Marna Rayl Greenberg

Food Protein-Induced Enterocolitis Syndrome as a Cause for Infant Hypotension

Infants with food protein-induced enterocolitis syndrome (FPIES) may present to the emergency department (ED) with vomiting and hypotension. A previously healthy, 5-month-old male presented with vomiting and hypotension 2 to 3 hours after eating squash. The patient was resuscitated with intravenous fluids, antibiotics, and admitted for presumed sepsis. No source of infection was ever found and the patient was discharged. The patient returned 8 days later with the same symptoms after eating sweet potatoes; the diagnosis of FPIES was made during this admission. Two additional ED visits occurred requiring hydration after new food exposure. FPIES should be considered in infants presenting with gastrointestinal complaints and hypotension. A dietary history, including if a new food has been introduced in the last few hours, may help facilitate earlier recognition of the syndrome.

Absolute and relative changes (delta) in troponin I for early diagnosis of myocardial infarction: Results of a prospective multicenter trial

OBJECTIVES We investigated absolute and relative cardiac troponin I (TnI) delta changes, optimal sampling protocols, and decision thresholds for early diagnosis of myocardial infarction (MI). Serial cardiac biomarker values demonstrating a rise and/or fall define MI diagnosis; however the magnitude of change, timing, and diagnostic accuracy of absolute versus relative (percentage) deltas remains unsettled. METHODS We prospectively measured TnI (AccuTnI+3™, Beckman Coulter) at serial time intervals in 1929 subjects with chest pain or equivalent symptoms of acute coronary syndrome at 14 medical centers. Diagnosis was adjudicated by an independent central committee. RESULTS Elevated TnI above a threshold of 0.03ng/mL demonstrated significant diagnostic efficacy (AUC 0.96). For patients with TnI<0.03ng/mL and symptom onset≥8h, 99.1% (NPV) were diagnosed with conditions other than MI. Absolute delta performed significantly better than relative delta at 1-3h (AUC 0.84 vs 0.69), 3-6h (0.85 vs 0.73), and 6-9h (0.91 vs 0.79). Current recommendations propose ≥20% delta within 3-6h; however, results were optimized using an absolute delta of 0.01 or 0.02ng/mL. Sensitivity results for absolute delta at 1-3h and 3-6h (75.8%, 78.3%) were superior to relative delta (48.0%, 61.3%). NPV (rule out) was 99.6% when baseline TnI<0.03ng/mL and absolute delta TnI<0.01ng/mL. CONCLUSIONS Absolute delta performed significantly better than relative delta at all time intervals. Baseline TnI and absolute delta may be used in conjunction to estimate probability of MI. Consensus recommendations are supported for sampling on admission and 3h later, repeated at 6h in patients when clinical suspicion remains high.

Diagnostic performance of cardiac Troponin I for early rule-in and rule-out of acute myocardial infarction: Results of a prospective multicenter trial☆

OBJECTIVES To compare emergency department TnI serial sampling intervals, determine optimal diagnostic thresholds, and report representative diagnostic performance characteristics for early rule-in and rule-out of MI. METHODS We prospectively measured TnI (AccuTnI+3™, Beckman Coulter) at serial time intervals in 1929 subjects with chest pain or equivalent ischemic symptoms suggestive of acute coronary syndromes at 14 medical centers. Diagnosis was adjudicated by an independent central committee. RESULTS TnI ≥0.03ng/mL provided 96.0% sensitivity and 89.4% specificity at 1-3h after admission, and 94.9% sensitivity and 86.7% specificity at 3-6h. NPV (rule-out, non-MI) was 99.5% at 1-3h, and 99.0% at 3-6h when TnI is <0.03ng/mL. NPV was 99.1% when TnI is <0.03ng/mL and time of symptom onset is ≥8h. Approximately 50-58% (PPV) of patients with TnI ≥0.03ng/mL were diagnosed with MI, depending upon time from onset or admission; PPVs emphasize the importance of serial samples and delta TnI (rising or falling pattern) when low cutoffs are used. Nevertheless, even a single elevated TnI value increased the risk of MI. As TnI values rose, the probability of MI increased. Values ≥0.20ng/mL were associated with nearly 90% probability of MI. CONCLUSIONS We report a large multicenter prospective adjudicated trial assessing troponin for early rule-in and rule-out using the Universal Definition of MI and conducted in primary care hospital-associated emergency departments. Our study demonstrates high diagnostic accuracy at early observation times, and reinforces consensus recommendations for sampling on admission and 3h later, repeated at 6h when clinical suspicion remains high.

Focusing a Gender Lens on Emergency Medicine Research: 2012 Update

The influence of sex and gender on patient care is just being recognized in emergency medicine (EM). Providers are realizing the need to improve outcomes for both men and women by incorporating sex- and gender-specific science into clinical practice, while EM researchers are now beginning to study novel sex- and gender-specific perspectives in the areas of acute care research. This article serves as an update on the sex differences in a variety of acute clinical care topics within the field of EM and showcases opportunities for improving patient care outcomes and expanding research to advance the science of gender-specific emergency care.

Impact of Education on Physician Attitudes toward Computed Tomography Utilization and Consent

BACKGROUND There are risks to ordering computed tomography (CT) scans. OBJECTIVE We set out to determine whether emergency physician attitudes and their predictions of CT ordering behaviors could be influenced by education. METHODS We surveyed emergency physicians at a Level I trauma center with a yearly census of 74,000. Physicians were given a baseline survey that encompassed demographics, attitudes toward CT informed consent, and ordering behaviors. After receiving an education session regarding CT risks, each participant received a follow-up survey. Data analysis was performed using frequencies and chi-squared. RESULTS Seventy-five physicians participated; 69% residents and 31% attendings; 34% were female and 66% male. Thirteen percent reported they did not know if informed consent was required for CT scans obtained in the Emergency Department. Pre-education, 89% reported sometimes ordering a CT scan due to a consultant request that they felt was not indicated, and 92% reported that they sometimes ordered a CT scan to appease a patient or family. Eighty-five percent reported that they sometimes ordered a CT scan defensively due to malpractice risk. After education, physicians were more likely to believe a patient should give informed consent before CT (p<0.01) and predicted that they would be more likely to discuss the risks/benefits of CT with their patients all of the time (p=0.001). CONCLUSION After education about the risks of CT utilization, emergency physicians were more likely to believe that patients should give informed consent before CT scan and predicted that they would be more likely to discuss the risks and benefits of CT with their patients.

Management of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial

BACKGROUND Benign paroxysmal positional vertigo (BPPV) is a common presenting problem. OBJECTIVE Our aim was to compare the efficacy of vestibular rehabilitation (maneuver) vs. conventional therapy (medications) in patients presenting to the emergency department (ED) with BPPV. METHODS This was a prospective, single-blinded physician, randomized pilot study comparing two groups of patients who presented to the ED with a diagnosis of BPPV at a Level 1 trauma center with an annual census of approximately 75,000. The first group received standard medications and the second group received a canalith repositioning maneuver. The Dizziness Handicap Inventory was used to measure symptom resolution. RESULTS Twenty-six patients were randomized; 11 to the standard treatment arm and 15 to the interventional arm. Mean age ± standard deviation of subjects randomized to receive maneuver and medication were 59 ± 12.6 years and 64 ± 11.2 years, respectively. There was no significant difference in mean ages between the two treatment arms (p = 0.310). Two hours after treatment, the symptoms between the groups showed no difference in measures of nausea (p = 0.548) or dizziness (p = 0.659). Both groups reported a high level of satisfaction, measured on a 0-10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 9 ± 1.5 and 9 ± 1.0, respectively; there was no significant difference in satisfaction between the two arms (p = 0.889). Length of stay during the ED visit did not differ between the treatment groups (p = 0.873). None of the patients returned to an ED for similar symptoms. CONCLUSIONS This pilot study shows promise, and would suggest that there is no difference in symptomatic resolution, ED length of stay, or patient satisfaction between standard medical care and canalith repositioning maneuver. Physicians should consider the canalith repositioning maneuver as a treatment option.

Unique Obstacle Race Injuries at an Extreme Sports Event: A Case Series

Obstacle course endurance events are becoming more common. Appropriate preparedness for the volume and unique types of injury patterns, as well as the effect on public health these events may cause, has yet to be reported in emergency literature. We describe 5 patients who presented with diverse injuries to illustrate the variety of injuries sustained in this competitive event. In particular, 4 of the patients had a history of contact with electrical discharge, an obstacle distinctive to the Tough Mudder experience.

Training Mothers in Infant Cardiopulmonary Resuscitation With an Instructional DVD and Manikin.

CONTEXT Classes in infant cardiopulmonary resuscitation (CPR) can be time consuming and costly. OBJECTIVE To determine whether mothers in an obstetric unit could learn infant CPR by using a 22-minute instructional kit and to assess the value and confidence they gained by learning CPR. DESIGN Quasi-experimental study with enrollment between January and December 2008. SETTING Obstetric unit in Lehigh Valley Hospital, a suburban teaching hospital in Allentown, Pennsylvania. PARTICIPANTS Mothers at least 18 years old who had given birth within the previous 24 hours. INTERVENTION The experimental group included mothers without prior CPR training who watched a 22-minute instructional DVD and practiced on a manikin. The control group included mothers with prior conventional CPR training. MAIN OUTCOME MEASURES In both groups, knowledge and proficiency were assessed with written and practical examinations developed by certified CPR instructors. Participant surveys were conducted at 3 times: immediately before dissemination of course materials, within 24 hours after the mother agreed to participate in the study, and 6 months after initial evaluation. RESULTS A total of 126 mothers were enrolled in the study: 79 in the experimental group, 25 in the control group, and 22 who withdrew from the study. Written and practical examinations were used to determine proficiency, and composite scores were generated, with a maximum composite score of 12. The composite scores were statistically significantly higher in the experimental group than in the control group, with median scores of 10 and 7, respectively (P<.001). Twenty-two mothers (21%) had been previously offered CPR training. In the experimental group, 76 mothers (96%) felt more confident as caregivers after learning CPR. Before training in both groups, 84 mothers (81%) stated that learning CPR was extremely important, compared with 100 mothers (96%) after training (P=.001). CONCLUSION Use of an instructional kit is an effective method of teaching CPR to new mothers. Mothers reported that learning CPR is extremely important and that it increases their confidence as caregivers.

Analysis of sex differences in preadmission management of ST-segment elevation (STEMI) myocardial infarction.

BACKGROUND Many reports suggest gender disparity in cardiac care as a contributor to the increased mortality among women with heart disease. OBJECTIVE We sought to identify gender differences in the management of Myocardial Infarction (MI) Alert-activated ST-segment elevation myocardial infarction (STEMI) patients that may have resulted from prehospital initiation. METHODS A retrospective database was created for MI Alert STEMI patients who presented to the emergency department (ED) of an academic community hospital with 74,000 annual visits from April 2000 through December 2008. Included were patients meeting criteria for an MI Alert (an institutional clinical practice guideline designed to expedite cardiac catheterization for STEMI patients). Data points (before and after initiation of a prehospital alert protocol) were compared and used as markers of therapy: time to ECG, receiving β-blockers, and time to the catheterization laboratory (cath lab). Differences in categorical variables by patient sex were assessed using the χ(2) test. Medians were estimated as the measure of central tendency. Quantile regression models were used to assess differences in median times between subgroups. RESULTS A total of 1231 MI Alert charts were identified and analyzed. The majority of the study population were male (70%), arrived at the ED via ambulance (60.1%), and were taking a β-blocker (67.8%) or aspirin (91.6%) at the time of the ED admission. Female patients were more likely than male patients to arrive at the ED via ambulance (65.9% vs 57.6%, respectively; P = 0.014). The median age of female patients was 68 years, whereas male patients were significantly younger (median age, 59 years; P < 0.001). The proportion of patients currently taking a β-blocker or low-dose aspirin did not vary by gender. Overall, 78.2% of the MI Alert patients arriving at the ED were MI2 (alert initiated by ED physician), and this did not vary by gender (P = 0.33). A total of 1064 MI Alert patients went to the cath lab: 766 male patients (88.9%) and 298 female patients (80.8%). Overall, the median time to cath lab arrival was 79 minutes for men and 81 minutes for women (P = 0.38). Overall, the median time to cath lab arrival significantly decreased from MI1 to MI3, (P(trend) < 0.001). For prehospital-initiated alerts (MI3), the median time to cath lab arrival was the same for men and women (64 minutes; P = 1.0). For hospital-initiated alerts, time to cath lab arrival was 82 minutes for male patients and 84 minutes for female patients (P = 0.38). Prehospital activation of the process decreased the time to the cath lab by 19 minutes (P < 0.001; 95% CI, 13.2-24.8). CONCLUSION No significant gender differences were apparent in the STEMI patients analyzed, whether the MI Alert was initiated in the ED or prehospital initiated. Initiating prehospital-based alerts significantly decreased the time to the cath lab.

Gender Disparity in Emergency Department Non-ST Elevation Myocardial Infarction Management

BACKGROUND Many studies have looked at differences between men and women with acute coronary syndrome. These studies demonstrate that women have worse outcomes, receive fewer invasive interventions, and experience delay in the initiation of established medical therapies. OBJECTIVE Using innovative technology, we set out to unveil and resolve any gender disparities in the evaluation and treatment of patients presenting with a positive troponin while in the emergency department. Our goal was to assess the feasibility of using a business management query system to create an automated data report that could identify deficiencies in standards of care and be used to improve the quality of treatment we provide our patients. METHODS Over a 12-month period, key markers for patients with non-ST elevation myocardial infarction (NSTEMI) were tracked (e.g., time to electrocardiogram, door to medications). During this time, educational endeavors were initiated utilizing McKessons Horizon Business Insight™ (McKesson Information Solutions, Alpharetta, GA) to illustrate gender differences in standard therapy. Subsequently, indicators were evaluated for improvement. RESULTS Substantial improvements in key indicators for management of NSTEMI were obtained and gender differences minimized where education was provided. CONCLUSION The integration of these information systems allowed us to create a successful performance improvement tool and, as an added benefit, nearly eliminated the need for manual retrospective chart reviews.