Article

The electrocardiogram in pulmonary embolus: Diagnostic applications

Correspondence / American Journal of Emergency Medicine 37 (2019) 151172 165

Table 2

End result of naloxone prescription.

Prescription outcome Number of patients

Brought naloxone prescription to pharmacy, (%) 14 (25.5) Completed training and obtained naloxone (CTON), total (%) 10 (18.2) CTON with primary diagnosis of overdose, (%) 4 (18.2)

CTON with other diagnosis than overdose, (%) 6 (18.2)

CTON and had other prescriptions, (%) 6 (24)

CTON and only had a naloxone prescription, (%) 4 (13.3)

be considered the gold standard for delivery where one patient trained equals one equipped to prevent an overdose death. These programs are associated with improving survival from an overdose [5]. The hospital environment is a much more complicated entity, and must follow regu- lations that can preclude easy dispensing of medications such as nalox- one for out of hospital use. Medications intended for home use must involve a licensed pharmacy unless a more complicated process is de- veloped in the ED to be in compliance with state prescribing and dis- pensing regulations. Given the constraints of the hospital ecosystem we have identified a barrier to deliver naloxone to patients for out of hospital use as successfully as community-based programs.

Another potential barrier to successful receipt of medication is the cost of a minimal dispensing fee charged at our pharmacy; however this can be waived one time for patients without the ability to pay. The major problem in our series is patients did not present to the phar- macy as expected. Understanding why the adherence with the process is poor in this patient population is multifactorial.

In light of this data, point-of-care delivery systems of naloxone should be developed. This may be accomplished by manually logging all dispensing in accordance with hospital policy and state regulations. However, this will add additional administrative burdens on an already busy ED staff. Additional steps should be taken at the legislative level to simplify point-of-care distribution by amending pharmacy and provider practice acts. This is needed in order to combat the opioid epidemic.

To our knowledge, this is the first retrospective study evaluating the rate of naloxone obtainment with a standardized process of prescribing in the ED and dispensing from an onsite pharmacy. We have provided observational evidence that even with a standardized process in place to expand the distribution of naloxone to a vulnerable patient popula- tion, the ability of patients to obtain the life-saving medication is poor. Hospital-based prescribing is complex, but hospital-based delivery of naloxone must become as efficient in delivery as community-based programs.

Source of support

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Miranda Verdier, PharmD Department of Pharmacy, Cook County Health and Hospitals System, 1901 West Harrison Street, Chicago, IL 60612, United States

Joanne C. Routsolias, PharmD, RN, BCPS Department of Pharmacy, Cook County Health and Hospitals System, 1901 West Harrison Street, Chicago, IL 60612, United States

Department of Emergency Medicine, Cook County Health and Hospitals System, 1901 West Harrison Street, Chicago, IL 60612, United States Corresponding author at: Department of Emergency Medicine and Pharmacy, Cook County Health and Hospitals System, 1901 West Har- rison Street LL 170, Chicago, IL 60612, United States.

E-mail address: [email protected].

Steven E. Aks, DO, FACMT, FACEP

Department of Emergency Medicine, Cook County Health and Hospitals System, 1901 West Harrison Street, Chicago, IL 60612, United States The Toxikon Consortium, 1900 W Polk St., 10th Floor, Administration

Building, Chicago, IL 60612, United States

12 April 2018

https://doi.org/10.1016/j.ajem.2018.05.044

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    The electrocardiogram in pulmonary embolus: Diagnostic applications

    To the Editor,

    We read the article by Omar et al. [1], with great interest. We would like to stress the importance and usefulness of electrocar- diographic (EKG) changes in pulmonary embolism (PE), as these were not brought out by the authors [1]. The authors may state that EKG is neither sensitive nor specific to confirm or refute the di- agnosis of PE, as it may be normal in around 18% of PE [2]. Invari- ably EKG of PE patients may reveal features of S1Q3T3, new RAD, RBBB or T-wave inversions which shall make the treating physician to suspect PE, and proceed for further diagnostic testing [3] and intervention.

    In fact, Daniel’s [4] twenty-one-point EKG scoring system has a sen- sitivity and specificity of 23.5 and 97.7% respectively to recognize high risk PE and the severity of pulmonary hypertension too.

    Meta-analysis of over 3000 patients of PE, Qaddoura et al. [5], identi- fied six key EKG findings to prognosticate PE and majority of their find- ings overlapped with Daniels [4] score. Quite a few other studies [6-9] have confirmed the predictive value of ST elevations in Lead aVR and de- scribed these as an independent predictor of mortality in PE. Furthermore, T wave inversions in both lead III and v1 (the two rightmost leads) occurs more frequently in PE with 88% of patients, but 1% of patients with ACS [10].

    In addition, several EKG findings have an odds ratio for circulatory collapse [11] which is higher than echo findings of RV strain or an elevated troponin. Radiologically, confirmed cases of PE too had EKG changes. Moreover resolution of anterior T-wave inversion was considered as a possible marker of pulmonary reperfusion following thrombolysis.

    To conclude, EKG is less expensive and helpful at the bedside to sus- pect and manage pulmonary embolism especially in resource limited environ and more so those with syncope of undetermined origin and also helped for risk stratification.

    Above all, students of health sciences were taught and trained to

    look/search for EKG changes in PE. Hence, their knowledge shall be uti- lized towards diagnosis, risk stratification and intervention. Since EKG changes portend poor prognosis, care givers shall be informed about the possible outcome in the era of enhanced expectations from care providers.

    166 Correspondence / American Journal of Emergency Medicine 37 (2019) 151172

    Financial support

    Nil.

    Conflict of interest

    Nil.

    Subramanian Senthilkumaran

    non-invasive ventilation in patients with community acquired pneumonia in the emergency department: Author’s response

    We thank the authors for their interest in our manuscript and would like to take the time to address some of the valid concerns that have been raised.

    We agree that the patient’s severity of acute respiratory failure has bearing on prognosis in community acquired pneumonia and subse-

    Department of Emergency and Critical Care, Manian Medical Center, Erode,

    Tamil Nadu, India Corresponding author at: Department of Emergency & Critical Care Medicine, Bewell Hospitals, Erode, Tamil Nadu, India.

    E-mail address: [email protected].

    Narendra Nath Jena

    Department of Emergency Medicine, Meenakshi Mission Hospital and

    Research Centre, Madurai, Tamil Nadu, India

    Namasivayam Balamurugan

    Department of Neurosciences, SIMS Chellam Hospital, Salem, Tamil Nadu,

    India

    Florence Benita Department of Emergency Medicine, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India

    Ponniah Thirumalaikolundusubramanian Department of Internal Medicine, Chennai Medical College Hospital and Research Center, Irungalur, Trichy, Tamil Nadu, India

    1 December 2017

    https://doi.org/10.1016/j.ajem.2018.05.045

    References

    Omar HR, Mirsaeidi M, Weinstock MB, Enten G, Mangar D, Camporesi EM. Syncope on presentation is a surrogate for sub massive and massive acute pulmonary embo- lism. Am J Emerg Med 2018;36(2):297-300.

  5. Hubloue I, Schoors D, Diltoer M, Van Tussenbroek F, de Wilde PP. Early electrocardio- graphic signs in Acute massive pulmonary embolism. Eur J Emerg Med 1996;3: 199-204.
  6. Kukla P, Mcintyre WF, Fijorek K, Mirek-Bryniarska E, Bryniarski L, Krupa E, et al. Elec- trocardiographic abnormalities in patients with acute pulmonary embolism compli- cated by cardiogenic shock. Am J Emerg Med 2014;32:507-10.
  7. Daniel KR, Courtney DM, Kline JA. Assessment of cardiac stress from massive

    pulmonary embolism with 12-lead electrocardiography. Chest 2001;120(2): 474-81.

    Qaddoura A, Digby GC, Kabali C, Kukla P, Zhan ZQ, Baranchuk AM. The value of elec- trocardiography in prognosticating clinical deterioration and mortality in acute pul- monary embolism: a systematic review and meta-analysis. Clin Cardiol 2017;40 (10):814-24.

  8. Zhong-Qun Z, Chong-Quan W, Nikus KC, Sclarovsky S, Chao-Rong H. A new electro-

    cardiogram finding for massive pulmonary embolism: ST elevation in lead aVR with ST depression in leads I and V(4) to V(6). Am J Emerg Med 2013;31(456):e5-8.

    Kukla P, Dlugopolski R, Krupa E, Furtak R, Mirek-Bryniarska E, Jastrzebski M, et al. The prognostic value of ST-segment elevation in the lead aVR in patients with acute pulmonary embolism. Kardiol Pol 2011;69(7):649-54.

  9. Pourafkari L, Ghaffari S, Tajlil A, Akbarzadeh F, Jamali F, Nader ND. Clinical signifi- cance of ST elevation in lead aVR in acute pulmonary embolism. Ann Noninvasive Electrocardiol 2017;22(2).
  10. Digby GC, Kukla P, Zhan ZQ, Pastore CA, Piotrowicz R, Schapachnik E, et al. The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: a consensus paper. Ann Noninvasive Electrocardiol 2015;20: 207-23.
  11. Kosuge M, Kimura K, Ishikawa T, Ebina T, Hibi K, Kusama I, et al. Electrocardio- graphic differentiation between acute pulmonary embolism and acute coronary syndromes on the basis of Negative T waves. Am J Cardiol 2007 Mar 15;99(6): 817-21.
  12. Shopp JD, Stewart LK, Emmett TW, Kline JA. Findings from 12-lead electrocardiogra-

    phy that predict circulatory shock from pulmonary embolism: systematic review and meta-analysis. Acad Emerg Med 2015;22:1127-37.

    quently the intervention (NIV) applied. We provided information on the baseline severity of acute respiratory failure in Table1 (PaO2/FiO2 ratio, mean (SD): Whole Cohort 145(91.1), Successful NIV161.3 (95.8), Failed NIV 133.1(86.3); P = value 0.10). However, given the ret- rospective nature of our study, there was a large amount of missing ar- terial blood gas data. We excluded it from the main analysis as over 50% of patients did not have an arterial blood gas. Multiple imputation is a potential solution for missing data but given the large amount missing it was not advisable.

    Our study demonstrates that most patients who presented to the ED with CAP and respiratory failure received NIV as first line ventilatory therapy. The study which was conducted in two centres with an experi- ence in the use of NIV showed that NIV failed in 50% of cases. As such, caution is even more advisable when using NIV in centers with less experience.

    We do agree that NIV in our study may not have been used in the same population as what has been conducted in trials of NIV in hypox- emic respiratory failure. That is most trials use NIV earlier and almost prophylactically. This may not be the case in our population but we feel strongly that it represents the “real world” application of NIV in an emergency room population. Furthermore, although the systematic review by Keenan and colleagues [1] of randomized trails suggest that patients with acute respiratory failure are less likely to be intubated when NIV support is added to the standard medical treatment, those randomized studies were conducted in ICU setting and of heteroge- neous group of patients which totally different form our study’s popula- tion and setting. As we illustrated in the discussion section of the paper, most of the other previous reports on NIV and CAP are from a small sam- ple size and single centers with most studies showing a high NIV failure rate, defined as a need for intubation and ventilation, ranging from 38% to 66%.

    Finally, the aim of the study was to provide both an epidemiological description and an analysis of the predictors of NIV failure in patients with CAP who receive NIV in the ED as a first line ventilatory therapy. We are in complete agreement with the authors that more studies, par- ticularly randomized controlled studies, are needed to evaluate NIV use in patients with community acquired pneumonia.

    Amjad Al-Rajhi, MD

    Critical care medicine department, McGill University, Montreal,

    Quebec, Canada

    Corresponding author.

    E-mail address: [email protected].

    Jason Shahin, MD, MSC, FRCPCDr. McGill University, Department of Medicine, Respiratory Division, Department of Critical Care, Montreal, QC, Canada

    23 May 2018

    https://doi.org/10.1016/j.ajem.2018.05.046

    References

    Does noninvasive positive pressure ventilation improve outcome inacute hypoxemic respiratory failure? A systematic review. Sean P. Keenan, MD, FRCPC, MSc (Epid); Tasnim Sinuff, MD, FRCPC; Deborah J. Cook, MD, FRCPC, MSc (Epid); Nicholas S. Hill, MD.

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