Pulmonary embolism severity index, age-based markers and evaluation in the emergency department.

OBJECTIVES: The purpose of this study was to assess the severity of pulmonary embolism in the emergency department using vital signs and age-based vital parameters and compare these parameters with pulmonary embolism severity index (PESI) score. METHODS: Between January 2011 and October 2014, there were 284 patients diagnosed with pulmonary embolism in the Emergency Unit of Selcuk University Hospital. Patient records were reviewed retrospectively. The PESI scores were calculated, and patients were divided into high- and low-risk groups. Shock index (SI), age-based shock index (SIA), maximum heart rate (MHR), minpulse (MP) and pulse maximum index (PMI) were calculated. The association of these parameters with PESI was evaluated. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the association of risk and mortality with age-based markers. RESULTS: There were 75 men (43%) in the 173 patients included in the study. The PESI classification showed 54 patients in the low-risk group and 119 patients in the high-risk group. Mortality was higher in the PESI high-risk group, and no deaths occurred in the low-risk group. Comparison of the age-based markers and PESI for patients who died or survived showed that AUC for PESI was 0.807, AUC for SI was 0.824 and AUC for SIA was 0.825. CONCLUSIONS: The SIA risk classification was more efficient than SI in pulmonary embolism patients who presented to the emergency unit. The SIA was more accurate than SI or PESI in predicting mortality.

Blunt chest trauma as a cause of acute myocardial infarction.

Chest pain after thoracic trauma may be a symptom of cardiac injury or myocardial infarction. A 63-year-old healthy man had chest pain after blunt chest trauma in a motor vehicle accident. Chest computed tomography scan showed a displaced sternal fracture, lung contusion in the left upper lobe, atelectasis and consolidation in both lower lobes, and bilateral haemothorax. Electrocardiography showed ST elevation (2 mm) in leads II, III, and aVF and ST depression (2 mm) in leads I and aVL, consistent with acute inferior myocardial infarction. Urgent coronary angiography showed ostial occlusion of the right coronary artery. After the right coronary occlusion was passed with a guide wire, dissection of the right coronary artery was observed and treated with a balloon and stent to reestablish normal flow. This case emphasizes the importance of a high index of suspicion for coronary artery injury and myocardial infarction after blunt chest trauma.

D-dimer and D-dimer/fibrinogen ratio in predicting pulmonary embolism in patients evaluated in a hospital emergency department.

OBJECTIVES: The D-dimer level, fibrinogen level, and D-dimer/fibrinogen ratio are used in the diagnosis of pulmonary embolism, but results vary. We evaluated these parameters in the diagnosis of pulmonary embolism in emergency clinic patients. METHODS: In this prospective study, 200 patients (pulmonary embolism, 100 patients; no pulmonary embolism, 100 patients) had D-dimer and fibrinogen levels measured before intervention. Pulmonary embolism was diagnosed with computed tomography angiography or ventilation-perfusion scintigraphy. RESULTS: Compared with patients who did not have pulmonary embolism, patients who had pulmonary embolism had significantly greater mean D-dimer level (pulmonary embolism, 6±7 µg/ml; no pulmonary embolism, 1±1 µg/ml; P⩽0·001) and D-dimer/fibrinogen ratio (pulmonary embolism, 3±3; no pulmonary embolism, 0·4±0·4; P⩽0·001), but similar mean fibrinogen levels (pulmonary embolism, 337±184 mg/dl; no pulmonary embolism, 384±200 mg/dl; not significant). In patients who had pulmonary embolism, mean D-dimer level and D-dimer/fibrinogen ratio were greater in high-risk than non-high-risk patients. With D-dimer cutoff 0·35 µg/ml, sensitivity was high (100%) and specificity was low (27%) for pulmonary embolism. With D-dimer/fibrinogen ratio cutoff 0·13, sensitivity was high (100%) and specificity was low (37%) for pulmonary embolism. CONCLUSION: A D-dimer level <0·35 µg/ml may exclude the diagnosis of pulmonary embolism. At a D-dimer cutoff 0·5 µg/ml and D-dimer/fibrinogen ratio cutoff 1·0, the D-dimer/fibrinogen ratio may have better specificity than D-dimer level in the diagnosis of pulmonary embolism, but the D-dimer/fibrinogen ratio may lack sufficient specificity in screening.

Peri-operative management of anticoagulation and antiplatelet therapy in gastrointestinal surgery.

Peri-operative management of the risks of hemorrhage and thrombosis related to gastrointestinal surgery tailored to patient characteristics are part of daily multidisciplinary practice tasks. The goal of this update is to discuss current practices concerning antithrombosis prophylaxis and the management of recently developed anticoagulants and antiplatelet agents. The duration of prophylaxis is 1 month for oncological surgery. The recommended doses in bariatric surgery are twice daily injections of low-molecular weight heparin without exceeding a total dose of 10,000 IU/day. Dual antiplatelet therapy is necessary for 6 weeks after placement of bare-metal stents, from 6-12 months for drug-eluting stents, and 12 months after an acute coronary artery syndrome. Abrupt discontinuation of antiplatelet therapy exposes the patient to an increased risk of thrombosis. Data are insufficient to make specific recommendations for antiplatelet therapy in gastrointestinal surgery. For major digestive surgery, prescription of daily aspirin should be discussed case by case. If discontinuation of treatment is absolutely necessary, this should be as short as possible (aspirin: 3 days, ticagrelor and clopidogrel: 5 days, prasugrel: 7 days). The modalities for elective management of new oral anticoagulants are similar to those for classical vitamin K antagonists (VKA) therapy, except that any overlapping with heparin administration must be avoided. In the emergency setting, an algorithm can be proposed depending on the drug, the available coagulation tests and the interval before performing surgery.

Prognostic value of auditory brainstem response for neurologic outcome in patients with neonatal indirect hyperbilirubinemia.

To investigate the value of the auditory brainstem response as a reliable test for the neurologic prognosis of infants with neonatal indirect hyperbilirubinemia, auditory brainstem response studies were performed in 22 infants. The patients were followed up until 12 months of age. Two patients demonstrated pathologic auditory brainstem response consistent with auditory neuropathy but had no neurologic finding except a lack of speech at 12 months of age. Two other patients had neurologic sequelae, one showing severe dyskinetic cerebral palsy, the other mild hypotonia and motor retardation, but their auditory brainstem response results were normal. These results suggested that auditory brainstem response examination might not provide reliable information for the neurologic prognosis. Neurologic disturbances resulting from bilirubin neurotoxicity can be seen in patients with a normal auditory brainstem response, but patients with an abnormal auditory brainstem response may not have any neurologic dysfunction apart from speech retardation.

Magnetic resonance imaging findings in patients with severe neonatal indirect hyperbilirubinemia.

The aim of this study was to document the magnetic resonance imaging (MRI) findings of cases with a history of severe neonatal indirect hyperbilirubinemia. Ten cases (eight cases with neurologic findings, two normal cases) with a history of severe neonatal indirect hyperbilirubinemia were studied. Neurologic findings and MRI results were described and correlated. Seven of eight cases with neurologic findings demonstrated symmetric and uniform increased T2 signal changes limited to globus pallidi. MRI scans of two cases without neurologic findings showed no abnormality. Severe neonatal indirect hyperbilirubinemia should be considered in the differential diagnosis of bilateral symmetric hyperintense signal changes in the globus pallidus on MRI. However, high levels of unconjugated bilirubin concentrations in the neonatal period may not always cause such lesions of globus pallidus on MRI despite the presence of neurologic findings.