American Journal of Emergency Medicine

Agreement on sedation-related events between a procedural sedation registry and computerized medical records

Kyle Shaver, Steven Weiss, Darren Braude — 2010-01-25

Abstract: Objectives: Little is known about the accuracy of the medical record to document sedation-related events (SREs). Our hypotheses were that, when compared to a reference database (RD), a procedural sedation quality assurance registry (PSQAR) and medical records were accurate documentation of SREs.Methods: All cases in our PSQAR over 13 months were examined. Those with SREs were entered into the RD. We reviewed the computerized medical record (CMR; both physician documentation and nursing documentation) to determine the presence of procedural sedation notes and documentation of SRE.Results: A total of 203 sedation cases were entered into the PSQAR. The RD consisted of 74 SREs during 60 cases. The PSQAR included 61 (82%) of 74 events (95% confidence interval [CI], 72%-90%), whereas the CMR included 44 (60%) of 74 events (95% CI, 47%-71%). Physician documentation completely matched the RD in 12 (20%) 60 cases (95% CI, 11-32) and nursing documentation completely matched the RD in 24 (40%) of 60 cases (95% CI, 28-53). Physician and nursing documentation were complete and agreed with each other in only 4 (9%) of 60 cases (95% CI, 2-16; κ = 0.13).Conclusion: When compared to the RD, the accuracy of the PSQAR was very good. However, the accuracy of the CMR, including both nursing and physician documentation, was poor and there was poor agreement between them. This has implications for chart review–based research and quality improvement.

Protective effects of Y-27632 on acute dichlorvos poisoning in rats

2009-10-26

Abstract: Anticholinesterase poisoning is an important health problem in developing countries, and understanding of its underlying mechanisms is essential for the effective treatment. This study is designed to examine the effects of Y-27632, a selective Rho-kinase inhibitor, on organophosphate-induced cardiac toxicity and mortality in rats. Rats were randomly divided into 4 groups: control (corn oil), dichlorvos (30 mg/kg intraperitoneally), and 1- and 10-mg/kg Y-27632 + dichlorvos groups. After 6 hours of intraperitoneal injection, venous blood and cardiac samples were obtained, biochemical or immunohistochemical analyses were performed, and the intensity of muscle fasciculation was recorded. Serum cholinesterase activities were suppressed with dichlorvos, and these reductions were inhibited with Y-27632 pretreatment. Serum creatine kinase, creatine kinase–MB activities, and myoglobin and N-terminal probrain natriuretic peptide concentrations were not markedly affected with poisoning or Y-27632. Although serum nitric oxide concentrations did not change with dichlorvos, cardiac nitric oxide levels were markedly increased with Y-27632 pretreatment. Cardiac glutathione levels also increased with 1 mg/kg Y-27632. There was no staining for apoptosis, and immunohistochemical analyses of inducible nitric oxide synthase showed no change in cardiac tissue for all of the groups. Both doses of Y-27632 abolished mortality in rats with acute dichlorvos exposure (100% survival). These results show that administration of Rho-kinase inhibitor can produce protective effects against dichlorvos intoxication in rats. These findings may provide new possibilities for the treatment of organophosphate poisoning.

Practice variation in the management for nontraumatic pediatric patients in the ED

Yu-Che Chang, Chip-Jin Ng, Yu-Chuan Chen, Jih-Chang Chen, David Hung Tsang Yen — 2010-03-01

Abstract: Study objective: To improve the management quality and monitoring for common pediatric illnesses in the general emergency department (ED), we examined the effect of physician specialty training on medical resource use and patient outcomes.Methods: This was a retrospective cohort review of visits by children less than 18 years to the ED of 2 university-affiliated teaching hospitals. Clinical management by 2 groups (emergency physicians [EPs] and pediatricians each working 168 h/wk) was compared with respect to demographics, ED resource use, short-term outcome, disposition, direct ED costs for each visit, and frequency of radiographic and laboratory test use. The effects of medical decision making on resource use was assessed by comparing costs of radiographic studies, laboratory studies, and medication.Results: Between-group differences in mean patient age, sex, and triage category were insignificant. Compared to pediatricians, EPs used radiographic and laboratory studies more frequently (respectively, 10.1% and 3.8% higher frequency and 90.5% and 7.6% higher cost) and less medication (12.5% lower cost). Patients managed by EPs had longer ED length of stay (LOS), higher admission rates to general wards, and shorter LOS per hospitalization but similar 72-hour revisit rates, needed more frequent referral for medical reasons, and left more frequently against medical advice.Conclusion: Emergency physicians spent more time and medical resources and admitted patients at a higher rate. Emergency physicians and pediatricians managed critical patients similarly.

What is the optimal dose of epinephrine during cardiopulmonary resuscitation in a rat model?

Meng-Hua Chen, Jun-Yu Lu, Lu Xie, Jun-Hui Zheng, Feng-Qing Song — 2010-01-25

Abstract: Objective: Because different species may require different doses of drug to produce the same physiologic response, we were provoked to evaluate the dose-response of epinephrine during cardiopulmonary resuscitation (CPR) and identify what is the optimal dose of epinephrine in a rat cardiac arrest model.Methods: Rat cardiac arrest was induced via asphyxia, and then the effects of different doses of epinephrine (0.04, 0.2, and 0.4 mg/kg IV, respectively) and saline on the outcome of CPR were compared (n = 10/each group). The primary outcome measure was restoration of spontaneous circulation (ROSC), and the secondary was the change of spontaneous respiration and hemodynamics after ROSC.Results: Rates of ROSC were 9 of 10, 8 of 10, 7 of 10, and 1 of 10 in the low-dose, medium-dose, and high-dose epinephrine groups and saline group, respectively. The rates of withdrawal from the ventilator within 60 minutes in the low-dose (7 of 9) and medium-dose epinephrine groups (7 of 8) were higher than in the high-dose epinephrine group (1 of 7, P < .05). Mean arterial pressures were comparable, but the heart rate in the high-dose epinephrine group was the lowest among epinephrine groups after ROSC. These differences in part of time points reached statistical significance (P < .05).Conclusion: Different doses of epinephrine produced the similar rate of ROSC, but high-dose epinephrine inhibited the recovery of spontaneous ventilation and caused relative bradycardia after CPR in an asphyxial rat model. Therefore, low and medium doses of epinephrine were more optimal for CPR in a rat asphyxial cardiac arrest model.

Does diagnosis change as a result of repeat renal colic computed tomography scan in patients with a history of kidney stones?

Adam Goldstone, Andrew Bushnell — 2009-10-26

Abstract: Study objective: We sought to determine the incidence of alternative diagnosis in patients with a history of kidney stones who experience recurrent symptoms and undergo repeat computed tomography (CT) imaging at their return to the emergency department (ED).Methods: This was a retrospective chart review of ED patients at a tertiary care hospital. Inclusion criteria were all adult ED patients who received a repeat CT for renal colic, after having previously received the diagnosis of obstructive kidney stone confirmed by CT, in our ED. Patients were identified by reviewing the charts of those patients with repeat visits to the ED after January 1, 2004, in which they complained of symptoms suggestive of renal colic and received a CT scan. We determined the frequency of the same diagnosis on repeat CT scan in this population compared with the frequency of alternative diagnosis.Results: Two hundred thirty-one patients met criteria for the study. Fifty-nine percent were male. One hundred eighty-nine (81.8%) patients had no change in diagnosis as a result of a repeat renal colic CT scan. Twenty-seven (11.6%) patients received an alternative diagnosis that did not require urgent intervention, and 15 (6.5%) patients received a diagnosis that did require an urgent intervention.Conclusion: Repeat CT imaging of patients with known nephrolithiasis changed management in a minority of patients (6.5%). Knowing the frequency of alternative diagnosis in this population may help clinicians and patients balance the risks and benefits of repeat renal colic CT scans in patients with a history of kidney stones who return to the ED with similar symptoms.

Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses

2009-10-26

Abstract: Introduction: This study proposes that intranasal (IN) naloxone administration is preferable to intravenous (IV) naloxone by emergency medical services for opioid overdoses. Our study attempts to establish that IN naloxone is as effective as IV naloxone but without the risk of needle exposure. We also attempt to validate the use of the Glasgow Coma Scale (GCS) in opioid intoxication.Methods: A retrospective chart review of prehospital advanced life support patients was performed on confirmed opioid overdose patients. Initial and final unassisted respiratory rates (RR) and GCS, recorded by paramedics, were used as indicators of naloxone effectiveness. The median changes in RR and GCS were determined.Results: Three hundred forty-four patients who received naloxone by paramedics from January 1, 2005, until December 31, 2007, were evaluated. Of confirmed opioid overdoses, change in RR was 6 for the IV group and 4 for the IN group (P = .08). Change in GCS was 4 for the IV group and 3 for the IN group (P = .19). Correlations between RR and GCS for initial, final, and change were significant at the 0.01 level (ρ = 0.577, 0.462, 0.568, respectively).Conclusion: Intranasal naloxone is statistically as effective as IV naloxone at reversing the effects of opioid overdose. The IV and IN groups had similar average increases in RR and GCS. Based on our results, IN naloxone is a viable alternative to IV naloxone while posing less risk of needle stick injury. Additionally, we demonstrated that GCS is correlated with RR in opioid intoxication.

ED overcrowding is associated with an increased frequency of medication errors

2010-02-08

Abstract: Objectives: Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists.Methods: We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves.Results: A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's ρ = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day.Conclusions: We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.

Factors associated with sustained return of spontaneous circulation in children after out-of-hospital cardiac arrest of noncardiac origin

2010-02-08

Abstract: Purpose: The study aimed to determine the factors predictive of sustained return of spontaneous circulation (ROSC) in children with out-of-hospital cardiac arrest (OHCA) of noncardiac origin.Methods: Eighty children were included in this retrospective study. The variables that lead to sustained ROSC and those that do not lead to sustained ROSC were analyzed. Survival analyses, including chance of achieving sustained ROSC and sum duration of ROSC, were conducted according to the duration of in-hospital cardiopulmonary resuscitation (CPR).Results: Etiologies of noncardiac OHCA differed significantly across different age groups (P < .001). Only 8.8% of children had initial arrest rhythms that were shockable. Predictors of sustained ROSC included the initial cardiac rhythm (P = .002), a shorter period between collapse and the first chest compression (P = .002), a shorter in-hospital CPR duration (P = .004), and prehospital CPR (P = .007). In children where ROSC was initially sustained, those with in-hospital CPR of more than 20 minutes, ROSC was sustained for less time (P < .001).Conclusions: Few children with noncardiac OHCA present with shockable cardiac rhythms. Furthermore, long-term ROSC is difficult to maintain in children who receive in-hospital CPR for more than 20 minutes.

Aspirin administration in ED patients who presented with undifferentiated chest pain: age, race, and sex effects

Kevin M. Takakuwa, Frances S. Shofer, Judd E. Hollander — 2010-02-08

Abstract: Study Objectives: The study aimed to determine whether aspirin therapy was differentially administered according to race, sex, or age in patients with undifferentiated chest pain who presented to an urban academic emergency department.Methods: This was a prospective observational cohort study of patients older than 24 years who presented with chest pain between July 1999 and March 2002. Patients were grouped according to 30-day final diagnosis: acute myocardial infarction AMI, unstable angina USA, and non–acute coronary syndrome (ACS) chest pain. Data were analyzed using Fisher exact test and relative risk regression using the Gaussian estimating equation.Results: There were 4478 patient visits, of which 4470 (99.8%) had complete information. Mean age was 52.2 ± 15.8 years. Blacks were 70.1% (n = 3135), whites 26.3% (n = 1175), and other 3.6% (n = 159). Women comprised 59.0% (n = 2639) of the patients. Aspirin therapy differed by race, sex, age, and final diagnosis. Patients who received aspirin were more likely to be white (60% vs 54%, P = .0009) or have an ACS diagnosis (82% vs 50%, P < .0001). By final diagnosis, there were no race, sex, or age differences for AMI or USA (P > .05). There were significant sex and age differences for non-ACS chest pain patients: men (53% vs 48% women, P = .0009) and older patients (>55 years, 60% vs 44% younger, P < .0001) had higher aspirin therapy due to administration to the patients with non-ACS chest pain.Conclusion: For patients with undifferentiated chest pain, overall race, sex, and age differences were explained by higher rates of aspirin administered to older men with non-ACS chest pain.

Patient population and factors determining length of stay in adult ED of a Turkish University Medical Center

Didem Ay, Meltem Akkas, Bulent Sivri — 2010-01-25

Abstract: This study is designed to analyze retrospectively patients who present to adult emergency department (ED) from January 1, 2002, to February 28, 2002. Age, sex, presentation time to ED, length of stay in emergency service, consultations, the number of patients who need to be hospitalized and also the number of hospitalized patients, diagnosis categories, and discharge instructions are analyzed. It is found that patients in most admissions are at 21 to 25 years of age. At night, the number of visits is decreased. Hospitalizations could be done to only about half of patients who in fact should be hospitalized. There is a correlation between the length of stay of patients in emergency service and the number of consultations per patient. There is also a correlation between patient complexity and length of stay in emergency service. The ED overcrowding rises with increased visits and patients staying in ED who should be hospitalized.

Stroke registry: hemorrhagic vs ischemic strokes

Joseph R. Shiber, Emily Fontane, Ademola Adewale — 2010-03-01

Abstract: Background: Epidemiologic studies of stroke in the 1970s and 1980s have reported the percentage of ischemic stroke as 73% to 86%, with hemorrhagic stroke as only 8% to 18%; the remainder was undetermined (due to not performing computed tomographic [CT] scanning or an autopsy). In our clinical work, it appeared anecdotally to the authors that we were seeing more hemorrhagic strokes than these previously quoted figures.Methods: We conducted a retrospective review for 1 year of all patients discharged from the hospital, a regional stroke center, with a diagnosis of stroke; we compared ischemic to hemorrhagic stroke types.Results: There were 757 patients included. Of the patients, 41.9% were hemorrhagic and 58.1% were ischemic.Conclusion: There were a much greater percentage of hemorrhagic strokes in this population than would have been predicted from previous studies. This finding may be due to improvement of CT scan availability and implementation unmasking a previous underestimation of the actual percentage or to an increase in therapeutic use of antiplatelet agents and warfarin causing an increase in the incidence of hemorrhage.

Injury patterns related to ultralight aircraft crashes

2010-01-25

Abstract: Purpose: Flying ultralight aircraft is a popular and growing form of recreation. However, there is considerable risk involved in this activity. This study was undertaken to catalogue the injury patterns, surgical procedures, and complications of patients involved in ultralight crashes in southwest Michigan.Basic procedures: The trauma registry at Bronson Methodist Hospital was used to retrospectively identify all ultralight crashes between 1983 and 2006. All patients who survived to the hospital were included in the study.Main findings: Seventeen patients were identified, all males with a mean age of 48.5 years. Mean injury severity score was 23, with all patients sustaining multiple injuries. Mortality was 17%. Lower extremity fractures were most common, followed by head/neck/facial injuries. Orthopedic extremity procedures were most commonly performed.Principal conclusions: Ultralight crashes result in complex high-energy injury patterns. These patients are likely to require the resources of designated trauma centers. Increased oversight may help prevent ultralight-related injuries.

Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED

James W. Tsung, Christopher C. Raio, Daniela Ramirez-Schrempp, Michael Blaivas — 2009-10-26

Abstract: Objective: The diagnosis of cholecystitis or biliary tract disease in children and adolescents is an uncommon occurrence in the emergency department and other acute care settings. Misdiagnosis and delays in diagnosing children with cholecystitis or biliary tract disease of up to months and years have been reported in the literature. We discuss the technique and potential utility of point-of-care ultrasound evaluation in a series of pediatric patients with suspected cholecystitis or biliary tract disease.Methods: We present a nonconsecutive case series of pediatric and adolescent patients with abdominal pain diagnosed with cholecystitis or biliary tract disease using point-of-care ultrasound. The published sonographic criteria is 3 mm or less for the upper limits of normal gallbladder wall thickness and is 3 mm or less for normal common bile duct diameter (measured from inner wall to inner wall) in children. Measurements above these limits were considered abnormal, in addition to the sonographic presence of gallstones, pericholecystic fluid, and a sonographic Murphy's sign.Results: Point-of care ultrasound screening detected 13 female pediatric patients with cholecystitis or biliary tract disease when the authors were on duty over a 5-year period. Diagnoses were confirmed by radiology imaging or at surgery and surgical pathology.Conclusions: Point-of-care ultrasound to detect pediatric cholecystitis or biliary tract disease may help avoid misdiagnosis or delays in diagnosis in children with abdominal pain.

Needle tip visualization during ultrasound-guided vascular access: short-axis vs long-axis approach

Michael B. Stone, Cynthia Moon, Darrell Sutijono, Michael Blaivas — 2009-10-26

Abstract: Objectives: Ultrasound guidance for central venous catheterization improves success rates and decreases complications when compared to the landmark technique. Prior research has demonstrated that arterial and/or posterior vein wall puncture still occurs despite real-time ultrasound guidance. The inability to maintain visualization of the needle tip may contribute to these complications. This study aims to identify whether long-axis or short-axis approaches to ultrasound-guided vascular access afford improved visibility of the needle tip.Methods: A prospective trial was conducted at a level I trauma center with an emergency medicine residency. Medical students and residents placed needles into vascular access tissue phantoms using long-axis and short-axis approaches. Ultrasound images obtained at the time of vessel puncture were then reviewed. Primary outcome measures were visibility of the needle tip at the time of puncture and total time to successful puncture of the vessel.Results: All subjects were able to successfully obtain simulated blood from the tissue phantom. Mean time to puncture was 14.8 seconds in the long-axis group and 12.4 seconds in the short-axis group (P = .48). Needle tip visibility at the time of vessel puncture was higher in the long-axis group (24/39, 62%) as opposed to the short-axis group (9/39, 23%) (P = .01).Conclusions: In a simulated vascular access model, the long-axis approach to ultrasound-guided vascular access was associated with improved visibility of the needle tip during vessel puncture. This approach may help decrease complications associated with ultrasound-guided central venous catheterization and should be prospectively evaluated in future studies.

Prescription use and survival among nonagenarians presenting to the ED

Rebecca L. Rao, Raquel M. Schears — 2009-11-23

Abstract: To characterize prescription medication use and survival effect among nonagenarians with an emergency department (ED) visit, we performed a retrospective chart review for all nonagenarians presenting to the ED in 2002. Data were collected on medication number and category and on survival after discharge. At admission, patients were taking no medications (3.2%), 1 to 4 medications (35%), 5 to 9 medications (51.9%), or at least 10 medications (9.9%); the median number increased by 2 at discharge (P < .001). Among 565 patients dismissed, 6-month survival was 77.8% and 1-year survival was 65.6%. Patients discharged with prescriptions for opioids or other analgesics were more likely to die within 12 months than those discharged without these medications. Patients taking aspirin had a 40% lower mortality compared with those not taking aspirin (P = .004). Patients discharged with medication in other categories had no excess mortality.

Prospective comparison of emergency physician–performed venous ultrasound and CT venography for deep venous thrombosis

Stephen A. Shiver, Matthew Lyon, Michael Blaivas, Srikar Adhikari — 2010-02-08

Abstract: Background: Venous thromboembolic disease is a major cause of mortality and morbidity.Objectives: The aim of this study is to compare emergency physician–performed ultrasound (EPPU) of the lower extremities with CT venography (CTV) in emergency department (ED) patients undergoing workup for pulmonary embolism (PE).Methods: This was a prospective study performed at a busy academic ED. Adult patients (>18) undergoing workup for PE were eligible for the study; enrollment was based on a convenience sample, during hours worked by the investigators. Study patients underwent EPPU of the lower extremities followed by CT angiogram (CTA) of the chest and CTV of the lower extremities. Sensitivity and specificity of the ultrasound examination were calculated using CTV as the gold standard.Results: A total of 61 patients were enrolled. Of 61 patients, 50 (82%; 95% confidence interval [CI], 72%-91%) had negative workups; 11 (18%; 95% CI, 8%-27%) were noted to have PE on CTA; 6 (10%; 95% CI, 2%-17%) were noted to have lower extremity deep venous thrombosis (DVT) on both EPPU and CTV evaluation; whereas 1 patient was found to have an external iliac DVT on CTV, which was not noted on EPPU. All patients with DVT (by either EPPU or CTV) were found to have PE on CTA. Sensitivity and specificity of EPPU when compared to CTV in the diagnosis of DVT was 86% (95% CI, 42%-99%) and 100% (95% CI, 91%-100%), respectively.Conclusions: Emergency physician–performed ultrasound produces results consistent with CTV in the diagnosis of femoropopliteal DVT. More proximal clots are not evaluated with EPPU and thus may result in a false negative.

Intravenous tissue plasminogen activator and stroke in the elderly

W.T. Longstreth, Ronit Katz, David L. Tirschwell, Mary Cushman, Bruce M. Psaty — 2010-02-08

Abstract: Objective: Since publication in 1995 of the National Institute of Neurological Disorders and Stroke (NINDS) trial of intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke, the benefit and frequency of use of IV tPA in the elderly have remained uncertain.Methods: We obtained data from the NINDS trial to summarize outcomes for randomized subjects older than 80 years. We used data from the Cardiovascular Health Study, a cohort study of 5888 elderly participants from 4 US communities followed longitudinally for stroke since 1989 to estimate the use of and hospital outcome after IV tPA in older adults following publication of the trial in 1995.Results: In the NINDS trial, 44 subjects older than 80 years were randomized, and their 3-month functional outcomes were not significantly improved with IV tPA. Of 25 randomized to IV tPA, 4 experienced symptomatic intracranial hemorrhages within 36 hours of treatment. Compared with younger patients, older patients were 2.87 times more likely to experience a symptomatic intracranial hemorrhage within 36 hours of IV tPA (95% confidence interval, 1.04-7.93). Of 227 Cardiovascular Health Study participants hospitalized for ischemic stroke between 1995 and 2002, seven, whose mean age was 84 years, were treated with IV tPA (3.1%; 95% confidence interval 1.2-6.2). Two had symptomatic intracranial hemorrhages, 3 failed to improve, and 2 of the 7 had good outcomes.Conclusions: These data highlight the need to clarify the risk-benefit profile of IV tPA in ischemic stroke victims who are older than 80 years.

Electrocardiographic manifestations of cardiac infectious-inflammatory disorders

2010-02-08

Abstract: Inflammatory disorders of the heart, although uncommon in the general population, often present initially to the emergency department. Symptoms and clinical manifestations are shared with other more common cardiopulmonary diseases, particularly acute coronary syndrome and congestive heart failure, making prompt diagnosis challenging. This review will highlight some of the clinical and electrocardiographic features that will help early diagnosis and differentiation of inflammatory cardiac disorders from other more common conditions.

Electrocardiographic differential diagnosis of narrow QRS complex tachycardia: an ED-oriented algorithmic approach

Matthew P. Borloz, Dustin G. Mark, Jesse M. Pines, William J. Brady — 2010-02-08

Abstract: The differentiation of narrow complex tachycardias is a common diagnostic conundrum encountered by emergency physicians. Although a number of published algorithms are available to assist the clinician in evaluating features of the 12-lead electrocardiogram (ECG), many of these are too cumbersome, requiring multiple decisions and introducing treatment suggestions within the diagnostic framework. To optimize the diagnosis of the narrow complex tachycardia, we propose 3 separate algorithms tailored to address varying levels of available clinical information. The static algorithm depends only on the 12-lead ECG without the benefit of historical data or diagnostic interventions. The comparative algorithm requires a baseline ECG to which the presenting ECG is compared. The dynamic algorithm encourages the clinician to take advantage of diagnostic maneuvers to further elucidate the tachycardia mechanism. Each of these algorithms requires the clinician to answer either “yes” or “no” for each criterion and does not include treatment recommendations.

The loading dose of clopidogrel in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty

Gen-Min Lin, Chih-Lu Han — 2010-03-01

Dangas et al reported that in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with contemporary anticoagulation regimens, a 600-mg loading dose of clopidogrel may safely reduce 30-day ischemic adverse event rates compared with a 300-mg loading dose. Although the higher dose demonstrated better 30-day clinical outcomes in multivariable and propensity score analysis, the emphasis should be put on whether the statistic advantages were mainly present in higher risk groups in this setting.

Pitfalls in salicylate toxicity

Keenan Bora, Cynthia Aaron — 2010-03-01

We read with great interest the report by Drs Herres, Ryan, and Salzman entitled “Delayed Salicylate Toxicity With Undetectable Initial Levels After Large-dose Aspirin Ingestion” . The authors have uncovered many of the pitfalls that have plagued treatment of aspirin-poisoned patients and make it such a difficult ingestion to treat appropriately. It also brings home the point that salicylate intoxication, like acetaminophen, may seem relatively innocuous in the face of worsening toxicity.

Prehospital physician management of pericardial tamponade due to penetrating trauma

Cliff Reid, Karel Habig — 2010-03-01

Dr Barthélémy and colleagues' interesting case report demonstrates the importance of the identification of pericardial tamponade, the utility of ultrasound, and the possibility of excellent outcome in patients with tamponade due to a right ventricular stab wound who receive timely surgical intervention .

Iatrogenic water intoxication after pelvic ultrasonography imaging

Meltem Akkaş Camkurt, Figen Coşkun, Nalan Metin Aksu, Erhan Akpınar, Didem Ay — 2010-02-08

Ultrasound (US) is a simple, easily accessible, and noninvasive method. Thus, it is commonly used. The bladder should be sufficiently filled to acquire pelvic images by US. This report describes water poisoning in 3 patients with no hepatic, cardiac, or renal disease. Both patients had a history of excessive fluid intake.

Fatal posterior sternoclavicular joint dislocation due to occult trauma

Mark Fenig, Robin Lowman, Byron P. Thompson, Philip H. Shayne — 2010-03-01

Posterior sternoclavicular joint dislocations (PSCJDs) are extremely rare, emergent injuries. We present an unprecedented case of a 16-year-old boy without any initial history or signs of trauma who died of a brachiocephalic vein laceration secondary to an occult PSCJD. The pathophysiology, treatment, and diagnosis of PSCJD are discussed.

Novel method for detecting brain abnormality in a patient with epidural hematoma: a case report

Rosanne S. Naunheim, Teya Casner — 2010-03-01

An estimated 1.5 million head injuries occur in the United States each year, with approximately 2% resulting in epidural hematomas. Epidural hematomas can be difficult to recognize clinically because the patient may not have a loss of consciousness or may have a brief loss of consciousness with a normal neurological examination. It is important to recognize patients with epidurals because the reported mortality for unrecognized epidural hematoma is as high as 40%. We report a novel method of identifying brain abnormality in a patient with a normal neurological examination result using a bedside handheld automated electroencephalogram device.

Reversible Leukoencephalopathy Syndrome

Kshitij Mankad, Edward Hoey, Ki Sing Yap — 2010-03-01

Reversible encephalopathy syndrome is a multietiological condition, the pathophysiology of which lies in the breach of the blood-brain barrier due to increased local cerebral perfusion pressure. Patients present clinically in nonspecific ways; acute computed tomography is often unrevealing, and as such, there should be a low threshold for early magnetic resonance imaging even in the acute setting because misdiagnosis may lead to mismanagement. Although initially described to present with changes depicted on imaging in the “posterior aspects” of the brain, more recent literature has focused attention on the fact that signal changes may occur anywhere in the brain. We present a case demonstrating such prolific changes throughout the brain stressing on the need for early appropriate use of radiodiagnostics.

FAST scan in the diagnosis of acute diaphragmatic rupture

Rip Gangahar, Deepak Doshi — 2010-03-01

Focused assessment with sonography in trauma (FAST) scan can be used by emergency physicians in the diagnosis of diaphragmatic rupture in blunt abdominal trauma. We introduce a new feature ‘Rip’s absent organ sign’ on FAST scan in the diagnosis of acute diaphragmatic rupture.

First case of stress cardiomyopathy as a result of methadone withdrawal secondary to drug-drug interaction

Frédéric Lemesle, Florence Lemesle, Walid Nicola, Annie Pierre Jonville-Béra — 2010-03-01

We describe the first case of stress cardiomyopathy secondary to a drug-drug interaction. A 44-year-old man was admitted for acute agitation, hallucinations, tachycardia, and fever within 2 hours of ingestion of naltrexone prescribed to stop alcohol consumption. He had been receiving methadone (120 mg/d) for several months for a history of heroin use; thus, acute opiate withdrawal syndrome secondary to naltrexone treatment was diagnosed. Because electrocardiography showed diffuse ST-segment elevation, a transthoracic echocardiography was performed. It revealed apical akinesia of the left ventricle with a reduction in systolic function. The echocardiogram showed an ejection fraction of 35%, apical and midventricular wall motion abnormalities of the left ventricle, and a cardiac output of 4 L/min without coronary stenosis. The patient was transferred to the cardiologic intensive care unit with a diagnosis of transient left ventricular apical ballooning syndrome secondary to acute opiate withdrawal syndrome. It is likely that opioid withdrawal, inducing a marked increase in catecholamine plasma concentrations, contributed to the development of stress cardiomyopathy. To our knowledge, this is the first case of stress cardiomyopathy described after abrupt opiate withdrawal secondary to a drug-drug interaction.

Computed tomography–guided pericardiocentesis: utility in the management of malignant pericardial effusion

Edward T.D. Hoey, Kshitij Mankad — 2010-03-01

Transthoracic echocardiography is an established means of diagnosing a pericardial effusion and has become the reference guidance modality for drainage of symptomatic collections. However, echocardiographic drainage is not feasible in all patients for a variety of technical and patient-related factors. Computed tomography (CT)–directed pericardiocentesis using a standard Seldinger technique is an alternative means of draining pericardial effusions and overcomes many of the limitations associated with echocardiography. We present a case in which a CT-guided approach was used to successfully drain a malignant pericardial effusion in the emergent setting. Clinicians should be aware of the potential role of CT in this setting.

Severe metabolic acidosis secondary to coadministration of creatine and metformin, a case report

Hossein Saidi, Mofidi Mani — 2010-03-01

Abstract: It is known from studies in young athletes that creatine supplements have beneficial effects on muscular functional capacity, so it is being widely used as a performance-enhancing substance in both professional and amateur sports men and women. They are approved and considered relatively safe, but there have been a few case reports of renal dysfunction associated with their use. We present the case of a patient who developed acute renal failure and lactic acidosis while using creatine and metformin simultaneously.

Prehospital lung ultrasound in the distinction between pulmonary edema and exacerbation of chronic obstructive pulmonary disease

2009-10-26

We present 2 cases of dyspneic patients, where prehospital lung ultrasound helped to distinguish between pulmonary edema and acute exacerbation of chronic obstructive pulmonary disease.

Pancreatic cholangiocarcinoma as an ST-elevation myocardial infarction with thrombolytic therapy

2010-03-01

We report the case of a 46-year-old patient who presented a chest pain with ST-segment elevation in precordial leads V1 (2 mm), V2 (4 mm), and V3 (3 mm). Thrombolytic therapy was initiated with the combination tenecteplase tissue plasminogene activator, aspirin, and heparin. Further electrocardiogram and cardiac enzymes measured every 2 hours during the first 24 hours remained normal, and after a computed tomography of the abdomen, the patient was taken to surgery for an exploratory abdominal operation that revealed pancreatic cholangiocarcinoma. No adverse effects were attributed to the initial thrombolytic therapy. Finally, myocardial ischemia was excluded because the electrocardiogram, cardiac enzymes, and a 1-month later cardiac stress test remained normal and because no coronary event occurred during the first year after surgery. Our case shows that it is sometimes difficult to make the share, in prehospital field, between coronary syndrome and other pathology, particularly digestive pathology. However, in the appropriate chest pain patient with presumed acute myocardial infarction, ST-segment elevation remains the primary criterion for the initiation of thrombolytic therapy, primary angioplasty, and/or other pharmacologic interventions.

Beneficial response to mild therapeutic hypothermia for comatose survivors of near-hanging

Dietrich Jehle, Michael Meyer, Seth Gemme — 2010-03-01

Therapeutic hypothermia has been shown to clearly benefit comatose survivors of cardiac arrest. It is reasonable to postulate that if therapeutic hypothermia is beneficial for the neurological injury of cardiac arrest, then it may have a role in the treatment of near-hanging suffocation injuries. We report a retrospective series of 2 patients who received mild therapeutic hypothermia for their comatose state after a near-hanging injury. The exclusionary criteria and protocols that we use for comatose survivors of cardiac arrest were used. After at least 24 hours of mild therapeutic hypothermia, both patients had a complete return of neurological function, with Glasgow Coma Scale scores of 15 at the time of discharge from the hospital. These data, taken with other case series, suggest that therapeutic hypothermia may be beneficial for comatose survivors of near-hanging.

Bilateral obstructing renal stones: an uncommon cause of acute renal failure

Jason R. Stone, Tristan L. Knutson, Christopher Kang — 2010-03-01

Bilateral renal calculi are an uncommon cause of acute renal failure (ARF). The causes of ARF include prerenal, obstructive (or postrenal), and intrinsic . Postrenal causes account for 5% to 15% of cases of ARF . This case report will present a case of acute renal failure secondary to bilateral obstructing ureteral calculi.

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2010-03-01

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2010-03-01

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2010-03-01

American Journal of Emergency Medicine

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Severe metabolic acidosis secondary to coadministration of creatine and metformin, a case report

Prehospital lung ultrasound in the distinction between pulmonary edema and exacerbation of chronic obstructive pulmonary disease

Pancreatic cholangiocarcinoma as an ST-elevation myocardial infarction with thrombolytic therapy

Beneficial response to mild therapeutic hypothermia for comatose survivors of near-hanging

Bilateral obstructing renal stones: an uncommon cause of acute renal failure

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