Biochemical markers in the management of suspected acute myocardial infarction in the emergency department.

OBJECTIVES: To compare cardiac troponin T, myoglobin, CK, CKMB activity, CKMB mass and the initial electrocardiogram in the early diagnosis of myocardial infarction in the emergency department. Methods-Biochemical markers were measured at presentation in patients with a possible diagnosis of acute myocardial infarction. Based on the clinical notes, patients were grouped as "definite myocardial infarction" (n = 50), "definite no myocardial infarction" (n = 81) and "uncertain" (n = 96). Sensitivity and specificity and positive and negative predictive values were calculated using the 131 patients with definitely present or absent myocardial infarction. RESULTS: The initial electrocardiogram was more sensitive than any of the markers in the first six hours from symptom onset-sensitivity 74% (95%CI 61% to 88%). The positive predictive value of the initial electrocardiogram was 97% in the first six hours; the markers ranged from 47% to 67%. The negative predictive value of the initial electrocardiogram was 85% in the first six hours; the markers ranged from 61% to 70%. Four patients with non-diagnostic electrocardiograms presenting beyond six hours after pain onset had a myocardial infarct detected by at least three of the biochemical markers in each case. CONCLUSIONS: The electrocardiogram is of more diagnostic use than biochemical markers in the first six hours after the onset of pain, but biochemical markers give additional positive diagnostic information in patients presenting later than this. The negative predictive accuracy of biochemical markers is too low for a single sample to be useful for excluding myocardial infarction in the first six hours after onset of symptoms.

Telephone follow-up of relatives after sudden death: a survey of relatives' views.

The report of the Working Group on Bereavement Care in A&E departments recommended both the provision of follow-up for relatives and the audit of bereavement care as examples of good practice. In our adult A&E department follow-up contact is made by support workers, who have often been involved with the family at the time of death, making telephone contact four to five days later. This paper describes the role of the support workers and the results of a questionnaire sent to relatives to seek their views on this telephone follow up. In a six-month period 98 families had relatives who died in A&E; 38 (39%) of them returned completed questionnaires. The telephone call was thought to be helpful by 37 (97%) of the respondents. The commonest reasons given were: 'It showed you cared' (95%) and 'It enabled me to ask questions' (46%). We have found that the experience and, more importantly, availability of the support workers allows a level of consistency and continuity in follow-up care which can otherwise be difficult to achieve.

Ruptured diaphragm: the latent phase.

Traumatic rupture of the diaphragm is an uncommon injury which can be missed unless there is a high index of suspicion. In the interval between rupture of the diaphragm and herniation of abdominal contents, signs and symptoms are nonspecific and the chest X-ray may be normal.

Bomb blast injuries to the ear: the London Bridge incident series.

Twelve patients who were treated for ear injuries at Guy's Hospital following the London Bridge bomb blast in February 1992 were reviewed. Among three there were four perforated eardrums, two of which closed spontaneously (50%). All three patients had a persistent mixed hearing loss. The remaining nine patients had acute sensorineural hearing loss and/or tinnitus only. Four of these had resolved completely by 4h, another one by 48h, and two by 4 weeks. Two patients had a residual high frequency hearing loss. In total, five patients (42%) have a persistent hearing loss. None of the patients suffered from balance problems. In summary, the ear is very susceptible to bomb blast injury, but there is a high rate of spontaneous closure of perforations and improvement of sensorineural hearing loss and tinnitus.

Use of anti-D in an accident and emergency department.

A retrospective study was made of the use of anti-D in an accident and emergency (A&E) department in 1 month. Patients who are discharged home with a diagnosis of threatened miscarriage should have their blood group determined and anti-D should be given to those who are rhesus negative. We found that only 8/29 patients discharged from the department had their blood group determined and none of the rhesus negative patients was given anti-D. We have introduced a practical method of reminding medical staff to give anti-D to patients who require it.