Use of troponin T and creatine kinase-MB subunit levels for risk stratification of emergency department patients with possible myocardial ischemia.

STUDY OBJECTIVES: To evaluate and compare the utility of measurement of troponin T and the creatine kinase MB subunit (CK-MB) for risk stratification of ED patients with possible myocardial ischemia. METHODS: Prospective observational study of ED patients with symptoms of possible myocardial ischemia with early, single sample serologic testing for cardiac troponin T and CK-MB using an identity-unlinked process. Chart review (ED, inpatient, outpatient), and telephone and mail surveys identified adverse events (AEs) during the 14 days following enrollment. AEs recorded included death, respiratory or cardiac arrest, myocardial infarction (MI), atrial and ventricular arrhythmias, pulmonary edema, conduction disturbances, and recurrent angina. Measures of the predictive ability for AEs were calculated for troponin T, CK-MB, and a combined troponin T/CK-MB index (defined as positive if either troponin T or CK-MB levels exceeded threshold values). RESULTS: Among 292 study patients, 45 (15.4%) experienced at least one AE, including seven deaths and 12 MIs. The troponin T result was positive in 34 patients, and the CK-MB result was positive in 15 patients; 6 patients had positive results for both markers and 43 patients had a positive combined troponin T/CK-MB index. Odds ratios (ORs) for occurrence of AEs among all patients were 4.4 (1.8 to 10.2), 10.0 (3.0 to 36.0), and 4.5 (2.0 to 9.8) for troponin T, CK-MB and the troponin T/CK-MB index, respectively. Both markers were individually predictive of AEs (troponin T = 4.3; CK-MB = 7.5) among all those with chest pain. Only the CK-MB level was significantly predictive of AEs among those presenting with symptoms other than chest pain (OR = 24.3 [1.1, 1448]), whereas only the troponin T level was significantly predictive among patients representing a disposition dilemma for the emergency physician (OR = 5.7 [1.4, 20.7]). When compared, the ORs for troponin T and CK-MB were not significantly different for any patient subgroup. The troponin T/CK-MB index did not have a higher prognostic value than either troponin T or CK-MB alone in any subgroup studied. CONCLUSION: A positive test result for either troponin T or CK-MB in the ED successfully identified patients at significantly higher risk of adverse events during the 2 weeks following their ED visit. The two markers may complement each other in that each appears to have prognostic ability among a unique patient subgroup. ED marker measurement can provide useful prognostic information for patients with a broad spectrum of presentations consistent with possible myocardial ischemia.

Pediatric injuries presenting to an emergency department in a developing country.

PURPOSE: To describe the causes and outcomes of pediatric injuries using the emergency departments (ED) as a surveillance site. METHOD: Prospective, 14-day surveys of all injuries were conducted in the EDs of the two national trauma referral hospitals of Trinidad and Tobago. Data on patient demographics, type, cause, and outcome of injuries were collected. The chi 2 test for significance was used for categorical variables. RESULTS: Pediatric patients (< 20 years) accounted for 41.5% (714/1722) of injury visits. Of these, 62.6% were male and 17.4% were < four years old, 26.2% four to nine years, 31.1% 10 to 14 years, and 25.4% were 15 to 19 years old. Three patients (0.4%) died, 68.6% were discharged, and 31.0% admitted. Intentional injuries accounted for 13.9% of injuries. Of the intentional injuries, the assailant was significantly more likely to be known than not (P < 0.01). The most common causes of all injuries were: falls, 44.4%; blunt objects, 12.3%; sharp objects, 11.8%; motor vehicle (including pedestrians), 7.4%; poison, 3.6%; and burns, 1.7%. Injuries occurring in the home accounted for 46.2%; in school, 25.5%; sports/recreation, 11.1%; and at work, 4.5%. The most common injuries were: lacerations, 30.8%, contusions/abrasions, 26.7%, fractures, 18.8%; and sprains/dislocations, 9.4%. CONCLUSION: Pediatric injuries are a significant cause of morbidity and mortality in this country, accounting for almost one third of injured patients. Because of the low frequency of pediatric injury deaths, ED surveillance may be a more effective means of identifying high risk groups and activities for injuries. Data from EDs may be useful in other developing countries to develop injury prevention programs.

Pediatric injuries presenting to an emergency department in a developing country

PURPOSE: To describe the causes and outcomes of pediatric injuries using the emergency departments (ED) as a surveillance site. METHOD: Prospective, 14-days surveys of all injuries were conducted in the EDs of the two national trauma referral hospitals of Trinidad and Tobago. Data on patient demographics, type, cause, and outcome of injuries were collected. The chi 2 test for significance was was used for categorical variables. RESULTS: Pediatric patients (< 20 years) accounted for 41.5 percent (714/1722) of injury visits. Of these, 62.6 percent were male and 17.4 percent were < four years old, 26.2 percent four to nine years, 31.1 percent 10 to 14 years, and 25.4 percent were 15 to 19 years old. Three patients (0.4 percent) died, 68.6 percent were discharged, and 31.0 percent admitted. Intentional injuries accounted for 13.9 percent of injuries. Of the intentional injuries, the assailant was significantly more likely to be known than not (P < 0.01). The most common causes of all injuries were: falls, 44.4 percent; blunt objects, 12.3 percent sharp objects, 11.8 percent; motor vehicle (including pedestrians), 7.4 percent; poison, 3.6 percent and burns 1.7 percent. Injuries occurring in the home accounted for 46.2 percent in school, 25.5 percent; sports/recreation, 11.1 percent and at work, 4.5 percent. The contusion/abrasions, 26.7 percent fractures, 18.8 percent; and sprains/dislocations, 9.4 percent. CONCLUSION: Pediatric injuries are significant cause of morbidity and mortality in this country, accounting for almost one third of injured patients. Because of the low frequency of pediatric injury deaths, ED surveillance may be a more effective means of identifying high risk groups and activities for injuries. Data from the EDs may be useful in other developing countries to develop injury prevention programs.(AU)