(95% CI 21%–33%) in patients with a history of prior VTE,and 41% (95% CI 38%–44%) in patients without a priorhistory of VTE. Pulmonary embolism was ruled out by anegative D-dimer in 33% of patients without a prior history ofVTE, but only 16% of patients with a prior history of VTE (p� 0.001). The 3-month thromboembolic risk in patients withprevious VTE and a negative D-dimer was 0% (95% CI 0%–8%). In multivariable analysis the twofold lower chance of anegative D-dimer test result in patients with prior VTE wasindependent of older age, active malignancy, fever, or recentsurgery. In summary, a negative D-dimer may still be used toexclude PE in patients with a prior history of VTE, although thelikelihood of a negative D-dimer is significantly reduced aswell.

[Todd Clever, MD,

Denver Health Medical Center, Denver, CO]

e A MULTICENTER, PROSPECTIVE VALIDATION OFDISSEMINATED INTRAVASCULAR COAGULATIONDIAGNOSTIC CRITERIA FOR CRITICALLY ILL PA-TIENTS: COMPARING CURRENT CRITERIA. Gando S,Iba T, Eguchi Y, et al. Crit Care Med 2006;34:1–7.

This was a prospective study with the primary aim ofvalidating a new algorithm, developed by the Japanese Asso-ciate for Acute Medicine (JAAM), for the diagnosis of dissem-inated intravascular coagulation (DIC). This algorithm is amodification of an algorithm previously established by thesame group. The study also sought to compare the JAAMcriteria to existing criteria for DIC from the Japanese Ministryof Heath and Welfare (JMHW) and the International Society onThrombosis and Haemostasis (ISTH). The new algorithm as-signs points based on four categories:

Systemic inflammatory response syndrome (SIRS) criteria:(T � 38°C or � 36°C, pulse � 90 beats/min, respirations � 20breaths/min or PaCO2 � 32 mm Hg, and a white blood cellcount � 12,000/mm3 or � 4000/mm3 or � 10% bandemia)

�3 2 points0–2 0 points

Platelet count (� 109/L)� 80 or � 50% decrease within 24 h 3 points� 80 and � 120 or � 30% decrease within 24 h 1 point� 120 0 points

Prothrombin time (value of patient/normal value)� 1.2 1 point� 1.2 0 points

Fibrin/fibrinogen degradation products (mg/L)� 25 3 points� 10 and � 25 1 point� 10 0 points

A score of four points or greater defined DIC. The studyprospectively enrolled 273 patients from 13 different criticalcare centers. Patients were eligible if their platelets droppedbelow 150 � 109/L. The following patients were excluded fromthe study: age � 15 years, hematopoietic malignancy, livercirrhosis classified as Child-Pugh grade C, concomitant cancertreatment, known clotting disorders, or anticoagulant therapy.The authors found that the JAAM scoring system was signifi-cantly more sensitive in the diagnosis of DIC than the JMHW

and the ISTH criteria. The JAAM criterion was also moresensitive on the first day of DIC than the other two criteria. TheJAAM criterion identified over 97% of all patients diagnosedby either of the other two criteria. Increasing JAAM scoreswere found to have significant correlation with organ failureand mortality.

[Todd Clever, MD,

Denver Health Medical Center, Denver, CO]

e INDUCTION OF HYPOTHERMIA IN PATIENTSWITH VARIOUS TYPES OF NEUROLOGICAL INJURYWITH USE OF LARGE VOLUMES OF ICE-COLD IN-TRAVENOUS FLUID. Polderman KH, Rijnsburger ER,Peerdeman SM, et al. Crit Care Med 2005;33:2744–51.

This prospective study was designed to test the hypoth-esis that infusion of refrigerated fluids (4°C) could be safelyused in conjunction with other surface cooling methods(e.g., Blanketroll II hyper-hypothermia cooling blankets,SubZero, or Arctic Sun cooling blankets) to increase the rateof cooling in patients with various types of neurologicinjuries to a goal temperature of 32–33°C. There were 134consecutive patients treated with hypothermia for neurologicinjury (mostly due to post-anoxic encephalopathy after CPR,subarachnoid hemorrhage, or traumatic brain injury) in-cluded in the study. In all patients, temperature, blood pres-sure, central venous pressure (CVP), and urine output werecontinuously monitored, whereas glucose and electrolyteswere measured at 30-min intervals during induction of hy-pothermia and at 6-h intervals after goal temperature wasreached. Patients without signs of cardiogenic shock (n �124) received 1000 mL saline and 500 mL geloplasma over30 min (n � 24), or 1500 mL saline alone over 30 min (n �100), whereas patients with signs on left ventricular failure(n � 10) received 1500 mL saline over 60 min. In patientswithout signs of cardiogenic shock, if temperatures re-mained � 33.5°C, an additional 500 mL of refrigeratedsaline was infused over a 10-min period and repeated until atemperature of � 33.5°C was reached. Similarly, in thecardiogenic shock group an additional 500 mL of refriger-ated saline was infused over a 30-min period and repeateduntil a temperature of � 33.5°C was reached. Most patientsreceived large amounts of potassium, magnesium, and phos-phate during initiation to prevent hypothermia-induced elec-trolyte depletion. In the group of 100 patients without signsof cardiogenic shock, an average of 2340 � 890 mL of fluidswere infused within 60 min; core temperatures decreasedfrom 36.9°C � 1.9° to 34.6°C � 1.5° at 30 min, and to32.9°C � 0.9° at 60 min. In the 24 patients receiving salineand geloplasma, 1680 � 630 mL of saline and 710 � 150mL of geloplasma were infused within 45 min, and coretemperatures decreased from 37.2°C � 1.9° to 34.4°C �1.3° at 30 min, and to 33.2°C � 0.8° at 60 min. In the 10patients with cardiac shock, 1420 � 770 mL of saline wereinfused over 60 min, and core temperatures decreased from36.8°C to 35.2°C � 1.7° at 30 min, to 34.2°C � 1.2° at 60min, and to 33.1°C � 0.9° at 120 min. Monitoring of bloodpressure, heart rhythm, CVP, arterial blood gases, electro-

The Journal of Emergency Medicine 125

lytes and glucose, and platelets revealed no significant ad-ditional adverse effects. Mean arterial pressures increased by15 mm Hg (largest increase in patients hemodynamicallyunstable before cooling). The authors conclude that largevolumes of refrigerated fluids (4°C) can be safely and ef-fectively used alongside traditional cooling techniques toquickly induce hypothermia in patients.

[Cliff Rice, MD,

Denver Health Medical Center, Denver, CO]

e A VALIDATED CLINICAL AND BIOCHEMICALSCORE FOR THE DIAGNOSIS OF ACUTE HEARTFAILURE: THE PROBNP INVESTIGATION OF DYS-PNEA IN THE EMERGENCY DEPARTMENT (PRIDE)ACUTE HEART FAILURE SCORE. Baggish AL, SiebertU, Lainchbury JG, et al. Am Heart J 2006;151:48–54.

Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is released from a stretched ventricular wall andhas been shown to be a sensitive marker of congestive heartfailure. This study sought to develop a scoring system bycombining NT-proBNP and clinical assessment for patientswith suspected congestive heart failure by analyzing theresults of a previous trial, the PRIDE study. Potential pre-dictors of acute heart failure were retrospectively identifiedfrom the prior series of 599 consecutive patients with dys-pnea, and analyzed to produce a weighted integeric score foreach predictor. The predictors included elevated NT-proBNP, interstitial edema on chest X-ray, orthopnea, ab-secnce of fever, loop diuretic use, age � 75 years, rales, andabsence of cough. The sum of these integers was calculatedand each patient was assigned a heart failure “score,” whichwere then analyzed to determine an optimal cut point for thediagnosis of acute heart failure. Using a cut point of � 6, theheart failure score had a sensitivity of 96% and a specificityof 84% for the diagnosis of acute heart failure. This scoringsystem was then applied to a separate cohort of 205 patientswith dyspnea in an effort to validate it. The authors concludethat the PRIDE Acute Heart Failure Score is a simple andaccurate scoring system for the diagnosis or exclusion ofheart failure in patients with dyspnea.

[David Whitling, MD,

Denver Health Medical Center, Denver, CO]

Comments: BNP testing has provided a useful tool in thediagnosis of heart failure, but results of this assay must becorrelated with clinical presentation. This trial provides anorganized, easy-to-use scoring system to facilitate the diagnosisor exclusion of heart failure in conjunction with BNP testing.

e NONTRAUMATIC ACUTE ABDOMINAL PAIN: UN-ENHANCED HELICAL CT COMPARED WITHTHREE-VIEW ACUTE ABDOMINAL SERIES. MacKer-sie AB, Lane MJ, Gerhardt RT, et al. Radiology 2005;237:114–22.

This prospective study compared the diagnostic accuracy ofunenhanced helical computed tomography (CT) with tradi-

tional abdominal X-rays for patients with non-traumatic acuteabdominal pain. The study enrolled 103 patients with non-traumatic abdominal pain of � 7 days duration; each under-went both unenhanced helical CT and a three-view acute ab-dominal series (AAS). Images obtained from CT and AASwere each interpreted by a different radiologist who wasblinded to the patient history and to images obtained by theother modality. Among the patients examined, unenhancedhelical CT yielded a sensitivity of 96.0%, specificity of 95.1%and accuracy of 95.6%. In contrast, AAS yielded a sensitivity,specificity, and accuracy of 30.0%, 87.8%, and 56.0%, respec-tively. No diagnoses were made via AAS that were not alsofound on helical CT. The authors conclude that AAS is aninsensitive technique in the evaluation of adults with non-traumatic acute abdominal pain, and suggest that unenhancedhelical CT be considered as the initial imaging modality in suchpatients.

[David Whitling, MD,

Denver Health Medical Center, Denver, CO]

Comments: This study suggests that the use of a three-viewabdominal series as the initial imaging modality in patientswith non-traumatic abdominal pain is outdated and likely notcost effective, considering the poor performance characteristicsof the test compared with helical CT.

e HIGH-DOSE ANTITHROMBIN III IN THE TREAT-MENT OF SEVERE SEPSIS IN PATIENTS WITH AHIGH RISK OF DEATH: EFFICACY AND SAFETY.Wiedermann CJ, Hoffman JN, Juers M, et al. Crit Care Med2006;34:285–92.

This subgroup analysis of a randomized, placebo-controlled, double-blind, prospective study examined whetherpatients with severe sepsis and a predicted mortality rate of30% to 60% (defined by the Simplified Acute Physiology ScoreII) benefited from high-dose antithrombin III therapy. Data forthis study were taken from a larger study that examined the useof antithrombin III therapy in all patients with severe sepsis,irrespective of expected mortality rate. This subgroup analysisincluded 1008 patients out of the total 2314 patients in theoriginal trial. Patients were randomized to receive either high-dose antithrombin III therapy intravenously or placebo. All-cause mortality at 90 days was determined for all patients.Patients treated with antithrombin III demonstrated a 6.1%absolute risk reduction in all-cause mortality at 90 days. Ad-verse events associated with bleeding were higher in the treat-ment group than the placebo group (24.1% vs. 12.9%) and wereassociated with concomitant treatment with heparin. The au-thors conclude that treatment with high-dose antithrombin III inpatients with severe sepsis and a high risk of death mayincrease survival, and that that this observation needs to beconfirmed in a prospective, randomized, controlled trial.

[David Whitling, MD,

Denver Health Medical Center, Denver, CO]

126 Abstracts