Sol Han, Sung Wook Song, Hansol Hong, Woo Jeong Kim, Young Joon Kang, Chang Bae Park, Jeong Ho Kang, Ji Hwan Bu, Sung Kgun Lee, Seo Young Ko, Soo Hoon Lee, Chul-Hoo Kang
Clin Exp Emerg Med 2023;10(2):213-223. Published online February 14, 2023
Objective This study investigated the hospital diagnoses and characteristics of uncooperative prehospital patients suspected of acute stroke who could not undergo a prehospital stroke screening test (PHSST).
Methods This retrospective observational study was conducted at a single academic hospital with a regional stroke center. We analyzed three scenario-based prehospital stroke screening performances using the final hospital diagnoses: (1) a conservative approach only in patients who underwent the PHSST, (2) a real-world approach that considered all uncooperative patients as screening positive, and (3) a contrapositive approach that all uncooperative patients were considered as negative.
Results Of the 2,836 emergency medical services (EMS)-transported adult patients who met the prehospital criteria for suspicion of acute stroke, 486 (17.1%) were uncooperative, and 570 (20.1%) had a confirmed final diagnosis of acute stroke. The diagnosis in the uncooperative group did not differ from that in the cooperative group (22.0% vs. 19.7%, P=0.246). The diagnostic performances of the PHSST in the conservative approach were as follows: 79.5% sensitivity (95% confidence interval [CI], 75.5%–83.1%), 90.2% specificity (95% CI, 88.8%–91.6%), and 0.849 area under the receiver operating characteristic curve (AUC; 95% CI, 0.829–0.868). The sensitivity and specificity were 83.3% (95% CI, 80.0%–86.3%) and 75.2% (95% CI, 73.3%–76.9%), respectively, in the real-world approach and 64.6% (95% CI, 60.5%–68.5%) and 91.9% (95% CI, 90.7%–93.0%), respectively, in the contrapositive approach. No significant difference was evident in the AUC between the real-world approach and the contrapositive approach (0.792 [95% CI, 0.775–0.810] vs. 0.782 [95% CI, 0.762–0.803], P>0.05).
Conclusion We found overestimation (false positive) and underestimation (false negative) in the uncooperative group depending on the scenario-based EMS stroke screening policy for uncooperative prehospital patients suspected of acute stroke.
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Objective For patients with acute myocardial infarction (AMI), symptoms assessed by emergency medical services (EMS) providers have a critical role in prehospital treatment decisions. The purpose of this study was to evaluate the diagnostic accuracy of EMS provider-assessed cardiac symptoms of AMI.
Methods Patients transported by EMS to 4 study hospitals from 2008 to 2012 were included. Using EMS and administrative emergency department databases, patients were stratified according to the presence of EMS-assessed cardiac symptoms and emergency department diagnosis of AMI. Cardiac symptoms were defined as chest pain, dyspnea, palpitations, and syncope. Disproportionate stratified sampling was used, and medical records of sampled patients were reviewed to identify an actual diagnosis of AMI. Using inverse probability weighting, verification bias-corrected diagnostic performance was estimated.
Results Overall, 92,353 patients were enrolled in the study. Of these, 13,971 (15.1%) complained of cardiac symptoms to EMS providers. A total of 775 patients were sampled for hospital record review. The sensitivity, specificity, positive predictive value, and negative predictive value of EMS provider-assessed cardiac symptoms for the final diagnosis of AMI was 73.3% (95% confidence interval [CI], 70.8 to 75.7), 85.3% (95% CI, 85.3 to 85.4), 3.9% (95% CI, 3.6 to 4.2), and 99.7% (95% CI, 99.7 to 99.8), respectively.
Conclusion We found that EMS provider-assessed cardiac symptoms had moderate sensitivity and high specificity for diagnosis of AMI. EMS policymakers can use these data to evaluate the pertinence of specific prehospital treatment of AMI.
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Objective Among infants and preschool children with complaint of upper extremity immobility, pulled elbow, also known as nursemaid’s elbow or radial head subluxation is the most common cause presenting to pediatric emergency departments. However, proper tools to diagnose pulled elbow remain limited. We conducted a study to determine the feasibility of ultrasonography in diagnosing pulled elbow.
Methods Infants and preschool children presenting to an urban emergency department with the complaint of upper extremity immobility between April and July 2013 were enrolled. The following ultrasonographic information was recorded: (1) whether there was a change in the shape of the supinator muscle, (2) whether there was an annular ligament in place, and (3) whether there was an enlargement of the synovial fringe. We used the affected arms’ ultrasonographic images as the study group and opposite arms’ ultrasonographic images as the control group.
Results When we diagnosed pulled elbow using ultrasonographic findings (i.e., the annular ligament was not in place), we found the following results: sensitivity, 64.9% (95% CI, 47.5% to 79.8%); specificity, 100.0% (95% CI, 90.5% to 100.0%); positive predictive value, 100.0% (95% CI, 85.8% to 100.0%); and negative predictive, 74.0% (95% CI, 59.7% to 85.4%).
Conclusion A pulled elbow can easily be confirmed by ultrasonography when the annular ligament is displaced.
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