Objective: To determine the test performance characteristics of serial creatine kinase-MB (CK-MB) mass measurements for acute myocardial infarction (MI) in patients presenting to the ED with chest pain and nondiagnostic ECGs. Methods: A prospective, observational test performance study was conducted. Hemodynamically stable patients aged 2 2 5 years with chest discomfort, but without ECGs diagnostic for MI, were enrolled at 7 university teaching hospitals. Presenting ECGs showing >1 -mV ST-segment elevation in 2 2 electrically contiguous leads were considered diagnostic for MI; patients with diagnostic ECGs on presentation were excluded. Real-time, serial CK-MB mass levels were obtained using a rapid serum immunochernical assay at the time of ED presentation (0-hour) and 3 hours later (3-hour). The following testing schemes were evaluated for their sensitivity and specificity for detection of MI during patient evaluation in the ED: 1) an elevated ( 2 8 ng/mL) presenting CK-MB level; 2) an elevated presenting and/or 3-hour CK-MB level; 3) a significant increase (i.e., 2 3 ng/mL) within the range of normal limits for CK-MB concentrations during the 3-hour period (A CK-MB); andor 4) development of ST-segment elevation during the 3 hours (second ECG). Results: Of the 1,042 patients enrolled, 777 (74.6%) were hospitalized, including all 67 MI patients (8.6% of admissions). As a function of duration of time in the ED, the test performance characteristics of serial CKMBs for MI ( Conclusion: Serial CK-MB monoclonal antibody mass measurements in the E D can identify MI patients with initially nondiagnostic ECGs. CK-MB sensitivity significantly increases over 3 hours of observation of stable chest discomfort patients in the ED; it also increases as a function of the total interval from onset until enzyme measurement.
Nursing home-acquired pneumonia (NHAP) is a leading cause of morbidity, hospitalization, and mortality among older nursing home residents. Too often, these patients are erroneously grouped with cases of community-acquired and hospital-acquired pneumonia. Yet, they differ in terms of most common pathogens, significant underlying disease, impaired functional and cognitive status, and poor nutrition. The NHAP emergency department treatment algorithm presented here shows that an important decision for initial care in the emergency department (ED) is whether the patient should return to the nursing home. This decision often is based on the facility's ability to administer parenteral antibiotics, and care for co-morbidities and complications. Cephalosporins are the foundation of initial treatment of NHAP in the ED, and are combined with other antibiotics in anticipation of the most likely pathogens and treatment variables discussed here. It is hoped the NHAP treatment algorithm will contribute to improved outcomes.
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