Academic Emergency Medicine最新文献

Background: Emergency department (ED) presentations after a ground-level fall (GLF) are common. Falls were suggested to be another possible presenting feature of a myocardial infarction (MI), as unrecognized MIs are common in older adults. Elevated high-sensitivity cardiac troponin (hs-cTn) concentrations could help determine the etiology of a GLF in ED. We investigated the prevalence of both MI and elevated high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of hs-cTnT and hs-cTnI regarding MI, and their prognostic value in older ED patients presenting after a GLF.

Methods: This was a prospective, international, multicenter, cohort study with a follow-up of up to 1 year. Patients aged 65 years or older presenting to the ED after a GLF were prospectively enrolled. Two outcome assessors independently reviewed all discharge records to ascertain final gold standard diagnoses. Hs-cTnT and hs-cTnI levels were determined from thawed samples for every patient.

Results: In total, 558 patients were included. Median (IQR) age was 83 (77-89) years, and 67.7% were female. Elevated hs-cTnT levels were found in 384 (68.8%) patients, and elevated hs-cTnI levels in 86 (15.4%) patients. Three patients (0.5%) were ascertained the gold standard diagnosis MI. Within 30 days, 18 (3.2%) patients had died. Nonsurvivors had higher hs-cTnT and hs-cTnI levels compared with survivors (hs-cTnT 40 [23-85] ng/L in nonsurvivors and 20 [13-33] ng/L in survivors; hs-cTnI 25 [14-54] ng/L in nonsurvivors and 8 [4-16] ng/L in survivors; p < 0.001 for both).

Conclusions: A majority of patients (n = 364, 68.8%) presenting to the ED after a fall had elevated hs-cTnT levels and 86 (15.4%) elevated hs-cTnI levels. However, the incidence of MI in these patients was low (n = 3, 0.5%). Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1 year.

Background: Diagnostic uncertainty exists surrounding the identification of radiographic pneumonia in children with wheeze. It is important to determine the prevalence and clinical predictors of pneumonia in this population to limit chest radiography (CXR) and promote judicious antibiotic use.

Objectives: The objectives were to (1) estimate the prevalence of radiographic pneumonia in children with wheeze and (2) systematically review the diagnostic accuracy of clinical findings for the identification of radiographic pneumonia.

Methods: Data sources were MEDLINE, PubMed Central, Cochrane Library, CINAHL, and Web of Science (January 1995 to September 2023). For study selection, two reviewers identified high-quality studies reporting on clinical characteristics associated with radiographic pneumonia in wheezing children (age 0-21 years). Using Covidence software, data regarding study characteristics, methodologic quality, and results were extracted. Data were pooled using random-effects meta-analysis.

Results: A total of 8333 unique titles and abstracts were reviewed. Twelve studies, representing 7398 patients, were included. Fifteen percent of children with wheeze undergoing CXR had pneumonia. Findings associated with radiographic pneumonia included temperature ≥ 38.4°C (positive likelihood ratio [LR+] 2.1, 95% CI 1.2-3.6, specificity 85%), oxygen saturation < 92% (LR+ 3.6, 95% CI 1.4-8.9, specificity 89%), and grunting (LR+ 2.7, 95% CI 1.6-4.4, pooled specificity 91%). Factors associated with the absence of radiographic pneumonia included lack of fever (negative likelihood ratio [LR-] 0.67, 95% CI 0.52-0.85) and oxygen saturation ≥ 95% (LR- 0.64, 95% CI 0.42-0.98). Tachypnea and auscultatory findings were not associated with radiographic pneumonia.

Discussion: Heterogeneity across studies limits generalizability. Additionally, all included studies overestimate the rate of radiographic pneumonia given the fact that all subjects had a CXR performed due to clinical suspicion of pneumonia.

Conclusions: Radiographic pneumonia occurs in 15% of wheezing children undergoing CXR for pneumonia. Auscultatory findings and tachypnea do not differentiate children with and without pneumonia, and the rate of radiographic pneumonia is very low in the absence of fever and hypoxemia.