David N. Zull

Prospective evaluation of syncope

One hundred seventy patients with syncope presenting to an emergency department were studied prospectively. A checklist was used to supplement the physicians history and physical to ensure adequate recording of potentially useful data. Follow-up data were available in 89% of patients with a mean follow-up period of 6.2 months. Patients were categorized by presumed etiology using specific criteria. Typical vasovagal syncope occurred in 37.1% of patients. Other etiologies included first seizure (8.8%), orthostasis (7.6%), cardiac (4.1%), micturition (2.4%), hypoglycemia (1.8%), and psychogenic (0.6%). Syncope of unknown etiology accounted for 37.6% of the patients. The estimated duration of warning period was significantly shorter in patients with cardiac syncope compared to patients with vasovagal syncope. The yield of laboratory tests was low with the exception of the serum bicarbonate, which was decreased in 70% of our seizure patients. Recommendations regarding initial evaluation and admission are discussed.

Acute paraplegia: A presenting manifestation of aortic dissection

Two patients who presented with acute paralysis of the lower extremities as an initial manifestation of aortic dissection are described. The first patient had transient chest pain followed by flaccid paralysis of her lower extremities and severe back pain. In the second patient, sudden paralysis of both legs developed without pain of any sort. The paraplegia completely resolved in a few minutes; however, chest and back pain later ensued. Both patients had a proximal (type I or A) aortic dissection. The first patients entrance tear in the aortic intima was just above the aortic valve with antegrade propagation, whereas in the second patient, the entrance tear was at the aortic isthmus, with both antegrade and retrograde dissection. Acute cardiac tamponade resulted in sudden deterioration and death in both patients, before any therapeutic intervention could be entertained.

Angina and sudden death resulting from papillary fibroelastoma of the aortic valve

A 75-year-old woman presented with recurrent severe chest pain radiating to her back. The initial ECG was normal, and clinically an aortic dissection was suspected. The patient became hypotensive during a chest computed tomography scan with infusion, had subsequent repeated cardiac arrests, and died. Autopsy revealed a 1.5-cm polypoid lesion, a papillary fibroelastoma, on the aortic valve, which effectively occluded the ostium of the left coronary artery in a ball-valve effect. In addition, an embolic fragment of the tumor was found in the left anterior descending artery. This is the sixth reported case of angina and/or sudden death resulting from this lesion. Of the 75 cases reported in the literature, most are incidental necropsy findings, although neurologic emboli and outflow tract obstruction have been described.

Massive ethylene glycol poisoning without evidence of crystalluria: A case for early intervention

A case of severe ethylene glycol poisoning is presented, characterized by protracted delirium, coma, and delayed adult respiratory distress syndrome. This patient never demonstrated evidence of calcium oxalate crystalluria or renal insufficiency. Ethylene glycol intoxication should be considered in the patient who presents with an altered mental status, unexplained metabolic acidosis, and elevated anion and osmolal gaps with or without crystalluria. Early empiric ethanol therapy and consideration of dialysis are recommended for those patients with such a presentation without evidence of abnormal levels of ketones, lactate, salicylate, or ethanol. It is proposed that early ethanol therapy may prevent the formation of ethylene glycol metabolites to the extent that calcium oxalate crystalluria is not seen.

Evaluating disparities in door-to-EKG time for patients with noncardiac chest pain.

INTRODUCTION Our objective was to examine gender, racial, and age differences in door-to-EKG time in patients diagnosed with non-cardiac chest pain. METHODS This was a prospective cohort study of adult patients with an explicitly stated chief complaint of chest pain at an urban, academic ED. Primary study outcome variable was time to initial EKG. Predictor variables included gender, race, and age. RESULTS The final sample consisted of 214 patients. The overall median time to EKG in this cohort of patients was 29 minutes. No difference in time to EKG was found between gender or racial category. Time to EKG was significantly greater for patients in age categories 18-39 and 40-59 when compared with subjects greater than 60 years old. DISCUSSION In this prospective cohort study of non-STEMI/ACS patients with a chief complaint of chest pain, there were no gender or racial disparities in door-to-EKG time.