Bryan G Kane

Management of isolated yew berry toxicity with sodium bicarbonate: A case report in treatment efficacy

IntroductionTaxus species are known to be toxic and may result in significant dysrhythmias. Treatment of taxus induced cardiac dysrhythmias is based largely on case reports. We describe a case of a 24-year-old male withTaxus cuspidate (yew berry) toxicity initially treated with amiodarone bolus and infusion and subsequently managed with sodium bicarbonate boluses and continuous infusion.Case ReportThe patient was found at home by his parents with witnessed “seizure-like” activity 2 hours after reportedly chewing and swallowing 168 yew seeds. The initial prehospital rhythm strip demonstrated ventricular tachycardia (VT); the patient was hypotensive with fluctuating levels of alertness. Prehospital cardioversion was attempted without success.Staff at the local presenting emergency department (ED) consulted toxicology for management of the presumed yew berry ingestion, complicated by cardiac dysrhythmias and mental status change with seizure. Amiodarone 300-mg IV and diazepam 5-mg IV were given. Cardioversion was attempted 4 times without change in the wide complex tachycardia, presumed to be VT, at a rate of 166. An amiodarone drip at 1 mg/min was initiated. The patient was transferred to an intensive care unit (ICU) at a regional toxicology center.On arrival to the toxicology center the patient was alert and verbally appropriate without complaints. Initial heart rate was 76 and regular with premature ventricular contractions (PVCs). A wide complex tachycardia associated with hypotension recurred; however, normal mental status was maintained. A bolus of 100 mEq of sodium bicarbonate (NaHCO3) was given intravenously followed by sodium bicarbonate infusion at 37.5 mEq/hr. The amiodarone drip was discontinued. Subsequent electrocardiograms (EKG’s) revealed a prolonged, but steadily narrowing QRS complex. Ultimately, the QRS complex closed to 92 ms, with a rate of 94, PR 154 and a QT/QTc of 390/487.ConclusionThis case describes successful treatment of an isolatedTaxus cuspidate (yew berry) ingestion with significant toxicity initially with amiodarone bolus and infusion. Due to lack of significant change in telemetry recordings with amiodarone, treatment with sodium bicarbonate bolus and infusion was initiated. While the QRS narrowed significantly temporally related to the bicarbonate, it is difficult to determine if correction of the cardiac dysrhythmias was solely due to the sodium bicarbonate, or the synergism of sodium bicarbonate and amiodarone, or possibly spontaneous improvement due to taxine clearance. One should use caution while drawing conclusions from a single case; however, based on the clinical improvement of this patient, both with EKG recordings and vital signs, this report would suggest that isolatedTaxus cuspidate ingestion from yew berry plants can be treated with sodium bicarbonate.

Tricyclic Antidepressant Toxicity Treated With Massive Sodium Bicarbonate

Tricyclic antidepressant (TCA) morbitity is primarily due to cardiac arrhythmias and hypotension, which become more refractory to treatment as acidosis progresses (Ann Emerg Med. 1985;14:1-9; Clin Toxicol. 2007;45:203-233; Flomenbaum N, Goldfrank L, Hoffman R, et al. Goldfranks toxicologic emergencies. 8th ed. McGraw-Hill Companies, Inc, 2006). Early recognition and aggressive treatment are necessary for patient survival.

Simultaneous Very Late Angiographic Stent Thrombosis of 2 Drug-Eluting Stents: A Case Report

Very late angiographic stent thrombosis (VAST) is a known serious complication of drug-eluting stents (DESs). Most VAST events occur shortly after the discontinuation of aspirin and/or clopidogrel. This case is unique in that the patient had recently discontinued only aspirin and involves simultaneous VAST of 2 separate stents. Although the safety profile of DES does not seem to differ from those of bare metal stents in regard to thrombosis in the acute (within 24 hours) and subacute (24 hours-30 days) phases, data suggest an increase in thrombotic events in the late (after 30 days) and very late (after 12 months) phases after DES deployment. Results from a recent pooled analysis suggest that DES does not increase the risk of stent thrombosis under appropriate multidrug antiplatelet therapy. In this case, the patient self-discontinued daily aspirin 2 months before the simultaneous total occlusion of 2 DESs 37 months after placement. This was 34 months after an initial 3-month course of clopidogrel and 13 months after a 30-day course of clopidogrel. This case provides additional evidence to the importance of continued dual antiplatelet therapy and attention to compliance in patients with DESs.

Computer-Based Reminder System Effectively Impacts Physician Documentation

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Dissemination and Implementation of Shared Decision Making Into Clinical Practice: A Research Agenda

Shared decision making (SDM) is essential to advancing patient-centered care in emergency medicine. Despite many documented benefits of SDM, prior research has demonstrated persistently low levels of patient engagement by clinicians across many disciplines, including emergency medicine. An effective dissemination and implementation (D&I) framework could be used to alter the process of delivering care and to facilitate SDM in routine clinical emergency medicine practice. Here we outline a research and policy agenda to support the D&I strategy needed to integrate SDM into emergency care.

The Role of Education in the Implementation of Shared Decision Making in Emergency Medicine: A Research Agenda.

Shared decision making (SDM) is a patient-centered communication skill that is essential for all physicians to provide quality care. Like any competency or procedural skill, it can and should be introduced to medical students during their clerkships (undergraduate medical education), taught and assessed during residency training (graduate medical education), and have documentation of maintenance throughout an emergency physicians career (denoted as continuing medical education). A subgroup representing academic emergency medicine (EM) faculty, residents, content experts, and patients convened at the 2016 Academic Emergency Medicine Consensus Conference on SDM to develop a research agenda toward improving implementation of SDM through sustainable education efforts. After developing a list of potential priorities, the subgroup presented the priorities in turn to the consensus group, to the EM program directors (CORD-EM), and finally at the conference itself. The two highest-priority questions were related to determining or developing EM-applicable available tools and on-shift interventions for SDM and working to determine the proportion of the broader SDM curriculum that should be taught and assessed at each level of training. Educating patients and the community about SDM was also raised as an important concept for consideration. The remaining research priorities were divided into high-, moderate-, and lower-priority groups. Moreover, there was consensus that the overall approach to SDM should be consistent with the high-quality educational design utilized for other pertinent topics in EM.

Using Lean Methodology to Decrease Wasted RN Time in Seeking Supplies in Emergency Departments

BACKGROUND: Timely stocking of essential supplies in an emergency department (ED) is crucial to efficient and effective patient care. OBJECTIVE: The objective of this study was to decrease wasted nursing time in obtaining needed supplies in an ED through the use of Lean process controls. METHODS: As part of a Lean project, the team conducted a “before and after” prospective observation study of ED nurses seeking supplies. Nurses were observed for an entire shift for the time spent outside the patient room obtaining supplies at baseline and after implementation of a point-of-use storage system. RESULTS: Before implementation, nurses were leaving patient rooms a median of 11 times per 8-hour shift (interquartile range [IQR], 8 times per 8-hour shift) and 10 times per 12-hour shift (IQR, 23 times per 12-hour shift). After implementation of the new system, the numbers decreased to 2.5 per 8-hour shift (IQR, 2 per 8-hour shift) and 1 per 12-hour shift (IQR, 1 per 12-hour shift). CONCLUSION: A redesigned process including a standardized stocking system significantly decreases the number of searches by nurses for supplies.

Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED

Objective We sought to evaluate the effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools in the Emergency Department (ED), stratified by sex. Methods This prospective cohort study was conducted at a Level 1 Trauma center. After consent, subjects performed the TUG and the Chair test. Subjects were contacted for phone follow‐up and asked to self‐report interim falling. Results Data from 192 subjects were analyzed. At baseline, 71.4% (n = 137) screened positive for increased falls risk based on the TUG evaluation, and 77.1% (n = 148) scored below average on the Chair test. There were no differences by patient sex. By the six‐month evaluation 51 (26.6%) study participants reported at least one fall. Females reported a non‐significant higher prevalence of falls compared to males (29.7% versus 22.2%, p = 0.24). TUG test had a sensitivity of 70.6% (95% CI: 56.2%–82.5%), a specificity of 28.4% (95% CI: 21.1%–36.6%), a positive predictive (PP) value 26.3% (95% CI: 19.1%–34.5%) and a negative predictive (NP) value of 72.7% (95% CI: 59.0%–83.9%). Similar results were observed with the Chair test. It had a sensitivity of 78.4% (95% CI: 64.7%–88.7%), a specificity of 23.4% (95% CI: 16.7%–31.3%), a PP value 27.0% (95% CI: 20.1%–34.9%) and a NP value of 75.0% (95% CI: 59.7%–86.8%). No significant differences were observed between sexes. Conclusions There were no sex specific significant differences in TUG or Chair test screening performance. Neither test performed well as a screening tool for future falls in the elderly in the ED setting.

Effect of Triage-Based Use of the Ottawa Foot and Ankle Rules on the Number of Orders for Radiographic Imaging

CONTEXT Reducing unnecessary testing lessens the cost burden of medical care, but decreasing use depends on consistently following evidence-based clinical decision rules. The Ottawa foot and ankle rules (OFARs) are validated, longstanding evidence-based guidelines to predict fractures. Frequently, radiography is automatically ordered for acute ankle injuries despite findings from OFARs suggesting no fracture. OBJECTIVES First, to determine whether implementation of protocol-driven use of the OFARs at triage would decrease the number of radiography orders and length of stay (LOS) in the emergency department. Second, to quantify the incidence of OFARs use at triage and to assess patient expectations of radiography use and patient satisfaction as rated by both patients and clinicians. METHODS In this prospective, 2-stage sequential pilot study, patients with acute ankle and foot injuries were screened in the emergency department between January 2013 and October 2013. In the first stage, clinicians (physician assistants, residents, and attending physicians) performed their usual practice habits for radiography use in the control group. For the second stage, they were educated to appropriately apply the OFARs before ordering radiography. For patients who were suspected of having a fracture at triage, nursing staff ordered radiography. For patients who were not suspected of having a fracture at triage, a clinician reassessed them using the OFARs after their triage assessment. Radiography was then ordered at the discretion of the clinician. Results gathered after training in the OFARs comprised the intervention group. After discharge, patients were surveyed regarding their expectations and satisfaction, and clinicians were surveyed on their perceptions of patient satisfaction. RESULTS A total of 131 patients were screened, 62 patients were enrolled in the study after consent was obtained, and 2 patients withdrew from the study prematurely, leaving 30 patients in each group. Fifty-eight of the 60 patients (97%) underwent radiography. Emergency department LOS decreased from 103 minutes to 96.5 minutes (P=.297) after the OFARs were applied. There was also a decrease in LOS in patients with a fracture (137 minutes vs 103 minutes [P=.112]). Radiography was expected to be ordered by 27 of 30 patients in the control group (90%) and 24 of 30 in the intervention group (80%) (P=.472). Patients were equally satisfied among the groups (54 of 60 [90%]) (with no difference between groups), and 27 of 30 (90%) vs 30 of 30 (100%) clinicians in the control and intervention groups, respectively, perceived that patients were satisfied with their treatment. CONCLUSION There was no statistical evidence that application of the OFARs decreases the number of imaging orders or decreases LOS. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.

Frontal sinusitis complicated by a brain abscess and subdural empyema

A 49-year-old male was brought to the Emergency Department after being found unresponsive. The patient had multiple seizures and was intubated in the prehospital setting. A computed tomography scan showed bilateral paranasal sinus disease, and magnetic resonance imaging showed a right frontal abscess and subdural empyema. Neurosurgery took the patient to the operating room, performed a craniotomy, and drained a large amount of purulent fluid. He was subsequently discharged for acute rehabilitation. Clinicians should consider complicated frontal sinusitis, especially in the undifferentiated patient presenting with neurologic deficits and signs or symptoms of sinus disease.