References

1. Gunduz A, Turedi S, Mentese A, Karahan SC, Hos G, Tatli O, et al. Ishemia-modified albumin in the diagnosis of Acute mesenteric ischemia: a preliminary study. Am J Emerg Med 2008;26:202-5.
2. Chan MY, Pronovost PJ. Clinical utility of biomarkers in myocardial injury. Curr Opin Anaesthesiol 2004;17:49-55.
3. Talwalkar SS, Bon-Homme M, Miller JJ, Elin RJ. Ischemia modified albumin, a marker of acute Ischemic events: a pilot study. Ann Clin Lab Sci 2008;38:132-7.
4. Falkensammer J, Stojakovic T, Huber K, Hammerer-Lercher A, Gruber I, Scharnagl H, et al. A. Serum levels of ischemia-modified albumin in healthy volunteers after exercise-induced calf-muscle ischemia. Clin Chem Lab Med 2007;45:535-40.
5. Turedi S, Gunduz A, Mentese A, Karahan SC, Yilmaz SE, Eroglu O, et al. Value of ischemia-modified albumin in the diagnosis of pulmonary embolism. Am J Emerg Med 2007;25:770-3.
6. Abboud H, Labreuche J, Meseguer E, Lavallee PC, Simon O, Olivot JM, et al. Ischemia-modified albumin in acute stroke. Cerebrovasc Dis 2007;23:216-20.
7. Montagnana M, Lippi G, Regis D, Fava C, Viola G, Bartolozzi P, et al. Evaluation of cardiac involvement following major orthopedic surgery. Clin Chem Lab Med 2006;44:1340-6.
8. Piszko P, Lewczuk J, Lenartowska L, Jagas J, Romaszkiewicz R, Blaszczyk D, et al. pulmonary thromboembolism in 102 consecutive patients with Chronic atrial fibrillation. Diagnostic value of echocardio- graphy. Kardiol Pol 2007;65:246-51.
9. Roy D, Quiles J, Sinha M, Aldama G, Gaze D, Kaski JC. Effect of direct-current cardioversion on ischemia-modified Albumin levels in patients with atrial fibrillation. Am J Cardiol 2004;93:366-8.

Emergency Coma Scale for patients in”>The author responds

To the Editor,

We are delighted with the interest shown in our articles on Ischemia modified albumin and ischemic diseases and welcome all constructive criticism [1-3]. Our publications are not perfect of course, and we are always trying to reach ever higher standards. We are setting out below my thoughts regarding 2 issues troubling the writer and hope to eliminate those particular question marks.

The author’s first question regard whether undetected pulmonary embolism may also be present in our mesenteric ischemia patients and whether that combination may have affected IMA levels.

We share that idea. In selecting our cases, we excluded patients with acute pulmonary embolism symptoms and findings and patients with suspected pulmonary embolism [1]. However, thoracic computed tomography was not used to rule out pulmonary embolism in our mesenteric embolism patients. That would in any case have been ethically impossible. That doubt is therefore a possible, albeit remote one.

The author’s second question is whether recent cardioversion could be the reason why IMA levels in our mesenteric embolism patients with atrial fibrillation were

higher than those in mesenteric embolism patients with no atrial fibrillation. This is indeed a noteworthy finding, but the literature contains no studies evaluating the effect of atrial fibrillation on IMA levels. Cardioversion can, however, raise IMA levels [4]. There was no history of recent or distant cardioversion in our cases. As stated in the text, new prospective studies may shed light on the matter. We are grateful to the author for his/her interest in our article.

Gunduz Abdulkadir MD Turedi Suleyman MD

Karadeniz Technical University Faculty of Medicine

Department of Emergency Medicine

Trabzon 61080, Turkey E-mail address: [email protected]

doi:10.1016/j.ajem.2008.10.014

References

1. Gunduz A, Turedi S, Mentese A, Karahan SC, Hos G, Tatli O, et al. Ischemia-modified albumin in the diagnosis of acute mesenteric ischemia: a preliminary study. Am J Emerg Med 2008; 26(2):202-5.
2. Turedi S, Gunduz A, Mentese A, Karahan SC, Yilmaz SE, Eroglu O, et al. Value of ischemia-modified albumin in the diagnosis of pulmonary embolism. Am J Emerg Med 2007;25(7):770-3.
3. Turedi S, Gunduz A, Mentese A, Topbas M, Karahan SC, Yeniocak S, et al. The value of ischemia-modified albumin compared with d-dimer in the diagnosis of pulmonary embolism. Respir Res 2008; 9:49.
4. Roy D, Quiles J, Sinha M, Aldama G, Gaze D, Kaski JC. Effect of direct-current cardioversion on ischemia-modified albumin levels in patients with atrial fibrillation. Am J Cardiol 2004;93(3):366-8.

The Emergency Coma Scale for patients in the ED: concept, validity and simplicity

To the Editor,

Various coma scales have been developed and used for evaluation of consciousness level in patients. Especially in the settings where patients in the acute phase are treated (such as the ED), a rapid and accurate grasp of consciousness level is very important. The Glasgow Coma Scale (GCS) [1-3] is internationally accepted when discussing patient level of consciousness with other professionals. However, the GCS has the disadvantages of complexity and overestimate [4-6]. For the purpose of overcoming these disadvantages, Ohta tried to design an easier and accurate coma scale in 2003, termed Emergency Coma Scale (Table 1) [7-10]. It was originated from a task force in cooperation with the Japanese Congress on NeuroSurgical emergencies and Japan Neurological Emer- gency Society [7]. The ECS is based on the concepts of

22.5). The ECS showed the higher weighted agreement (72.0k) in whole raters. Next, we calculated the weighted agreements according to the kinds of diseases. The

Table 1 The Emergency Coma Scale (Ohta)

Category 1 : The patients open their eyes, speak and/or behave spontaneously (awake) and

1 can say correct date, place and person

2 cannot say correct date, place and person

Category 2 : The patients can open their eyes, speak and/or behave (aroused) by

10 speech

20 painful stimuli

Category 3 : The patients can neither open their eyes, nor speak by painful stimuli (not aroused) but respond with

100L localization

100W withdraw forearm with opened armpits 200F flex forearm with closed armpits

200E extend forearm with closed armpits 300 none

L indicates localization; W, withdrawal; F, flexion; E, extension.

Table 2 Manual for Evaluation by the Emergency Coma Scale developed in 2004 (Okudera)

Manual for Evaluation by the Emergency Coma Scale (2004)

[Category 1 (1 digit code)] Discerning whether the patients are wakeful or not.

STEP1 Check the spontaneous eye opening, speaking, movements of patients (Category 1 or not?)

If raters could observe at least one of the following three actions: eye opening, speaking, movements of the patients, they are wakeful.

Be wakeful?

Yes Y go to STEP 2 No Y go to STEP 3

the GCS and the Japan Coma Scale which have been used widely in Japan [11].

The ECS consists of 3 major categories divided depending on the severity of Consciousness disturbance that derives from the comprehensible structure of the JCS. Grading of 3 major categories is similar to that of the triage tag in disaster or traffic signal. Category 1 and category 2 have 2 subcategories. Category 3 represents the coma state and has 5 subcategories based on the best motor response of the GCS. Thus, the severity of consciousness disturbance is graded into

9 subcategories.

To evaluate the validity of the ECS, we designed a multicenter study named bECS Co-Operative Multi center Evaluation Trial: E-COMETQ [12]. Eight medical facilities including 4 university hospitals in Japan participated in this study. We included patients transported to the ED by ambulance. From April 2007 to June 2008, we prospectively collected data. When the patients arrived at the ED, all members of the covering team evaluated the level of consciousness immediately by the ECS and GCS. In each hospital, instructors oriented all raters about the evaluation method of the 2 scales, referring to the manual for evaluation from the ECS website (http://www. ecs.gr.jp), with particular emphasis on the new ECS (Table 2).

Statistical analysis on the collected data compared the weighted agreements among multiple raters by calculating the j coefficient using a cross-tabulation table and used 95k confidence intervals (95% CI) calculated from standard error for test. All analyses were performed using Microsoft Office Excel 2007 (Microsoft Corp, Redmond, Wash).

A total of 329 patients were included in the study, 153 women and 176 men, aged 7 to 99 years (mean, 56.7; SD,

STEP2 Check the orientation of the patients (Category 1 or Category 2?)

Ask the patients whether they can say time, person, place exactly.

Do they have orientation? Yes Y ECS 1

No Y ECS 2

[Category 2 (2 digit code)] Observation of the response for stimulation

STEP3 Observe the response for speech.

Call out the patients with loud voice. Raters also can touch and shake the patients.

Can they awake by voice stimuli? Yes Y ECS 10

No Y go to STEP 4

STEP4 Observe the response for painful stimuli

If there are any attendance for patients, raters should get agreement for painful stimuli to them.

If there are not any wound in trunk of patients, raters push the sternum hard with a fist.

Raters also can push nails of the patients hard to evaluate the response.

Raters must stimulate the patients with calling out them. Can they awake by painful stimuli?

Yes Y ECS 20

No Y go to STEP5

[Category 3 (3 digit code)] The state the patients cannot awake with all stimulations

STEP5 Observe the response for painful stimuli.

Evaluate the consciousness level rapidly with painful stimuli as same as STEP4

localize the parts with painful stimuli Y 100L withdraw forearm with opened armpits Y 100W flex forearm with closed armpits Y 200F

extend forearm with closed armpits Y 200E no movement Y 300

We instructed method of evaluation by ECS with reference to this manual.

agreement was higher in ECS for patients with Traumatic brain injury (83.9k). In patients with trauma and cerebrovascular disease (CVD), the ECS also tended to show higher weighted agreement (85.1k and 69.8k) (Table 3). Finally, we analyzed the data according to the coma scales that each rater used in medical examination and treatment routinely. For the raters who did not use any scales, the ECS showed the highest agreement (77.6 k); however, in the GCS users and both users, the there was no significant difference in the agreement between both coma scales (Table 4).

We thought better that a new coma scale would be easy to use by all medical staffs and represent accurate scores in patients quickly. The structure of the ECS, with 3 major categories, is very useful. If the medical staff in emergency settings have no time to evaluate the subcategories of ECS deliberately, they can simply note the major category of consciousness level.

The ECS is designed to be able to quickly find critical brain herniation in patients with a disturbance in consciousness [10]. Weighted agreements were high for patients with TBI and CVD that could cause brain herniation. We thought the ECS may be suitable for neUrologic emergency.

Interestingly, scores among the raters who did not use any scales showed the highest agreement in the ECS. The ECS is straightforward and understandable for beginners in evaluat- ing consciousness level and may be very useful for staff education. If various professionals can agree on a consensus for evaluating consciousness level by the ECS, we thought it could take less time to decide whether the patients require emergency treatment. This may improve the outcome of the patients especially with CVD or severe TBI.

These are only interim results and we are planning a follow-on study to prove the accuracy of the ECS.

Table 3 The disease-by disease weighted agreements of both coma scale scores among multiple raters

Scale Disease Agreement % (95k CI)

GCS Whole rater 72.0 (70.9-72.4)

CVD 56.2 (51.3-61.1)

Epilepsy 26.8 (21.3-32.4)

All trauma 75.2 (73.9-76.6)

TBI 65.6 (63.0-68.2)

Mental disorder 57.6 (51.8-63.4)

Toxicosis 44.4 (35.2-53.6)

ECS Whole rater 60.6 (59.3-61.9)

CVD 69.8 (67.9-71.8)

Epilepsy 39.2 (36.0-42.5)

All trauma 85.1 (83.9-86.3)

TBI 83.9 (83.0-84.9)

Mental disorder 78.3 (74.9-81.7)

Toxicosis 68.4 (62.1-74.8)

CI indicates confidence interval. Values are shown as weighted agreements (95k CI).

Table 4 The weighted agreements of both coma scale scores among multiple raters divided by the scales each rater used routinely
Scale	Scales each rater used routinely	Agreement % (95k CI)
GCS	JCS	61.4 (57.5-64.4)
	GCS	45.5 (34.0-57.0)
	Both	70.2 (66.0-74.4)
	Nothing	63.5 (60.4-66.7)
ECS	JCS	77.5 (75.0-80.0)
	GCS	37.6 (28.6-46.6)
	Both	71.5 (68.8-74.2)
	Nothing	77.6 (76.3-78.9)
Values are shown as weighted agreements (95k CI).

Acknowledgment

We thank our colleagues, Dr Masahiro Wakasugi, Dr Takashi Asahi, Dr Daisuke Tange, Dr Joji Hamada, nurses, and trainee doctors in the ED of the Toyama University Hospital. We gratefully acknowledge the support of the following people: Dr Kobata, Kyoto Fushimishimizu Hospital; Dr Ono, Department of neurosurgery, Okayama University Hospital; Dr Fukuda, Dr Koyama, and Dr Ohara, Department of Neurosurgery, Saito Memorial Hospital.

Chiaki Takahashi MD Hiroshi Okudera MD, PhD Department of Crisis Medicine

Graduate School of Medicine, University of Toyama

Toyama 930-0194, Japan E-mail address: [email protected]

Tetsuya Sakamoto MD, PhD Trauma and Critical Care Center Teikyo University School of Medicine Itabashi, Tokyo 173-8606, Japan

Tohru Aruga MD, PhD

Department of Emergency and Critical Care Medicine

Showa University Shinagawa, Tokyo 142-8666, Japan

Tomio Ohta MD, PhD Osaka Neurological Institute Toyonaka, Osaka 561-0836, Japan

doi:10.1016/j.ajem.2008.10.015

References

1. Teasdale G, Jenett B. Assessment of coma and impaired conscious- ness. Lancet 1974;13:81-2.
2. Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir 1976;34:45-55.
3. Jennett B, Teasdale G. Aspects of coma after severe head injury. Lancet 1977;23:878-81.
4. Riechers RGII, Ramage A, Brown W, Kalehua A, Rhee P, Ecklund JM, et al. Physician knowledge of the Glasgow Coma Scale. J Neurotrauma 2005;22:1327-34.
5. Teoh LSG, Gowardman JR, Larsen PD, Green R, Galletly DC. Glasgow Coma Scale: variation in mortality among permutations of specific total scores. Intensive Care Med 2000;26:157-61.
6. Fischer J, Mthieson C. The history of Glasgow Coma Scale: implications for practice. Crit Care Nurs Q 2001;23:52-8.
7. Okudera H, Ohta T, Aruga T, Ueda M, Kamitsuhara K, Otaka H, et al. Development of an Emergency Coma Scale by the ECS task force: 2003 report. J Jpn Congr Neurol Emerg 2004;17:66-8.
8. Wakasugi M, Okudera H, Ohta T, Asahi T, Igawa A, Tange D. Development of the new coma scale: Emergency Coma Scale (ECS). In: Kanno T, Kato Y, editors. Minimally Invasive Neurosurgery and Multidisciplinary Neurotraumatology. Tokyo: Springer-Verlag; 2006.

p. 400-3.

1. Ohta T. Phenomenological aspects of consciousness-its distur- bance in acute and chronic stages. Acta Neurochir [Suppl] 2005;93: 191-3.
2. Takahashi C, Okudera H, Wakasugi M, Asahi T, Hamada J, Okazawa S, et al. Emergency Coma Scale-A basic concept of new coma scale for consciousness disturbance. In: European Association of Neurosurgical Societies, editor. 13th Congress of the European Association of Neurosurgical Societies. Bologna: Medimond; 2007.

p. 321-5.

1. Ohta T, Kikuchi H, Hayashi K, Kudo Y. Nizofenone administration in the Acute stage following subarachnoid hemorrhage. Results of a multi- center controlled double-blind clinical study. J Neurosurg 1986;64: 420-6.
2. Takahashi C, Okudera H, Wakasugi M, Asahi T, Hamada J, Okazawa S, et al. A multi-center comparative study of Glasgow Coma Scale and Emergency Coma Scale-intermediate report. In: European Association of Neurosurgical Societies, editor. 13th Congress of the European Association of Neurosurgical Societies. Bologna: Medi- mond; 2007. p. 317-20.

Extrapontine myelinolysis after correction of hyponatraemia presenting as generalised tonic seizures

To the Editor,

We read with interest the article in American Journal of Emergency Medicine by Lin C and Po H entitled “Extrapontine myelinolysis after correction of hyponatrae- mia presenting as generalised tonic seizures” [1]. In their article, the authors describe the development of myelino- lysis after correction of hyponatremia and the etiology and treatment of central and extrapontine myelinolysis.

Recently, in our institution, a 55-year-old woman presented with a 2-week history of confusion and was found to be hyponatremic. She had no prior medical history and was on no medication. Magnetic resonance imaging at that time was normal. After correction of hyponatremia, she was discharged; however, she re- presented 8 days later with confusion and ataxia. serum sodium was normal at this time; however, magnetic resonance imaging showed changes typical of central pontine myelinolysis (CPM) (Fig. 1).

Fig. 1

Further questioning revealed that the patient had been performing twice weekly caffeine enemas as part of a colonic-cleansing regimen. A diagnosis of caffeine enema- induced CPM was made.

The administration of enemas dates back to ancient Greece and is popular as a form of detoxification advocated usually by nonmedical personnel. Enemas have been previously been shown to result in electrolyte disturbances, and indeed, 2 deaths have previously been attributed to caffeine enema-induced electrolyte distur- bance [2]. We believe that this is the first described incidence of CPM due to enema use.

We congratulate the authors on an interesting case and an informative synopsis of myelinolysis and believe that our unusual case further emphases the diverse nature of both etiology and presentation of myelinolysis.

Graeme McNeill Darragh Halpenny Aisling Snow

A. Geoghegan William C. Torreggiani Department of Radiology

AMNCH Tallaght Dublin 24, Ireland

E-mail address: [email protected] doi:10.1016/j.ajem.2008.10.012

References

1. Lin CM, Po HL. Extrapontine myelinolysis after correction of hyponatraemia presenting as generalized tonic seizures. Am J Emerg Med 2008;26(5):632.e5-6.
2. Eisele JW, Reay DT. Deaths related to coffee enemas. JAMA 1980;244:

1608-9.