Acute chest pain fast track at the emergency department: who was misdiagnosed for acute coronary syndrome?

BACKGROUND: Acute coronary syndrome (ACS) is a commonly treated disease in the emergency department (ED). Acute chest pain is a common presenting symptom of ACS. Acute chest pain fast track (ACPFT) is a triage to cover patients presenting with chest pain with the aims of early detection and treatment for ACS. This study aimed to assess the quality of the ACPFT with the aim of improving the quality of care for ACS patients. METHODS: This study was conducted at the ED in Mahidol University, Bangkok, Thailand. The inclusion criterion was patients presenting with acute chest pain at the ED. We retrospectively reviewed the medical records of all eligible patients. The primary outcomes of this study were to determine time from door to electrocardiogram and time from door to treatment (coronary angiogram with percutaneous coronary intervention or thrombolytic therapy in the case of ST elevation myocardial infarction). The outcome was compared between those who were in and not in the ACPFT. RESULTS: During the study period, there were 616 eligible patients who were divided into ACPFT (n=352 patients; 57.1%) and non-ACPFT (n=264 patients; 42.9%) groups. In the ACPFT group (n=352), 315 patients (89.5%) received an electrocardiogram within 10 minutes. The final diagnosis of ACS was made in 80 patients (22.7%) in the ACPFT group and 13 patients (4.9%) in the non-ACPFT group (P-value <0.01). After adjustment using multivariate logistic regression analysis, only epigastric pain was independently associated with being in the ACPFT group (adjusted odds ratio of 0.11; 95% confidence interval of 0.02, 0.56). CONCLUSION: The ACPFT at the ED facilitated the prompt work-ups and intervention for ACS.

Is retrograde intubation more successful than direct laryngoscopic technique in difficult endotracheal intubation?

BACKGROUND: Difficult airway intubation is an emergency condition both at the emergency department (ED) and in out-of-hospital situations. Retrograde intubation (RI) is another option for difficult airway management. There are limited data regarding the successful rate of RI compared with direct laryngoscopy (DL) intubation, the commonly used method in the ED. METHODS: This study was a randomized, controlled trial. Participants were randomly assigned to either the RI or the DL technique to attempt intubation on a difficult airway mannequin (Cormack and Lehane grades 3-4). First, all participants received the training on the RI or DL, and then attempted intubation. After the training, the participants had 2 chances to intubate. The outcomes of this study included numbers of participants who successfully intubated and times of successful intubation. RESULTS: There were 100 participants in this study, with 50 participants in each group (RI and DL). There was no significant difference between the groups in terms of experience at the ED or DL. The successful rate of intubation was significantly higher in the RI group than in the DL group (74% vs 12%; P = .001), as was the rate of successful intubation on the first attempt (34% vs 8%; P = .026). There were no statistical differences between physicians and medical students in any of the 3 outcomes in either the DL or RI group. CONCLUSIONS: The RI technique had a higher success rate in difficult airway intubation than the DL technique, regardless of experience.

Cancer Patients Are at High Risk of Mortality if Presenting with Sepsis at an Emergency Department.

BACKGROUND: Sepsis is an emergency condition with high mortality and morbidity rate. There are limited data on the association of cancer as a risk factor for mortality in sepsis patients in the emergency department (ED). MATERIALS AND METHODS: This retrospective study was conducted at the ED, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand. The study period was between January 1st and December 31st, 2014. The inclusion criteria were as follows: adult patients over 15 years of age who presented at the ED with suspicion of sepsis, received treatment at the ED, and whose blood culture was found to be positive. Clinical data were recorded from medical records including the Mortality in Emergency Department Sepsis score (MEDS score). The primary outcome of this study was mortality at one month. Multivariate logistic regression analysis was used to identify independent factors associated with death. RESULTS: During the study period, there were 775 eligible patients. The two most common pathogens identified from blood cultures were Staphylococcus aureus (193 patients; 24.9%) and Escherichia coli (158 patients; 20.4%). At one month after presenting at the ED, 110 patients (14.2%) had died. There were four significant factors for death, having cancer, being on an endotracheal tube, initial diagnosis of bacteremia, and high MED scores. Having cancer had an adjusted OR of 2.12 (95% CI of 1.29, 3.47). CONCLUSIONS: Cancer patients have double the risk of mortality if presenting with sepsis at the ED.