2 Evaluation of Mid-Regional Pro-Adrenomedullin, Mid-RegionalPro-atrial Natriuretic Peptide, and Procalcitonin for theDiagnosis and Risk Stratification of Emergency DepartmentPatients With Dyspnea

Cinar O, Cevik E, Acar A, Kaya C, Ardic S, Comert B, Yokusoglu M, Bilgi C,Madsen T/University of Utah, Salt Lake City, UT; Gulhane Military MedicalAcademy, Ankara, Turkey

Introduction: Several newly described pro-hormones may aid in diagnosis andprognosis in emergency department (ED) patients with dyspnea: mid-regional pro-adrenomedullin (MR-proANP) as a marker of congestive heart failure (congestiveheart failure); procalcitonin (procalcitonin) as a marker of an infectious etiology suchas pneumonia or chronic obstructive pulmonary disease exacerbation; and mid-regional pro-adrenomedullin (MR-proADM) for risk statification and prognosis.

Study Objectives: The aim of this study was to evaluate the diagnostic and theprognostic value of a laboratory panel consisting of MR-proANP, procalcitonin, andMR-proADM for patients presenting to the ED with acute dyspnea.

Methods: We prospectively enrolled ED patients who presented with a chiefcomplaint of dyspnea and who had an uncertain diagnosis after physician evaluation.All patients underwent a laboratory panel consisting of MR-proANP, procalcitonin,and MR-proADM. Final diagnosis of the cause of shortness of breath was confirmedthrough additional testing per physician discretion and was based on the physiciandiagnosis either at the time of discharge from the ED or, in admitted patients, at thetime of discharge from the inpatient unit. We recorded inpatient admission and 30-day mortality rates. Results of the laboratory panel were available to the treatingphysician and were used as part of the diagnostic process. We evaluated the influenceof the marker profile on the physician’s final diagnosis by comparing the physician’sinitial diagnosis to the final diagnosis and the marker profile. We also askedphysicians to rate the diagnostic probability on a 5-point Likert scale (1-unsure to5-sure).

Results: 154 patients presented to the ED with a chief complaint of shortness ofbreath and were enrolled in the study. Mean age was 72 � 11 years and 50.4% ofpatients were women. 50.4% of patients were admitted to an inpatient unit, while15.3% of patients died during the 30-day follow-up period. congestive heart failurewas the final diagnosis in 42% of patients while infectious etiology was diagnosed in33% of patients. For the diagnosis of congestive heart failure, MR-proANP had asensitivity of 92.7% and specificity of 36.8%, with a negative likelihood ratio (LR-)of 0.16 and a positive likelihood ratio (LR�) of 1.44 (cut-off value: 120 pmol/L). Forthe diagnosis of an infectious etiology (pneumonia or chronic obstructive pulmonarydisease), procalcitonin had a 96.5% specificity and 48.8% sensitivity (LR-: 0.07,LR�: 1.88, Cut-off value: 0.25 ng/mL). As a prognostic indicator, MR-proADMdemonstrated similar value: odds ratio for 30-day mortality was 8.5 (95% CI: 2.5-28.5, cut-off value: 1.5 nmol/L) and the area under the receiver operatingcharacteristic curve (AUC) in predicting mortality was 0.81 (95% CI 0.71 to 0.91).Markers changed the initial diagnosis in 17% of patients with an ultimate diagnosisof congestive heart failure and 20% diagnosed with an infectious etiology. Diagnosticprobability increased 3.7 to 4.3 (p�0.001) in congestive heart failure patients and 3.4to 3.8 (p�0.001) in infectious etiology patients.

Conclusion: The high sensitivity of MR-proANP and procalcitonin suggest a rolefor these markers in the early diagnosis of ED patients with dyspnea. Further, MR-proADM may assist in risk stratification and prognosis in these patients. Additionalstudies may assist in determining the utility of these markers in combination withclinical characteristics and diagnostic testing results in the ED setting.

3 Point-of-Care Beta-Hydroxybutyrate Testing for AssessingDiabetic Ketoacidosis Severity Prior to Treatment in theEmergency Department

Arora S, Probst MA, Agy C, Menchine M/Keck School of Medicine at theUniversity of Southern California, Los Angeles, CA

Study Objectives: According to current American Diabetes Associationguidelines, diagnosing DKA and estimating DKA severity is accomplished bymeasuring laboratory values of blood pH, bicarbonate and anion gap. Evidence isgrowing that a point-of-care capillary beta-hydroxybutyrate (point-of-care �-OHB)value above the manufacturer’s suggested cutoff can rapidly and accurately diagnoseDKA, allowing for faster treatment and disposition decisions. However, it is unclearwhether the absolute value of point-of-care �-OHB prior to initiation of therapy canbe used to assess DKA severity. The goal of this study was to determine thecorrelation between traditional markers of DKA severity (pH, bicarbonate and anion

gap) and measured initial point-of-care �-OHB levels in adult emergency departmentpatients with DKA prior to therapeutic intervention.

Methods: Patients over the age of 18 who presented to emergency departmenttriage with a blood glucose �250mg/dL were approached for enrollment. Those whoprovided written consent had a urinalysis, chemistry panel, venous blood gas, and apoint-of-care �-OHB measurement (Precision Xtra meter: Medisense/AbbottLaboratories). The diagnosis of DKA was made if patients met all criteria set by theADA including: blood glucose �250mg/dL, ketosis, anion gap �10mmol/L, carbondioxide �18mmol/L and serum pH �7.30. Subjects’ age, sex, ethnicity, prior historyof diabetes and insulin use were recorded. Correlations between �-OHB and pH,bicarbonate and anion gap were established by Pearson correlation analysis usingSTATA version 10.0 (StataCorp lubar puncture, College Station, TX).

Results: Of the 859 patients with screened, 616 provided informed consent and516 (83.7%) had all data elements necessary for data analysis. In our final sample,54/516 subjects (10.5%) met ADA criteria for DKA. The characteristics of our studysample are as follows: mean age 41 years (IQR 30-48), 72.2% male, 79.2% Hispanic,29.9% newly diagnosed diabetes and 56.6% insulin dependent. The mean point-of-care �-OHB for patients with DKA was 4.9 mmol/L (IQR 3.7-5.6). The correlationcoefficients between �-OHB and pH, bicarbonate and anion gap were 0.33, 0.25 and0.16 respectively.

Conclusion: Previous studies using point-of-care �-OHB devices to assess DKAseverity are limited by extremely small sample sizes. This is the largest study to datedescribing point-of-care �-OHB correlations in patients with DKA prior to receivingtherapy. We found extremely poor correlations between point-of-care �-OHB valuesand pH, bicarbonate and anion gap leading us to conclude that point-of-care �-OHBtesting cannot replace these tests to reliably assess DKA severity at the time of initialdiagnosis.

4 The Usefulness of Bedside Ultrasonography for AcuteEpiglottitis in Emergency Department: Preliminary Study

Ko D, You J, Chung Y, Park Y, Park I/Yonsei University, College of Medicine,Seoul, Republic of Korea

Study Objectives: Acute epiglottitis is a serious, fatal disease characterized byinflammation of supraglottic structures. Early diagnosis is most important because ofthe rapid and progressive course. If clinicians have no high suspicion in theemergency department (ED), it is difficult to diagnose acute epiglottitis in adults.Recently, ultrasonography is available in most EDs. Several studies reported thatultrasound can accurately evaluate the epiglottis in emergency setting. However, nostudies show the comparison for ultrasound in ED between normal epiglottis andepiglottis with acute epiglottitis. The purpose of this study was to investigate theability of ultrasonography to identify the acute epiglottitis in ED.

Methods: Fourteen patients with a final diagnosis of acute epiglottitis by indirectlaryngoscopy of otolaryngologist were enrolled in this study. To compare betweennormal epiglottis and epiglottis with acute epiglottitis, 14 volunteers were assigned tothe control group. Emergency physicians performing US were blinded to the resultsof the clinical results. Subjects were imaged in upright seated position with the neckminimally extended. The epiglottis was visible through the thyrohyoid membrane as ahypoechoic curvilinear structure on transverse view. The sonographic appearance ofepiglottitis and the pre-epiglottic space were recorded. The anteroposterior (AP)diameter of epiglottis at the midpoint (B) and both edges (A, C) in the transverseview was measured in all subjects.

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Results: Table 1 shows the demographic results and anteroposterior (AP)diameter in 3 points of epiglottis. There was statistically significant difference in APdiameter of epiglottis between the group with epiglottitis and group with normalepiglottis. By the receiver operating characteristic (receiver operating characteristic)curve, cut-off value of the anteroposterior (AP) diameter of epiglottis at the midpoint(B) was 0.32 with sensitivity and specificity being 85.7% and 78.6%, respectively(area under the curve (AUC) 0.8776). There was significant difference in APdiameter of epiglottis at both edge (A, C) between the group with epiglottitis andgroup with normal epiglottis. There were no overlapping areas between the 2 groupsin both A and C. Cut-off value of A and C was 0.37 by lowest limit value of thegroup with epiglottitis.

Conclusion: There was statistically significant difference in AP diameter ofepiglottis between the group with epiglottitis and group with normal epiglottis. Byusing significant difference in AP diameter of epiglottis, ultrasonography can be arapid, noninvasive, and effective diagnostic tool for the identification of theepiglottitis in ED.

5 Sickle Cell Disease in the Emergency Department, Predictorsof Adverse Outcomes: A Prospective Cohort Study

Al-Reesi A, Stiell I, Wells G, Tinmouth A, Al-Zadjali N, Al-Shibli A, Al-Balushi A/Sultan Qaboos University Hospital, Muscat, Oman; The Ottawa Hospital,University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Heart Institute,University of Ottawa, Ottawa, Ontario, Canada

Introduction: Current evidence does not provide a clear risk stratification strategyfor sickle cell disease patients in the emergency department (ED).

Study Objectives: The goal of this study was to determine the risk factors forshort term adverse events.

Methods: We conducted a prospective cohort study of sickle cell disease patientspresenting to a tertiary care ED over 6 consecutive months. All patients were assessedby emergency physicians during the ED visit. All the patients had a 2-week structuredtelephone follow-up or a chart review if they had a repeat ED visit within 2 weeks oradmitted. The adverse outcomes were classified as a clinically significant outcome(death, cerebrovascular accidents, acute chest syndrome, sepsis, hyper-hemolytic crisisand exchange blood transfusion) or not. We analyzed the predictors of adverseoutcomes using descriptive statistics and multiple logistic regression.

Results: Over 6 consecutive months, we enrolled 732 patients. Seventy-fivepatients had a clinically significant outcome. Using multivariate analysis, we found 9statistically significant predictors of a clinically significant adverse outcome: aprolonged painful episode (OR 10.1; 95%CI 5.3-19.3), age less than 8 years (OR2.4; 95%CI 1.001 -5.9), oxygen saturation less than 96% (OR 3.9; 95%CI 1.6-10.9), patient appearing toxic (OR 7.8; 95%CI 2.2-27.2), presence of chest crackles(OR 6.5; 95%CI 2.3-18.6), splenomegaly (OR 2.6; 95%CI 1.2-5.5), local limbtenderness (OR 0.2; 95%CI 0.08-0.7), hemoglobin less than 7 g/dL (OR 3.6;95%CI 1.1-11.6), reticulocyte count more than 15% (OR 4.0; 95%CI 1.4-11.5).

Conclusion: Our study of identified 9 variables which can help to predict thepossibility of developing a clinically significant adverse outcome. This might be usedin the future to risk stratify the sickle cell disease patients who presents to the ED anddevelop strategies to prevent those adverse outcomes.

6 Prognostic Accuracy of Pulmonary Embolism Rule-out Criteria:A Systematic Review and Meta-Analysis

Agarwal D, Singh B, Parsiak A, Surana A, Chandra S/Mayo Clinic, Rochester,MN; S N Medical College, Jodhpur, India

Study Objectives: To perform a systematic review and meta-analysis of studiesconducted in emergency department to define prognostic performance of pulmonaryembolism rule-out criteria (pulmonary embolism rule-out criteria) in deferring theneed for D-dimer testing to rule out pulmonary embolism.

Methods: A comprehensive search of 5 major databases of biomedicalpublications: EMBASE, Medline, SCOPUS, Web of knowledge and all the EBMreviews which include Cochrane database of systematic reviews, was performed in lastweek of February 2011. To minimize the publication bias, references cited inpotentially eligible articles and conferences proceeding of major emergency medicineorganizations for last 2 years were hand searched. Study selection criteria were: 1)reported prognostic performance of pulmonary embolism rule-out criteria 2) basedon original research and 3) conducted in emergency department. No languagerestrictions were applied. Two investigators identified eligible studies and extracteddata independently. Methodology quality assessment was done using an initialized

checklist for this study. Contingency table (2 � 2) was constructed to calculatesensitivity, specificity and likelihood ratios.

Results: Ten cohorts (studying 13,660 patients with 1381 positive outcomes), 8prospective and 2 retrospective, from 6 different countries were included in analysis.Pooled (95% CI) sensitivity, specificity, positive likelihood ratio and negativelikelihood ratio for 10 included studies were 0.97 (0.96 - 0.98), 0.23 (0.22 - 0.24),1.239 (1.177 - 1.306) and 0.172 (0.129 - 0.229), respectively (Figure 1). Significantheterogeneity was observed in specificity (I-square�97.3%) and positive likelihoodratio (I-square�86.2%). A subgroup analysis was performed based on pulmonaryembolism prevalence.

Conclusion: Moderate to good level of evidence suggests consistently highsensitivity and acceptable specificity in ruling out the need for D-dimer testing torule-out pulmonary embolism in patients with low pre-test probability based on theclinical presentation. This could potentially avoid unnecessary testing associated withhigh sensitive and low specific D-dimer testing.

7 Skipping Lines: Predicting Unattempted Thoracic CentralVenous Catheterization in Septic Patients Eligible for EarlyGoal-Directed Therapy

Vinson DR, Ballard DW, Stevenson MD, Reed ME, Rauchwerger AS, ChettipallyUK, Offerman SR/The Permanente Medical Group, Oakland, CA; KaiserPermanente Division of Research, Oakland, CA

Study Objectives: Implementation of the Rivers protocol of early goal-directedtherapy has been demonstrated to reduce morbidity, mortality, and health careresource consumption in patients with severe sepsis and septic shock. Despite theevidence in its favor, however, emergency department (ED) implementation of earlygoal-directed therapy has been variable and incomplete. One impediment to protocoladherence is the requirement for thoracic central venous catheterization, a procedureboth time- and resource-intensive. This study sought to determine which clinicalvariables were predictive of unattempted central venous catheterization in EDpatients recognized by their treating physicians as eligible for early goal-directedtherapy.

Methods: This retrospective electronic records review was undertaken betweenAugust 1, 2009 and May 30, 2010 in 5 community emergency departments (EDs)within Kaiser Permanente of Northern California. The study period followed theregion-wide implementation of a standardized modified Rivers protocol. Adultpatients with serious infection identified in the ED were eligible for the study if theyhad an elevation in at least 2 of 4 markers of the systemic inflammatory responsesyndrome and either an elevated serum lactate level (� 4mmol/l) or systolic bloodpressure � 90 mmHg refractory to volume resuscitation. Excluded were patients witha pre-existing thoracic central line or port, those who declined thoracic central venouscatheterization, and patients who were receiving only comfort care. The outcomemeasure was failure to attempt internal jugular or subclavian central venouscatheterization in the ED. Multivariate regression analysis was used to determine the

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