Robert J Zalenski

An Evaluation of Technologies for Identifying Acute Cardiac Ischemia in the Emergency Department: A Report from a National Heart Attack Alert Program Working Group

Abstract [Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, Gibler WB, Hagen MD, Johnson P, Lau J, McNutt RA, Ornato J, Schwartz JS, Scott JD, Tunick PA, Weaver WD: An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: A report from a National Heart Attack Alert Program Working Group. Ann Emerg Med January 1997;29:13-87.]

Value of Posterior and Right Ventricular Leads in Comparison to the Standard 12-Lead Electrocardiogram in Evaluation of ST-Segment Elevation in Suspected Acute Myocardial Infarction

In this multicenter prospective trial, we studied posterior (V7 to V9) and right ventricular (V4R to V6R) leads to assess their accuracy compared with standard 12-lead electrocardiograms (ECGs) for the diagnosis of acute myocardial infarction (AMI). Patients aged >34 years with suspected AMI received posterior and right ventricular leads immediately after the initial 12-lead ECG. ST elevation of 0.1 mV in 2 leads was blindly determined and inter-rater reliability estimated. AMI was diagnosed by World Health Organization criteria. The diagnostic value of nonstandard leads was determined when 12-lead ST elevation was absent and present and multivariate stepwise regression analysis was also performed. Of 533 study patients, 64.7% (345 of 533) had AMI and 24.8% received thrombolytic therapy. Posterior and right ventricular leads increased sensitivity for AMI by 8.4% (p = 0.03) but decreased specificity by 7.0% (p = 0.06). The likelihood ratios of a positive test for 12, 12 + posterior, and 12 + right ventricular ECGs were 6.4, 5.6, and 4.5, respectively. Increased AMI rates (positive predictive values) were found when ST elevation was present on 6 nonstandard leads (69.1%), on 12 leads only (88.4%), and on both 6 and 12 leads (96.8%; p <0.001). Treatment rates with thrombolytic therapy increased in parallel with this electrocardiographic gradient. Logistic regression analysis showed that 4 leads were independently predictive of AMI (p <0.001): leads I, II, V3, V5R; V9 approached statistical significance (p = 0.055). The standard ECG is not optimal for detecting ST-segment elevation in AMI, but its accuracy is only modestly improved by the addition of posterior and right ventricular leads.

An Evaluation of Technologies for Identifying Acute Cardiac Ischemia in the Emergency Department: Executive Summary of a National Heart Attack Alert Program Working Group Report ☆ ☆☆ ★

Abstract [Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, Gibler WB, Hagen MD, Johnson P, Lau J, McNutt RA, Ornato J, Schwartz JS, Scott JD, Tunick PA, Weaver WD: An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: Executive Summary of a National Heart Attack Alert Program Working Group report. Ann Emerg Med January 1997;29:1-12.]

Patient Satisfaction with an Emergency Department Chest Pain Observation Unit

STUDY OBJECTIVEnPatient satisfaction is an essential outcome measure in the diagnosis and treatment of acute chest pain in the emergency department. We compared patient satisfaction with the diagnostic protocol of a chest pain observation unit (CPOU) and standard inpatient hospitalization.nnnMETHODSnWe prospectively studied patients who presented to the ED with chest pain and were found to have a low risk of acute myocardial infarction (AMI) but who still might have benefited from a diagnostic protocol to rule out AMI. Consenting patients (N = 104) were randomized to the CPOU (experimental) arm or the hospital inpatient (control) arm and assessed for satisfaction by means of an interview before hospital discharge.nnnRESULTSnThe CPOU protocol scored higher on four summary ratings of overall patient satisfaction. Correlations between overall satisfaction, number, and type of problems with care, and patient characteristics demonstrated content validity and revealed strengths and improvements that might be made in CPOUs.nnnCONCLUSIONnPatients were more satisfied with rapid diagnosis in the CPOU than with inpatient stays for acute chest pain. Our findings add important information to the standard practice of weighing clinical and cost outcomes between two medical care alternatives.

Occupational Blood Contact Among Prehospital Providers

STUDY OBJECTIVEnTo assess the nature and frequency of blood contact (BC) among emergency medical service (EMS) workers.nnnDESIGNnDuring an 8-month period, we interviewed EMS workers returning from emergency transport calls on a sample of shifts. We simultaneously conducted an HIV seroprevalence survey among EMS-transported patients at receiving hospitals served by these workers.nnnSETTINGnThree US cities with high AIDS incidence.nnnPARTICIPANTSnEMS workers.nnnRESULTSnDuring 165 shifts, 2,472 patients were attended. Sixty-two BCs (1 needlestick and 61 skin contacts) were reported. Individual EMS workers had a mean of 1.25 BCs, including .02 percutaneous exposures, per 100 patients attended. The estimated annual frequency of BC for an EMS worker at the study sites was 12.3, including .2 percutaneous exposures. For 93.5% of the BCs, the HIV serostatus of the source patients was unknown to the EMS worker. HIV seroprevalences among EMS-transported patients at the three receiving hospital emergency departments were 8.3, 7.7, and 4.1 per 100 patients; the highest rates were among male patients 15 to 44 years old who presented with pneumonia.nnnCONCLUSIONnEMS personnel regularly experience BCs, most of which are skin contacts. Because the HIV serostatus of the patient is usually unknown, EMS workers should practice universal precautions. Postexposure management should include a mechanism for voluntary HIV counseling and testing of the patient after transport and transmittal of the results to the EMS.

Research directions in emergency medicine

Abstract The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care which will benefit not only the patients emergency physicians serve but also, ultimately, the nations health.

Descriptive analysis of the in-hospital course of patients who initially survive out-of-hospital cardiac arrest but die in-hospital.

OBJECTIVEnTo describe the postresuscitative hospital course of emergency department patients who initially survive nontraumatic out-of-hospital cardiac arrests (OOHCA) but die in the hospital.nnnMETHODSnA 12-month case series of all nontraumatic OOHCA patients at two large urban Midwestern teaching hospitals who survived to hospital admission but died before discharge. Medical records from identified patients were reviewed for demographics, resuscitation sequelae, do-not-attempt-resuscitation (DNAR) code status, pain declarations, and withdrawal of life support. Descriptive statistics are reported.nnnRESULTSnBetween August 31, 2005 and July 31, 2006, there were 468 nontraumatic OOHCA patients treated at the study hospitals. Forty-one (8.8%) patients initially survived and were admitted to the hospital, of whom 32 (78.0%) expired before hospital discharge. Pain declarations were noted in 8 (25.0%) patients, of whom 4 had more than one assessment. Median postresuscitation survival time was 1.5 days (range, 9.3 hours to 18.6 days). Overall, 19 (59.4%) patients died after withdrawal of life support, 8 (25.0%) while actively on life support, and 5 (15.6%) died with subsequent cardiopulmonary resuscitation (CPR). Possible complications of CPR included pneumothorax in 2 (6.3%) and intracranial hemorrhage in 1 (3.1%).nnnCONCLUSIONSnIn this urban setting, approximately three of four OOHCA patients who are initially resuscitated do not survive to hospital discharge. This short in-hospital course post-CPR is often marked by pain and ends with the withdrawal of life support. This information may be an important component of advance planning discussions and may assist patients as they weigh the pros and cons associated with resuscitation preferences.

Nonstandard ECG Leads and Body-Surface Mapping

Abstract [Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, Gibler WB, Hagen MD, Johnson P, Lau J, McNutt RA, Ornato J, Schwartz JS, Scott JD, Tunick PA, Weaver WD: An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: A report from a National Heart Attack Alert Program Working Group. Ann Emerg Med January 1997;29:13-87.]

Research Directions in Emergency Medicine

The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care which will benefit not only the patients emergency physicians serve but also, ultimately, the nations health.

Other Biochemical Tests

Abstract [Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, Gibler WB, Hagen MD, Johnson P, Lau J, McNutt RA, Ornato J, Schwartz JS, Scott JD, Tunick PA, Weaver WD: An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: A report from a National Heart Attack Alert Program Working Group. Ann Emerg Med January 1997;29:13-87.]