A portrait of patients who die in-hospital from acute pulmonary embolism
1914 Correspondence / American Journal of Emergency Medicine 36 (2018) 1895–1921
Table 2
The Quality of chest compressions and ventilation.
PHASE I (before refresher course) PHASE II (2 months after refresher course)
Study group
prehospital CPR Hospital CPR Prehospital CPR Hospital CPR
Subgroup PRE/CW PRE/IW HOS/CW HOS/IW PRE/CW PRE/IW HOS/CW HOS/IW
Depth of chest Median |
compressions 50 |
48 |
47 |
46 |
56 |
52 |
55? |
54? |
IQR |
43.5-57.5 |
40.25-53.75 |
37.75-54.00 |
40.5-52.0 |
52.0-59.0 |
46.0-57.5 |
51.0-60.0 |
51.0-58.0 |
Frequency of chest compressions |
||||||||
Median |
121 |
113.5 |
116 |
110 |
119 |
116 |
108 |
113 |
IQR |
93-131 |
97.5-123 |
106.5-122 |
102-122.5 |
104-127 |
104-123 |
95-116.5 |
104-118 |
Number of chest compression delivered during the 2-min CPR period |
||||||||
Median |
151 |
151 |
149 |
151 |
149 |
152 |
139? |
148 |
IQR |
127.5-180 |
137.25-174 |
142.75-166 |
145-161.5 |
139-167 |
140.5-163.5 |
122-150 |
133-162 |
% of compete chest recoil |
||||||||
Median |
98 |
99 |
97 |
95 |
92 |
97 |
99 |
91 |
IQR |
80.5-100 |
82.75-100 |
86-100 |
54-100 |
76-99 |
83-99,5 |
88.25-100 |
51-99 |
Number of rescue breaths delivered during the 2-min CPR period |
||||||||
Median |
8 |
8 |
0 |
1 |
9 |
9 |
2? |
2 |
IQR |
1-10 |
0.25-10 |
0-1 |
0-4.5 |
7-10 |
8-10 |
0-6.25? |
0-4 |
Tidal volume (Vt) ml |
||||||||
Median |
401 |
452.5 |
0 |
191 |
546 |
457 |
208? |
225 |
IQR |
121.5-581.5 |
53-563.75 |
0-194.25 |
0-261.5 |
382-615 |
381-660 |
0-252 |
0-287 |
Data are given as median and interquartile range IQR; PRE/CW: nurses from conservative wards performing “prehospital” CPR; PRE/IW: nurses from interventional wards performing
“prehospital” CPR; HOS/CW: nurses from conservative wards performing “hospital” CPR; HOS/IW: nurses from interventional wards performing “hospital” CPR. The significant of bold p b 0.05.
* p b 0.05 when compared with the results before the refresher course.
Pawel Wiech, RN, MN, CEN, DHSc*
Institute of Nursing and Health Sciences, Faculty of Medicine, University of
Rzeszow, Rzeszow, Poland
*Corresponding author at: Institute of Nursing and Health Sciences, University of Rzeszow, Al. mjr.W.Kopisto 2 a, 35 – 310 Rzeszow, Poland.
E-mail address: [email protected].
Marek Muster, MSc, EMT-P
Centre for Innovative Research in Medical and Natural Sciences, University
of Rzeszow, Rzeszow, Poland
Dariusz Bazalinski, RN, MN, CEN, DHSc
Institute of Nursing and Health Sciences, Faculty of Medicine, University of
Rzeszow, Rzeszow, Poland
Grzegorz Kucaba, MSc, EMT-P
Institute of Midwifery and Medical Lifesaving, Faculty of Medicine,
University of Rzeszow, Rzeszow, Poland
Izabela Salacinska, RN, MN, CRNA Pawel Januszewicz, Prof., MD, PhD
Institute of Nursing and Health Sciences, Faculty of Medicine, University of
Rzeszow, Rzeszow, Poland
Bogumila Woloszczuk-Gebicka, MD., PhD
Institute of Midwifery and Medical Lifesaving, Faculty of Medicine,
University of Rzeszow, Rzeszow, Poland
14 December 2017
https://doi.org/10.1016/j.ajem.2018.02.033
References
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- Buck-Barrett I, Squire I. The use of basic life support by hospital staff: what skills should be taught? Resuscitation 2004;60:39-44.
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A portrait of patients who die in-hospital from acute pulmonary embolism
Acute pulmonary embolism is a prevalent disease occur- ring in 100-200/100,000 inhabitants/year with a mortality rate of 17.4% at 90-days in the Unselected population [1]. The predictors of early death after APE include advanced age, comorbidities, and clinical picture at presentation [2], where mortality ranges from 8.1% in cases with right ventricular dysfunction to 24.5% in cardio- genic shock and 64.8% when cardiopulmonary resuscitation is re- quired [3]. Herein, we present the characteristics of a series of patients who died in-hospital from APE.
We retrospectively reviewed charts of 17 adults (N18 years) who died in the period from 2010 to 2015 at Tampa General Hos- pital from APE that was confirmed by computed tomography an- giogram (CTA). Continuous variables will be presented as median and interquartile range (IQR) and categorical variables will be listed as counts and percentages. Patients presented to the emer- gency department within 2.5 (1, 5.8) hours from symptom onset
Correspondence / American Journal of Emergency Medicine 36 (2018) 1895–1921 1915
Fig. 1. 12-lead electrocardiograms of 2 patients who die in-hospital from acute pulmonary embolism showing ST-segment elevation and T-wave inversion in precordial leads (panel a) and S1 Q3 T3 pattern with T wave inversion in precordial leads (panel b).
and the diagnosis of APE was established within 5 (2, 13) hours from arrival to emergency department. Death occurred within a median of 6 days since arrival to the emergency department. In 53% of the cases, the diagnosis of APE was established by emergen- cy physician and in 47% by floor physician. 77% of the cases were classified to have either massive or submassive APE and 47% (8/ 17) were considered to have massive APE due to requirement of pressor support [4].
Analysis of patients’ demographics showed a median age of 68 (57, 74) years, a body mass index of 28 (24, 32) kg/m2, 65% were men, 60% were white, 35% were smokers, 29% had history of cancer, and 41% had history of prior venous thromboembolism. 25% of the cases had orthopedic surgery in the preceding 90 days. With regard to the clinical presentation, 71% complained of chest pain, 47% had dyspnea and one case had syncope and one had presyncope as the main presenting complaint. 35% were tachycardic on admission
1916 Correspondence / American Journal of Emergency Medicine 36 (2018) 1895–1921
and 18% developed a new onset atrial fibrillation, and 24% had an admission oxygen saturation b 88%. Imaging showed that 46% had Right ventricular dilation and/or hypokinesis on echocardiogram and 36% had concomitant deep venous thrombosis. 70% of the cases required either bi-level positive airway pressure (BiPAP) sup- port (41%) or mechanical ventilation (29%). The duration of hospi- talization was 6 (2, 28) days.
15 cases had available Electrocardiogram on admission and only 13 cases were analyzed after excluding 2 cases with Left bundle branch block and paced ventricular rhythm, respectively. The commonest ECG abnormality was sinus tachycardia which was present in 53% (8/15) of the cases. This was followed in de- scending order by ST-segment elevation in lead V1 which was pres- ent in 46% (6/13) of the cases, ST-segment elevation in both V1 and aVR in 38% (5/13), poor R wave progression in 38% (5/13), ST- segment depression in V4-V6 in 36% (5/14), T wave inversion in in- ferior leads in 31% (4/13), ST-segment elevation in leads III, V1 and aVR in 23% (3/13), Right axis deviation in 23% (3/13), ST-segment elevation in V1-V4 in 15% (2/13), ST-segment elevation in inferior leads in 15% (2/13), T-wave inversion in V1-V4 in 15% (2/13), S1Q3T3 pattern in 15% (2/13), QTc prolongation in 15% (2/13), and 15% (2/13) had >=9/12 leads with T-wave inversion. Fig. 1 shows an example of 2 different EKG patterns encountered on ad- mission in patients who die in-hospital from APE.
Prior work showed that two out of every three patients
succumbing to APE die within two hours after presentation, and that 10% of APE is fatal in the first hour [5]. Stulz and colleagues also showed that in patients with massive APE, 50% die within 30 min, 70% die within 1 h, and N85% die within 6 h of the onset of symptoms [6]. In our cohort, death occurred within a median of 6 days since arrival to the emergency department and only 2 cases (12%) died in the first 24 h (19 and 22 h). The early presenta- tion to the emergency department within a median of 2.5 h of the onset of symptoms allowed for early diagnosis and treatment, like- ly leading to significant reduction of death very early in the course of disease, despite that half the cases in our cohort were classified to have massive APE. These cases presented early likely due to the notable degree of hemodynamic instability evident in the require- ment of 70% of the cases to either Bipap or mechanical ventilation support and pressors in approximately half the cases. Surprisingly, despite this degree of hemodynamic instability in the majority of our cases, and the fact that emergency physicians tend to utilize CTA excessively to rule our APE (one-third of imaging performed in the emergency for suspected APE is categorized as avoidable [7]), only half of the cases in our cohort were diagnosed by emer- gency physicians. This conforms with prior observations which show that half of the cases with APE get diagnosed with initiation of treatment in the emergency department [8,9], suggesting that symptoms and signs of APE remain nonspecific ina significant por- tion of cases. Although on-admission EKG in this cohort exemplify its low sensitivity in identifying future non-survivors, certain find- ings occurred with high frequency including ST-segment elevation in lead V1 which was present in 46% and ST-segment elevation in both V1 and aVR which occurred in 38% of the cases, which at- least support prior data showing that these two signs were inde- pendent predictors of death and complications during hospitaliza- tion in APE, respectively [10]. This descriptive-only analysis allows the awareness of characteristics of a group of patients with APE who die in-hospital, which may help in risk stratification, early diagnosis and treatment hoping to improve outcomes.
Hesham R. Omar
Internal Medicine Department, Mercy Medical Center, Clinton, IA, USA
Corresponding author.
E-mail address: [email protected]
Mehdi Mirsaeidi
Division of Pulmonary, Critical Care, Sleep and Allergy, University ofMiami,
Miller School of Medicine, Florida, USA Section of Pulmonary, Department of Medicine, Miami VA Medical Center,
Miami, FL, USA
Bishoy Abraham
Tampa General Hospital, Tampa, FL, USA
Garett Enten
Tampa General Hospital, Tampa, FL, USA
Devanand Mangar
Tampa General Hospital, TEAM Health, Tampa, FL, USA
Enrico M. Camporesi
University of South Florida, FGTBA and TEAM Health, Tampa, FL, USA
16 February 2018
https://doi.org/10.1016/j.ajem.2018.02.035
References
Belohlavek J, Dytrych V, Linhart A. Pulmonary embolism, part I: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol 2013;18(2):129-38.
- Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353(9162):1386-9.
- Kasper W, et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997;30(5):1165-71.
- Jaff MR, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hyper- tension: a scientific statement from the American Heart Association. Circulation 2011;123(16):1788-830.
- Kearon C. Natural history of venous thromboembolism. Circulation 2003;107(23 Suppl 1):I22-30.
- Stulz P, et al. Decision making in the surgical treatment of massive pulmonary em- bolism. Eur J Cardiothorac Surg 1994;8(4):188-93.
- Venkatesh AK, et al. Evaluation of pulmonary embolism in the emergency depart- ment and consistency with a national quality measure: quantifying the opportunity for improvement. Arch Intern Med 2012;172(13):1028-32.
- Jones AE, Kline JA. Availability of technology to evaluate for pulmonary embolism in academic emergency departments in the United States. J Thromb Haemost 2003; 1(10):2240-2.
- Pollack CV, et al. Clinical characteristics, management, and outcomes of patients di- agnosed with acute pulmonary embolism in the emergency department: initial re- port of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol 2011;57(6):700-6.
- Kukla P, et al. Electrocardiography and prognosis of patients with acute pulmonary embolism. Cardiol J 2011;18(6):648-53.
Emergency services response to Elder abuse and neglect – Then and now
As defined by the Centers for Disease Control (CDC), elder abuse is an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older (aged >=60) adult [1]. Forms of elder abuse in- clude Physical abuse, sexual abuse or abusive sexual contact, emotional or psychological abuse, neglect, and financial abuse or exploitation [1]. All states within the US have a mandatory reporting statute for elder
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