Impact of technetium-99m sestamibi imaging on the emergency department management and costs in the evaluation of low-risk chest pain.

OBJECTIVES: To assess the impact of rest sestamibi scanning on emergency physicians' (EPs') diagnostic certainty and decision making (as assessed by the hypothetical disposition of patients) for 69 consenting stable patients with suspected acute cardiac ischemia and nondiagnostic electrocardiograms. The resultant impact on costs was examined as a secondary outcome. METHODS: Patients with suspected acute cardiac ischemia were injected with 25 mCi of sestamibi within two hours of active pain in one of three emergency department study sites. The probability of acute myocardial infarction (AMI) and unstable angina (UA), and hypothetical disposition decisions were recorded immediately before and after physicians were notified of scan results. Changes in disposition were classified as optimal or suboptimal. For the cost determinations, a cost-based decision support program was used. RESULTS: For the subgroup found to be free of acute cardiac events (ACEs) (n = 62), the EPs' post-sestamibi scan probabilities for AMI decreased by 11% and UA by 18% (p < 0.001 for both conditions). In seven patients with ACEs, the post-scan probabilities of AMI and UA increased, but neither was statistically significant. Scan results led to hypothetical disposition changes in 29 patients (42%), of which 27 (93%) were optimal (nine patients were reassigned to a lower level of care, two to a higher level, and 16 additional patients to "discharge-home" status). The strategy of scanning all patients who were low to moderate risk for acute cardiac ischemia would result in an increase of direct costs of care of $222 per patient evaluated, due to added cost of sestamibi scanning. CONCLUSIONS: Sestamibi scanning results appropriately affected the EPs' estimates of the probability of AMI and UA and improved disposition decisions. Scanning all low-risk patients would likely be associated with increased costs at this medical center.

Lactic acidosis and acute ethanol intoxication.

Ethanol intoxication has been widely reported as a cause of lactic acidosis. To determine the frequency and severity of ethanol-induced lactic acidosis, patients who presented to an emergency department with a clinical diagnosis of acute ethanol intoxication and a serum ethanol concentration of at least 100 mg/dL were studied. Arterial blood was sampled for lactate and blood gas determinations. A total of 60 patients (mean age, 41 years) were studied. Twenty-two patients sustained minor trauma. Ethanol concentrations ranged from 100 to 667 mg/dL (mean, 287 mg/dL). Lactate concentrations were abnormal (> 2.4 mmol/L) in seven patients (11.7%). In all cases, blood lactate was less than 5 mmol/L. Of the patients with elevated lactate, other potential causes for lactic acidosis, including hypoxia, seizures, and hypoperfusion, were also present. Only one case with elevated blood lactate concentration had associated acidemia. Significant elevations of blood lactate are uncommon in acute ethanol intoxication. In patients with ethanol intoxication who are found to have lactic acidosis, other etiologies for the elevated lactate level should be considered.

Acute suppurative salpingitis with concomitant intrauterine pregnancy.

A 20-year-old woman presented to the emergency department with a history of lower abdominal pain and recent loss of consciousness. She was admitted with a primary diagnosis of abdominal pain; ectopic pregnancy was ruled out. The culture of the endocervix was positive for Neisseria gonorrhoeae. Surgical exploration of the pelvis was performed, and histological analysis of the specimen showed an acute suppurative salpingitis and an intrauterine pregnancy. The patient was placed on intravenous antibiotics. Postoperative course was unremarkable, and the patient was discharged on oral antibiotics. Although a rare entity acute suppurative salpingitis with concomitant intrauterine pregnancy are not mutually exclusive. Ectopic pregnancy should be the presumptive diagnosis when clinical presentation is consistent with pelvic inflammatory disease and pregnancy especially in the first trimester. Patients who are pregnant and exhibit clinical signs and symptoms that are consistent with salpingitis should be admitted for aggressive management of their high-risk pregnancy. Fetal wastage seems to be significant in spite of aggressive management. Endocervical culture for N gonorrhoeae should be obtained from all pregnant patients with follow-up treatment pending culture results. The following is a case presentation along with a review of the existing cases in the English literature and discussion of the possible pathogenesis and clinical outcome of this entity.

The traumatic air myelogram.

A case of a pneumomyelogram of the cervical spine resulting from blunt trauma to the head is presented. The patient had pneumocephalus and skull fractures. On presentation the patient had no neurological deficits and remained neurologically stable throughout the hospital course. This is the first report of a traumatic pneumomyelogram and pneumocephalus with multiple skull fractures where the patient sustained no neurological sequelae.

Ruptured intracerebral aneurysm resulting in a subdural hematoma.

We present the case of a 28-year-old woman whose clinical presentation was that of an intracerebral hemorrhage with rapid neurologic deterioration. A nonenhanced computed tomography scan demonstrated an acute subdural hematoma with no evidence of blood in the subarachnoid space. The patient subsequently herniated and died 24 hours after admission.