Volume 16, Issue 5, September 2015.
Kelly N. Sawyer, MD, MS, et al.

Introduction: Undifferentiated chest pain in the emergency department (ED) is a diagnostic
challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary
embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a
coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study
was to describe the ED patient course and short-term safety for these evaluation methods.
Methods: This was a retrospective observational study of adult patients presenting to a large,
community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal
biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation
exposures. We evaluated 30-day return visits for major adverse cardiac events.
Results: A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing
TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs.
30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to
incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs.
16.6mSv). No patient in either group had a related 30-day revisit.
Conclusion: Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO
safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to
further assess this approach to ED chest pain evaluation.

Volume 16, Issue 5, September 2015.
Ann-Jean CC. Beck, MD

Introduction: Guidelines are designed to encompass the needs of the majority of patients with a
particular condition. The American Heart Association (AHA) in conjunction with the American College
of Cardiology (ACC) and the American College of Emergency Physicians (ACEP) developed risk
stratification guidelines to aid physicians with accurate and efficient diagnosis and management
of patients with acute coronary syndrome (ACS). While useful in a primary care setting, in the
unique environment of an emergency department (ED), the feasibility of incorporating guidelines
into clinical workflow remains in question. We aim to compare emergency physicians’ (EP) clinical
risk stratification ability to AHA/ACC/ACEP guidelines for ACS, and assessed each for accuracy in
predicting ACS.
Methods: We conducted a prospective observational cohort study in an urban teaching hospital
ED. All patients presenting to the ED with chest pain who were evaluated for ACS had two risk
stratification scores assigned: one by the treating physician based on clinical evaluation and
the other by the AHA/ACC/ACEP guideline aforementioned. The patient’s ACS risk stratification
classified by the EP was compared to AHA/ACC/ACEP guidelines. Patients were contacted at 30
days following the index ED visit to determine all cause mortality, unscheduled hospital/ED revisits,
and objective cardiac testing performed.
Results: We enrolled 641 patients presenting for evaluation by 21 different EPs. There was a
difference between the physician’s clinical assessment used in the ED, and the AHA/ACC/ACEP
task force guidelines. EPs were more likely to assess patients as low risk (40%), while AHA/ACC/
ACEP guidelines were more likely to classify patients as intermediate (45%) or high (45%) risk. Of
the 119 (19%) patients deemed high risk by EP evaluation, 38 (32%) were diagnosed with ACS.
AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk with 56 (98%) of those patients
diagnosed with no ACS.
Conclusion: In the ED, physicians are more efficient at correctly placing patients with underlying
ACS into a high-risk category. A small percentage of patients were considered low risk when
applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to
make an efficient assessment of cardiac risk and established criteria may be overly conservative
when applied to an acute care population.

Volume 16, Issue 4, July 2015
Jay B. Baker, MD, et al.

We compared intubating with a preloaded bougie (PB) against standard bougie
technique in terms of success rates, time to successful intubation and provider preference on a
cadaveric airway model.

Volume 15, Issue 4, July 2014
Sarah Vitello, DO et al.

To provide an epidemiological description of radial head subluxation, also known as nursemaid’s elbow, from a database of emergency department visits.