David B. Burmeister

Management of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial

BACKGROUND Benign paroxysmal positional vertigo (BPPV) is a common presenting problem. OBJECTIVE Our aim was to compare the efficacy of vestibular rehabilitation (maneuver) vs. conventional therapy (medications) in patients presenting to the emergency department (ED) with BPPV. METHODS This was a prospective, single-blinded physician, randomized pilot study comparing two groups of patients who presented to the ED with a diagnosis of BPPV at a Level 1 trauma center with an annual census of approximately 75,000. The first group received standard medications and the second group received a canalith repositioning maneuver. The Dizziness Handicap Inventory was used to measure symptom resolution. RESULTS Twenty-six patients were randomized; 11 to the standard treatment arm and 15 to the interventional arm. Mean age ± standard deviation of subjects randomized to receive maneuver and medication were 59 ± 12.6 years and 64 ± 11.2 years, respectively. There was no significant difference in mean ages between the two treatment arms (p = 0.310). Two hours after treatment, the symptoms between the groups showed no difference in measures of nausea (p = 0.548) or dizziness (p = 0.659). Both groups reported a high level of satisfaction, measured on a 0-10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 9 ± 1.5 and 9 ± 1.0, respectively; there was no significant difference in satisfaction between the two arms (p = 0.889). Length of stay during the ED visit did not differ between the treatment groups (p = 0.873). None of the patients returned to an ED for similar symptoms. CONCLUSIONS This pilot study shows promise, and would suggest that there is no difference in symptomatic resolution, ED length of stay, or patient satisfaction between standard medical care and canalith repositioning maneuver. Physicians should consider the canalith repositioning maneuver as a treatment option.

Frequency of Serious Outcomes in Patients With Hypertension as a Chief Complaint in the Emergency Department

CONTEXT Hypertension is a common incidental finding in the emergency department (ED). However, the authors noticed a segment of patients who present to the ED specifically because their blood pressure is found to be elevated outside of the hospital. Emergency medicine physicians are often unsure of the level of intervention that is required for these patients. OBJECTIVE To determine if these patients have serious outcomes (ie, final diagnosis of myocardial infarction, angina, coronary syndrome, congestive heart failure, pulmonary edema, hypertensive encephalopathy, malignant hypertension, stroke, transient ischemic attack, subarachnoid hemorrhage, loss of vision, kidney failure, or aortic dissection) within 7 days of the initial ED visit. METHODS The authors retrospectively reviewed ED medical records from 2008 with a chief complaint of high blood pressure or hypertension in the physician or nursing notes. Age, sex, blood pressure, history of hypertension, associated symptoms, tests, medications, admission or discharge information, final diagnoses, and return visits within 7 days were recorded. RESULTS Of the 316 medical records that were reviewed, 149 met the study criteria and were included in analysis. Patient age range was 19 to 94 years (mean, 59.8 years; median, 61 years). Sixty patients (40%) were men and 89 (60%) were women. Of the 149 patients, 121 (81%) had a previous diagnosis of hypertension and 28 (19%) did not. Five patients (3%) had a normal initial blood pressure in the ED. Sixteen patients (11%) did not undergo diagnostic tests, and 77 patients (52%) received medication in the ED. Twenty-six patients (17%) were admitted to the hospital, and 123 (83%) were discharged or eloped. Four patients (2.7%; 95% confidence interval, 0.7-6.7) had a serious outcome noted within 7 days of initial presentation to the ED. CONCLUSION Among patients presenting to the ED with a chief complaint of hypertension or high blood pressure and no serious associated complaint, the risk of serious outcome within 7 days is low.

Using LEAN to improve a segment of emergency department flow.

Emergency department (ED) overcrowding is an organizational concern. This article describes how Toyota LEAN methods were used as a performance improvement framework to address ED overcrowding. This initiative also impacted “bolus of patients” or “batching” concerns, which occur when inpatient units receive an influx of patients from EDs and other areas at the same time. In addition to decreased incidence of overcrowding, the organization realized increased interprofessional collaboration.

Analysis of sex differences in preadmission management of ST-segment elevation (STEMI) myocardial infarction.

BACKGROUND Many reports suggest gender disparity in cardiac care as a contributor to the increased mortality among women with heart disease. OBJECTIVE We sought to identify gender differences in the management of Myocardial Infarction (MI) Alert-activated ST-segment elevation myocardial infarction (STEMI) patients that may have resulted from prehospital initiation. METHODS A retrospective database was created for MI Alert STEMI patients who presented to the emergency department (ED) of an academic community hospital with 74,000 annual visits from April 2000 through December 2008. Included were patients meeting criteria for an MI Alert (an institutional clinical practice guideline designed to expedite cardiac catheterization for STEMI patients). Data points (before and after initiation of a prehospital alert protocol) were compared and used as markers of therapy: time to ECG, receiving β-blockers, and time to the catheterization laboratory (cath lab). Differences in categorical variables by patient sex were assessed using the χ(2) test. Medians were estimated as the measure of central tendency. Quantile regression models were used to assess differences in median times between subgroups. RESULTS A total of 1231 MI Alert charts were identified and analyzed. The majority of the study population were male (70%), arrived at the ED via ambulance (60.1%), and were taking a β-blocker (67.8%) or aspirin (91.6%) at the time of the ED admission. Female patients were more likely than male patients to arrive at the ED via ambulance (65.9% vs 57.6%, respectively; P = 0.014). The median age of female patients was 68 years, whereas male patients were significantly younger (median age, 59 years; P < 0.001). The proportion of patients currently taking a β-blocker or low-dose aspirin did not vary by gender. Overall, 78.2% of the MI Alert patients arriving at the ED were MI2 (alert initiated by ED physician), and this did not vary by gender (P = 0.33). A total of 1064 MI Alert patients went to the cath lab: 766 male patients (88.9%) and 298 female patients (80.8%). Overall, the median time to cath lab arrival was 79 minutes for men and 81 minutes for women (P = 0.38). Overall, the median time to cath lab arrival significantly decreased from MI1 to MI3, (P(trend) < 0.001). For prehospital-initiated alerts (MI3), the median time to cath lab arrival was the same for men and women (64 minutes; P = 1.0). For hospital-initiated alerts, time to cath lab arrival was 82 minutes for male patients and 84 minutes for female patients (P = 0.38). Prehospital activation of the process decreased the time to the cath lab by 19 minutes (P < 0.001; 95% CI, 13.2-24.8). CONCLUSION No significant gender differences were apparent in the STEMI patients analyzed, whether the MI Alert was initiated in the ED or prehospital initiated. Initiating prehospital-based alerts significantly decreased the time to the cath lab.

Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians.

Advanced Practice Clinicians (APCs) in collaborative practice represent a diverse and valuable group of health care professionals, including nurse practitioners, physician assistants, nurse anesthetists, and nurse midwives. Because these healthcare professionals have been identified as part of the solution to physician shortages, it is critical for health networks to examine and address issues affecting collaborative relationships. We invited our network APCs to participate in focus group sessions to determine both attributes and barriers to an ideal work environment. Four major themes emerged: (1) compensation, (2) network representation, (3) employment structure, and (4) workplace culture. While issues relating to compensation and representation were prevalent, discussions also revealed the importance of relationships and communication. To ensure successful collaboration and, thereby, reduce clinician turnover, leaders must address gaps between the existing and ideal states in structural factors affecting job satisfaction (Themes 1-3) as well as the behavioral factors represented in workplace culture (Theme 4).

Complications of atrial myxoma

Wepresent a rare case ofmultiple intracranial hemorrhages that developed in an otherwise healthy patient, whose significant history was that of a myxomatous tumor that had been removed in a prior cardiothoracic surgery. The presentation of the patient was unique, and the findings were unexpected. The purpose of this article is to bring awareness to an uncommon disease pattern that, if missed or misdiagnosed, could end in significantmorbidity, if not mortality. Appropriate imaging of a patient with a similar medical history is of the utmost importance. Delay in diagnosis could be costly. Cardiacmyxomas are benign tumors that comprise 80% of tumors of the heart [1]. Most patients presentwith varied cardiac, pulmonary, and constitutional symptoms. Many constitutional symptoms such as fatigue, weight loss, and arthralgias are thought to be due to production of IL-6 or symptoms and signs mimicking vasculitis [2]. Myxomas are typically friable or villous, which leads to a higher risk of embolization; they are therefore removed for this reason [2]. A 58-year-oldwomanwith a history of hypertension and anxiety presented to the emergency department (ED)withmuscle spasms of her left upper extremity. She was raking her lawn when her symptoms started. Initially, she was seen in the ED and discharged home after symptom resolution. Her symptoms recurred, and she returned to the ED a second time. Her home medications include metoprolol, hydrochlorothiazide, potassium supplements, and alprazolam. Her surgical history was significant for removal of an atrial myxoma 1 year before her presentation. Vital signs were as follows: temperature, 98.6°F; pulse, 68; respirations, 20; oxygen saturation, 99%; and blood pressure, 160/104. A detailed neurologic examination showed no focal neurological deficits but revealed myoclonal jerking of her left upper extremity; otherwise, result of her examination was normal. Laboratory data including a complete blood count and chemistry panel were essentially normal. Computed tomography of the head without contrast revealed multiple areas of acute intraparenchymal hemorrhage within the right frontoparietal region (Figs. 1 and 2). At least 3 areas of hemorrhage were identified, the 2 largest measuring 1.1 × 1.3 × 1.1 cm (0.8 mL) and 0.9 × 0.7 × 1.5 cm (0.9 mL). There was also a small amount of subarachnoid hemorrhage in that region. Furthermore, a small amount of subarachnoid hemorrhage was seen in the left frontoparietal and parieto-occipital regions. The patient was admitted and underwent a cerebral angiogram, which revealed several peripheral arterial aneurysms involving the left anterior and middle cerebral arteries compatible with myxoma ☆ The authors have no outside support information, conflicts, or financial interest to disclose. 0735-6757/© 2016 Elsevier Inc. All rights reserved. Please cite this article as: Rios RE, et al, Complications of atrial myxoma, A embolization. The patient also underwent an electroencephalogram and a transesophageal echocardiogram, both of which had normal results. The first atrial myxomawas diagnosed premortem by Goldberg et al [3], whose patient had right hemiparesis. Since then, there have been multiple reports of neurological manifestations of myxoma, and on average, these manifestations appear in about 25%-45% of patients [4]. One article in the literature reports that transient ischemic attack is the most common neurological finding, followed by ischemic stroke due to embolism [5]. Consistently, however, there appears to be a classic triad in patients with atrial myxomas: valve obstruction, embolism, and constitutional symptoms (fever, malaise, weight loss) [2]. In the embolic triad, pulmonary embolism or any other potential embolic presentation (of various organ systems) is possible and could cause delayed diagnosis. Because of the diverse nature of the potential presentation, a low threshold for consideration of myxoma in the differential is recommended. Standard management of these patients includes an electrocardiogram which could show effects of the tumor (atrial enlargement or other arrhythmias). However, without high suspicion, it is likely that the diagnosis would be missed. Laboratory studies are usually not diagnostic; however, they should be ordered. Ultimately, however, an echocardiogram is the most likely way to confirm the diagnosis of atrial myxoma (bedside ultrasonography or formal studydependent onprovider comfort level). Computed tomographic scans or cardiacmagnetic resonance imaging could help with the diagnosis; however, they are more likely part of an inpatient assessment [6]. Once a myxoma is found, the standard of care is surgical removal to prevent above complications [2]. Valvular symptoms of cardiac myxomas are often related to the secondary effects and dependent onwhere themyxomas are located. Heart failure symptoms which include paroxysmal nocturnal dyspnea, orthopnea, or dyspnea on exertion are often seen if they are due to mitral valve involvement or peripheral edema and abdominal distention if due to tricuspid valve involvement [2,7]. Symptomsof syncope andnear syncope can occur if the tumor obstructs the mitral valve [8]. Neurologic manifestations that are related to embolization can cause patients to present as a cerebrovascular accident (CVA) (ischemic or hemorrhagic) or with aneurysmal disease [9]. Furthermore, aneurysms secondary to myxoma can be a delayed presentation and can be foundbefore resection of myxoma or even after resection of myxoma, as in our case [10,11]. The purpose of this case report is to bring awareness of the delayed complications as a result of myxomatous tumors. Our patient had removal of atrial myxoma a year earlier and presented to the ED with a somewhat muted symptomatology. As an emergency medicine physician, it is important to recognize quickly that those patientswho present to the EDwith history of atrial myxoma that presentwith a neurological manifestation are potentially having a life-threatening complication of an otherwise benign cardiac tumor. m J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.079 Fig. 1. Computed Tomography of the head (Lateral). Fig. 2. Intraparenchymal hemorrhage seen in Computed Tomography of the head. 2 R.E. Rios et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx Rolando E. Rios MD David B. Burmeister DO Eric W. Bean DO⁎ Lehigh Valley Hospital and Health Network/USF MCOM, Department of Emergency Medicine, CC & I-78, Allentown, PA 18103 ⁎Corresponding author at: Department of Emergency Medicine, 2545 Schoenersville Rd, Muhlenberg Campus LVH, 5th Floor EM Residency Suite Tel.: +1 484 884 7514; fax: +1 484 884 7510 E-mail address: Eric_W.Bean@lvhn.org http://dx.doi.org/10.1016/j.ajem.2016.05.079