RESUMO
Objective: Chest pain is a common Emergency Department (ED) presentation, but most patients will not have an Acute Coronary Syndrome (ACS). Decision tools have been developed to limit admissions to those at high risk of ACS, whilst allowing safe discharge of those at low risk. We aimed to evaluate the performance of three international decision tools (HEART, EDACS and VCPR) in the local setting. Design and Methodology: A prospective, observational cohort study was conducted to include ED patients presenting with low/intermediate risk chest pain. Participants were followed up at 6 weeks for Major Adverse Cardiac Events (MACE). Performance of clinical gestalt and the 3 scores were estimated. Results: 537 patients were enrolled, with 12 lost to followup, leaving 525 for analysis. Six patients developed MACE (1.14%). HEART had sensitivity, 16.67% (95% CI; 0.42% - 64.12%); specificity, 96.15% (95% CI; 94.11% - 97.63%); negative likelihood ratio (NLR), 0.87 (95% CI; 0.61 1.24). EDACS had sensitivity, 16.67% (95% CI; 0.42% - 64.12%); specificity, 95.38% (95% CI; 93.2% - 97.02%); NLR, 0.87 (95% CI; 0.61 1.25). VCPR had sensitivity 83.33% (95% CI; 35.88% - 99.58%); specificity, 67.05% (95% CI; 62.82% - 71.09%); NLR, 0.25 (95% CI; 0.04 1.49). Clinician gestalt had sensitivity 16.67% (95% CI; 0.42% - 64.12%); specificity, 97.5% (95% CI; 95.75% - 98.66%); NLR, 0.85 (95% CI; 0.6 1.22). Conclusion: In local patients with chest pain, the VCPR performed best for identifying patients for safe discharge, as well as with the lowest risk of MACE. The HEART, EDACS and clinical gestalt appear to be poorer decision tools.
Assuntos
Humanos , Masculino , Feminino , Doenças Cardiovasculares , Trinidad e Tobago , Serviço Hospitalar de Emergência , Síndrome Coronariana AgudaRESUMO
Objective: Thrombolysis is the standard treatment for STEMI in most developing countries. However, adverse events attributable to thrombolysis occur, and must be considered in risk -benefit decisions. We aimed to estimate the local incidence of thrombolysis complications, whilst determining factors predisposing to adverse outcomes. Design and Methodology: A multicentre, prospective, observational cohort study was conducted; including consecutive adults with STEMI presenting to 3 Emergency Departments (EDs). Primary outcomes were complications and 30-day mortality. Results: 236 participants were enrolled (78.0% Indo- Trinidadian; 72.9% Male; 46.2% Hypertensive; 44.9% Diabetic; 57.9% Smokers). 27.5% of patients experienced complications; mainly a c u t e h e a r t f a i l u r e ( AHF) (8.5%) and cardiogenic shock (8.1%). In-hospital and 30-day mortality rates were 5.9 % and 9.2% respectively. Adverse outcomes of thrombolysis occurred in 9 (3.8%) patients (one intracerebral haemorrhage). No deaths were directly attributable to thrombolysis. No risk factor correlated with complications of thrombolysis, however a t r i o v e n t r i c u l a r ( AV) block (OR 9.73, CI 1.70 - 55.87, p = 0.011) and b l o o d u r e a n i t r o g e n ( BUN) (OR 1.09, CI 1.04 - 1.14, p < 0.001) were associated with increased in hospital mortality. Age ≥ 75 (OR 16.72, CI 1.45 - 192.44, p = 0.024), Systolic blood pressure (SBP) (OR 0.97, CI 0.96 - 0.99, p = 0.009) and BUN (adjusted OR 1.08, CI 1.03 - 1.13, p = 0.002) correlated with increased 30-day mortality. Conclusion: Thrombolysis for STEMI was associated with a low incidence of adverse events and similar mortality to developed nations. No factor was associated with adverse outcomes, although older age, high BUN, low SBP or AVB increased mortality risk. These findings can guide local physicians counselling patients/relatives regarding thrombolysis for STEMI.
Assuntos
Humanos , Masculino , Feminino , Terapia Trombolítica , Trinidad e Tobago , Região do Caribe/etnologia , Infarto do Miocárdio com Supradesnível do Segmento STRESUMO
PURPOSE: While falls are common in older people, causing significant mortality and morbidity, this phenomenon has not been extensively studied in the Caribbean. This study aimed to compare falls in older and younger people in this setting. METHODS: We conducted a prospective observational study of older trauma patients in Trinidad, comparing older and younger patients sustaining falls. RESULTS: 1432 adult trauma patients were included (1141 aged 18-64 years and 291 aged 65 years and older). Older fallers were more likely to be female (66.7 vs 47.2%; p < 0.001), suffer from multiple pre-existing diseases (24.7 vs 2.4%; p < 0.001) and take multiple medications (16.1 vs 0.8%; p < 0.001). They also sustained more severe injuries and presented with higher acuity than younger fallers. Admission rates were higher among older fallers (29.9 vs 13.1%; p < 0.001). CONCLUSIONS: In our study, older patients who fell were a distinct group from younger falls victims, with unique demographic, clinical and injury related characteristics. Their increased risk of injury within the home, coupled with their propensity for more severe injuries made them a high risk patient group. More research is needed to better understand this patient group and plan specific preventive interventions.
Assuntos
Acidentes por Quedas/estatística & dados numéricos , Acidentes por Quedas/mortalidade , Adolescente , Adulto , Fatores Etários , Idoso , Países em Desenvolvimento , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Trinidad e Tobago/epidemiologiaRESUMO
This article provides a brief description of the conceptual framework of some specific areas of research carried out either collaboratively or independently in the Emergency Department in an effort to positively impact on health issues in an era of evidence-based medicine. The paper focusses on epidemiological studies of infectious diseases, chronic non-communicable diseases, and a recent update on trauma patterns. Conduction of clinical trials is also highlighted. The role of collaboration in Emergency medicine is also discussed. Research must be developed deliberately to facilitate the primary goal of improved patient care and outcomes. Further recommendations are suggested.
Assuntos
Medicina de Emergência , Pesquisa sobre Serviços de Saúde , Asma/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Ferimentos e Lesões/epidemiologiaRESUMO
This article provides a brief description of the conceptual framework of some specific areas of research carried out either collaboratively or independently in the Emergency Department in an effort to positively impact on health issues in an era of evidence-based medicine. The paper focusses on epidemiological studies of infectious diseases, chronic non-communicable diseases, and a recent update on trauma patterns. Conduction of clinical trials is also highlighted. The role of collaboration in Emergency medicine is also discussed. Research must be developed deliberately to facilitate the primary goal of improved patient care and outcomes. Further recommendations are suggested.
Este artículo ofrece una descripción breve del marco conceptual de algunas áreas específicas de investigación llevada a cabo de forma colaborativa o independiente en el Departamento de Emergencias, en un esfuerzo por lograr un impacto positivo en los problemas de salud en una era de medicina basada en la evidencia. El trabajo se centra en los estudios epidemiológicos sobre enfermedades infecciosas, enfermedades crónicas no comunicables, y una actualización reciente de los patrones de trauma. También se subraya la conducción de ensayos clínicos, y se discute el papel de la colaboración en la medicina de la emergencia. Deben desarrollarse investigaciones con el propósito deliberado de facilitar el objetivo primario de mejorar la atención y los resultados clínicos del paciente. Se hacen algunas recomendaciones.
Assuntos
Humanos , Medicina de Emergência , Pesquisa sobre Serviços de Saúde , Asma/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Ferimentos e Lesões/epidemiologiaRESUMO
OBJECTIVE: To explore the perspectives of parents with non-urgent conditions who attend a Paediatric Emergency Department (ED) rather than a primary care facility or private health care provider. Study Design: A qualitative study using a semi-structured approach. SUBJECTS and METHODS: Demographic data were collected over a period of three months from 134 parents if children through a self administered questionnaire. Of these, 24 parents were interviewed to determine their reason for attending the ED: their knowledge of the health service and to explain their understanding of their child's illness. RESULTS: Five major factors were identified as influencing parents' decisions to attend the ED: age of the child, ease of access; confidence of staff in the facilities; perception that ED was more patient friendly and cost of private health care. While most parents were willing to initiate treatment for minor illnesses at home, many indicated they preferred the ED rather than the health centre if their child's acute illness was more severe. CONCLUSIONS: We found that the deterrents to seeking health care in the primary care setting included concerns about the competence of doctors and nurses in treating sick children and communicating with parents. In addition, insufficient paediatric clinics days, long waiting time and inadequate child friendly facilities were also named as barriers to accessing primary care health centres.
Assuntos
Hospitais Pediátricos , Serviços Médicos de Emergência , Trinidad e TobagoRESUMO
Periluntae dislocation as well as other perilunate injuries are significant disorders of the wrist usually caused by high energy falls, and are associated with a high incidence of chronic pain and disability. A case is presented of a 27 year old footballer with a complicated perilunate fracture dislocation. The mechanisms involved in this injury are discussed, as well as the appropriate clinical and radiological examination of these patients to reduce the risk of a missed perilunate injury.
Assuntos
Adulto , Humanos , Masculino , Articulações do Carpo , Traumatismos do Punho , Articulação do Punho , Trinidad e TobagoRESUMO
Between September 1998 and February 2003, 204 children underwent cardiac surgery in Trinidad and Tobago to correct or palliate congenital heart disease. The defects included isolated ventricular or atrial septal defects as well as tetralogy of fallot and coarctation of the aorta. A few patients also had complex cyanotic congenital heart disease. The patients ranged in age from 2 days to 17 years. In some cases, palliative surgery was undertaken as a first step towards complete correction but the majority of patients underwent complete repair. The commonest postoperative complications were haemorrhage and small transient pericardial effusions. The overall mortality rate was < 1%. This paper describes the cardiac lesions, post-operative morbidity and mortality of these patients.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Cardiopatias Congênitas/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Morbidade , Cuidados Paliativos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Trinidad e TobagoRESUMO
Between September 1998 and February 2003, 204 children underwent cardiac surgery in Trinidad and Tobago to correct or palliate congenital heart disease. The defects included isolated ventricular or atrial septal defects as well as tetralogy of fallot and coarctation of the aorta. A few patients also had complex cyanotic congenital heart disease. The patients ranged in age from 2 days to 17 years. In some cases, palliative surgery was undertaken as a first step towards complete correction but the majority of patients underwent complete repair. The commonest postoperative complications were haemorrhage and small transient pericardial effusions. The overall mortality rate was < 1. This paper describes the cardiac lesions, post-operative morbidity and mortality of these patients
Entre septiembre de 1998 y febrero de 2003, 204 niños fueron sometidos a cirugía cardíaca en Trinidad y Tobago, a fin de corregir o paliar la enfermedad cardíaca congénita. Las cardiopatías incluían defectos septales atriales o venticulares aislados, así como tetralogía de Fallot y coartación de la aorta. Algunos pacientes también presentaban cardiopatía congénita cianótica compleja. Los pacientes tenían edades que fluctuaban de dos días a 17 años. En algunos casos, la cirugía paliativa se emprendió como un primer paso hacia la corrección completa pero a la mayoría de los pacientes se les practicó la reparación completa. Las complicaciones más comunes del post-operatorio fueron hemorragias y pequeñas efusiones pericadiales transitorias. La tasa general de mortalidad fue <1%. Este trabajo describe las lesiones cardíacas, la morbilidad y mortalidad post-operatoria de estos pacientes.