Correspondence / American Journal of Emergency Medicine 31 (2013) 1710-1718

brain magnetic resonance imaging was not performed to exclude

1711

Sevket Balta MD

lesions in the brain stem. Although the patient had the symptoms of bilateral ptosis and diplopia, dysarthria, dysphagia, and respiratory muscle weakness, she did not show any symptoms of injury of the pyramidal tracts, which were most common when bilateral brain stem lesions were involved. Her motor system symptoms were the injuries of lower motor neuron or peripheral nerve symptoms. Hence, brain stem lesions were not considered. In addition, this patient was ventilated 3 days after admission, and brain magnetic resonance imaging could not be performed.

Juan Zhang MD¹

Jian Li MD¹ Wenli Hu MD

Department of Neurology, Beijing Chaoyang Hospital Capital Medical University, Beijing, China E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.08.034

¹ Juan Zhang MD and Jian Li MD are joint first authors.

N-terminal pro-B-type natriuretic peptide should be used in all dyspneic patients in the ED^B

To the Editor,

We intentionally read the article “Predective Cutoff Point of Admission N-terminal Pro-B-type Natriuretic Peptide (NT-proBNP) Testing in the Emergency Department (ED) for Prognosis of Patients With Acute Heart Failure” written by Yalcin Golcuk et al [1] with interest. They concluded that elevated Nt-proBNP levels upon admission were a strong and independent predictor of all-cause mortality in patients with heart failure [1].

Acute dyspnea is a key symptom of HF and one of the most common causes of admission to the ED [2]. Patients presenting at the ED with a dyspnea and who are diagnosed as having Acute HF have an increased risk of death [1]. Several studies showed that NT-proBNP yielded moderate to good diagnostic accuracy for HF in the ED [2]. Optimal NT-proBNP concentrations for comfirming or excluding the presence of acute destabilized HF in acutely dyspneic patients have yet to be definitively established [3]. There is a relationship between age and natriuretic peptide levels consequent to age-related changes in left ventricular compliance [4]. The importance of age stratification to improve the accuracy of Natriuretic peptide testing to confirm the diagnosis of acute HF is supported by the observation of a direct relationship between age and levels of NT-proBNP [3]. As a result, we think that the current evidence remains inconclusive on whether routine use of NT- proBNP should be used in all dyspneic patients-especially in younger patients-in the ED.

Hakan Sarlak MD Muharrem Akhan MD Mustafa Cakar MD Omer Kurt MD

Erol Arslan MD

Department of Internal Medicine, Gulhane Medical Academy,

Etlik-Ankara 06010, Turkey E-mail address: [email protected]

Department of Cardiology, Gulhane Medical Academy

Ankara, Turkey

http://dx.doi.org/10.1016/j.ajem.2013.08.039

References

1. Golcuk Yalcin, Golcuk Burcu, Velibey Yalcin, et al. Predective cutoff point of admission N-terminal pro-B-type natriuretic peptide testing in the ED for prognosis of patients with acute heart failure. Am J Emerg Med 2013.
2. Trinquart L, Ray P, Riou B, et al. Natriuretic peptide testing in EDs for managing acute dyspnea: a meta-analysis. Am J Emerg Med 2011;29:757-67.
3. Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international Pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J 2006;27:330-7.
4. Chenevier-Gobeaux Camille, Allo Jean-Christophe, Arthaud Martine, et al. N- terminal pro B-type natriuretic peptide testing for short-term prognosis in breathless older adults. Am J Emerg Med 2008;26:555-60.

   Regarding “Repeated pulse Intramuscular injection of pralidoxime chloride in severe acute organophosphorus pesticide poisoning“^B

   We read with interest the recent article on the use of pralidoxime in acute organophosphorus (OP)-Poisoned patients (AOPP) [1]. Clarification of several issues would greatly assist in our ability to determine whether the results presented are valid and broadly applicable. Although not clearly stated, it seems that this retrospec- tive study was a comparison of protocols from 2 Intensive care units that care for AOPP. Therefore, it is unclear whether the treated populations are comparable, which makes interpretation of the results challenging. The treatment protocol used for one group of patients is detailed with regard to pralidoxime and atropine dosing, whereas the other is vague and uncertain. Interestingly, the cumulative atropine dose was evaluated as an end point when atropine, not pralidoxime, is regarded as the cornerstone of AOPP. The use of pralidoxime is still debated [2,3]. The failure to standardize the atropine dosing between the 2 groups jeopardizes the conclusions regarding pralidoxime as it introduces another variable. The authors note a shorter ICU stay for those in the strict pralidoxime group, but patients remain in the ICU for many reasons apart from their initial ingestion. Information on why patients remained in the ICU for longer periods would have been helpful. Finally, it is unclear why some patients received hemodialysis as OPs have a large volume of distribution and it is unlikely that hemodialysis is clinically beneficial. It would be helpful to note whether patients developed acute kidney injury, fluid overload, or refractory acidosis from their exposures or whether dialysis was performed to clear solvents that are potentially as problematic as the OP chemicals in AOPP [4].

   Given the amount of OP exposure at the 2 study centers, we

   believe that an important opportunity exists to study a unique data set. The authors likely have very valuable information that may help to establish the role of pralidoxime in the treatment of AOPP. Unfortunately, the data presented do not give the reader enough information to adequately assess the results. We, therefore, cannot endorse the conclusion that pralidoxime dosing, at the expense of atropine dosing, is advisable to AOPP. We ask the authors to consider implementing a study that is prospective and randomized with standardized protocols and look foremost at pralidoxime dosing. The

   ? There is no conflict of interests. ? No support received for this work.