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Background: Few data exist on the frequency with which multidetector computed axial tomography (MDCT) scan of the coronary arteries changes the admission decisions of emergency physicians (EP) caring for patients with possible acute coronary syndrome (ACS). We measured if and how often these changes in decision-making would occur. Methods: The theoretical dispositions of 27 emergency department patients who presented with possible ACS were determined by four board-certified EPs after case presentations. Paired disposition decisions were made before and after knowledge of the MDCT scan results. Patients were selected from a sample of 103 from a prior study. Results: The study included 27 patients with a mean age of 55 ± 9 years; 58% were male. The low-, intermediate-, and high-risk MDCT scan results were evenly distributed, as were the original providers' standard clinical risk assessments of ACS. Three patients had ACS and all were admitted both before and after review of MDCT scan results. Among 24 patients without ACS, a decision to admit was changed to discharge in 16 of 90 admission decisions (18%, 95% confidence interval [CI] 10–26%). Among 6 patients with projected discharges, 2 were inappropriately admitted after review of MDCT scan results. The odds ratio of discharge for patients without ACS increased by 3.95 (95% CI 1.96–7.95) after introduction of the MDCT scan results. Conclusion: An MDCT scan of the coronary arteries will likely change emergency physicians' decisions on the disposition of patients presenting with possible ACS, many to appropriate discharges but also a minority to inappropriate admissions.

a t i r. David Peak: Today’s case is that of a 23-year-old ale who was brought to the Emergency Department ED) by Emergency Medical Services (EMS) after being tabbed repeatedly by an assailant who broke into his partment. Paramedics found him seated with multiple tab wounds to his anterior chest and abdomen. The atient was awake, alert and agitated. Vital signs were: eart rate (HR) 120 beats per minute, systolic blood ressure (BP) 110 mm Hg, and respiratory rate (RR) 18 reaths per minute. Breath sounds were reportedly symetrical. He was placed on oxygen by non-rebreather ace mask, two large-bore antecubital intravenous (i.v.) ines were inserted, and boluses of normal saline were dministered. During the brief transport to the hospital, is mental status deteriorated from agitation to lethargy. Dr. Eric Nadel: Are there any questions about the nitial presentation? Dr. Tracy Wimbush: Was there any other informaion about the patient or the weapon used? Dr. Peak: The patient was an otherwise healthy male ith no past medical or surgical history, allergies or edications. There was no evidence of drug parapheralia at the scene. Details on the knife were unavailable. The patient arrived in the ED at 6:55 a.m., approxiately 20 minutes after being stabbed. Vital signs were P 90/50 mm Hg, HR 130 beats/minute, RR 30 breaths/ inute, and oxygen saturation 92% on the non-rereather oxygen mask. The primary survey revealed that e was somnolent, verbalizing only with physical stim