The prognostic significance of the risk scores at upper gastrointestinal bleeding.

BACKGROUND: Upper gastrointestinal system (GIS) bleeding is one of the most common causes of mortality and morbidity. The predictive values of pre-endoscopic Rockall score (PERS), full Rockall score (FRS), Glasgow-Blatchford score (GBS), pre-endoscopic Baylor score (PEBS), and full Baylor score (FBS) to predict bleeding at follow-up, endoscopic therapy, blood transfusion requirement, and death are investigated in our study. METHODS: This study was retrospectively conducted in patients admitted to emergency department with upper GIS bleeding. Demographic and clinical characteristics of the patients were recorded. The relationships of the aforementioned scores with in-hospital termination, bleeding at follow-up, endoscopic therapy, blood transfusion requirement, and death were explored. RESULTS: The study included a total of 420 subjects, of which 269 (64%) were men. All scoring systems were able to predict transfusion need and GBS was superior to other scores (P < 0.0001). In terms of endoscopic treatment, it was determined that only PERS, FRS, and FBS were statistically significant in predicting ability and PERS >3, FRS >5 and FBS >10 patients needed endoscopic treatment. All scoring systems were able to predict rebleeding. In comparison of two groups for rebleeding, it was found that PEBS was better able to predict bleeding during follow-up than both FRS and FBS, and PERS was better able to predict bleeding during follow-up than both FRS and FBS. All scoring systems were able to predict mortality. FRS and PERS scores had a greater discriminatory power for predicting death than the rest of the scores (P < 0.001). CONCLUSION: All scoring systems were effective for predicting need for blood transfusion, rebleeding, and death. GBS had more predictive power for transfusion need, PERS and PEBS for rebleeding, and FRS for mortality. PERS, FRS, and FBS were found to be effective in predicting endoscopic treatment.

Seeing the invisible: painless aortic dissection in the emergency setting.

Acute dissection of the aorta can be one of the most dramatic cardiovascular emergencies. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterised as ripping or tearing in nature. However, a timely diagnosis can be elusive in the event of an atypical presentation. In this report, the authors present two patients with painless aortic dissection who were misdiagnosed during their initial evaluation in the emergency department.

A case report of an unusual sternal fracture.

Most sternal fractures are transverse, and a lateral chest radiograph is diagnostic. We report a case of vertical sternal fracture that was not seen on plain radiographs but was revealed using computed tomography (CT). Thoracic CT with coronal reformatted images can also demonstrate sternal fracture lines, supernumerary synchondrosis, and costosternal joint abnormalities.

Adverse events associated with aggressive treatment of increased blood pressure.

Patients with severely increased blood pressure often present to the emergency department. Rapid lowering of blood pressure can precipitate or worsen end organ damage. We report two cases that developed cerebrovascular and cardiovascular adverse events associated with aggressive treatment of increased blood pressure by the use of sublingual nifedipine capsule. The first patient had developed ischaemic stroke; the second patient actually had acute left ventricular failure causing deteriorated, and required positive inotropic treatment for persistent hypotension. These cases emphasise that the pseudoemergency may rapidly progress into a real emergency when blood pressure is rapidly and aggressively reduced.

Are cervical spine X-rays mandatory in all blunt trauma patients?

Traumatic cervical spine injuries can result in severe disability or death unless promptly diagnosed and treated. Advanced trauma life support guidelines recommend that three-view cervical spine X-rays should be obtained routinely in all blunt trauma patients. In this retrospective study, we evaluated whether cervical spine X-rays are indeed necessary in all such patients. The study comprised those patients who were conscious, fully orientated, co-operative and non-intoxicated. Among the 303 blunt trauma patients seen at our emergency department between January and December 1993, a total of 267 patients had well-written charts and met our inclusion criteria. Thirteen (5%) patients who complained of neck pain or had neck tenderness on initial examination were found to harbour cervical spine injuries. Of those patients sustaining cervical spine injuries, examination of three (23%) disclosed abnormal neurological findings. On the other hand, none of the patients without neck pain and tenderness were found to have cervical spine injury. We conclude that pain and/or tenderness in the neck area are valid criteria with regard to the timely diagnosis of cervical spine injuries, and that routine cervical spine X-rays may be unnecessary for those blunt trauma patients who are conscious, fully orientated, co-operative, non-intoxicated, exhibit no neurological deficits and who do not have neck pain or tenderness. Omitting cervical X-rays speeds up patient evaluation, protects the department staff from unnecessary exposure to ionizing radiation and mitigates treatment costs, while maintaining the quality of the healthcare provided.