood renal failure that were well controlled with pantoprazole, homocysteine (42 and 37 lmol/L on the second and fifth amlodipine, furosemide, lisinopril, metformin, regular insu- day of hospital stay; normal values, b15); circulating lin, and glargine. vitamin B6, B12, and folate concentrations were normal. Physical examination revealed orthopnea, tachycardia We added folate and vitamin B6 to his regimen, and the (140/min), tachypnea (30/min), and elevated blood pressure patient was discharged free of symptoms on the 15th day; (190/105 mm Hg). We heard a systolic bruit along the left at this time, blood homocysteine level was 20 lmol/L. sternal border with no bruits around the neck and rales over At a follow-up visit 2 months later, while still taking both lower lungs; no other abnormalities were noted. warfarin, folate, and vitamin B6, he was doing well with An electrocardiogram was normal, and a chest x-ray no clinical or laboratory evidence of active pulmo- showed bilateral, patchy alveolar infiltrates without effu- nary thromboembolism. sion or consolidation and a mildly enlarged cardiac Pulmonary embolism masquerading as acute pulmonary silhouette. Laboratory tests revealed leukocytosis (11.3 Â edema is rare [3-8]. Parenchymal areas with patent 109 cells per liter, 81% of which were neutrophils), pulmonary arteries are more likely involved with alveolar hematocrit at 0.485, and creatinine level at 2.8 mg/dL; test edema than lung segments where arteries are occluded,

0735-6757/$ – see front matter D 2007 Elsevier Inc. All rights reserved. 1086.e2 Case Report which points to blood overflow to those areas as the central Giuseppe Famularo MD, PhD mechanism leading to extravasation of fluid into the Giovanni Minisola MD alveoli across pulmonary capillary and precapillary vessel Giulio Cesare Nicotra MD membranes [3,4]. However, the experimental findings Department of Internal Medicine from Erhart and colleagues [9,10], who demonstrated that San Camillo Hospital arterial blood pressure, even if increased, is poorly 00152 Rome, Italy transmitted to filtering lung capillaries, suggest that the E-mail address: [email protected] mechanical effects of the obstruction of one or more pulmonary arteries may cause by themselves only minimal Claudio De Simone MD alveolar edema or none at all. This hypothesis fits well with Department of Experimental Medicine those patients with a pattern of focal or unilateral alveolar University of L’Aquila edema but does not fully explain the development of 67100 L’Aquila, Italy diffuse and bilateral alveolar edema as seen in our patient. Proinflammatory cytokines, thromboxanes, and other medi- doi:10.1016/j.ajem.2007.03.014 ators of inflammation are probably responsible in this second scenario for the disrupted permeability of pulmo- References nary microvasculature with excess transudate into [1] Ware LB, Matthay MA. Acute pulmonary edema. N Engl J Med the alveoli [9-11]. However, these 2 different patterns of 2005;353:2788-96. lung injury leading to alveolar edema are not mutually [2] Kearon C. Diagnosis of pulmonary embolism. CMAJ 2003;168: exclusive and may coexist in subjects with massive 1430-1. pulmonary embolism. [3] Hyers TM, Fowler AA, Wicks AB. Focal pulmonary edema after It is known that pulmonary edema is more frequent massive pulmonary embolism. Am Rev Respir Dis 1981;123:232-3. [4] Manier G, Mora B, Castaing Y, Guenard H. Pulmonary edema in with air pulmonary embolism than with clot embolism [7]. pulmonary embolism. Bull Eur Physiopathol Respir 1984;20:55-60. The reason is not completely understood, and experimen- [5] Dombert MC, Rouby JJ, Smiejan JM, Brun P, Saraux JL, Marmuse JP. tal studies of vascular resistance, permeability, and Pulmonary oedema during pulmonary embolism. Br J Dis Chest 1987; occlusion pressures have not definitely answered the 81:407-10. question [12,13]. [6] Jobe RL, Forman MB. Focal pulmonary embolism presenting as diffuse pulmonary edema. Chest 1993;103:644-6. Patients in whom pulmonary embolism presents with [7] Shlim DR, Papenfus K. Pulmonary embolism presenting as high- features mimicking those of pulmonary edema may altitude pulmonary edema. Wilderness Environ Med 1995;6:220-4. reasonably represent a subset raising strong diagnostic [8] Thomas F, Clavier H, Mebtouche B, Kalfon P. Pulmonary embolism challenges even to skilled physicians. The use of standard- with overflow pulmonary edema. Rev Pneumol Clin 2003;59:360-4. ized and validated clinical prediction scores to rule in [9] Erhart IC, Granger WM, Hofman WF. Effects of arterial pressure on lung capillary pressure and edema after microembolism. J Appl pulmonary embolism is reasonably less helpful in this Physiol 1986;60:133-40. setting. For example, application of the Geneva score [10] Erhart IC, Hall JE, Hofman WF. Vascular pressure effects on lung would set our patient into a low-probability category for edema formation after glass bead embolism. J Appl Physiol 1987;62: pulmonary embolism [14]. This means that the use of 1989-96. recognizable clinical variables, which is the hallmark of [11] Lee BC, van der Zee H, Malik AB. Site of pulmonary edema after unilateral microembolization. J Appl Physiol 1979;47:555-60. management decisions in patients with suspected pulmo- [12] Hall JE, Hofman WF, Erhart IC. Venous occlusion pressure and nary embolism, does not correctly guide manage- vascular permeability in the dog lung after air embolization. J Appl ment strategy in this case, and the correct diagnosis Physiol 1988;65:34-40. would have missed. [13] Takeoka M, Sakai A, Ueda G, Ge RL, Panos RJ, Taniguchi S. Physicians should consider the diagnosis of pulmonary Influence of hypoxia and pulmonary air embolism on lung injury in perfused rat lungs. Respiration 1996;63:346-51. embolism when patients with features of cardiogenic [14] Le Gal J, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, pulmonary edema do not have a prompt response to standard et al. Prediction of pulmonary embolism in the emergency department: treatment with diuretics, nitroglycerin, and morphine. the revised Geneva score. Ann Intern Med 2006;144:165-71. American Journal of Emergency Medicine (2007) 25, 1086.e3–1086.e5

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Case Report Spontaneous splenic rupture associated with Listeria intestines, diagnosed as ascites. Contrast-enhanced comput- endocarditis ed tomographic (CT) imaging of the abdomen revealed the presence of free intraperitoneal fluid and abnormal density Spontaneous splenic rupture is a rare event usually patterns in the splenic region—findings indicative of a occurring during the course of hematologic or infectious rupture of the spleen with signs strongly suggestive of active diseases. A patient with a history of mitral valve replacement subcapsular and perisplenic hemorrhaging. Emergency and long-term acenocoumarol treatment who developed splenectomy was performed. splenic rupture subsequently to Listeria endocarditis is Pathologic report described a ruptured spleen of normal reported. Splenic involvement, whether in the form of size, containing a subcapsular hematoma 6 cm in length. abscesses or infarctions, often accompanies infective endocar- Histologic examination result revealed a red pulp showing ditis. Hemorrhage is a less common presentation resulting from signs of congestion. No other evidence of underlying destruction of the wall of splenic arterioles by septic emboli. pathology was found. Rupture of the spleen occurs most commonly as a result Although good recovery took place immediately after of blunt trauma to the abdomen, infection, or malignancy. the procedure, 3 days later the patient became severely Other causes are rarely encountered. A few cases regarding hypoxic despite oxygen therapy and was transferred to the anticoagulant and endocarditis-related rupture have been intensive care unit. Pulmonary embolism was ruled out by reported in the literature as separate entities. An association pulmonary angiography. The patient’s medical history, of these 2 causes has so far not been reported. clinical picture, and the presence of inflammatory syn- We detail an unusual case of a spontaneous splenic drome made it difficult to distinguish between an rupture in a patient on long-term acenocoumarol treatment, inflammatory or cardiogenic basis for the deterioration with a subsequent diagnosis of Listeria endocarditis. of his condition. The patient was thus treated for both A 76-year-old man presented to the emergency depart- eventualities. However, 3 days later the patient’s state had ment with sudden onset of diffuse abdominal pain worsen- not improved. The so-called inflammatory syndrome was ing on inspiration. He denied any fever, nausea or vomiting, failing to respond to antibiotic therapy, and the patient diarrhea, chest pain, or shortness of breath. Pain did not was still pyrexial. Blood cultures were positive for respond to analgesics. No history of trauma was reported. Listeria monocytogenes. Echocardiography was per- Medical history included long-standing hypertension, formed, showing large vegetations on the prosthetic valve hyperlipidemia, and heavy smoking up until 1987. Most and a perivalvular abscess. Listeria-causing endocarditis notable components were a double coronary artery bypass was diagnosed, explaining the combination of septic performed 6 years ago and a mitral valve replacement 16 features and cardiac compromise. Valve replacement years ago, for which he had since been on acenocoumarol. surgery was immediately performed. An episode of rectal On presentation, the patient was pale and fully conscious; bleeding while in the intensive care unit was diagnosed as his vital signs were stable with a pulse rate of 70, blood due to invasive rectal carcinoma. The patient died 1 pressure of 127/52, and temperature of 35.88C. Abdominal month later of multiple organ failure. examination revealed diffuse tenderness throughout with Nontraumatic rupture of the spleen seldom arises. Its guarding. Normal bowel sounds were present. Auscultation presenting features—most frequently sudden and diffuse of the heart elicited a systolic click best heard at the apex, abdominal or chest pain (or both)—are often vague and consistent with the medical history. confusing. The symptoms are at risk of being mistakenly Blood test results revealed low hemoglobin level attributed to more commonly occurring disease such as (9.1dg/L), hematocrit (0.26), erythrocyte count (3.1/pL), cardiac events or gastrointestinal illness, especially in a and mean corpuscular volume (79 fL). Leukocyte count patient with existing comorbidity. Indeed, in the case cited was markedly raised to 26700/lL. C-reactive protein was above, a preliminary diagnosis of ischemic colitis had been raised to 77 mg/L. Prothrombin time was reduced (37%), suggested. The consequences of such misdiagnosis are resulting from anticoagulant treatment. potentially serious in so far as rupture of the spleen rapidly Plain abdominal x-ray result showed diffuse haziness leads to hemorrhagic shock, requiring immediate treatment throughout the abdomen, with central positioning of the [1]. Although abdominal ultrasound is usually sufficient to

Table 1 Spontaneous splenic rupture: etiologies and incidences Infections 30% ! Mononucleosis, hepatitis A, AIDS, measles, cytomegalovirus 18% ! Bacterial endocarditis, Staphylococcus septicemia or abscess, legionaries disease, 8% Q fever, salmonellosis, meningococcus septicemia, tuberculosis, Haemophilus septicemia, Klebsiella, Streptococcus ! Parasites: malaria, hydatid disease 4% Hematologic disorders 27% ! Central malignant hemopathy, acute leukemias, chronic myeloid or lymphoid leukemias 15% ! Peripheral malignant hemopathy: malignant Hodgkin or non-Hodgkin lymphoma 9% ! Benign hemopathy: thalassemia, idiopathic thrombopenia, hemophilia, hemolytic anemia 3% Solid and cystic tumors 11% ! Malignancies: sarcomas and metastases 7% ! Benign tumors: hamartoma, angioma 4% Digestive tract disorders Pancreatitis, portal hypertension, splenic artery aneurysm, Crohn disease 10% Rheumatologic disorders Chronic arthritis, lupus 4% Renal dialysis 3% Other Amyloidosis, postpartum, fibrinolysis, and anticoagulants 15% Reprinted with permission from Kianmanesh et al Ann Chir. 2003;128:303-309 [3].

detect the rupture and resulting intraperitoneal hemorrhage, tear, resulting in intraperitoneal bleeding. In this case, studies have shown CT scanning to be more sensitive and however, apart from the presence of a subcapsular hema- hence the investigation of choice when splenic rupture is toma, histologic examination of the resected spleen showed suspected [2]. signs evocative of endocarditis. A review of the histology A variety of etiologies have been attributed to spontane- slides after the diagnosis of endocarditis revealed no ous splenic rupture [3].(Table 1) Taking into account the evidence of infarction, necrosis, or presence of septic patient’s history, the most apparent risk factor would appear emboli. Nevertheless, this remains a plausible and likely to be the enhanced susceptibility to bleeding associated with correlation. Given the low incidence of both spontaneous acenocoumarol therapy. Although hemorrhage is evidently a splenic rupture and endocarditis, as well as the relative recognized complication of anticoagulation therapy, in- frequency of some degree of splenic involvement in volvement of the spleen is rarely seen. Only a small number endocarditis, the concurrence of the 2 conditions in this of similar events have been described in the literature [4-6]. case is unlikely to be coincidental. In patients with deranged hemostatic mechanisms, it is Our patient was most probably not a suitable candidate thought that minor trauma such as coughing or vomiting for nonoperative management of the rupture. Although in may trigger the injury. the initial phase the bleeding did not appear extensive and Nevertheless, the primary cause of splenic rupture in classic signs of shock were absent, the deterioration of the the present case appears to be Listeria endocarditis and patient’s state, evidence of active bleeding shown on CT septicemia. Only 58 cases of L monocytogenes endocar- imaging, and the association with long-term anticoagulant ditis had been documented worldwide up until 1997 [7]. therapy were all indications for splenectomy. Other reports It carries a 40% mortality rate, especially in the elderly of spontaneous ruptures associated with anticoagulants or and those with previous cardiac pathology. Immune endocarditis report in most cases recourse to splenectomy depression linked to invasive rectal cancer may have that, accordingly, appears to remain the mainstay of contributed to the severity of Listeria infection in this treatment in cases such as these [10]. Abstention from patient. It is probable that endocarditis had been running surgery remains indicated in patients who are hemodymami- a subacute asymptomatic course days or weeks before cally stable [11]. hospital admission. Infective endocarditis is a recognized albeit rare etiology of spontaneous splenic rupture [8]. Moreover, in up to 35% Nadia Llanwarne MD of cases of endocarditis, splenic involvement, whether in the Bogdan Badic MD form of abscesses or infarctions, is thought to occur [9]. Ve´ronique Delugeau MD Although infarction arises with the occlusion of arterioles by Serge Landen MD septic emboli originating from the colonized valvular cusps, Department of Surgery, St. Elisabeth Hospital the hemorrhagic component is provoked by formation of 1180 Brussels, Belgium mycotic aneurysms coupled with pyogenic wall necrosis of E-mail address: [email protected] the splenic arterioles. Subcapsular hematomas then form, which distort and exert pressure on the capsule, causing it to doi:10.1016/j.ajem.2007.03.018 Case Report 1086.e5

References [6] Burg MD, Dallara JJ. Rupture of a previously normal spleen in association with enoxaparin: an unusual cause of shock. J Emerg Med 2001;20(4):349-52. [1] Debnath D. Lessons learnt: don’t prescribe heparin for haemoper- [7] Spyrou N, Anderson M, Foale R. Listeria endocarditis: current itoneum. Emerg Med J 2005;20(2):206-7. management and patient outcome-world literature review. Heart 1997; [2] Trouillet JL, Hoen B, Battik R, et al. Splenic involvement in infectious 77:380-3. endocarditis. Rev Med Interne 2003;20(3):258-63. [8] Stfllberger C, Finsterer J, Pratter A, et al. Ischaemic stroke and splenic [3] Kianmanesh R, Aguirre HI, Enjaume F, Valverde A, Brugie`re O, rupture in a case of Streptococcus bovis endocarditis. J Clin Microbiol Vacher B, et al. Spontaneous splenic rupture: report of three new cases 2003;41(6):2654-8. and review of the literature. Ann Chir 2003;128:303-9. [9] Ting W, Silverman NA, Arzouman DA, Levitsky S. Splenic septic [4] Badaoui R, Chebboubi K, Delmas J, et al. Splenic rupture emboli in endocarditis. Circulation 1990;82(5 Suppl):105-9. and anticoagulant therapy. Ann Fr Anesth Reanim 2004;23: [10] Blankenship JC, Indeck M. Spontaneous splenic rupture compli- 748-50. cating anticoagulant or thrombolytic therapy. Am J Med 1993;94: [5] Taccone FS, Starc JM, Sculier JP. Splenic spontaneous rupture and 433-7. hemoperitoneum associated with low molecular weight heparin: a case [11] Duverger V, Muller L, Szymszyczyn P, et al. Surgical abstention in report. Support Care Cancer 2003;11:336-8. closed injuries of the spleen. Ann Chir 2000;125:380-4. American Journal of Emergency Medicine (2007) 25, 1087.e1–1087.e2

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Case Report An unusual presentation of an unusual injury: The patient was admitted with a diagnosis of peroneal atraumatic avulsion of the Achilles tendon tendon injury. Subsequent ultrasound examination revealed an avulsion of the TA from the os calcis. No other injury was We present an unusual case of rupture of the Achilles noted. She was taken to theater and underwent operative tendon. The case presented without trauma and with purely repair of her TA avulsion using bone anchors to re-attach the lateral sided symptoms, suggesting a peroneal pathology. tendon insertion (Fig. 2). She had an uneventful recovery and Ultrasound imaging confirmed complete avulsion of the was discharged with a non–weight-bearing plaster in full tendon insertion, with no bony component. We review the equinus. After 6 months, she was fully weight-bearing, with a common presentation of this entity and its associated normal range of ankle motion and no other complaints. conditions and describe a method of surgical repair using Avulsion of the Achilles tendon has been previously bone anchors. described, but it is rare and has always been reported as a Tendo Achillis rupture is a common injury in the United consequence of trauma. Previous descriptions have also Kingdom. Exact numbers of incidence are not described mentioned the bony injury as being a major component because there are a large number of variables contributing to [1,7]. Our case presented in a quite different way; having no injury and a wide variation across racial backgrounds. It bony element and being virtually asymptomatic. This is usually affects bweekend athletesQ and causes a great deal of even more remarkable because there were no other social and financial cost to those affected [1]. Usually, the associated risk factors for TA rupture [1,5,6,8]. diagnosis is relatively straightforward, with a sharp, painful The presentation of our case highlights the need for snap being classic. Other clues to the diagnosis include clinicians to keep this diagnosis in mind. The woman previous local steroid injections, Achilles tendinopathy, presented with no trauma, purely lateral swelling and gout, hyperparathyroidism, and recent fluoroquinolone tenderness, and a normal Simmonds test result. None of antibiotic use. The mechanism usually involves eccentric the usually reliable stigmata of TA rupture were present, loading on a dorsiflexed ankle with the knee extended [2].It even to an experienced senior clinician [9]. is in this position that the soleus and gastrocnemius muscles We present this case to highlight that TA avulsion can are under maximal stretch. Commonly, rupture occurs present in the absence of significant trauma. It can present around 5 centimeters from the insertion point in the os with purely lateral signs. We would like to reinforce the calcis. Historically, this was thought to be a point of message that one must be wary of a common condition vascular watershed [3]. However, more recent evidence has presenting in an uncommon way and have a low threshold refuted this as a sole cause, and it may, in fact, be one of for diagnostic imaging when the diagnosis is not apparent. several contributing factors in a complex etiology [4]. We present a case that not only presented in a very unusual way but that also had a unique pathoanatomical variation. This case highlights the need for clinicians to keep in mind this very common diagnosis and to have a high index of suspicion and low threshold for imaging the area. A 42-year-old woman presented to our accident and emergency department complaining of sudden-onset pain and swelling in her left ankle while she was walking down the street. There was no history of previous injury or other pathology involving her affected ankle. There was no significant medical history, she was not taking any medication, and she was a nonsmoker. On examination, the tenderness and swelling were limited to the lateral malleolus only. In particular, there was no palpable defect in her TA; she had a soft calf and a good range of motion, and Simmonds test result was negative. X-rays were also unremarkable (Fig. 1). Fig. 1 X-ray showing no bony component to injury.

Fig. 2 Intraoperative picture showing avulsion from os calcis and repair.

Laurence Dodd MD [2] Wheelees’ textbook of orthopaedics. Available at: http://wheeless- Alistair Tindall MD online.com/ortho/achilles_tendon_rupture. Accessed April 2007. Richard Hargrove MD [3] Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br 1989;71(1):100-1. Andrew Crockett MBBS [4] Hargrove R, Mclean C. Achilles tendon pathology. eMedicine, 2005. Ananthram Shetty MD [5] Seeger JD, West WA, Fife D, Noel GJ, Johnson LN, Walker AM. Kings College Hospital Achilles tendon rupture and its association with fluoroquinolone London, SE5 9RS UK antibiotics and other potential risk factors in a managed care population. Drug Saf 2006;29(10):889-96. [6] Fisher P. Role of steroids in tendon rupture or disintegration known for doi:10.1016/j.ajem.2007.03.019 decades. Arch Intern Med 2004;164(6):678. [7] Florian M, Novotny F. Avulsion of the Achilles tendon ligament from the calcaneus. Acta Chir Orthop Traumatol Cech 1970;37(5): References 287-90. [8] Ozgurtas T, Yildiz C, Serdar M, Atesalp S, Kutluay T. Is high concentration of serum lipids a risk factor for Achilles tendon rupture. [1] Jarvinen TA, Kannus P, Maffulli N, Khan KM. Achilles tendon Clin Chim Acta 2003;331(1-2):25-8. disorders: etiology and epidemiology. Foot Ankle Clin 2005;10(2): [9] Apley G, Soloman L. Concise system of orthopaedics & fractures. 255-66. 2nd ed. London: Butterworth & Heinemann; 1988, p. 220. American Journal of Emergency Medicine (2007) 25, 1088–1092

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INDEX TO VOLUME 25

Authors

Aagaard, E., 631 Ballesteros, M.A., 730 Bowman, S., 1082 Chan, S.S.-W., 724, 808 Abdelhalim, E., 733 Balls, A., 442 Bo´zsik, B., 1077 Chang, C.-Y., 273 Abernathy, M.K., 977 Band, R.A., 268 Braat, S.H., 1078 Chang, H.-C., 863 Abramo, T.J., 6 Barai, S., 122 Bracken, A., 6 Chang, S.-C., 597 Abroug, F., 414 Barker, R., 887 Brady, W.J., 15, 72, 258, 576, Chang, S.-H., 218, 736 Ackerman, J., 488 Barlotta, K., 15 672, 688, 942, 960, 1073 Chang, W.-H., 861 Adams, M., 942 Baronia, A.K., 122 Bragulat, E., 865 Chang, W.-K., 662 Adhikari, S., 591 Barry, M.C., 860 Brahmi, N., 485 Chang, W.-T., 318 Adnet, F., 385, 529 Baud, F.J., 551 Braiteh, F., 207 Chao, C.-C., 226 Agarwal, R., 129, 844 Baumann, M.R., 834 Brand, D.W., 996 Chao, Y.-C., 662 Age´silas, F., 196 Beecroft, M.J., 378 Branda˜o-Neto, R.A., 1083 Chase, M., 1015 Aggarwal, A.N., 129 Beers, S.L., 6 Braude, D., 907 Chauvin, M., 588 Aguiar, F.J.B., 1083 Behringer, W., 420 Brearley, W.D., Jr, 584 Chen, B.-H., 859 Aksay, E., 120, 138, 242 Bekeredjian, R., 101 Brebbia, J., 666 Chen, C.-C., 237, 251, 406, 1004 Allegra, J.R., 535 Bekkers, S.C., 1078 Brederlau, J., 1057 Chen, E.H., 925 Al Samman, W., 200 Bellazzini, M.A., 734 Bresler, M.J., 353 Chen, I.-C., 108, 774 Alexandre, J.-A., 588 Bellemare, S., 1080 Brizendine, E.J., 918 Chen, J.-C., 108, 437, 774, 858 Algier, J., 931 Bendahou, M., 637 Brohon-Sayag, S., 586 Chen, J.-D., 114 Allegra, J.R., 651 Benner, J.P., 942 Brophy, D.P., 860 Chen, J.-H., 218, 984 Allo, J.-C., 987 Berger, M.J., 240 Brown, A.M., 39, 523, 1015 Chen, K.-C., 1004 Alonso, J.R., 865 Bern, A.I., 762 Bryan, D., 10 Chen, M.-H., 509, 623, 1032 Anderson, C.L., 307 Berrett, C., 442 Bryson, M., 739 Chen, R.-J., 988 Anderson, F.P., 873 Berthelot, P., 880 Bukiran, A., 232 Chen, S.-C., 318, 597 Andres, R.H., 702 Bertrand, J.C., 880 Bulbul, Y., 737 Chen, S.-G., 722 A¨ ngquist, K.-A., 1025 Besbes, L., 414 Bulloch, B., 739 Chen, S.-L., 722 Antonelli, F., 727 Bilotta, F., 198 Bush, A.J., 654 Chen, S.-Y., 597 Aouad, R., 1084 Biros, M., 60 Bustamante-Fermosel, A., 515 Chen, T.-M., 722 Appe´re´-De-Vecchi, C., 210 Biros, M.H., 743 Butler, M., 858 Chen, W.-J., 318, 597 Arnold, D.H., 425 Bismuth, C., 551 Byers, S.E., 340 Chen, W.-L., 218, 984 Arthaud, M., 179 Blaivas, M., 396, 591 Chen, Y.-C., 597 Asai, Y., 481, 848 Blank, F.S., 753 Cady, C.E., 240 Chen, Y.-J., 736 Assadi, R., 859 Bleich, S., 239 Calello, D.P., 481 Cheng, S.-T., 863 Attari, M., 812 Boari, B., 728 Calkavur, T., 242 Cheng, T.-Y., 49 Austin, R.B., 734 Boatright, C.J., 185 Camargo, C.A., Jr., 631 Cheng-Huang, C.-Y., 251 Aydin, A., 488 Bonel, H.M., 702 Cannon, R.D., 931 Cheong, I., 1085 Azim, A., 122 Bonnett, C.J., 297 Cantrill, S.V., 297 Chern, C.-H., 114, 253 Borloz, M.P., 942 Caovan, D., 258 Chew, H.C., 459, 572 Badarou-Acossi, G., 179 Borron, S.W., 551 Cardelli, P., 335 Chiang, T.-H., 49, 273 Badic, B., 1086 Borschke, F.A., 864 Cardoni, A.L., 240 Chiang, W.-C., 127, 318, 597 Baer, M., 588 Bosson, J.-L., 502 Carr, B.G., 894 Chiang, Y.-H., 69 Baevsky, R.H., 753 Boukef, R., 414 Carricajo, A., 880 Chien, J.-Y., 494 Baker, W.E., 80 Boulouffe, C., 243 Catineau, J., 385 Chien, K.-L., 597 Bakker, F.C., 144 Boutayeb, F., 733 Ceriani, E., 983 Chieregato, A., 728 Ballardini, P., 737 Boutoille, D., 179 Chan, K., 158 Chin, A., 116 Ballbe, R., 486 Bouvat, E., 502 Chan, S.B., 213, 1019 Chin, L.-W., 864

0735-6757/$ – see front matter doi:10.1016/S0735-6757(07)00677-8 INDEX TO VOLUME 25 1089

Chinnan, N.K., 200 Deming, D.A., 734 Filipiak, K.J., 65, 170 Gurjar, M., 122 Chinnock, B., 934 Denny, F.J., 185 Fiorani, B., 198 Gushimiyagi, M., 152 Chiu, T.-F., 108, 437, 722, 774, Der Sahakian, G., 987 Fletcher, D., 588 Guyomarc’h, S., 880 858 Derksen, R.J., 144 Floch, Y., 529 Chiu, Y.-H., 253 Derr, C., 96 Foldspang, A., 23 Haarman, H.J., 144 Chmielewski, L., 1015 Descatha, A., 588 Follath, F., 174 Haber, M.D., 753 Chong, C.-F., 226, 237, 250, 406, Dewitz, A., 80 Fontane, E., 726 Habi, S., 733 488, 860, 864, 1004 Dhainaut, J.-F., 987 Forte, P., 335 Hager, H., 887 Christos, S., 1019 Di Marco, J.-N., 863 Fosnocht, D.E., 791 Haguiga, H., 414 Chu, H.-C., 662 Di Somma, S., 335 Francis, J.L., 279 Haig, A., 464 Chu, S.-J., 722 Diaz, M., 907 Freeman, K., 80 Hall, J., 704 Chudnofsky, C.R., 340 Diaz, M.C.G., 99 Frey, N., 101 Halpern, E., 450 Chung, H.S., 984 Dillard, E., 823 Friedberg, R.P., 749 Hamadouche, M., 502 Chung, S., 249 D’Incognito, C., 57 Frqhwald, P., 1057 Hamzavi, S., 834 Chung, S.P., 246, 984, 986 Divani, A.A., 32 Fujimori, K., 848 Hancock, J.A., 185 Claessens, Y.-E., 987 Dodd, L., 1087 Fukuda, D., 256 Hanson, J.A., 1040 Clark, L., 116 Doezema, D., 616 Funovits, V., 887 Hareyama, M., 848 Clarkson, F.A., 244 Dohrenwend, P.B., 651 Hargrove, R., 1087 Cocciolo, F., 728 Dolveck, F., 385, 588 Gabriel, L., 243 Harrison, B.P., 725 Cochrane, D.G., 535, 651 Domıńguez-Rodrı´guez, A., 723 Gackowski, A., 852 Hart, R.G., 704 Coll-Vinent, B., 865 Dominici, P., 340 Gaetz, A., 743 Hartert, T.V., 425 Colwell, C.B., 297 Dfner, E., 219 Gaieski, D.F., 268 Hashiguchi, M., 152 Combes, X., 385, 586 Dosanjh, A., 476 Galinski, M., 385, 529 Hatem, K., 845 Corbella, X., 486 Dovgalyuk, J., 688 Gallerani, M., 728 Haugh, D., 15 Cordell, W.H., 918 Drexler, A., 279 Gamberini, S., 737, 1082 Haukoos, J.S., 285, 297 Corrigan, K.J., 1085 Dubourg, O., 588 Gambhir, S., 122 Hauter, W.H., 918 Coskun, A.K., 862 Duffort-Falco´, M., 515 Gamelli, R.L., 823 Hayashi, T., 989 Costa, I., 620 Duncan, C.E., 918 Garcıá, C.R.-I., 723 He, T., 509, 623, 1032 Costantino, G., 983 Durmus, I., 737 Garcıá-Gonza´lez, M.J., 723 Heard, K., 285, 1040 Cotant, C.L., 92 Durukan, P., 391 Gardner, R.L., 643 Heilbron, E.A., 144 Counselman, F.L., 221, 313 Dyer, D.S., 1040 Garg, R., 873 Hellermann, J.P., 174 Crandall, C.S., 616 Garner, D., 911 Herbland, A., 196 Crijns, H.J., 1078 Edlow, J.A., 608, 749 Gaufberg, S.V., 379 Herkner, H., 545 Crockett, A., 1087 Eggers, G., 559 Gavin, P.J., 225 Herlitz, J., 1025 Crombe´, C., 196 Egipto, P., 620 Gebretsadik, T., 425 Herold, T., 197 Crounse, L., 996 Eikemans, B.J., 1078 Geddes, L.A., 786 Higgins, S., 425 Cruz Santana, A.N., 1083 Eken, C., 487, 589, 852 Gelberg, J., 1025 Hill, R.J., 985 Crystal, C.S., 482 El Massri, N., 852 Geninatti, M., 202 Hillemacher, T., 239 Cuevas, S., 735 Elatrous, S., 414 Gentiloni, N., 335 Ho, J.D., 780 Cunha-Ribeiro, L.M., 620 Elmrini, A., 733 Gerlach, L.B., 1047 Ho, P.M., 996 Curry, S.C., 931 Emilio Salvi, A., 590 Germann, C.A., 834 Hoekstra, J., 1063 Cutler, K.O., 654 Engdahl, J., 1025 Gey, F., 196 Hoerauf, K., 887 Er, T.-K., 859 Ghaly, R.F., 106 Hoffman, R.S., 735 Dabreteau, A., 987 Erdur, B., 232 Giannopoulos, S., 982 Hollander, J.E., 39, 268, 353, Dagorn, J., 210 Eroglu, O., 737, 770 Gibbons, W.P., 106 523, 925, 1015, 1025, 1047 Dahle, J.M., 105 Ersel, M., 120, 242 Gilmore, B., 654 Holmberg, S., 1025 Dailey, M.W., 215, 985, 1082 Erwin, E.A., 221 Givens, M.L., 612 Holstege, C., 688 Dan, E., 738 Eskin, B., 535 Go, A.S., 996 Holstege, C.P., 672 Dassen, W., 1078 Espinosa, J., 95 Godambe, S.A., 654 Holzer, M., 420, 545 Datner, E.M., 1047 Esposito, T.J., 823 Goddet, N.S., 588 Hong, C., 158 David, M., 863 Everett, W.W., 894 Gokce, M., 737 Hopfner, W., 1057 Dawes, D.M., 780 Exadaktylos, A.K., 702 Goldman, R.D., 400 Horan, A., 894 de Carvalho, A.L., 1083 Eygi, B., 242 Go´mez-Angelats, E., 865 Hos, G., 737 De Jonghe, B., 210 Ezzeddine, M.A., 32 Gonzales, R., 631, 643 Houdijk, W.P., 255 de Krom, M.C., 1078 Gonza´lez-Castro, A., 730 House, H.R., 263 de Lange-de Klerk, E.S., 144 Faergeman, O., 23 Gorouhi, F., 850 How, C.-K., 114, 253 De Leva, R., 335 Famularo, G., 1086 Grabowski, M., 65. 170 Hrynkiewicz, A., 65, 170 De Miguel-Yanes, J.M., 515 Fan, J.-S., 114, 1009 Gracias, V.H., 894 Hsia, S.-H., 118 De Simone, C., 1086 Fang, F.-M., 1051 Graeme, K.A., 931 Hsiao, C.-T., 774 de Zwaan, C., 1078 Fangio, P., 210 Graham, R.J., 98 Hsieh, A., 1085 Dean, A.J., 894 Farahnak, M., 850 Green, R., 799 Hsieh, C.-C., 318 Delaney, K., 612 Farokhi, F., 235, 831 Greenberg, K., 95 Hsieh, C.-T., 69 DeLashaw, M., 313 Fengler, B.T., 576 Grinberg, D., 45 Hsieh, M.-J., 1051 Delerme, S., 637 Ferraro, R., 858 Grossman, M., 735 Hsieh, T.-Y., 662 Delfini, R., 198 Ferre, R.M., 291 GqmqY, H., 87 Hsiu-Hsi Chen, T., 597 Delk, C., 672 Ferri, E., 335 Gunduz, A., 737, 770 Hsu, C.T., 99 Delugeau, V., 1086 Fiesseler, F.W., 651 Gupta, D., 129 Hsu, C.-Y., 318 1090 Author Index

Hsu, J., 127 Kim, T.M., 846 Lerner, E.B., 326 Marill, K., 10 Hsueh, P.-R., 494 Kirmani, J.F., 32 Lester, J., 1019 Marinaro, J., 616, 733 Huang, C.-C., 164, 430, 736 Kiyan, S., 120, 138, 242 Letaief, M., 414 Marinella, M.A., 89 Huang, C.-H., 49, 318, 736 Ko, S.-F., 430, 1051 Levine, R.L., 279 Marino, R., 335 Huang, C.-I., 114, 164, 253, 1009 Ko, S.-Y., 251 Levsky, M.E., 199 Marjollet, O., 880 Huang, H.-H., 164 Kober, A., 887 Lewis, L.M., 794 Mark, D.G., 894 Huang, M.-K., 251 Kocheril, A.G., 235, 859 Li, C.-H., 858 Martin, C., 863 Huang, S.-P., 49, 273 Kochman, J., 170 Li, S.F., 45 Martin, M.L., 15 Huang, T.-Y., 226 Koenig, K.L., 185 Li, Y., 983 Martin-Gill, C., 15 Huei-Ming Ma, M., 318 Kogan, A., 1 Liao, S.-C., 437 Martins, H.S., 1083 Hui-Min, G., 597 Koito, K., 848 Lien, W.-C., 126 Marty, J., 586 Hundley, S., 313 Kfklq, E., 87 Lim, K.E., 863 Maselli, J., 631 Hung, M.-S., 774 Kolkebeck, T.E., 92 Lim, S.H., 459, 572 Maselli, J.H., 643 Hung, S.-W., 860 Konduracka, E., 852 Limkakeng, A.T., 450 Masneri, D.A., 197 Hursting, M.J., 279 Konstantopoulos, W.M., 158 Limoges, V., 385 Masotti, L., 727 Hurtado, T.R., 244 Kontos, M.C., 873 Lin, A.C.-M., 1004 Masoudi, F.A., 996 Hussein, H.M., 32 Kordick, M.F., 1019 Lin, C.-C., 861 Mattu, A., 72, 688, 960 Hustey, F.M., 133, 804 Kornhuber, J., 239 Lin, C.-M., 488 Mazzone, M., 335 Hwang, S.O., 846 Kowalzyk, D.R., 1085 Lin, H.-H., 662 McArthur, T., 482 Kozak, O., 862 Lin, H.-J., 90 McCabe, C.J., 708 Ide, T., 483 Krasuski, R.A., 92 Lin, H.-Y., 237 McColgan, B.P., 864 Ilhan, N., 391 Kraus, T., 239 Lin, I.-Y., 488, 1004 McConahay, T., 739 Imaizumi, S., 989 Ku, B.S., 894 Lin, J.-J., 118 McCubbin, T., 285 Incasa, E., 737, 1082 Kuan, J.-T., 437 Lin, J.-T., 49, 273 McGee, M.P., 735 Iserson, K.V., 105 Kucewicz, A., 862 Lin, K.-L., 118 McGillicuddy, D., 608 Kue, R., 228 Lin, L.-J., 861 McGillicuddy, D.C., 749 Jabre, P., 529, 586 Kuhns, D.W., 222 Lin, L.-W., 860 McGrail, M., 911 Jacobs, I., 464 KumandaY, S., 87 Lin, W.-P., 988 McKay, R., 489 Jaffrelot, M., 529 Kumar, S., 122 Lin, Y.-M., 226 McLean, A., 911 Jalali, A., 850 Kung, C.-T., 430, 1051 Lindsay, M.B., 53, 345 McMullan, J., 812 Janata, A., 420 Kuo, C.-D., 406 Litkey, J., 215 McVaney, K.E., 297 Jendrin, J., 529 Kuo, H.-Y., 984 Littmann, L., 584 Me´garbane, B., 551 Jesse, R.L., 873 Kurimoto, Y., 848 Liu, B.-M., 430, 1051 Mehdaoui, H., 196 Jimeńez, S., 865 Kuru, O., 232 Liu, C.-F., 430 Mentes, O., 862 Johnson, M.A., 780 Kutz, J.E., 1084 Liu, K.-L., 126 Mentese, A., 770 Jones, R., 838 Kwon, O., 249 Liu, P.-P., 1051 Metlay, J.P., 631 Jong, Y.-J., 859 Kyritsis, A.P., 982 Liu, T.-M., 90 Meyer, F.J., 101 Joseph, T., 588 Liu, T.-W., 509, 623, 1032 Meyer, T.D., 445 Ju, D.-T., 69 Lache´rade, J.-C., 210 Llanwarne, N., 1086 Michael, G.E., 901 Juan, A., 486 Lagier, P., 863 Lo, H.-C., 164 Michel, F., 863 Juan, C.-W., 1083 Lagos, G., 982 Lo, H.-Y., 437 Miller, J., 804 Jwayyed, S., 331 Lagron, P., 588 Lockey, D., 529 Miller, M.A., 197, 199, 482, 725, Lai, Y.-C., 861 Lo´pez, B., 865 862 Kahn, C.A., 185, 307 Lainscak, M., 110 Losert, U.M., 420 Mills, A.M., 268, 925 Kameyama, M., 989 Lakhal Salah, B., 845 Lottes, A., 786 Minãmbres, E., 730 Kamii, H., 989 Lakshminarayanan, B., 859 LoVecchio, F., 57, 442, 855, 856, Miner, J.R., 60, 743, 780 Kamijo, Y., 483 Landen, S., 1086 931 Ming-Fang Yen, A., 597 Kaneko, N., 217 Landini, G., 727 Lovett, B., 735 Minisola, G., 1086 Kang, B.S., 223 Lang, T., 887 Lowe, S., 313 Minton, P.A., 425 Kang, G., 858 Lapostolle, F., 385, 529 Lu, J.J., 378 Miro´, O` ., 865 Kantarci, M., 211 Larsen, M.L., 23 Luchette, F.A., 823 Mo, S.-R., 509, 623, 1032 Kao, P.-C., 127 Latacz, P., 852 Lundin, E.J., 780 Monroe, M.H., 584 Kao, T.-L., 1083 Le Lievre, P., 911 Lvovschi, V., 637 Montano, N., 983 Kao, W.-F., 164, 1009 Le Manach, Y., 637 Lyon, M., 396, 591 Moore, J., 60 Kapickis, M., 1084 Lebrun, J., 196 Lyons, E.E., 996 Morishita, K., 152 Karahan, S.C., 770 Lecoules, N., 502 Moscati, R.M., 326 Karakqkçq, M., 87 Lee, C.C., 488, 846 Maatougui, K., 733 Mountain, D., 464 Karasen, R.M., 211 Lee, C.-C., 597, 736 Mace, S.E., 762 Moutran, H., 1084 Karpin´ski, G., 65, 170 Lee, C.-H., 164, 863, 1009 MacLeod, S.L., 96 Moy, R.K., 213 Kathryn Duncan, M., 279 Lee, C.-T., 49, 273 Magid, D.J., 996 Mukherjee, R., 174 Kaufman, M.W., 225 Lee, H.S., 984, 986 Magrini, L., 335 Munõz, J., 515 Kavalci, C., 391 Lee, K., 249 Mahadevan, S.V., 559 Mycyk, M.B., 378 Kelly, B.S., 72 Lee, K.-W., 988 Mayek, x.A., 170 Kemeny, A., 786 Lee, S.-C., 662 Manfredini, R., 728, 737, 1082 Nara, S., 848 Kilicaslan, I˙., 487 Lee, T.-C., 273 Margenet, A., 586 Narimatsu, E., 481, 848 Kim, G., 158 Lefebvre, C., 1063 Margutti, G., 737 Narula, G., 122 Kim, S., 249 Leleu, J.M., 733 Marik, P.E., 376 Nasar, A., 32 INDEX TO VOLUME 25 1091

Nathanson, L.A., 749 Plautz, C.U., 576 Sakamoto, T., 217, 757 Spear, J., 608 Naviaux, N.W., 285 Pliakas, J., 158 Salazar, A., 486 Spencer, S.M., 986 Nciri, N., 414 Poddar, B., 122 Salazar, A.M., 213 Sporer, K.A., 901 Nentwich, L., 158 Pommier, V., 385 Samama, C.M., 502 Springer, S., 313 Nerenberg, R.H., 39 Pons, P.T., 297 Sami, A., 57, 845 Srinivas, R., 844 Ng, C.-J., 437 Price, D.D., 208, 472 Sańchez, M., 865 Stajic, M., 735 Ng, S.-H., 430, 1051 Pugh, J.L., 326 Sandridge, L., 15 Stark, J.J., 247 Nguyen, H.B., 564 Sandrone, G., 983 Stegelmeier, K., 285 Nicaise, C., 863 Quan, D., 856 Sarkar, U., 643 Stein, G.H., 152 Nicotra, G.C., 1086 Queralt, C., 865 Savelli, S., 1082 Stein, P., 98 Nielsen, K.M., 23 Quinn, J.V., 559 Scalabrini-Neto, A., 1083 Steinlechner, B., 887 Nishijima, D., 734 Qureshi, A.I., 32 Scali, V., 95 Sterz, F., 420, 545 Niu, K.-C., 90 Schafer, J., 612 Stiffler, K.A., 331 Nolt, B.R., 631 Radeleff, B., 101 Schaller, B.B., 702 Stolarz, P., 65, 170 Nordenholz, K.E., 285, 1040 Rankin, T.J., 985 Schanze, A., 239 Stone, M.B., 472 Norris, R., 559 Rappaport, D., 99 Schauer, B., 208 Su, C.-P., 127, 597 Norton, J., 823 Rassi, S., 1084 Schechter, E., 735 Su, W.-C., 49 Nouira, S., 414 Rathore, A., 200 Schermer, C.R., 823 Su, Y.-J., 861 Nuhoglu, I., 770 Ravaud, P., 502 Schlossmacher, P., 196 Suberviola, B., 730 Ray, P., 179, 485, 637 Schock, R.B., 420 Sultani, D., 307 O’Connor, B.J., 96 Reddi, A.S., 32 Schratter, A., 420 Sun, J.-M., 69 O’Connor, J.E., 53, 345 Reed, R.L., II, 823 Schreiber, W., 545 Suri, M.F.K., 32 Ogul, H., 211 Rehman, T.-U., 733 Schultz, C.H., 185 Svenson, J., 987 Ohigashi-Suzuki, S., 230 Renault, R., 637 Schultz, E., 488 Svenson, J.E., 53, 345, 445, Ohley, W.J., 420 Rennert, G., 1 Schussler, J.M., 367 977 Ohman-Strickland, P., 535 Renzi, F., 228 Seak, C.-J., 861 Svensson, L., 1025 Okada, Y., 217, 757 Reynaert, M., 986 Sears, B.W., 823 Swanson, E.R., 791 Okusanya, O., 894 Richling, N., 545 Sease, K.L., 268, 523, 925 Sweeney, T.W., 291 Oman, J.A., 307 Richter, C.J., 794 Seckin, D., 391 Syed, M.I., 116 O’Meara, P., 911 Rickard, C., 911 Seow, V.-K., 250, 251, 488, 1004 Szyld, D., 540 Ong, J.-R., 250 Riedmueller, E., 545 Serhatlioglu, S., 391 Szyman´ski, F.M., 65, 170 Onuma, T., 989 Rieux, D., 196 Shabaan, A.I.M., 200 Opolski, G., 65, 170 Riley, B., 57, 855 Shah, K.H., 608, 749 Tabacco, F., 335 Ore˛ziak, A., 65 Riou, B., 179, 502, 637 Shapira, R., 1 Tagliaferri, F., 728 Ornato, J.P., 873 Rizzioli, E., 1082 Shen, S.-T., 226 Tahan, F., 87 Ortega, M., 865 Robert, F., 880 Shen, Y.-S., 984 Tai, C.-C., 126 Ortı´z-Meloń, F., 730 Roberts, C.S., 873 Shepherd, J., 489, 858 Tai, C.-H., 984 Osterhoudt, K.C., 481 Robey, J.L., 39, 268, 523, 925, Sherman, S.C., 104 Tai, C.-M., 49, 273 Otlewski, M., 786 1015, 1047 Shetty, A., 1087 Takakuwa, K.M., 450 Ots, E., 730 Robinson, A., 331 Shiber, J.R., 726 Takeyama, Y., 481 Outin, H., 210 Rochdil, N., 845 Shimada, K., 256 Talaei-Khoei, M., 850 Ouyang, H., 559 Roche-Nagle, G.M., 860 Shofer, F.S., 39, 268, 523, 925, 1015 Talucci, V., 335 Overton, D., 985 Rodgers, D.R., 248 Sidebottom, M., 15 Tamir, A., 1 Rodriguez, V.A., 535 Silfverstolpe, J., 1025 Tampieri, M., 737, 1082 Padgett, T.G., 996 Roeseler, J., 986 Silverman, M.E., 535 Tan, K.-H., 251 Park, Y.S., 984 Roewer, N., 1057 Sinert, R., 938 Tang, C.-T., 69 Parrillo, S.J., 340 Rogovik, A.L., 400 Singer, A.J., 666, 846 Tanno, K., 481 Partouns, J., 1078 Roman, C.S., 102 Sivrikoz, M.C., 219 Tarabar, A., 735 Pawelec, T., 852 Rosa, G., 198 Skipper, B., 907 Tatsuno, I., 230 Peacock, W.F., 353 Rosin, A., 102 SmaRl, N., 385 Tatum, J.L., 873 Pearson, B.V., 222 Rostoff, P., 852 Smalling, R.W., 353 Taylor, L., III, 584 Peery, B.N., 297 Rothman, J., 535 Smith, D., 564 Teeter, D.S., 185 Pekdemir, M., 97, 391 Rothmann, C., 502 Smith, E.R., 367 Templier, F., 385, 588 Pelidou, H.-S., 982 Row, M.B., 207 Smith, M.D., 133 Terville, J.-P., 210 Pemberton, L.B., 199 Rudiger, A., 174 Smith, S.W., 60 Thames, M., 202 Pentier, C., 586 Rudkin, S.E., 307 Smithline, H., 753 Thomachot, L., 863 Per, H., 87 Rudowski, R., 65, 170 Smithline, H.A., 124 Thomas, S.H., 158, 842 Pernat, A., 110 Ruger, J.P., 794 Soares-Oliveira, M., 620 Thomson, R.B., Jr, 225 Perruche, F., 987 Ruha, A.-M., 931 Soghoian, S., 938 Thys, F., 986 Petrella, R., 858 Ruiz Gine´s, M.A´ ., 859 Sojka, B., 15 Tieleman, R., 1078 Pines, J.M., 258, 540 Rumsfeld, J.S., 996 Soma, K., 483 Tieng, N., 45 Pinto, R., 198 Rundell, A., 786 Somers, M.P., 258 Tilman, K., 313 Pittoni, V., 335 Russi, C.S., 263 Song, F.-Q., 509, 623, 1032 Tindall, A., 1087 Piwowarska, W., 852 Ryan, R., 860 Soroff, H.H., 666 Tokuda, Y., 152 Pizon, A., 57 Sorondo, B., 340 Tomassi, M.P., 985 Pizon, A.F., 442, 855 Saadatmand, B., 104 Sovari, A.A., 235, 831, 859 Tomcsańyi, J., 1077 Plackett, T.P., 106 Saito, Y., 230 Spaans, I.M., 144 Topbas, M., 770 1092 Author Index

Tricomi, A.J., 996 Viallon, A., 179, 880 Wians, F., Jr, 612 Yao, C.-T., 984 Trystram, D., 179 Villani, L., 727 Wiebe, D.J., 1047 Yarici, M., 862 Tsai, L.-Y., 859 Vinson, D.R., 996 Wiebe, R.A., 6 Yeh, C.-T., 860 Tsai, M.-S., 318 Volpicelli, G., 981 Wilber, S.T., 331 Yen, D.H.-T., 164, 1009 Tsai, S.-H., 981 Wilcox, C.L., 263 Yi, P., 988 Tseng, W.-K., 494 W. Hendey, G., 934 Williamson, A., 15 Yildiz, M., 391 Tu, C.-H., 273 Wagner, T.W., 247 Wilson, A.L., 225 Y1lmaz, S., 97 Tufan, T., 862 Wa´gner, V., 1077 Wilson, S.R., 208 Yilmaz, S.E., 770 Tulay, M.C., 219 Wake, R., 256 Wisten, A., 1025 Yoder, A., 15 Tung, C.-C., 988 Wald, R., 612 Wolf, S.J., 285 Yonas, H., 733 Turan, I., 770 Walker, J.M., 279 Workman, T.P., 379 Yonatan, Y., 738 Turedi, S., 737, 770 Wallace, G., 199 Wu, C.-C., 494 Yoneta, S., 848 Turina, J., 174 Wallace, K.L., 931 Wu, C.-T., 118 Yoshikawa, J., 256 Turkcuer, I., 232 Wallis, N., 804 Wu, K.-C., 90 Yoshiyama, M., 256 Walta, M.J., 379 Wu, M.-S., 273 You, J.S., 246, 984, 986 Ulke, E., 862 Wan, Y.-L., 1051 Wu, S.-C., 988 Young, L.L., 348 Wang, H., 983 Wu, Y.-L., 218, 984 Youngblood, G.M., 901 Valentino, R., 196 Wang, H.-P., 49, 126, 273, 864 Wurmb, T.E., 1057 Yu, C.-F., 860 Valento, M., 812 Wang, H.-S., 118 Yu, C.-J., 494 Valkanas, M.A., 1082 Wang, L.-M., 114, 164, 253, Xie, L., 509, 623, 1032 Yu, J.-S., 984 van der Vlugt, T.M., 996 1009 Xu, T., 983 Yuan, A., 736 Vanpee, D., 243 Wang, R., 472 Yuan, Y.-D., 861 Varol, I., 232 Wang, T.-L., 237, 250, 406, 488, Varon, J., 376, 479, 949 1004 Yama, N., 848 Zangirolami, A., 737, 1082 Veenings, B., 144 Watring, N.J., 247 Yamamoto, L.G., 348 Zehbtachi, S., 734, 938 Velasco, I.T., 1083 Watts, D., 735 Yanagawa, Y., 217, 757 Zeng, Z.-Y., 509, 623, 1032 Venkat, A., 812 Watts, S., 10 Yang, C.-W., 318 Zeni, F., 880 Vergne, M., 529 Weaver, C.S., 918 Yang, K.-C., 494 Zieske, M., 1040 Verschuren, F., 986 Weihs, W., 420 Yang, M.-C., 863 Zmudka, K., 852 Vialet, R., 863 Wen, Y.-S., 736 Yanturali, S., 120, 138 Zogby, K.E., 1015, 1047 American Journal of Emergency Medicine (2007) 25, 1093–1108

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INDEX TO VOLUME 25

Keywords

Abdominal compression, rhythmic, new CPR method using only, 786-790 Acute coronary syndrome (ACS) (continued) Abdominal distention, pediatric, due to omental cyst, 99-101 SAH, and PE differences in the risk tolerance for disease exclusion Abdominal injury, blunt, complete transection of common iliac artery as a according to published guidelines, 540-544 fatal complication of, 251-253 triage flowchart to rule out, 865-872 Abdominal pain Acute emphysematous cholecystitis, with initial normal radiological acute evaluation, 488.e3-488.e5 bedside ultrasound in diagnosis of pneumoperitoneum in critically ill Acute heart failure. see Heart failure, acute patients presenting with, 838-841 Acute meningococcemia. see Meningococcemia, acute emergency physicians on use of resources to evaluate obese patients Acute myocardial infarction. see Myocardial infarction, acute with, 925-930 Acute pulmonary embolism. see Pulmonary embolism, acute discordance between serum Cr and CrCl for identification of ED patients Acute renal infarction. see Renal infarction, acute with, at risk for contrast-induced nephropathy, 268-272 Adrenal hemorrhage, isolated, after minor blunt trauma, 984.e5-984.e6 in presentation of acute renal infarction in ED, 164-169 Adult Abdominal trauma, blunt, isolated jejunal perforation after, 862.e1-862.e4 accuracy of estimation of weight of, performed by ED personnel, 307-312 Abducens nerve, isolated, palsy and pontine hemorrhage, 104-105 with acute cough illness, vital-sign abnormalities as predictors of Abscesses, upper extremity, ultrasound-guided supraclavicular block for, pneumonia in, 631-636 472-475 and children, relationship of air pollution to ED visits for asthma Absenteeism, sickness, association between influenza vaccination of health (letter), 852 care workers in ED and, 808-811 Aeromedical transport, assessment of intracuff pressures in intubated

Accessory muscle use, association with FEV1 in persons with asthma patients before, in the ED and prehospital setting, 53-56 requiring hospital admissions, 425-429 Afebrile streptococcal meningitis, fatal, in a chronic alcoholic patients, Acetic acid, small amounts of, systemic manifestations after ingestion by a 106-108 child of, 738.e1-738.e2 Africanized honeybees, swarmings in children, 931-933 Achilles tendon, atraumatic avulsion of, as unusual presentation of injury, Age 1087.e1-1087.e2 characteristics of cardiac arrest and resuscitation by, 1025-1031 Activated charcoal, multiple-dose, in CBZ poisoning (letter), 378, 485 effect on patterns of incidence of gastroenteritis disease in the ED, Acupressure, at Baihui and Hegu points, in patients with radial fractures, 535-539 prehospital analgesia with, 887-893 Agitation Acute abdominal pain. see Abdominal pain, acute as neuropsychiatric manifestations, in a patient with imidacloprid Acute appendicitis. see Appendicitis, acute poisoning (letter), 844-845 Acute clinical deterioration (ACD), acute epidural hematoma of posterior and sedation, association of level of awareness and blood alcohol fossa as case of, 989-995 concentration with both, in intoxicated patients in the ED, Acute coronary syndrome (ACS) 743-748 associated with atrial fibrillation among ED patients with chest pain Air compressor injury, into orbit resulting to disseminated head and neck syndrome, risk assessment for, 523-528 emphysema with pneumocephalus, 223-225 identification of low- and high-risk patients among unselected patients, Air pollution, relation to ED visits for asthma in children and adults 23-31 (letter), 852 12-lead electrocardiogram in patient with, 1073-1076 Airway management non-ST-segment elevation, qualitative versus quantitative cardiac marker digital intubation as option in (letter), 726 assay in prehospital evaluation of (letter), 588-589 laryngeal tube as an adjunct for, 263-267 prognostic implications of myocardial necrosis triad markers’ Albumin, ischemia-modified, value in the diagnosis of pulmonary concentration measured at admission in patients with, 65-68 embolism, 770-773

0735-6757/$ – see front matter doi:10.1016/S0735-6757(07)00722-X 1094 Keyword Index 25

Alcohol Antithrombotic therapy, for prevention of stroke in clinical practice in the blood levels, and level of awareness, association with both agitation and ED, 1-5 sedation of, in intoxicated patients in the ED, 743-748 Aortic dissection, image pitfall of CT in diagnosis of (letter), 127-129 toxic, ingestion of, management at tertiary care center after the Appendicitis introduction of fomepizole, 799-803 acute Alcoholism, chronic, fatal afebrile streptococcal meningitis in, 106-108 Alvarado score and antibiotics therapy versus conventional clinical Alternating current (AC), transesophageal stimulation for VF induction in management, as corporate protocol for (letter), 850-852 rats, 623-630 clinical prediction rule to distinguish PID from, in women of Alvarado clinical score childbearing age, 152-157 and antibiotic therapy versus conventional clinical management, as CT scanning guidelines development based on Alvarado clinical scores corporate protocol for acute appendicitis (letter), 850-852 for patients with suspected and confirmed cases of, 489-493 CT scanning guidelines development based on, for patients with Arteriopathy, dilatative, of internal carotid artery, severe headache caused suspected and confirmed cases of appendicitis, 489-493 by (erratum), 857 Alveolar-interstitial syndrome (AIS), bedside lung ultrasound in diagnosis Arthritis, septic, sensitivity of synovial fluid WBC count in diagnosis of, of (letter), 724-725 749-752 Ambulance diversion, effects of RAP on ED length of stay and time spent Arthrocentesis, hip, ultrasound-guided, in the ED, 80-86 on, 559-563 Artifacts, ECG, frequency of electrode misplacement in different clinical Amino-terminal pro-B-type natriuretic peptide (NTproBNP), in settings, 174-178 management of acute decompensated heart failure, potential role Ascitic fluid, clear appearance of, in detection of spontaneous bacterial of sequential measurement of, 335-339 peritonitis, 934-937 Amiodarone, intravenous loading of, acute toxic hepatitis after, Asphyxia, cardiac arrest, epinephrine improves survival rates in an adult 1082.e1-1082.e4 rabbit model of, 509-514 Analgesia Aspiration, pneumonitis, and Newton’s law of gravitation, 987.e1-987.e2 effectiveness of triage pain protocol in improving frequency and time to Aspirin, for coronary artery disease, risk prediction score for identification delivery of, for painful musculoskeletal injuries in the ED, of silent myocardial ischemia in patients under, presenting with 791-793 upper gastrointestinal hemorrhage, 406-413 prehospital Asthma

with Baihui and Hegu acupressure points, in patients with radial clinical measures of severity of, associated with FEV1 in persons with fractures, 887-893 asthma requiring hospital admissions, 425-429 for children with extremity injuries, 400-405 ED visits in children and adults, relation to air pollution (letter), 852 fentanyl for, 842-843 near-fatal, rhabdomyolysis after successful resuscitation of a patient with, intranasal fentanyl versus intravenous morphine for, 911-917 736.e3-736.e4 for isolated extreme injuries, women versus men on receiving, use of LTCM for patients being discharged from the ED with, 476-478 901-906 Asymptomatic elevated blood pressure (AEBP), ability of emergency Analgesics, narcotics, for pain management of clavicle fractures in very physicians to determine ED patients with, 313-317 young and elderly patients, prescription of, 651-653 Atrial fibrillation Anaphylactic shock, after laboratory rat bite, 985.e1-985.e2 among ED patients with chest pain syndrome, risk assessment for ACS Anaphylaxis, after application of topical bacitracin ointment to a fresh associated with, 523-528 tattoo, 95-96 broad complex, intravenous procainamide for, 459-463 Anesthesia unstable, cardiogenic shock after cardioversion in thyrotoxic patients brainstem, ED treatment after retrobulbar block, 105-106 with (letter), 981 topical, sequential layered application of topical lidocaine with in the WPW syndrome, ECG recognition and treatment in the ED of, epinephrine for larger wound management, 379-384 576-583 Aneurysm Atrial flutter, with cardiac tamponade, as initial presentation of tuberculosis rebleeding, after lumbar puncture, 984.e1-984.e3 pericarditis, 108-110 of splenic artery, encountered in ED, 430-436 Avulsion, atraumatic, of Achilles tendon, as unusual presentation of injury, Anger, as neuropsychiatric manifestations, in a patient with imidacloprid 1087.e1-1087.e2 poisoning (letter), 844-845 Awakening signs, after rapid-sequence intubation, prevention of, 529-534 Angioembolization, as an effective alternative for hemostasis in Awareness, level of, and blood alcohol concentration, association of both intractable life-threatening maxillofacial trauma hemorrhage, agitation and sedation with, in intoxicated patients in the ED, 988.e1-988.e5 743-748 Angiography, coronary, sixty-four-slice CT, for chest pain evaluation in the Axillary artery, dissection due to blunt shoulder trauma, 242-243 ED, 367-375 Ankle and foot injuries, treatment of, assessment of the ability of Bacitracin, topical ointment, anaphylaxis after application to a fresh tattoo, specialized emergency nurses in, 144-151 95-96 Antibiotic therapy, and Alvarado clinical score versus conventional clinical Bacteremia, antimicrobial-resistant Gram-negative, predictive model of, in management, as corporate protocol for acute appendicitis (letter), the ED, 597-607 850-852 Bacterial peritonitis, spontaneous, clear appearance of ascitic fluid in Antibodies, heparin-PF4, prevalence in patients presenting to the ED with detection of, 934-937 thrombosis or chest pain, 279-284 Baihui points, and Hegu acupressure points, as prehospital analgesia in Anticholinergic agent, toxicity, from ingestion of lupini beans, 215-217 patients with radial fractures, 887-893 Anticoagulants, for right atrium mobile thrombus in elderly, transthoracic Bark scorpions, venomous, in southwest United States and northern Mexico echocardiograph on efficiency visualization of, 983.e3-983.e4 (letter), 856 Antimicrobial-resistant Gram-negative bacteremia, predictive model of, in Beers criteria, prevalence of inappropriate prescribing in older ED the ED, 597-607 population based on, 804-807 Antispastic agent, infantile case of seizure induced by intoxication after Bee stings, multiple, spontaneous subarachnoid hemorrhage after accidental consumption of (letter), 481-482 intravenous epinephrine use for, 249-250 INDEX TO VOLUME 25 1095

Bee swarmings, in children, 931-933 Cardiac arrest Beta-adrenergic channel blockers, poisoning, ECG abnormalities associated by age group, characteristics of, 1025-1031 with, 672-687 asphyxia, epinephrine improves survival rates in an adult rabbit model of, Beta-2 agonist, in the treatment of status asthmaticus in pediatrics, 6-9 509-514 Bilevel positive airway pressure glucocorticoids in (editorial), 376-377 prehospital noninvasive, support in a 101-year-old patient with severe induction of mild hypothermia using water-circulating cooling device cardiogenic pulmonary edema (letter), 586-588 after (letter), 730-732 in the treatment of status asthmaticus in pediatrics, 6-9 out-of-hospital (see Out-of-hospital cardiac arrest (OHCA)) Biological marker, qualitative versus quantitative cardiac marker assay in prehospital, effect of sodium bicarbonate on outcome of (letter), 589 prehospital evaluation of non-ST-segment elevation ACS (letter), refractory, and myocarditis, CPB and ECMO for acute-onset 588-589 dysrhythmia presenting with, 348-352 BiPAP. see Bilevel positive airway pressure simpler model of, transesophageal AC stimulation for VF induction in Bispectral index, assessment of association with 2 clinical sedation scales, rats, 623-630 918-924 VF, due to acute STEMI, effect of thrombolytic therapy versus primary Bites and stings PCI on outcome of patients after, 545-550 of bee, multiple, spontaneous subarachnoid hemorrhage after intravenous Cardiac defibrillation epinephrine use for, 249-250 external, during wet-surface cooling, 420-424 of laboratory rat, anaphylactic shock from, 985.e1-985.e2 and therapeutic hypothermia, 479-480 of Latrodectus, uncommon cardiovascular manifestations after, 232-235 Cardiac ischemia, inverted U wave as a specific electrocardiographic sign Blast injury, primary, traumatic brain injury from, 97-98 of, 235-237 Blatchford score, versus clinical Rockall score versus complete Rockall Cardiac memory phenomenon, T wave inversion after conversion from score, to predict need for clinical intervention in patients with atrial flutter to sinus rhythm due to, 831-833 acute nonvariceal upper gastrointestinal bleeding, 774-779 Cardiac pacing, with epinephrine, on outcome improvement of CPR, Bleeding, gastric variceal, diaphragmatic embolism after endoscopic 1032-1039 injection sclerotherapy for, 860.e5-860.e6 Cardiac tamponade Blood pressure with atrial flutter, as initial presentation of tuberculosis pericarditis, asymptomatic elevated, ability of emergency physicians to determine ED 108-110 patients with, 313-317 caused by leaking coronary saphenous vein graft aneurysm, elevated, prevalence in adult patients with acute stroke presenting to the 858.e1-858.e2 ED in the US, 32-38 as unusual presentation of underlying unrecognized cancer, 737.e5-737.e6 elevated diastolic, prevalence of cocaine use in ED patients with, Cardiac troponin I. see Troponin I, cardiac 612-615 Cardiogenic pulmonary edema, prehospital noninvasive bilevel positive labile, diagnosis and management during acute CVA and other airway pressure support in a 101-year-old patient with (letter), hypertensive crises, 949-959 586-588 lower, associated with MI after emergency endoscopy for upper Cardiogenic shock, after cardioversion, in thyrotoxic patients with unstable gastrointestinal bleeding in high-risk patients, 49-52 atrial fibrillation (letter), 981 Blunt injury, abdominal, complete transection of common iliac artery as a Cardiomyopathy fatal complication of, 251-253 hyperthyroid, or cardioversion, in an unrecognized thyrotoxicosis patient, Body mass index (BMI), various, spatial relationships of lumbar puncture acute right ventricular dysfunction after (letter), 723-724 landmarks in patients of, 331-334 hypertrophic Body position, supine versus semirecumbent versus upright, effect on electrocardiographic manifestations and other important considerations interpretation of 12-lead ECG for ischemia and STEMI, for the emergency physician, 72-79 753-756 12-lead ECG in, 688-701 Body surface mapping (BSM), next-generation and user-friendly electro stress-induced, takotsubo left ventricular dysfunction, 243-244 cardiographic, on early detection and diagnosis of acute MI, Takotsubo 1063-1072 associated with sepsis in type 2 diabetes mellitus, 230-232 Body temperature, low, accuracy of PiCCO monitoring in (letter), 845-846 diagnosis and treatment in ED patient, 202-207 Bone scintigraphy, with Technetium Tc 99m methylene diphosphonate, of mimicking ST-segment elevation myocardial infarction, 92-95 rhabdomyolysis after near-drowning in cold seawater (letter), Cardiopulmonary bypass (CPB), for acute-onset dysrhythmia presenting 848-850 myocarditis and refractory cardiac arrest, 348-352 Brachiocephalic veins, left, perforation of, CT features and treatment Cardiopulmonary resuscitation (CPR). see also Resuscitation considerations for, 1051-1056 cardiac pacing with epinephrine on outcome improvement of, 1032-1039 Brain injury massive tissue emphysema after, 101-102 inflicted, versus shaken baby syndrome (letter), 1080 new method using only rhythmic abdominal compression, 786-790 traumatic, due to primary blast injury, 97-98 Cardiovascular collapse, importance of bedside echocardiography for Brainstem, anesthesia, ED treatment after retrobulbar block, 105-106 detection of isolated right ventricular infarction as a cause of, Brugada syndrome, 12-lead ECG in, 688-701 110-114 Burn, local, management in ED, 666-671 Cardiovascular manifestations, uncommon, after Latrodectus bite, 232-235 Cardioversion Calcium channel blockers, poisoning, ECG abnormalities associated with, electrical, in thyrotoxic patients with unstable atrial fibrillation, 672-687 cardiogenic shock after (letter), 981 Cancer, unrecognized, cardiac tamponade as unusual presentation of, or hyperthyroid cardiomyopathy, in an unrecognized thyrotoxicosis 737.e5-737.e6 patient, acute right ventricular dysfunction after (letter), 723-724 Carbamazepine (CBZ), poisoning, MDAC in (letter), 378, 485 Carotid artery, internal Carbon monoxide poisoning, recurrent myelin basic protein elevation in severe headache caused by dilatative arteriopathy of (erratum), 857 cerebrospinal fluid as a predictive marker of delayed traumatic pseudoaneurysm of, cause of life-threatening epistaxis, encephalopathy after (letter), 483-485 116-118 1096 Keyword Index 25

Centuroides exilicauda, venomous scorpion in North America (letter), 856 Compartment syndrome, and laceration of popliteal artery, from stingray Cerebral pyogenic ventriculitis, due to infective endocarditis, a rare ED envenomation, 96-97 diagnosis of, 120-122 Complete Rockall score, versus clinical Rockall score, versus Blatchford Cerebrospinal fluid score, to predict need for clinical intervention in patients with accuracy of results to differentiate bacterial from non bacterial meningitis acute nonvariceal upper gastrointestinal bleeding, 774-779 in case of negative gram-stained smear, 179-184 Complication, fatal, of blunt abdominal injury, complete transection of recurrent myelin basic protein elevation in, as a predictive marker of common iliac artery, 251-253 delayed encephalopathy after carbon monoxide poisoning (letter), Computed tomography (CT) 483-485 abdominal, frequency and cost of radiology self-referral in, 396-399 Cerebrovascular accident care regionalization, ischemic, and helicopter body scans, discrepancies in interpretation by radiology residents in ED, EMS, assessment of system improvements in, 158-163 45-48 Cerebrovascular accident (CVA), acute, diagnosis and management of head, as screening examination for facial fractures, 616-619 labile BP during, 949-959 image pitfall of, in diagnosis of aortic dissection (letter), 127-129 Cervical spine fractures, application of clinical criteria for ordering multidetector radiographs for detection of, 326-330 for acute myocardial infarction diagnosis, 114-116 Chest injuries, diagnosed by chest radiograph, clinician versus statistical and multiplanar reconstruction imaging, for giant wooden foreign models for prediction of, 823-830 body detection, 211-213 Chest pain scanning guidelines development based on Alvarado clinical scores for cocaine-associated, application of TIMI risk score in ED patients with, patients with suspected and confirmed cases of appendicitis, 1015-1018 489-493 impact of negative stress test on emergency physician disposition sixty four-slice, coronary angiography, for chest pain evaluation in the decision in ED patients with, 39-44 ED, 367-375 prevalence of heparin-PF4 antibodies in patients presenting to the ED sixty-four-slice multidetector, for diagnosis of life-threatening illnesses in with, 279-284 ED, 450-458 risk assessment for ACS associated with atrial fibrillation among ED and treatment considerations, of left brachiocephalic vein perforation, patients with, 523-528 1051-1056 sixty-four-slice CT coronary angiography for evaluation of, 367-375 whole-body multislice, as primary and sole diagnostic tool for blunt triage flowchart to rule out acs among patients with, 865-872 trauma, 1057-1062 Chest radiography, clinician versus statistical models for prediction of chest Conducted electrical weapons (CEWs), impact on mentally ill population, injuries diagnosed by, 823-830 780-785 Chest trauma, blunt, extensive anterolateral MI caused by left main Contrast media coronary artery dissection after, 858.e3-858.e5 nephropathy induced by Children. see Pediatrics Cockcroft-Gault equation and MDRD for predicting patients at risk for Chronic alcoholism, fatal afebrile streptococcal meningitis in, 106-108 (letter), 487 Chronic obstructive pulmonary disease (COPD) discordance between serum Cr and CrCl for identification of ED acute exacerbation, emergency short-stay unit as an effective alternative patients with abdominal pain at risk for, 268-272 to in-hospital admission for (letter), 486-487 Coronary angiography, sixty-four slice CT, for chest pain evaluation in the mortality-related factors after hospitalization for acute exacerbation of, ED, 367-375 515-522 Coronary artery disease, risk prediction score for identification of silent Circadian rhythms, influence on onset and outcomes of nontraumatic SAH myocardial ischemia in patients with, under aspirin therapy (letter), 728-730 presenting with upper gastrointestinal hemorrhage, 406-413 Circulatory insufficiency, sign of, correlation with duration of Coronary artery dissection, left main, after blunt chest trauma, extensive unconsciousness induced by psychotropic drug overdose, 757-761 anterolateral MI caused by, 858.e3-858.e5 Classification and regression tree analysis, versus clinician, for prediction Coronary artery occlusion, acute left main, ECG prediction of (letter), of chest injuries diagnosed by chest radiograph, 823-830 852-855 Clavicle fractures, prescription of narcotic analgesics for management of Coronary perfusion, amount obtainable with only rhythmic abdominal pain from, in very young and elderly patients, 651-653 compression and with standard chest-compression CPR versus Clenbuterol, pulmonary edema and respiratory failure associated with coronary perfusion for normally beating heart, 786-790 exposure to, 735.e1-735.e3 Coronary saphenous vein graft aneurysm, leaking, cardiac tamponade Clinical guidelines, published, differences in the risk tolerance for ACS, caused by, 858.e1-858.e2 SAH and PE disease exclusion according to, 540-544 Costs, of radiology self-referral in abdominal CT scans, 396-399 Clinical Rockall score, versus Blatchford score, versus complete Rockall Cough, acute, vital-sign abnormalities as predictors of pneumonia in adults score, to predict need for clinical intervention in patients with with, 631-636 acute nonvariceal upper gastrointestinal bleeding, 774-779 Creatine kinase-MB Clinician, versus statistical models, for prediction of chest injuries concentration measured at admission, prognostic implications in ACS, diagnosed by chest radiograph, 823-830 65-68 Cocaine identification of false positive activity of, in a patient with nonketotic application of TIMI risk score in ED patients with chest pain associated hyperglycemia, 859.e9-859.e10 with, 1015-1018 Creatinine clearance (CrCl), discordance between serum Cr and, for prevalence of use of, in ED patients with severe hypertension, 612-615 identification of ED patients with abdominal pain at risk for Cockcroft-Gault equation, and MDRD, for predicting patients at risk for contrast-induced nephropathy, 268-272 contrast-induced nephropathy (letter), 487 Creatinine (Cr), serum level of, discordance between CrCl and, for Color analog scale, for quantification of improvement in pain scores in the identification of ED patients with abdominal pain at risk for pediatric ED, 739-742 contrast-induced nephropathy, 268-272 Coma, prolonged, after eszopiclone overdose, 735.e5-735.e6 Critical illness Community acquired pneumonia (CAP), vital-sign abnormalities as bedside ultrasound in diagnosis of pneumoperitoneum in patients with, predictors of, in adults with acute cough illness, 631-636 presenting with acute abdominal pain, 838-841 INDEX TO VOLUME 25 1097

Critical illness (continued) Diastolic blood pressure, elevated, prevalence of cocaine use in ED patients direct bedside transthoracic echocardiography as preferred cardiac with, 612-615 window for LVEF estimation, 894-900 Dietary foreign bodies, in esophagus, emergency endoscopic management Cyanide, severe acute poisoning by ingestion or inhalation of, of, 662-665 hydroxocobalamin for, 551-558 Digital intubation, as option in airway management (letter), 726 Disaster D-dimer enzyme linked immunosorbent assay pediatric, needs assessment of DMATS regarding the challenge of, 762-769 referent proposed conceptual framework of surge capacity of healthcare facility for exclusion of venous thromboembolism in the ED, patient-related during, 297-306 factors in the use of (letter), 255-256 Disaster Medical Assistance Teams (DMATs), needs assessment of, for exclusion of VTED in ED, patient-related factors in the use of regarding the challenge of pediatric disaster, 762-769 (letter), 485-486 Dislocation role in diagnosis of venous thromboembolism in elderly (letter), 727-728 bilateral anterior shoulder, in a young and healthy man without obvious Dead-on-arrival patient, PUBS in, 861.e5-861.e6 cause, 734.e1-734.e3 Death, and delayed clinical decompensation, after pediatric nifedipine lateral patellar, with vertical axis rotation of 908, 733.e1-733.e2 overdose, 197-198 posterior knee, an irreducible case, 240-242 Decision making, of emergency physician, impact of a negative prior stress upper extremity, ultrasound-guided supraclavicular block for, 472-475 test among ED patients with chest pain syndromes on, 39-44 Dissection, axillary artery, due to blunt shoulder trauma, 242-243 Decompression, transorbital ventricular, in acutely decompensated Drug overdose hydrocephalic ED patient, 208-210 methadone, onset of symptoms after, 57-59 Deep venous thrombosis (DVT) methadone, onset of symptoms after (letter), 855-856 considerations in diagnosis and therapy for, 860.e1-860.e4 psychotropic, correlation of factors on arrival with duration of in paradoxical embolism involving 4 organ systems, 737.e1-737.e3 unconsciousness induced by, 757-761 sensitivity and specificity of VIDAS D-dimer test for diagnosis of, Dural sinus 464-471 thrombosis Defibrillator, implantable cardioverter, care of patient with, in the ED, isolated headache as sole manifestation of, 218-219 812-822 isolated headache as sole manifestation of (letter), 982 Dental extraction, retrobulbar hemorrhage resulting from syncopal seizures Dyspnea, impedance cardiography for differentiation of cardiac from after, 228-230 noncardiac causes of, in ED, 437-441 Depression, screen and intervention for older ED patients, 133-137 Dysrhythmia, acute-onset, presenting myocarditis and refractory cardiac Desmopressin, overdosing, as a possible cause of recurrent hyponatremia, arrest, CPB and ECMO for, 348-352 239-240 Diabetes mellitus, type 2, Takotsubo cardiomyopathy associated with sepsis Echocardiography in, 230-232 bedside, for detection of isolated right ventricular infarction as a cause of Diagnosis. see also Diagnosis, differential cardiovascular collapse, 110-114 of deep venous thromboembolism and pulmonary embolism, sensitivity transthoracic and specificity of VIDAS D-dimer test for, 464-471 direct bedside, as preferred cardiac window for LVEF estimation in delayed traumatic thoracic spinal epidural hematoma after compression critically ill patients, 894-900 fracture, 69-71 visualization of anticoagulant therapy efficiency, for right atrium differential, ST-segment myocardial infarction versus Takotsubo mobile thrombus in elderly, 983.e3-983.e4 cardiomyopathy, 92-95 Ectopic pregnancy of DVT, considerations in, 860.e1-860.e4 bedside transvaginal ultrasonography in the ED for diagnosis and early, of HSE in ED, diffusion-weighted MRI for, 986.e5-986.e6 management of, 591-596 early and accurate, of gastric distention to avoid lethal complications, ovarian, in second-trimester patient, 1085.e3-1085.e4 207-208 presenting as rectal pain, 221-222 of ectopic pregnancy, bedside transvaginal ultrasonography in the ED for, 591-596 Editorials, 376-377, 479-480 intracranial injury in minor head trauma, role of serum tau protein in, Elderly patients. see Geriatric patients 391-395 Electrical weapons, conducted, impact on mentally ill population, 780-785 of life-threatening illnesses in ED, sixty-four-slice mutidetector CT for, Electrocardiography (ECG) 450-458 abnormalities in, associated with poisoning, 672-687 Lodox Statscan for visualization of VP shunts (erratum), 1081 additional lead, and fibrinolysis of posterior and right ventricular acute ophthalmic, of optic neuritis in the ED, 834-837 myocardial infarction, internet-based survey on the use of (letter), of pulmonary embolism, value of IMA in, 770-773 258-261 radiologic, of patients who received imaging for venous cases and electrocardiograms of HATWs, 859.e1-859.e8 thromboembolism despite negative D-dimer tests, 1040-1046 double counting of heart rate by interpretation software of, as a sign of of septic arthritis, sensitivity of synovial fluid WBC count in, 749-752 severe hyperkalemia (letter), 584-586 of venous thromboembolism in the elderly, role of D-dimer enzyme features and prognosis in patients with acute myocardial infarction linked immunosorbent assay in (letter), 727-728 related to diagonal or marginal branch occlusion, 170-173 of whole-body multislice CT, as primary and sole tool for blunt trauma, frequency of electrode misplacement in different clinical settings, 1057-1062 174-178 Diagnosis, differential interpretation software, double counting of heart rate by, in hyperkalemia bacterial versus non bacterial meningitis, with negative gram-stained (letter), 1077-1078 smear of CSF, accuracy of results, 179-184 inverted U wave as specific sign of cardiac ischemia, 235-237 of HATWs, 859.e1-859.e8 12-lead Diaphragmatic embolism, after endoscopic injection sclerotherapy for effect of body position, supine versus semirecumbent versus upright, gastric variceal bleeding, 860.e5-860.e6 on interpretation for ischemia and STEMI, 753-756 1098 Keyword Index 25

Electrocardiography (ECG) (continued) ketamine and opioids for procedural sedation and pain management impact on ED evaluation and management, 942-948 (letter), 725-726 in patient with ACS, 1073-1076 loupe magnification versus naked eye for wound visualization, 704-707 in patient with syncope, 688-701 management of local burn wounds in, 666-671 MI, without structural lesion in setting of acute hymenoptera McKittrick-Wheelock syndrome as cause of severe hydro-electrolyte envenomation, 1082.e5-1082.e8 disorders in, 1083.e1-1083.e3 and other important considerations in HCM for the emergency physician, morphine alone and in combination with ketamine for severe acute pain 72-79 in, 385-390 prediction of acute left main coronary artery occlusion (letter), 852-855 nonnarcotic analgesics for acute exacerbations of chronic nonmalignant recognition and treatment in the ED of atrial fibrillation in WPW pain, 445-449 syndrome, 576-583 before and after OHP cutbacks (erratum), 857 T wave inversion, due to cardiac memory phenomenon after conversion ophthalmic diagnoses of optic neuritis, 834-837 from atrial flutter to sinus rhythm, 831-833 outcomes of high-risk patients with nonvariceal upper gastrointestinal Electrodes, ECG, frequency of misplacement in different clinical settings, hemorrhage undergoing emergency versus urgent endoscopy, 174-178 273-278 Emergency department (ED) outcomes of patients with presumed environmental hyperthermia, antithrombotic therapy for prevention of stroke in clinical practice in, 1-5 442-444 association between sickness absenteeism and influenza vaccination of patient-related factors health care workers in, 808-811 in the use of referent D-dimer enzyme linked immunosorbent assay, atrial fibrillation in WPW syndrome, ECG recognition and treatment in, for exclusion of venous thromboembolism in (letter), 255-256 576-583 in the use of referent D-dimer enzyme linked immunosorbent assay, bedside transvaginal ultrasonography for diagnosis and management of for exclusion of VTED in (letter), 485-486 ectopic pregnancy, 591-596 patient sex and quality of care for MI patients in, 996-1003 care of pacemaker and implantable cardioverter defibrillator patient, patterns of incidence of gastroenteritis disease by season and age in, 812-822 535-539 cerebral pyogenic ventriculitis due to infective endocarditis, a rare pediatric, quantification of improvement in pain scale scores using color diagnosis in, 120-122 analog scale, 739-742 cocaine use in patients with severe hypertension, 612-615 Penrose drain for entrapped ring removal from a finger (letter), 722-723 CPB and ECMO for acute-onset dysrhythmia presenting myocarditis and predictive model of antimicrobial-resistant Gram-negative bacteremia, refractory cardiac arrest, 348-352 597-607 CT scanning guidelines based on Alvarado clinical scores for patients and prehospital setting, assessment of endotracheal intracuff pressures in with suspected and confirmed cases of appendicitis, 489-493 intubated patients before aeromedical transport, 53-56 depression screen and intervention for older patients, 133-137 prescription of narcotic analgesics for pain management of clavicle diagnosis fractures in very young and elderly patients, 651-653 of gastric volvulus in patient with bent nasogastric tube, 213-215 presentations of acute renal infarction in, 164-169 and treatment of Takotsubo cardiomyopathy, 202-207 prevalence of heparin-PF4 antibodies in patients presenting with diffusion-weighted MRI for early diagnosis of HSE, 986.e5-986.e6 thrombosis or chest pain, 279-284 discordance between serum Cr and CrCl for identification of ED patients PUBS in a dead-on-arrival patient, 861.e5-861.e6 with abdominal pain at risk for contrast-induced nephropathy, relationship of air pollution to asthma in children and adults (letter), 852 268-272 reperfusion strategies in the emergency treatment of STEMI, 353-366 discrepancies in interpretation of body computed tomographic scans by risk assessment for ACS associated with atrial fibrillation among ED radiology residents in, 45-48 patients with chest pain syndrome, 523-528 early diagnosis of gas-forming pyometra in an aged patient (letter), risk factors and prognostic predictors of unexpected ICU admission 126-127 within 3 days after discharge in, 1009-1014 effectiveness of triage pain protocol in improving frequency and time risk factors associated with MRSA in patients admitted to, 880-886 to delivery of analgesia for painful musculoskeletal injuries, short-stay unit in, as an effective alternative to in-hospital admission for 791-793 acute COPD exacerbation (letter), 486-487 effects of RAP on length of stay in, and time spent on ambulance sixty-four-slice CT coronary angiography for evaluation of chest pain, diversion, 559-563 367-375 elevated blood pressure in adults with acute stroke presenting to the, in sixty-four-slice multidetector CT for diagnosis of life-threatening the US, 32-38 illnesses, 450-458 emergency versus pediatric physicians on different patterns for managing splenic artery aneurysms encountered in, 430-436 febrile children in, 1004-1008 Stewart’s strong ion difference as predictor of major injury after trauma endoscopic management of dietary foreign bodies in the esophagus, in, 938-941 662-665 sumatriptan for the treatment of undifferentiated primary headaches, factors associated with longer lengths of stay in, 643-650 60-64 identifying high-risk patients for triage and resource allocation, 794-798 treatment of brainstem anesthesia after retrobulbar block, 105-106 impact of 12-lead electrocardiogram on evaluation and management in, triage flowchart to rule out ACS, 865-872 942-948 ultrasonography diagnosis of superior mesenteric artery syndrome, impedance cardiography for differentiation of cardiac from noncardiac 864.e5-864.e6 causes of dyspnea in, 437-441 ultrasound-guided inappropriate prescribing in older population based on Beers criteria, hip arthrocentesis, 80-86 804-807 supraclavicular block for upper extremity fractures, dislocations, and incidence of occult upper gastrointestinal bleeding in patients presenting abscesses, 472-475 with hematochezia, 340-344 use of LTCM for asthmatic patients being discharged from, 476-478 integration of nurse-physician teams at a mass gathering medical care Emergency medical services event, 15-22 current status in Korea (letter), 846-848 INDEX TO VOLUME 25 1099

Emergency medical services (continued) Epididymitis, idiopathic testicular infarction masquerading as, helicopter, and ischemic cerebrovascular accident care regionalization, 736.e1-736.e2 assessment of system improvements in, 158-163 Epidural blood patch, pneumocephalus secondary to, 244-246 lack of correlation in welfare check distribution and transport patterns in Epidural hematoma, acute, of the posterior fossa, 989-995 rural critical care transport service, 345-347 Epigastric pain, in acute emphysematous cholecystitis, 488.e3-488.e5 medical emergency motorcycle in, 620-622 Epinephrine Emergency nurses, specialized, assessment of ability to treat ankle and foot with cardiac pacing, on outcome improvement of CPR, 1032-1039 injuries, 144-151 improves survival rates in an adult rabbit model of asphyxia cardiac Emergency physicians arrest, 509-514 ability to determine ED patients with AEBP, 313-317 intravenous, for multiple bee stings, spontaneous subarachnoid ability to obtain ultrasound images of landmarks relevant to lumbar hemorrhage after, 249-250 puncture, 291-296 topical lidocaine with, for larger wound management, 379-384 annotated "cardiac" literature—2006, 960-976 Epistaxis, life-threatening, caused by traumatic pseudoaneurysm of the in critically ill patients, direct bedside transthoracic echocardiography as ICA, 116-118 preferred cardiac window for LVEF estimation by, 894-900 Esophagus, emergency endoscopic management of dietary foreign bodies on identification of terrorism syndromes, 1019-1024 in, 662-665 impact of negative stress test on disposition decision of, in ED patients Eszopiclone, overdose, prolonged coma after, 735.e5-735.e6 with chest pain syndrome, 39-44 Ethylene glycol, ingestion of, management at tertiary care center after the manifestations and other important considerations in HCM for, 72-79 introduction of fomepizole, 799-803 pediatric, sedation service for children during imaging staffed by, Exercise, marathon running, hypoelectrolytemia with acute renal failure in 654-661 exertional heatstroke (erratum), 857 on use of resources to evaluate obese patients with acute abdominal pain, Extracorporeal membrane oxygenation (ECMO), for acute-onset 925-930 dysrhythmia presenting myocarditis and refractory cardiac arrest, Emphysema 348-352 disseminated head and neck, with pneumocephalus, due to air Extremity, lower, nonsurgical isolated injuries of, incidence and risk factors compressor injury into orbit, 223-225 for venous thromboembolism in patients with, 502-508 massive tissue, after CPR, 101-102 Extremity injury/trauma Emphysematous cholecystitis, acute, with initial normal radiological isolated, women versus men on receiving prehospital analgesia for, evaluation, 488.e3-488.e5 901-906 Encephalitis, herpes simplex virus, bilateral thalamic involvement and prehospital use of analgesics in children with, 400-405 normal imaging of early stage of the unusual presentation of, upper, ultrasound-guided supraclavicular block for, 472-475 87-89 Encephalopathy, delayed, after carbon monoxide poisoning, recurrent Face, fractures of, head CT for screening examination of, 616-619 myelin basic protein elevation in cerebrospinal fluid as a Fatal afebrile streptococcal meningitis, in a chronic alcoholic patients, predictive marker of (letter), 483-485 106-108 Endocardial tumor, right ventricular, mimicking acute massive PE, Fat embolism syndrome, with multiple hypointensity signals, detected by 863.e3-863.e5 head MRI demonstrate a favorable outcome, 217-218 Endocarditis Fentanyl infective, a rare ED diagnosis of cerebral pyogenic ventriculitis due to, intranasal, versus intravenous morphine, for prehospital analgesia, 120-122 911-917 Listeria, spontaneous splenic rupture associated with, 1086.e3-1086.e5 for prehospital analgesia, 842-843 Endoscopy Fibrinolysis, and additional lead electrocardiograms, of posterior and right emergency ventricular acute myocardial infarction, internet-based survey on factors associated with MI after, for upper gastrointestinal bleeding in the use of (letter), 258-261 high-risk patients, 49-52 Finger, Penrose drain for entrapped ring removal from, under emergent versus urgent, outcomes of high-risk ED patients with nonvariceal conditions (letter), 722-723 upper gastrointestinal hemorrhage undergoing, 273-278 Finger injuries, titanium alloy ring crush, 1084.e3-1084.e5 for emergency management of dietary foreign bodies in the esophagus, Flank pain, presentation of acute renal infarction in ED, 164-169 662-665 Fomepizole, management of toxic alcohol ingestion at tertiary care center injection sclerotherapy, for gastric variceal bleeding, diaphragmatic after the introduction of, 799-803 embolism after, 860.e5-860.e6 Foot Endotracheal tube cuff, assessment of pressure in intubated patients before and ankle injuries, treatment of, assessment of the ability of specialized aeromedical transport in the ED and prehospital setting, 53-56 emergency nurses in, 144-151 End-stage renal disease, unilateral pulmonary edema related to (letter), injury, from sea urchin, eosinophilic pneumonia associated with, 129-131 862.e5-862.e6

Envenomation, stingray, popliteal artery laceration and compartment Forced expiratory volume in one-second (FEV1), clinical measures syndrome from, 96-97 associated with, in persons with asthma requiring hospital Enzyme linked immunosorbent assay admission, 425-429 referent D-dimer Foreign body for exclusion of venous thromboembolism in the ED, patient-related dietary, in esophagus, emergency endoscopic management of, factors in the use of (letter), 255-256 662-665 for exclusion of VTED in ED, patient-related factors in the use of giant wooden, detection with multidetector CT and multiplanar (letter), 485-486 reconstruction imaging, 211-213 Eosinophilic pneumonia, associated with foot injury from sea urchin, periorbital penetrating wound complicated by, 198-199 862.e5-862.e6 Fracture Eperisone hydrochloride, infantile case of seizure induced by intoxication cervical spine, application of clinical criteria for ordering radiographs for after accidental consumption of (letter), 481-482 detection of, 326-330 1100 Keyword Index 25

Fracture (continued) Headache (continued) of clavicle, prescription of narcotic analgesics for management of pain explosive, as sole presentation of acute myocardial infarction in a from, in very young and elderly patients, 651-653 young man, 250-251 facial, head CT for screening examination of, 616-619 undifferentiated primary, ED treatment of sumatriptan for, 60-64 radial, prehospital analgesia with Baihui and Hegu points in patients Head trauma, minor, role of serum tau protein in diagnosis of intracranial with, 887-893 injury in, 391-395 upper extremity, ultrasound-guided supraclavicular block for, 472-475 Healthcare facility Frequency, of radiology self-referral in abdominal CT scans, 396-399 a deliberate process for recommending personal protective equipment for staff of, 185-195 Gastric distention, early and accurate diagnosis to avoid lethal proposed conceptual framework of surge capacity of, 297-306 complications, 207-208 Health care provider Gastric outlet obstruction, in an infant, due to lactobezoar, 98-99 accuracy of adult weight estimation in ED, 307-312 Gastric variceal bleeding, diaphragmatic embolism after endoscopic in the ED, association between sickness absenteeism and influenza injection sclerotherapy for, 860.e5-860.e6 vaccination of, 808-811 Gastric volvulus, diagnosis in ED patient with bent nasogastric tube, Heart defects, associated with MI after emergency endoscopy for upper 213-215 gastrointestinal bleeding in high-risk patients, 49-52 Gastroenteritis, by season and age in the ED, patterns of incidence of, Heart failure, acute decompensated 535-539 potential role of sequential measurement of NTproBNP in management Gastrointestinal bleeding of, 335-339 upper thiamine for the treatment of (letter), 124-126 acute nonvariceal, risk scoring system to predict need for clinical Heart failure acute, associated with venlafaxine poisoning, 210-211 intervention in patients with, 774-779 Heart rate nonvariceal, outcomes of high-risk ED patients with, undergoing double counting of, by ECG interpretation software, as ECG sign of emergency versus urgent endoscopy, 273-278 severe hyperkalemia (letter), 584-586 occult, incidence in patients presenting to the ED with hematochezia, in hyperkalemia, double counting of (letter), 1077-1078 340-344 Heatstroke, exertional, hypoelectrolytemia with acute renal failure in risk prediction score for identification of silent myocardial ischemia in (erratum), 857 patients with coronary artery disease under aspirin therapy Hegu points, and Baihui acupressure points, as prehospital analgesia in presenting with, 406-413 patients with radial fractures, 887-893 Gastrothorax, acute postraumatic tension, mimicking acute tension pneu Helicopter emergency medical services, and ischemic cerebrovascular mothorax, 734.e5-734.e6 accident care regionalization, assessment of system improvements Geriatric patients in, 158-163 in ED, effect of depression screening on the care of, 133-137 Hematochezia, incidence of occult upper gastrointestinal bleeding in prescription of narcotic analgesics for pain management of clavicle patients presenting to the ED with, 340-344 fractures, 651-653 Hemoglobin, level of, associated with MI after emergency endoscopy for prevalence of inappropriate prescribing in ED, 804-807 upper gastrointestinal bleeding in high-risk patients, 49-52 right atrium mobile thrombus in, transthoracic echocardiograph on Hemolysis, after ingestion of small amounts of acetic acid by a child, visualization of anticoagulant therapy efficiency for, 738.e1-738.e2 983.e3-983.e4 Hemorrhage role of D-dimer enzyme linked immunosorbent assay in diagnosis of adrenal, isolated, after minor blunt trauma, 984.e5-984.e6 venous thromboembolism in (letter), 727-728 brain stem, and isolated abducens nerve palsy, 104-105 with severe cardiogenic pulmonary edema, prehospital noninvasive maxillofacial, angioembolization as an effective alternative for bilevel positive airway pressure support in (letter), 586-588 hemostasis in intractable life-threatening trauma, 988.e1-988.e5 88-year-old woman, metabolism study of severe hypothermia during spontaneous intracranial, caused by sustained hypertension in a child, rewarming, 986.e1-986.e3 118-120 Glasgow Coma Scale, correlation with duration of unconsciousness spontaneous subarachnoid, after intravenous epinephrine use for multiple induced by psychotropic drug overdose, 757-761 bee stings, 249-250 Glomerular filtration rate (GFR), different calculation methods of, for subarachnoid, concordance of historical questions for risk stratifying predicting patients at risk for contrast-induced nephropathy patients with, 907-910 (letter), 487 Hemostasis, in intractable life-threatening maxillofacial trauma Glucocorticoids, in cardiac arrest (editorial), 376-377 hemorrhage, angioembolization as an effective alternative for, Gluteal artery, inferior, traumatic pseudoaneurysm of, 488.e1-488.e3 988.e1-988.e5 Gram-negative bacteremia, antimicrobial-resistant, predictive model of, in Heparin-platelet factor 4 (PF4) antibodies, prevalence in patients presenting the ED, 597-607 to the ED with thrombosis or chest pain, 279-284 Gram’s stain, negative, accuracy of CSF results to differentiate bacterial Hepatic artery, pulmonary, renal, and splenic artery involvement in from non bacterial meningitis in case of, 179-184 paradoxical embolism, 737.e1-737.e3 Gravitation of the moon, effect on acute myocardial infarction (letter), Hepatic dysfunction, after ingestion of small amounts of acetic acid by a 256-258 child, 738.e1-738.e2 Hepatitis, acute toxic, after amiodarone intravenous loading, Headache 1082.e1-1082.e4 concordance of historical questions for risk stratifying patients with, Herpes simplex encephalitis (HSE), in ED, diffusion-weighted MRI for 907-910 early diagnosis of, 986.e5-986.e6 isolated, as sole manifestation of dural sinus thrombosis, 218-219 Herpes simplex virus encephalitis (HSE), bilateral thalamic involvement isolated, as sole manifestation of dural sinus thrombosis (letter), 982 and normal imaging of early stage of the unusual presentation of, severe 87-89 caused by dilatative arteriopathy of the internal carotid artery Hiatal hernia, massive, masquerading as tension pneumothorax, 226-228 (erratum), 857 Hip, arthrocentesis, ultrasound-guided, in the ED, 80-86 INDEX TO VOLUME 25 1101

Hospital admissions Impedance cardiography, for differentiation of cardiac from noncardiac

clinical measures associated with FEV1 in persons with asthma requiring, causes of dyspnea in ED, 437-441 425-429 Implantable cardioverter defibrillator, care of patient with, in the ED, emergency short-stay unit as an effective alternative to, for acute COPD 812-822 exacerbation (letter), 486-487 Incidence unexpected, in ICU, within 3 days after ED discharge, risk factors and of occult upper gastrointestinal bleeding in patients presenting to the ED prognostic predictors of, 1009-1014 with hematochezia, 340-344 Hospitalization of venous thromboembolism in patients with nonsurgical isolated lower mortality-related factors after, for acute exacerbation of COPD, 515-522 limb injuries, 502-508 in scorpion envenomation, clinical score predicting the need for, Infant. see Pediatrics 414-419 Infarction, isolated right ventricular, bedside echocardiography for in scorpion envenomation, clinical score predicting the need for detection of, as a cause of cardiovascular collapse, 110-114 (letter), 856 Infective endocarditis, a rare ED diagnosis of cerebral pyogenic ventriculitis Hydrocephalus, acutely decompensated, transorbital ventricular due to, 120-122 decompression in ED patient, 208-210 Inferior gluteal artery, traumatic pseudoaneurysm of, 488.e1-488.e3 Hydrocortisone, effect on outcome of OHCA, 318-325 Influenza vaccination, of health care workers in the ED, association Hydrogen peroxide, accidental ingestion of, acute paraplegia from, 90-92 between sickness absenteeism and, 808-811 Hydronephrosis, during pregnancy (letter), 482-483 Ingestion Hydroxocobalamin, for severe acute cyanide poisoning by ingestion or accidental, of hydrogen peroxide, acute paraplegia from, 90-92 inhalation, 551-558 hydroxocobalamin for severe acute cyanide poisoning by, 551-558 Hymenoptera envenomation, acute, electrocardiographic MI without of lupini beans, anticholinergic toxicity from, 215-217 structural lesion in setting of, 1082.e5-1082.e8 of small amounts of acetic acid by a child, systemic manifestations after, Hyperacute T waves (HATWs) 738.e1-738.e2 cases and electrocardiograms of, and its main differential diagnoses, time from, to arrival, correlation with duration of unconsciousness 859.e1-859.e8 induced by psychotropic drug overdose, 757-761 as early sign of acute MI, 859.e1-859.e8 of toxic alcohol, management at tertiary care center after the introduction Hyperbilirubinemia, link with positive urine nitrite test and positive urine of fomepizole, 799-803 culture, 10-14 Inhalation, hydroxocobalamin for severe acute cyanide poisoning by, Hyperglycemia, nonketotic, identification of false positive creatine 551-558 kinase-MB activity in a patient with, 859.e9-859.e10 Injection Hyperkalemia endoscopic, sclerotherapy, for gastric variceal bleeding, diaphragmatic double counting of heart rate in (letter), 1077-1078 embolism after, 860.e5-860.e6 severe, double counting of heart rate by ECG interpretation software, as a intra-articular, accidental, of PPV, pseudoseptic arthritis after, sign of severe hyperkalemia (letter), 584-586 864.e1-864.e3 Hypertension Injury diagnosis and management of labile BP during, 949-959 atraumatic avulsion of Achilles tendon as unusual presentation of, severe, prevalence of cocaine use in ED patients with, 612-615 1087.e1-1087.e2 sustained, cause of spontaneous intracranial hemorrhage in a child, foot, from sea urchin, eosinophilic pneumonia associated with, 118-120 862.e5-862.e6 Hyperthermia, environmental, outcomes of patients who presented to ED major, after trauma in ED, Stewart’s strong ion difference as predictor of, with, 442-444 938-941 Hyperthyroid cardiomyopathy Intensive care unit (ICU), risk factors and prognostic predictors of or cardioversion, in an unrecognized thyrotoxicosis patient, acute right unexpected admission within 3 days after ED discharge in, ventricular dysfunction after (letter), 723-724 1009-1014 Hypertrophic cardiomyopathy Interaction, reduced, as neuropsychiatric manifestations, in a patient with electrocardiographic manifestations and other important considerations imidacloprid poisoning (letter), 844-845 for the emergency physician, 72-79 Internal carotid artery 12-lead ECG in, 688-701 severe headache caused by dilatative arteriopathy of (erratum), 857 Hypoelectrolytemia, with acute renal failure in exertional heatstroke traumatic pseudoaneurysm of, cause of life-threatening epistaxis, (erratum), 857 116-118 Hyponatremia, recurrent, desmopressin overdosing as a possible cause of, Internet-based survey, on the use of additional lead electrocardiograms and 239-240 fibrinolysis of posterior and right ventricular acute myocardial Hypothermia infarction (letter), 258-261 mild, after cardiac arrest, water-circulating cooling device for induction Interrater reliability, of risk assessment using screening tools for PE, of (letter), 730-732 285-290 for OHCA survivors (letter), 1078-1080 Intimate partner violence (IPV), screening of, effect of screener sex in, severe, during rewarming, metabolism study in an 88-year-old woman 1047-1050 with, 986.e1-986.e3 Intoxication therapeutic, and cardiac defibrillation (editorial), 479-480 after accidental consumption of eperisone hydrochloride, infantile case of seizure induced by (letter), 481-482 Iliac artery, common, complete transection of, fatal complication of blunt organophosphate, thyroid storm precipitated by, 861.e1-861.e3 abdominal injury, 251-253 Intra-aortic balloon counterpulsation, in refractory shock due to acute Image pitfall, of CT in diagnosis of aortic dissection (letter), 127-129 meningococcemia, 253-254 Imaging, sedation service staffed by PEM physicians for children during, Intracranial hemorrhage, spontaneous, caused by sustained hypertension in 654-661 a child, 118-120 Imidacloprid, poisoning, severe neuropsychiatric manifestations and Intracranial injury, in minor head trauma, role of serum tau protein in rhabdomyolysis in patient with (letter), 844-845 diagnosis of, 391-395 1102 Keyword Index 25

Intracranial penetration Lumbar puncture (continued) of nail, periorbital penetrating wound complicated by, 198-199 aneurysmal rebleeding after, 984.e1-984.e3 of TASER dart, 733.e3-733.e4 difficult or traumatic, visual and tactile inspection of the spine for Intravenous injection, of amiodarone, acute toxic hepatitis after, prediction of, 608-611 1082.e1-1082.e4 spatial relationships of landmarks in patients of various BMI, 331-334 Intubation use of ultrasound to identify pertinent landmarks for, 331-334 digital, as option in airway management (letter), 726 Lung carcinoma, non-small-cell, spontaneous splenic rupture from rapid sequence pegfilgrastim to prevent neutropenia in a patient with, 247-248 masseter muscle rigidity associated with, 102-104 Lung ultrasonography prevention of awakening signs after, 529-534 bedside Ischemia, effect of body position, supine versus semirecumbent versus comet-tail artifact sign at (letter), 981-982 upright, on interpretation of 12-lead ECG for, 753-756 in diagnosis of AIS (letter), 724-725 Ischemia-modified albumin (IMA), value in the diagnosis of pulmonary Lupini beans, anticholinergic toxicity from ingestion of, 215-217 embolism, 770-773 Ischemic cerebrovascular accident care regionalization, and helicopter Magnetic resonance imaging (MRI) EMS, assessment of system improvements in, 158-163 of delayed traumatic thoracic spinal epidural hematoma, 69-71 Ischemic stroke, in a man with naphazoline abuse history, 983.e1-983.e2 diffusion-weighted, early diagnosis of HSE in ED, 986.e5-986.e6 of the head, fat embolism syndrome with multiple hypointensity signals Jehovah’s Witnesses, use of Recombinant activated factor VII in, detected by, demonstrate a favorable outcome, 217-218 1085.e1-1085.e2 Masseter muscle, succinylcholine-induced rigidity of, associated with rapid Jejunal perforation, after blunt abdominal trauma, 862.e1-862.e4 sequence intubation, 102-104 Mass screening, of facial fractures, head CT for, 616-619 Ketamine Maxillofacial hemorrhage, angioembolization as an effective alternative for morphine alone and in combination with, for severe acute pain in hemostasis in intractable life-threatening trauma, 988.e1-988.e5 emergency setting, 385-390 May-Thurner syndrome, considerations in diagnosis and therapy for, and opioids, for procedural sedation and pain management in the ED 860.e1-860.e4 (letter), 725-726 McKittrick-Wheelock syndrome, as cause of severe hydro-electrolyte for prehospital use, 977-980 disorders in ED, 1083.e1-1083.e3 Kidney failure, acute, with hypoelectrolytemia in exertional heatstroke Medicaid beneficiaries, and uninsured, changes in access to primary care (erratum), 857 (erratum), 857 Korea, current status of the emergency medical system (letter), 846-848 Medical emergency motorcycle (MEM), in medical emergency system, 620-622 Laceration, of popliteal artery and compartment syndrome from stingray Medication error, in vaccination, 199-200 envenomation, 96-97 Meningitis Lactate dehydrogenase, elevated serum level of, presentation of acute renal bacterial versus non bacterial, accuracy of results for differential infarction in ED, 164-169 diagnosis of, with negative gram-stained smear of CSF, Lactobezoar 179-184 in an infant, 98-99 fatal afebrile streptococcal, in a chronic alcoholic patient, 106-108 cause of gastric outlet obstruction in an infant, 98-99 Meningococcal septic shock, continuous low-dose infusion of terlipressin Laryngeal tube device, as an adjunct for airway management, 263-267 as rescue therapy in, 863.e1-863.e2 Laryngotracheal disruption, after blunt neck trauma, 1084.e1-1084.e2 Meningococcemia, acute, intra-aortic balloon counterpulsation in refractory Latrodectus, uncommon cardiovascular manifestations after bite from, shock due to, 253-254 232-235 Mental illness, impact of CEWs on a population with, 780-785 Lead electrocardiograms, additional, and fibrinolysis of posterior and right Methadone ventricular acute myocardial infarction, internet-based survey on time frame for onset of symptoms after overdose of, 57-59 the use of (letter), 258-261 time frame for onset of symptoms after overdose of (letter), 855-856 Left ventricular ejection fraction (LVEF), in critically ill patients, direct Methanol, ingestion of, management at tertiary care center after the bedside transthoracic echocardiography as preferred cardiac introduction of fomepizole, 799-803 window for, 894-900 Methicillin-resistant Staphylococcus aureus (MRSA), in patients admitted Leg, passive raising of, in spontaneously breathing volunteers induce to ED, risk factors associated with, 880-886 variations in pulse oximetry plethysmographic waveform Micrographia, subcortical stroke presenting as, 89-90 amplitude, 637-642 Mitral regurgitation, right upper lobe pulmonary edema as a consequence Length of stay of, 196-197 in ED, effects of RAP on time spent on ambulance diversion and, 559-563 Modification of diet in renal disease (MDRD), and Cockcroft-Gault longer, in ED, factors associated with, 643-650 equation, for predicting patients at risk for contrast-induced Lidocaine, topical, with epinephrine for larger wound management, 379-384 nephropathy (letter), 487 Listeria, endocarditis, spontaneous splenic rupture associated with, Moon, gravitation of, effect on acute myocardial infarction (letter), 256-258 1086.e3-1086.e5 Morphine Lodox Statscan, for visualization of VP shunts (erratum), 1081 alone and in combination with ketamine, for severe acute pain in Long QT syndrome, 12-lead ECG in, 688-701 emergency setting, 385-390 Long-term controller medications (LTCM), in asthmatic patients being intravenous, versus intranasal fentanyl, for prehospital analgesia, discharged from ED, 476-478 911-917 Loupe magnification, versus naked eye, for visualization of wound in ED, Mortality 704-707 factors related to, after hospitalization for acute exacerbation of COPD, Lumbar puncture 515-522 ability of emergency physicians to obtain ultrasound images of identification of risk factors of, among unselected patients with possible landmarks relevant to, 291-296 ACS, 23-31 INDEX TO VOLUME 25 1103

Mortality (continued) Narcotics, analgesic, for pain management of clavicle fractures in very in-hospital, and complicated clinical course, elevated cardiac troponin I young and elderly patients, prescription of, 651-653 for prediction of acute PE, 138-143 Nasogastric tube, bent, diagnosis of gastric volvulus in ED patient with, in patients admitted for exclusion of MI, ability of myoglobin to predict, 213-215 873-879 Natriuretic peptide, amino-terminal pro-B-type, in management of acute short-term, in an oriental population with sepsis, effect of statins on, decompensated heart failure, potential role of sequential 494-501 measurement of, 335-339 Multiplanar reconstruction imaging, and multidetector CT for giant wooden Near-drowning, in cold seawater, Technetium Tc 99m methylene foreign body detection, 211-213 diphosphonate bone scintigraphy of rhabdomyolysis due to Multiple-dose activated charcoal (MDAC), in CBZ poisoning (letter), (letter), 848-850 378, 485 Needs assessment, of DMATs regarding the challenge of pediatric disaster, Multiple hypointensity signals, detected by head MRI, fat embolism 762-769 syndrome with, demonstrate a favorable outcome, 217-218 Nephropathy, contrast-induced Muscle rigidity, masseter, succinylcholine-induced, associated with rapid Cockcroft-Gault equation and MDRD for predicting patients at risk for sequence intubation, 102-104 (letter), 487 Musculoskeletal injuries, effectiveness of triage pain protocol in improving discordance between serum Cr and CrCl for identification of ED patients frequency and time to delivery of analgesia for, 791-793 with abdominal pain at risk for, 268-272 Myelin basic protein, recurrent elevation in cerebrospinal fluid as a Neuritis, optic, ophthalmic diagnoses in the ED, 834-837 predictive marker of delayed encephalopathy after carbon Neurologic disease, and vitamin B12 deficiency, 987.e3-987.e4 monoxide poisoning (letter), 483-485 Neutropenia, spontaneous splenic rupture from pegfilgrastrim for Myocardial infarction (MI) prevention of, in patient with non-small-cell lung carcinoma, ability of myoglobin on mortality prediction in patients admitted for 247-248 exclusion of, 873-879 Newton’s law of gravitation, aspiration pneumonitis and, 987.e1-987.e2 acute Nifedipine, pediatric overdose, delayed clinical decompensation and death diagnosed by multidetector CT, 114-116 after, 197-198 effect of gravitation of the moon on (letter), 256-258 Nonketotic hyperglycemia, identification of false positive creatine-MB electrocardiographic features and prognosis in patients with, related to activity in a patient with, 859.e9-859.e10 diagonal or marginal branch occlusion, 170-173 Nonnarcotic analgesics, for acute exacerbations of chronic nonmalignant HATWs as early sign of, 859.e1-859.e8 pain, 445-449 next-generation and user friendly electrocardiographic BSM on early Non-small-cell lung carcinoma, spontaneous splenic rupture from pegfil detection and diagnosis of, 1063-1072 grastim to prevent neutropenia in a patient with, 247-248 posterior and right ventricular, internet-based survey on the use of Nursemaid’s elbow, in a 31-year-old female, 222-223 additional lead electrocardiograms and fibrinolysis of (letter), 258-261 Obesity, with acute abdominal pain, emergency physicians on use of in the setting of apparent pacemaker anomaly, ventricular resources to evaluate, 925-930 pseudofusion, 248-249 Obtundation, in toddler, naloxone for (letter), 481 severe explosive headache as sole presentation of, in a young man, Occlusion, of diagonal or marginal branch, electrocardiographic features 250-251 and prognosis in patients with acute myocardial infarction related electrocardiographic, without structural lesion, in setting of acute to, 170-173 hymenoptera envenomation, 1082.e5-1082.e8 Occupational exposure, unusual, tongue viability after snakebite as, extensive anterolateral, caused by left main coronary artery dissection 1083.e5-1083.e7 after blunt chest trauma, 858.e3-858.e5 Ointment, topical bacitracin, anaphylaxis after application to a fresh tattoo, factors associated with, after emergency endoscopy or upper 95-96 gastrointestinal bleeding in high-risk patients, 49-52 Older patients. see Geriatric patients patient sex and quality of ED care for patients with, 996-1003 Omental cyst, causing pediatric abdominal distention, 99-101 ST-segment elevation Ophthalmic diagnosis, of optic neuritis in the ED, 834-837 acute, effect of thrombolytic therapy versus primary PCI on outcome Opioids, and ketamine, for procedural sedation and pain management in the of patients after VF cardiac arrest due to, 545-550 ED (letter), 725-726 reperfusion strategies in the emergency treatment of, 353-366 Optic neuritis, ophthalmic diagnoses in the ED, 834-837 Takotsubo cardiomyopathy mimicking, 92-95 Orbit, air compressor injury into, disseminated head and neck emphysema Myocardial ischemia, silent, in patients with coronary artery disease under with pneumocephalus from, 223-225 aspirin therapy presenting with upper gastrointestinal hemorrhage, Oregon Health Plan (OHP), ED use before and after cutbacks risk prediction score for identification of, 406-413 (erratum), 857 Myocardial necrosis triad markers, concentration of, measured at admission Organophosphate intoxication, thyroid storm precipitated by, 861.e1-861.e3 in patients with suspected ACS, prognostic implications of, 65-68 Oriental population, with sepsis, effect of statins on short-term survival in, Myocarditis 494-501 fulminant, venous oximetry in diagnosis and management of, 122-123 Outcomes and refractory cardiac arrest, CPB and ECMO for acute-onset of high-risk ED patients with nonvariceal upper gastrointestinal hemorrhage dysrhythmia presenting with, 348-352 undergoing emergency versus urgent endoscopy, 273-278 Myoglobin of OHCA, effect of hydrocortisone on, 318-325 concentration measured at admission, prognostic implications in ACS, and onset, of nontraumatic SAH, influence of circadian rhythms on 65-68 (letter), 728-730 on prediction mortality in patients admitted for exclusion of MI, 873-879 of patients after VF cardiac arrest due to acute STEMI, effect of thrombolytic therapy versus primary PCI on, 545-550 Naloxone, for obtundation in toddler (letter), 481 of patients who presented to ED with presumed environmental Naphazoline, history of abuse of, ischemic stroke in an man with, hyperthermia, 442-444 983.e1-983.e2 of prehospital cardiac arrest, effect of sodium bicarbonate (letter), 589 1104 Keyword Index 25

Out-of-hospital Cardiac Arrest (OHCA) quantification of improvement in pain scale scores using color analog effect of hydrocortisone on the outcome of, 318-325 scale in the ED, 739-742 hypothermia for survivors of (letter), 1078-1080 sedation service during imaging staffed by PEM, 654-661 Overdose spontaneous intracranial hemorrhage caused by sustained hypertension, of desmopressin, as a possible cause of recurrent hyponatremia, 239-240 118-120 eszopiclone, prolonged coma after, 735.e5-735.e6 tension pyopneumothorax, 200-201 of nifedipine, pediatric, delayed clinical decompensation and death after, unusual case of abdominal distention due to omental cyst, 99-101 197-198 Pegfilgrastrim, spontaneous splenic rupture from, for prevention of of psychotropic drugs, correlation of factors on arrival with duration of neutropenia in a patient with non-small-cell lung carcinoma, unconsciousness induced by, 757-761 247-248 Pelvic inflammatory disease (PID), clinical prediction rule to distinguish Pacemaker acute appendicitis from, in women of childbearing age, apparent anomaly of, acute myocardial infarction in the setting of, 152-157 248-249 Penrose drain, for entrapped ring removal from a finger under emergent care of patient with, in the ED, 812-822 conditions (letter), 722-723 Pain. see also specific type of site Percutaneous coronary intervention, primary, versus thrombolytic therapy, chronic nonmalignant, nonnarcotic analgesics for acute exacerbations of, effect on outcome of patients after VF cardiac arrest due to acute 445-449 STEMI, 545-550 from clavicle fractures, prescription of narcotic analgesics for Pericarditis, tuberculosis, atrial flutter with cardiac tamponade as initial management of, in very young and elderly patients, 651-653 presentation of, 108-110 management of, and procedural sedation in the ED, ketamine and opioids Periorbital penetrating wound, complicated by intracranial nail penetration, for (letter), 725-726 198-199 migratory, misleading the diagnosis of acute renal infarction, 237-239 Personal protective equipment, a deliberate process of recommendation for severe acute, in emergency setting, morphine alone and in combination health care facility staff, 185-195 with ketamine for, 385-390 Physician-nurse teams, integration in a mass gathering medical care event, unremitting right flank, in hydronephrosis during pregnancy (letter), 15-22 482-483 Physicians Pain management, prehospital, using Baihui and Hegu acupressure points, emergency versus pediatric, on different patterns for managing febrile in patients with radial fractures, 887-893 children in ED, 1004-1008 Pain scores, quantification of improvement in, using color analog scale in PiCCO monitor, accuracy in low body temperature (letter), 845-846 the pediatric ED, 739-742 Plethysmographic waveform amplitude, pulse oximetry, passive leg raising Palsy, isolated abducens nerve, and pontine hemorrhage, 104-105 in spontaneously breathing volunteers induce variations in, Paraplegia, acute, from an accidental ingestion of hydrogen peroxide, 90-92 637-642 Patellar dislocation, lateral, with vertical axis rotation of 908, 733.e1-733.e2 Pneumocephalus Patent foramen ovale, in paradoxical embolism involving 4 organ systems, with disseminated head and neck emphysema, due to air compressor 737.e1-737.e3 injury into orbit, 223-225 Patient-related factors secondary to an epidural blood patch, 244-246 in the use of referent D-dimer enzyme linked immunosorbent assay for Pneumococcal polyvalent vaccine (PPV), pseudoseptic arthritis after exclusion of venous thromboembolism in the ED (letter), 255-256 accidental intra-articular deposition of, 864.e1-864.e3 in the use of referent D-dimer enzyme linked immunosorbent assay for Pneumonia exclusion of VTED in ED (letter), 485-486 community acquired, vital-sign abnormalities as predictors of, in adults Patient transport, lack of correlation in welfare check distribution and with acute cough illness, 631-636 transport patterns in rural critical care transport service, 345-347 eosinophilic, associated with foot injury from sea urchin, 862.e5-862.e6

Peak expiratory flow rate, association with FEV1 in persons with asthma Pneumonitis, aspiration, and Newton’s law of gravitation, 987.e1-987.e2 requiring hospital admissions, 425-429 Pneumoperitoneum, bedside ultrasound in diagnosis of, in critically ill Pediatric emergency medicine (PEM), sedation service for children during patients presenting with acute abdominal pain, 838-841 imaging staffed by physicians of, 654-661 Pneumothorax Pediatrics acute tension, acute posttraumatic tension gastrothorax mimicking, and adults, relationship of air pollution to ED visits for asthma 734.e5-734.e6 (letter), 852 tension, massive hiatal hernia masquerading as, 226-228 bee swarmings in, 931-933 tension, mimicking tension viscerothorax, 219-221 bilevel positive airway pressure in the treatment of status asthmaticus, Poisoning 6-9 with carbon monoxide, recurrent myelin basic protein elevation in delayed clinical decompensation and death after nifedipine overdose, cerebrospinal fluid as a predictive marker of delayed 197-198 encephalopathy after (letter), 483-485 disaster, needs assessment of DMATS regarding the challenge of, with CBZ, MDAC in (letter), 378, 485 762-769 with cyanide, by ingestion or inhalation, hydroxocobalamin for severe febrile, in ED, emergency versus pediatric physicians on different acute, 551-558 patterns for management of, 1004-1008 ECG abnormalities associated with, 672-687 gastric outlet obstruction due to lactobezoar, 98-99 venlafaxine, acute heart failure associated with, 210-211 infantile case of seizure induced by intoxication after accidental Pontine hemorrhage, and isolated abducens nerve palsy, 104-105 consumption of eperisone hydrochloride (letter), 481-482 Popliteal artery, laceration of, and compartment syndrome from stingray massive stroke in a previously healthy 7-year-old, 985.e3-985.e5 envenomation, 96-97 naloxone for obtundation in toddler (letter), 481 Posterior fossa, acute epidural hematoma of, 989-995 prehospital use of analgesics in children with extremity injuries, 400-405 Posterior knee, an irreducible case dislocation of, 240-242 prescription of narcotic analgesics for pain management of clavicle Potassium efflux blockers, poisoning, ECG abnormalities associated with, fractures, 651-653 672-687 INDEX TO VOLUME 25 1105

Potentially inappropriate medication (PIMs), prevalence in older ED Quality of care, and sex, in ED patients, with MI, 996-1003 population based on Beers criteria, 804-807 Pregnancy, ectopic Radial head subluxation, in adult female, 222-223 bedside transvaginal ultrasonography in the ED for diagnosis and Radiography management of, 591-596 for cervical spine fracture detection, application of clinical criteria in presenting as rectal pain, 221-222 ordering of, 326-330 Pregnancy, hydronephrosis during (letter), 482-483 chest, clinician versus statistical models for prediction of chest injuries Pregnancy trimester, second, ectopic ovarian in, 1085.e3-1085.e4 diagnosed by, 823-830 Prehospital care diagnosis, of patients who received imaging for venous analgesia in thromboembolism despite negative tests for, 1040-1046 Baihui and Hegu acupressure points in patients with radial fractures, Radiology 887-893 self-referral, frequency and potential cost of, in abdominal CT scans, intranasal fentanyl versus intravenous morphine, 911-917 396-399 for isolated extreme injuries, men versus women on receiving, Rapid admission policy (RAP), effects on ED length of stay and time spent 901-906 on ambulance diversion, 559-563 fentanyl in prehospital setting, 842-843 Rapid-sequence intubation (RSI), prevention of awakening signs after, ketamine use for, 977-980 529-534 noninvasive bilevel positive airway pressure support in a 101-year-old Recombinant activated factor VII, use in Jehovah’s Witness patient, patient with severe cardiogenic pulmonary edema (letter), 1085.e1-1085.e2 586-588 Recombinant human activated protein C (rhAPC), for sepsis in the 21st qualitative versus quantitative cardiac marker assay in prehospital century, 564-571 evaluation of non-ST-segment elevation ACS (letter), 588-589 Rectal pain, ectopic pregnancy presenting as, 221-222 use of analgesics in children with extremity injuries, 400-405 Refractory shock, due to acute meningococcemia, intra-aortic balloon Primary care, for Medicaid beneficiaries and uninsured, changes in access counterpulsation in, 253-254 to (erratum), 857 Regional air transport, lack of correlation in welfare check distribution Procainamide, intravenous, for broad complex atrial fibrillation, 459-463 and transport patterns in rural critical care transport service, Proteinuria, presentation of acute renal infarction in ED, 164-169 345-347 Pseudoaneurysm, traumatic Renal artery, pulmonary, splenic, and hepatic artery involvement in of the ICA, cause of life-threatening epistaxis, 116-118 paradoxical embolism, 737.e1-737.e3 inferior gluteal artery, 488.e1-488.e3 Renal infarction Pseudoseptic arthritis, after accidental intra-articular deposition of PPV, acute 864.e1-864.e3 misleading migratory pain in, 237-239 Psychotropic drug, overdose, correlation of factors on arrival with duration presentations in ED, 164-169 of unconsciousness induced by, 757-761 Reperfusion therapy, in the emergency treatment of STEMI, strategies for, Pulmonary artery, renal, splenic, and hepatic artery involvement in 353-366 paradoxical embolism, 737.e1-737.e3 Rescue therapy, continuous low-dose infusion of terlipressin as, in Pulmonary edema meningococcal septic shock, 863.e1-863.e2 cardiogenic, prehospital noninvasive bilevel positive airway pressure Residents, in radiology, discrepancies in interpretation of ED body support in a 101-year-old patient with (letter), 586-588 computed tomographic scans by, 45-48 massive, masquerading as pulmonary edema, 1086.e1-1086.e2 Resource allocation, in the ED, identifying high-risk patients for, and respiratory failure, associated with clenbuterol exposure, 794-798 735.e1-735.e3 Respiratory failure, and pulmonary edema, associated with clenbuterol right upper lobe, as consequence of mitral regurgitation, 196-197 exposure, 735.e1-735.e3 unilateral, related to end-stage renal disease (letter), 129-131 Resuscitation Pulmonary embolism (PE) by age group, characteristics of, 1025-1031 acute, elevated cardiac troponin I for prediction of complicated clinical successful, rhabdomyolysis after, of a patient with near-fatal asthma, course and in-hospital mortality in patients with, 138-143 736.e3-736.e4 acute massive, right ventricular endocardial tumor mimicking, Retrobulbar block, ED treatment of brainstem anesthesia after, 105-106 863.e3-863.e5 Retrobulbar hemorrhage, resulting from syncopal seizures after a dental interrater reliability of risk assessment using screening tools for, 285-290 extraction, 228-230 SAH and ACS differences in the risk tolerance for disease exclusion Rewarming, metabolism study in an 88-year-old woman with severe according to published guidelines, 540-544 hypothermia during, 986.e1-986.e3 sensitivity and specificity of VIDAS D-dimer test for diagnosis of, Rhabdomyolysis 464-471 due to near-drowning in cold seawater, Technetium Tc 99m methylene value of IMA in diagnosis of, 770-773 diphosphonate bone scintigraphy of (letter), 848-850 Pulse oximetry plethysmographic waveform amplitude, passive leg raising in a patient with imidacloprid poisoning (letter), 844-845 in spontaneously breathing volunteers induce variations in, after successful resuscitation of a patient with near-fatal asthma, 637-642 736.e3-736.e4

Pulsus paradoxus, manually determined, association with FEV1 in persons Right atrium, of elderly with mobile thrombus, transthoracic with asthma requiring hospital admissions, 425-429 echocardiograph on visualization of anticoagulant therapy Purple urine bag syndrome (PUBS), in a dead-on-arrival patient in the ED, efficiency for, 983.e3-983.e4 861.e5-861.e6 Right ventricle, isolated infarction of, bedside echocardiography for Pyogenic ventriculitis, cerebral, due to infective endocarditis, a rare ED detection of, as a cause of cardiovascular collapse, 110-114 diagnosis, 120-122 Right ventricular endocardial tumor, mimicking acute massive PE, Pyometra, gas-forming, early diagnosis of, in an aged patient in ED (letter), 863.e3-863.e5 126-127 Ring, entrapped, Penrose drain for removal of, from a finger under Pyopneumothorax, tension, in a tracheostomized child, 200-201 emergent conditions (letter), 722-723 1106 Keyword Index 25

Risk assessment Septic arthritis, sensitivity of synovial fluid WBC count in diagnosis of, for ACS associated with atrial fibrillation among ED patients with chest 749-752 pain syndrome, 523-528 Septic shock, meningococcal, continuous low-dose infusion of terlipressin using screening tools for PE, interrater reliability in, 285-290 as rescue therapy in, 863.e1-863.e2 Risk factors Sex factors associated with MRSA in patients admitted to ED, 880-886 and quality of ED care, in patients with MI, 996-1003 identification among unselected patients with possible ACS at low or of screener, effect on IPV screening, 1047-1050 high mortality risk, 23-31 Shaken baby syndrome, versus inflicted brain injury (letter), 1080 for venous thromboembolism in patients with nonsurgical isolated lower Shock limb injuries, 502-508 persistent, associated with MI after endoscopy for upper gastrointestinal Risk prediction score, for identification of silent myocardial ischemia in bleeding in high-risk patients, 49-52 patients with coronary artery disease under aspirin therapy refractory, due to acute meningococcemia, intra-aortic balloon presenting with upper gastrointestinal hemorrhage, 406-413 counterpulsation in, 253-254 Risk scoring system, to predict need for clinical intervention in patients Short-stay unit, in ED, as an effective alternative to in-hospital admission with acute nonvariceal upper gastrointestinal bleeding, 774-779 for acute COPD exacerbation (letter), 486-487 Risk stratification, of patients with headache, concordance of historical Shoulder dislocation questions for, 907-910 bilateral anterior, in a young and healthy man without obvious cause, Risk tolerance, for ACS SAH and PE disease exclusion according to 734.e1-734.e3 published guidelines, differences in, 540-544 Spaso technique for (letter), 590 Rupture, splenic, spontaneous, associated with Listeria endocarditis, Shoulder trauma, blunt, axillary artery dissection due to, 242-243 1086.e3-1086.e5 Silent myocardial ischemia. see Myocardial ischemia, silent Rural health services, critical care transport service, lack of correlation in Snakebite, tongue viability after, 1083.e5-1083.e7 welfare check distribution and transport patterns in, 345-347 Socioeconomic factors, effect on administration of prehospital analgesia for isolated extreme injuries, 901-906 Saphenous vein graft aneurysm, leaking coronary, cardiac tamponade Sodium bicarbonate, effect on outcome of prehospital cardiac arrest caused by, 858.e1-858.e2 (letter), 589 Scintigraphy, bone. see Bone scintigraphy Sodium channel blockers, poisoning, ECG abnormalities associated with, Sclerotherapy, endoscopic injection, for gastric variceal bleeding, 672-687 diaphragmatic embolism after, 860.e5-860.e6 Sodium-potassium adenosine triphosphate blockers, poisoning, ECG Scorpions abnormalities associated with, 672-687 envenomation, clinical score predicting the need for hospitalization in, Software, for ECG interpretation, ECG sign of severe hyperkalemia, double 414-419 counting of heart rate by (letter), 584-586 envenomation, clinical score predicting the need for hospitalization in Spaso technique, for shoulder dislocation (letter), 590 (letter), 856 Spinal epidural hematoma, delayed traumatic thoracic, after compression Screening, for depression, effect on the care of older ED patients, 133-137 fracture, 69-71 Screening tools, for PE, interrater reliability in risk assessment using, Spine, visual and tactile inspection of, for prediction of difficult or 285-290 traumatic lumbar puncture, 608-611 Season, effect on patterns of incidence of gastroenteritis disease in the ED, Splenic artery 535-539 aneurysms, encountered in ED, 430-436 Sea urchin, eosinophilic pneumonia associated with foot injury from, pulmonary, renal, and hepatic artery involvement in paradoxical 862.e5-862.e6 embolism, 737.e1-737.e3 Seawater, cold, Technetium Tc 99m methylene diphosphonate bone Splenic rupture, spontaneous scintigraphy of rhabdomyolysis due to near-drowning in (letter), associated with Listeria endocarditis, 1086.e3-1086.e5 848-850 from pegfilgrastim to prevent neutropenia in a patient with non-small-cell Sedation lung carcinoma, 247-248 and agitation, association of level of awareness and blood alcohol Spontaneous subarachnoid hemorrhage, after intravenous epinephrine use concentration with both, in intoxicated patients in the ED, for multiple bee stings, 249-250 743-748 Staphylococcus aureus procedural, and pain management in the ED, ketamine and opioids for fulminant fatal toxic shock syndrome with, 225-226 (letter), 725-726 methicillin-resistant, in patients admitted to ED, risk factors associated service staffed by PEM physicians for children during imaging, 654-661 with, 880-886 Sedation scales, 2 clinical, assessment of association with bispectral index, Statins, effect on short-term survival in an oriental population with sepsis, 918-924 494-501 Seizure Statistical model induced by intoxication after accidental consumption of eperisone versus clinician, for prediction of chest injuries diagnosed by chest hydrochloride, infantile case of (letter), 481-482 radiograph, 823-830 syncopal, resulting to retrobulbar hemorrhage after a dental extraction, for identification of low- and high-risk patients among unselected 228-230 patients with possible ACS, 23-31 Sensitivity and specificity Status asthmaticus, bilevel positive airway pressure and h-2 agonist in the of synovial fluid WBC count in diagnosis of septic arthritis, 749-752 treatment of pediatric patients with, 6-9 of VIDAS D-dimer test, for diagnosis of DVT and PE, 464-471 Steroids, in cardiac arrest (editorial), 376-377 Sepsis Stewart’s strong ion difference, as predictor of major injury after trauma in effect of statins on short-term survival in an oriental population with, ED, 938-941 494-501 Stingray, envenomation, popliteal artery laceration and compartment 21st century definitions and therapeutic advances for, 564-571 syndrome from, 96-97 in type 2 diabetes mellitus, Takotsubo cardiomyopathy associated with, Streptococcal meningitis, fatal afebrile, in a chronic alcoholic patient, 230-232 106-108 INDEX TO VOLUME 25 1107

Stress testing, negative, impact on emergency physician disposition Tension pyopneumothorax decision in ED patients with chest pain syndrome, 39-44 in a tracheostomized child, 200-201 Stroke Tension viscerothorax, mimicking tension pneumothorax, 219-221 acute, prevalence of elevated blood pressure in adults with, presenting to Terlipressin, continuous low-dose infusion of, as rescue therapy in the ED in the US, 32-38 meningococcal septic shock, 863.e1-863.e2 massive, in a previously healthy 7-year-old, 985.e3-985.e5 Terrorism syndromes, EM physicians on identification of, 1019-1024 prevention of, antithrombotic therapy in clinical practice in the ED for, Tertiary care center, management of toxic alcohol ingestion after the 1-5 introduction of fomepizole at, 799-803 subcortical, presenting as micrographia, 89-90 Testicular infarction, idiopathic, masquerading as urolithiasis and ST-segment elevation myocardial infarction (STEMI) epididymitis, 736.e1-736.e2 acute, effect of thrombolytic therapy versus primary PCI on outcome of Thalamus, bilateral, involvement and normal imaging of early stage of the patients after VF cardiac arrest due to, 545-550 unusual presentation of HSE, 87-89 effect of body position, supine versus semirecumbent versus upright, on Therapeutic hypothermia, and cardiac defibrillation (editorial), 479-480 interpretation of 12-lead ECG for, 753-756 Therapy, for DVT, considerations in, 860.e1-860.e4 reperfusion strategies in the emergency treatment of, 353-366 Thiamine, for the treatment of acute decompensated heart failure (letter), Takotsubo cardiomyopathy mimicking, 92-95 124-126 Subarachnoid hemorrhage Thromboembolism, venous, radiologic diagnoses of patients who received concordance of historical questions for risk stratifying patients with, imaging despite negative D-dimer tests for, 1040-1046 907-910 Thrombolytic therapy, versus primary PCI, effect on outcome of patients nontraumatic, influence of circadian rhythms on onset and outcomes of after VF cardiac arrest due to acute STEMI, 545-550 (letter), 728-730 Thrombosis PE and ACS differences in the risk tolerance for disease exclusion dural sinus according to published guidelines, 540-544 isolated headache as sole manifestation of, 218-219 spontaneous, after intravenous epinephrine use for multiple bee stings, isolated headache as sole manifestation of (letter), 982 249-250 mobile, in right atrium of elderly, transthoracic echocardiograph on Substance abuse, naphazoline, ischemic stroke in an man with, visualization of anticoagulant therapy efficiency for, 983.e1-983.e2 983.e3-983.e4 Succinylcholine, masseter muscle rigidity induced by, associated with rapid prevalence of heparin-PF4 antibodies in patients presenting to the ED sequence intubation, 102-104 with, 279-284 Sumatriptan, for the treatment of undifferentiated primary headaches in the Thyroid storm, precipitated by organophosphate intoxication, 861.e1-861.e3 ED, 60-64 Thyrotoxicosis, unrecognized, acute right ventricular dysfunction after Superior mesenteric artery syndrome, ultrasonography diagnosis in the ED, cardioversion or hyperthyroid cardiomyopathy in (letter), 723-724 864.e5-864.e6 TIMI risk score, application in ED patients with cocaine-associated chest Supraclavicular blocks, ultrasound-guided, for upper extremity fractures, pain, 1015-1018 dislocations and abscesses in the ED, 472-475 Titanium alloy, ring crush injury, 1084.e3-1084.e5 Surge capacity, a proposed conceptual framework for, 297-306 Toddler. see Pediatrics Surgical emergency, for patient diagnosed with gastric volvulus, 213-215 Tongue, viability, after snakebite, 1083.e5-1083.e7 Survival Topical anesthesia, sequential layered application of topical lidocaine with rates of, improved by epinephrine in an adult rabbit model of asphyxia epinephrine for larger wound management, 379-384 cardiac arrest, 509-514 Toxicity, anticholinergic, from lupini beans ingestion, 215-217 short-term, in an oriental population with sepsis, effect of statins on, Toxic shock syndrome, fulminant fatal, with Staphylococcus aureus, 494-501 225-226 Swedish Cardiac Arrest Registry, analysis of characteristics of cardiac arrest Transection, complete, of common iliac artery, fatal complication of blunt and resuscitation by age group, 1025-1031 abdominal injury, 251-253 Syncope, 12-lead ECG in patient with, 688-701 Transorbital ventricular decompression, in acutely decompensated Synovial fluid, WBC count of, sensitivity in diagnosis of septic arthritis, hydrocephalic ED patient, 208-210 749-752 Transport patterns, lack of correlation in welfare check distribution and, in rural critical care transport service, 345-347 Tachycardia, ventricular, verapamil for, 572-575 Transthoracic defibrillation Tactile inspection, of the spine for prediction of difficult or traumatic safety and effectiveness of, during wet-surface cooling, 420-424 lumbar puncture, 608-611 and therapeutic hypothermia in wet conditions (editorial), 479-480 Takotsubo cardiomyopathy Transvaginal ultrasonography, bedside, for diagnosis and management of associated with sepsis in type 2 diabetes mellitus, 230-232 ectopic pregnancy in the ED, 591-596 diagnosis and treatment in ED patient, 202-207 Trauma mimicking an ST-elevation myocardial infarction, 92-95 annotated bibliography of recent literature—2006, 708-721 Takotsubo dysfunction, stress-induced cardiomyopathy, 243-244 blunt TASER dart, intracranial penetration of, 733.e3-733.e4 abdominal, complete transection of common iliac artery, fatal Tau protein, role in diagnosis of intracranial injury in minor head trauma, complication of, 251-253 391-395 abdominal, isolated jejunal perforation after, 862.e1-862.e4 Technetium Tc 99m methylene diphosphonate, bone scintigraphy with, of chest, extensive anterolateral MI caused by left main coronary artery rhabdomyolysis after near-drowning in cold seawater (letter), dissection after, 858.e3-858.e5 848-850 neck, laryngotracheal disruption after, 1084.e1-1084.e2 Temperature, of body, low, accuracy of PiCCO monitoring in (letter), shoulder, axillary artery dissection due to, 242-243 845-846 whole-body multislice CT as primary and sole diagnostic tool for, Tension pneumothorax 1057-1062 massive hiatal hernia masquerading as, 226-228 in ED, Stewart’s strong ion difference as predictor of major injury after, mimicking tension viscerothorax, 219-221 938-941 1108 Keyword Index 25

Trauma (continued) Venous thromboembolic disease (continued) inferior gluteal artery pseudoaneurysm due to, 488.e1-488.e3 patient-related factors minor blunt, isolated adrenal hemorrhage after, 984.e5-984.e6 in the use of referent D-dimer enzyme linked immunosorbent assay for penetrating, intracranial, of TASER dart, 733.e3-733.e4 exclusion of, in the ED (letter), 255-256 Triage, in the ED, identifying high-risk patients for, 794-798 in the use of referent D-dimer enzyme linked immunosorbent assay for Triage flowchart, to rule out ACS, 865-872 exclusion of (letter), 485-486 Triage pain protocol, effectiveness in improving frequency and time to Venous thromboembolism, in patients with nonsurgical isolated lower limb delivery of analgesia for painful musculoskeletal injuries in the injuries, incidence and risk factors for, 502-508 ED, 791-793 Ventricular dysfunction, acute right, after cardioversion or hyperthyroid Troponin I cardiomyopathy in an unrecognized thyrotoxicosis patient (letter), cardiac, elevated, for prediction of complicated clinical course and 723-724 in-hospital mortality in patients with acute PE, 138-143 Ventricular fibrillation (VF) concentration measured at admission, prognostic implications in ACS, cardiac arrest due to acute STEMI, effect of thrombolytic therapy versus 65-68 primary PCI on outcome of patients after, 545-550 Tuberculosis pericarditis, atrial flutter with cardiac tamponade as initial transesophageal AC stimulation for induction of, in rats, 623-630 presentation of, 108-110 Ventricular pseudofusion, acute myocardial infarction in the setting of an T wave inversion, due to cardiac memory phenomenon after conversion apparent pacemaker anomaly, 248-249 from atrial flutter to sinus rhythm, 831-833 Ventricular tachycardia (VT), verapamil for, 572-575 Ventriculitis, cerebral pyogenic, due to infective endocarditis, a rare ED Ultrasonography diagnosis, 120-122 ability of emergency physicians to obtain ultrasound images of Ventriculoperitoneal (VP) shunts, Lodox Statscan for visualization of landmarks relevant to lumbar puncture, 291-296 (erratum), 1081 ability to identify pertinent landmarks for lumbar puncture, 331-334 Verapamil, for ventricular tachycardia, 572-575 bedside, in diagnosis of pneumoperitoneum in critically ill patients VIDAS D-dimer test, sensitivity and specificity for diagnosis of DVT and presenting with acute abdominal pain, 838-841 PE, 464-471 bedside transvaginal, for diagnosis and management of ectopic Viscerothorax, tension, mimicking tension pneumothorax, 219-221 pregnancy in the ED, 591-596 Visual inspection, of the spine for prediction of difficult or traumatic lumbar diagnosis of superior mesenteric artery syndrome in the ED, 864.e5-864.e6 puncture, 608-611 for early diagnosis of gas-forming pyometra in an aged patient in ED Vital signs (letter), 126-127 abnormalities, as predictors of pneumonia in adults with acute cough hip arthrocentesis in the ED, 80-86 illness, 631-636

lung association with FEV1 in persons with asthma requiring hospital bedside, in diagnosis of AIS (letter), 724-725 admissions, 425-429 comet-tail artifact sign at (letter), 981-982 Vitamin B12 deficiency, and neurologic disease, 987.e3-987.e4 renal, for hydronephrosis during pregnancy (letter), 482-483 supraclavicular block for upper extremity fractures, dislocations and Water-circulating cooling device, for induction of mild hypothermia after abscesses in the ED, 472-475 cardiac arrest (letter), 730-732 Unconsciousness, induced by psychotropic drug overdose, correlation of Weight, adult, accuracy of estimation performed by ED personnel, 307-312 factors on arrival with duration of, 757-761 Welfare check distribution, lack of correlation in transport patterns and, in Upright, versus semirecumbent versus supine, effect of body position rural critical care transport service, 345-347 on interpretation of 12-lead ECG for ischemia and STEMI, White blood cell (WBC) count, of synovial fluid, sensitivity in diagnosis of 753-756 septic arthritis, 749-752 Urine culture, positive, and hyperbilirubinemia, 10-14 Wolff-Parkinson-White (WPW) syndrome Urine nitrite test, positive, and hyperbilirubinemia, 10-14 atrial fibrillation in, ECG recognition and treatment in the ED of, Urolithiasis, idiopathic testicular infarction masquerading as, 736.e1-736.e2 576-583 broad complex atrial fibrillation in, 459-463 Vaccination 12-lead ECG in, 688-701 influenza, of health care workers in the ED, association between sickness Wood, giant foreign body, detection with multidetector CT and multiplanar absenteeism and, 808-811 reconstruction imaging, 211-213 medication error in, 199-200 Wounds and injuries. see also specific type or site Venlafaxine, poisoning, acute heart failure associated with, 210-211 local burn, management in ED, 666-671 Venous oximetry, in diagnosis and management of fulminant myocarditis, loupe magnification versus naked eye for visualization of, in ED, 122-123 704-707 Venous thromboembolic disease in the elderly, role of D-dimer enzyme linked immunosorbent assay in Young man, severe explosive headache as sole presentation of acute diagnosis of (letter), 727-728 myocardial infarction in, 250-251