Alan Jon Smally

GASTRIC RUPTURE FOLLOWING BAG-VALVE-MASK VENTILATION

Bag-valve-mask ventilation is a frequently used, generally safe and effective method of oxygenating and ventilating patients who are unable to do so themselves. The common complications of aspiration, inability to oxygenate, and gastric dilatation are recognized fairly quickly, although not always easily remedied. We report a case of a much rarer complication: gastric rupture with pneumoperitoneum. Prompt recognition and surgical intervention help minimize adverse outcomes from complications such as tension pneumoperitoneum with shock, peritonitis, and sepsis.

Hyperkalemia and Digoxin Toxicity in a Patient with Kidney Failure

Hyperkalemia resulting from digoxin toxicity is a well-recognized phenomenon. We report a case in which hyperkalemia, bradycardia, and hypotension were unresponsive to standard therapy but appeared to respond to digoxin-specific antibodies (Fab). This case highlights the importance of a high index of suspicion for digoxin toxicity as a potential cause of refractory hyperkalemia.

Point-of-care testing for coagulation studies in a stroke protocol: a time-saving innovation

STUDY OBJECTIVES Time counts in thrombolytic therapy for stroke. An international normalized ratio (INR) greater than 1.7 may preclude its use. We studied whether the use of point-of-care testing (POCT) for INR in the emergency department (ED) may substitute for the same test done in the central hospital laboratory, thereby reducing time to treatment. METHODS We performed a prospective observational study comparing a POCT analysis of INR (i-STAT-1; Abbott Inc, Abbott Park, Ill) with a simultaneously drawn sample sent to the central laboratory. We tested a convenience sample of adult patients taking warfarin who presented to the ED of a tertiary teaching hospital. RESULTS Thirty-two patients were enrolled. A receiver operator curve analysis was performed. Sensitivity and specificity were calculated for laboratory INR cutoff of 1.7. The area under the curve was 0.979 (95% confidence interval [CI], 0.843-0.991). When POCT INR was 2.1, the sensitivity for laboratory INR being higher than 1.7 was 100% (CI, 62.9%-100.0%), and the specificity was 90.5 (CI, 69.6-98.5). When POCT INR was 1.8, the specificity for laboratory INR being lower than 1.7 was 100% (CI, 83.7%-100%), and the sensitivity was 62.5% (CI, 24.7%-91.0%). The regression coefficient (r) value was 0.9648. CONCLUSION Correlation of POCT INR with that of the central laboratory and receiver operator curve characteristics are excellent. In general, POCT INR is about 0.3 higher than the laboratory INR. This is not generally of clinical importance, but when using cutoff of 1.7 (central laboratory), it may be. We describe a 3-tiered system for use of POCT INR in determining use of tissue-type plasminogen activator.

Using pharmacists to optimize patient outcomes and costs in the ED.

Participation of hospital clinical pharmacists in the care of inpatients is widespread, often encouraged by the dicta promulgated by regulatory bodies. For years, clinical pharmacists have ventured out of the pharmacy to participate in rounds and, otherwise, in the care of patients on hospital floors and in intensive care units. In fact, it has been well documented in many research studies published in the last 20 years that having pharmacists prospectively involved with orders generates significant cost savings for the hospital and benefit to patients. Until recently, the emergency department (ED) seemed to be a hectic environment that would be inhospitable to the careful, meticulous, and usually deliberate process of many clinical pharmacists. The potential benefits were recognized, but the pace and costs seemed prohibitive. The addition of pharmacists in the ED has reduced medication errors and provided numerous other benefits that will be discussed in this article. We will show that recent data indicate that using an ED clinical pharmacist promotes patient safety and is cost-effective.

POSTPERICARDIOTOMY SYNDROME FOLLOWING MINIMALLY INVASIVE CORONARY ARTERY BYPASS

A 62-year-old woman presented to the Emergency Department (ED) with chest pain, cough, subjective fever and chills. Symptoms had begun on the previous evening, three days after minimally invasive coronary artery bypass surgery (MICAB). A presumptive diagnosis of postpericardiotomy syndrome (postcardiac injury syndrome) was made and the patient admitted. This new, minimally invasive surgery allows discharge on the second postoperative day. Emergency physicians should be aware of this procedure since probably there will be increasing performance of MICAB procedures and patients will present to the ED with postoperative complications.