Dustin G. Mark

Preexcitation syndromes: diagnostic consideration in the ED

Preexcitation syndromes are a common cause of paroxysmal tachycardias presenting to the ED. Emergency physicians should be familiar with the common electrocardiographic manifestations of preexcitation, particularly the Wolff-Parkinson-White abnormality, as these conditions require specific therapeutic management. This article reviews the pathophysiology of preexcitation, along with the electrocardiographic findings of Wolff-Parkinson-White and its associated tachyarrhythmias.

Electrocardiographic manifestations of cardiac infectious-inflammatory disorders

Inflammatory disorders of the heart, although uncommon in the general population, often present initially to the emergency department. Symptoms and clinical manifestations are shared with other more common cardiopulmonary diseases, particularly acute coronary syndrome and congestive heart failure, making prompt diagnosis challenging. This review will highlight some of the clinical and electrocardiographic features that will help early diagnosis and differentiation of inflammatory cardiac disorders from other more common conditions.

Timing of discharge follow-up for acute pulmonary embolism: retrospective cohort study.

Introduction Historically, emergency department (ED) patients with pulmonary embolism (PE) have been admitted for several days of inpatient care. Growing evidence suggests that selected ED patients with PE can be safely discharged home after a short length of stay. However, the optimal timing of follow up is unknown. We hypothesized that higher-risk patients with short length of stay (<24 hours from ED registration) would more commonly receive expedited follow up (≤3 days). Methods This retrospective cohort study included adults treated for acute PE in six community EDs. We ascertained the PE Severity Index risk class (for 30-day mortality), facility length of stay, the first follow-up clinician encounter, unscheduled return ED visits ≤3 days, 5-day PE-related readmissions, and 30-day all-cause mortality. Stratifying by risk class, we used multivariable analysis to examine age- and sex-adjusted associations between length of stay and expedited follow up. Results The mean age of our 175 patients was 63.2 (±16.8) years. Overall, 93.1% (n=163) of our cohort received follow up within one week of discharge. Fifty-six patients (32.0%) were sent home within 24 hours and 100 (57.1%) received expedited follow up, often by telephone (67/100). The short and longer length-of-stay groups were comparable in age and sex, but differed in rates of low-risk status (63% vs 37%; p<0.01) and expedited follow up (70% vs 51%; p=0.03). After adjustment, we found that short length of stay was independently associated with expedited follow up in higher-risk patients (adjusted odds ratio [aOR] 3.5; 95% CI [1.0–11.8]; p=0.04), but not in low-risk patients (aOR 2.2; 95% CI [0.8–5.7]; p=0.11). Adverse outcomes were uncommon (<2%) and were not significantly different between the two length-of-stay groups. Conclusion Higher-risk patients with acute PE and short length of stay more commonly received expedited follow up in our community setting than other groups of patients. These practice patterns are associated with low rates of 30-day adverse events.

Sensitivity of a Clinical Decision Rule and Early Computed Tomography in Aneurysmal Subarachnoid Hemorrhage.

Introduction Application of a clinical decision rule for subarachnoid hemorrhage, in combination with cranial computed tomography (CT) performed within six hours of ictus (early cranial CT), may be able to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). This study’s objective was to examine the sensitivity of both early cranial CT and a previously validated clinical decision rule among emergency department (ED) patients with aSAH and a normal mental status. Methods Patients were evaluated in the 21 EDs of an integrated health delivery system between January 2007 and June 2013. We identified by chart review a retrospective cohort of patients diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT. Variables comprising the SAH clinical decision rule (age ≥40, presence of neck pain or stiffness, headache onset with exertion, loss of consciousness at headache onset) were abstracted from the chart and assessed for inter-rater reliability. Results One hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of early cranial CT was 95.5% (95% CI [90.9–98.2]). The sensitivity of the SAH clinical decision rule was also 95.5% (95% CI [90.9–98.2]). Since all false negative cases for each diagnostic modality were mutually independent, the combined use of both early cranial CT and the clinical decision rule improved sensitivity to 100% (95% CI [97.6–100.0]). Conclusion Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might optimize sensitivity for this life-threatening disease.

Predictors of Unattempted Central Venous Catheterization in Septic Patients Eligible for Early Goal-directed Therapy

Introduction Central venous catheterization (CVC) can be an important component of the management of patients with severe sepsis and septic shock. CVC, however, is a time- and resource-intensive procedure associated with serious complications. The effects of the absence of shock or the presence of relative contraindications on undertaking central line placement in septic emergency department (ED) patients eligible for early goal-directed therapy (EGDT) have not been well described. We sought to determine the association of relative normotension (sustained systolic blood pressure >90 mmHg independent of or in response to an initial crystalloid resuscitation of 20 mL/kg), obesity (body mass index [BMI] ≥30), moderate thrombocytopenia (platelet count <50,000 per μL), and coagulopathy (international normalized ratio ≥2.0) with unattempted CVC in EGDT-eligible patients. Methods This was a retrospective cohort study of 421 adults who met EGDT criteria in 5 community EDs over a period of 13 months. We compared patients with attempted thoracic (internal jugular or subclavian) CVC with those who did not undergo an attempted thoracic line. We also compared patients with any attempted CVC (either thoracic or femoral) with those who did not undergo any attempted central line. We used multivariate logistic regression analysis to calculate adjusted odd ratios (AORs). Results In our study, 364 (86.5%) patients underwent attempted thoracic CVC and 57 (13.5%) did not. Relative normotension was significantly associated with unattempted thoracic CVC (AOR 2.6 95% confidence interval [CI], 1.6–4.3), as were moderate thrombocytopenia (AOR 3.9; 95% CI, 1.5–10.1) and coagulopathy (AOR 2.7; 95% CI, 1.3–5.6). When assessing for attempted catheterization of any central venous site (thoracic or femoral), 382 (90.7%) patients underwent attempted catheterization and 39 (9.3%) patients did not. Relative normotension (AOR 2.3; 95% CI, 1.2–4.5) and moderate thrombocytopenia (AOR 3.9; 95% CI, 1.5–10.3) were significantly associated with unattempted CVC, whereas coagulopathy was not (AOR 0.6; 95% CI, 0.2–1.8). Obesity was not significantly associated with unattempted CVC, either thoracic in location or at any site. Conclusion Septic patients eligible for EGDT with relative normotension and those with moderate thrombocytopenia were less likely to undergo attempted CVC at any site. Those with coagulopathy were also less likely to undergo attempted thoracic central line placement. Knowledge of the decision-making calculus at play for physicians considering central venous catheterization in this population can help inform physician education and performance improvement programs.

Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes

Study objective: Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility‐level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge. Methods: The Management of Acute Pulmonary Embolism (MAPLE) study is a retrospective cohort study of patients with acute pulmonary embolism undertaken in 21 community EDs from January 2013 to April 2015. We gathered demographic and clinical variables from comprehensive electronic health records and structured manual chart review. We used multivariable logistic regression to assess the association between patient characteristics and home discharge. We report ED length of stay, consultations, 5‐day pulmonary embolism–related return visits and 30‐day major hemorrhage, recurrent venous thromboembolism, and all‐cause mortality. Results: Of 2,387 patients, 179 were discharged home (7.5%). Home discharge varied significantly between EDs, from 0% to 14.3% (median 7.0%; interquartile range 4.2% to 10.9%). Median length of stay for home discharge patients (excluding those who arrived with a new pulmonary embolism diagnosis) was 6.0 hours (interquartile range 4.6 to 7.2 hours) and 81% received consultations. On adjusted analysis, ambulance arrival, abnormal vital signs, syncope or presyncope, deep venous thrombosis, elevated cardiac biomarker levels, and more proximal emboli were inversely associated with home discharge. Thirteen patients (7.2%) who were discharged home had a 5‐day pulmonary embolism–related return visit. Thirty‐day major hemorrhage and recurrent venous thromboembolism were uncommon and similar between patients hospitalized and those discharged home. All‐cause 30‐day mortality was lower in the home discharge group (1.1% versus 4.4%). Conclusion: Home discharge of ED patients with acute pulmonary embolism was uncommon and varied significantly between facilities. Patients selected for outpatient management had a low incidence of adverse outcomes.

Shared decision making in low risk chest pain: looking ahead

We commend Hess and colleagues for studying shared decision making,1 which is best suited for forks in the road, where neither course is clearly superior.23 This currently seems to be the case for patients with low risk chest pain in the …

1876: DUODENAL PERFORATION FROM METHOTREXATE TREATMENT OF PSORIATIC ARTHRITIS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Vancomycin was monitored by pharmacy and levels were obtained at steady state. Hypothermia occurred frequently during her ICU stay. After each hypothermic episode, the vancomycin level was supratherapeutic and the elimination rate constant (ke) was significantly decreased. During one episode, her temperature was less than 34.3°C for 23 hours. A vancomycin level obtained prior to the hypothermic episode was 19.2mcg/ml which was extrapolated to an estimated true trough of 14mcg/mL with a ke 0.114. The vancomycin level obtained following the hypothermic episode was 34.8mcg/mL with a ke 0.063. Burn debridement only occurred once during this time, prior to the first level being obtained. The patient did not require vasopressor support, her serum creatinine did not significantly change, and her urine output remained adequate during this time. The only observed difference was the patient being moderately hypothermic the day before and the day of the second level. The same trend occurred with vancomycin levels and elimination during other hypothermia episodes. Results: Based on this case, burn patients should be monitored closely for hypothermia. Vancomycin levels should be obtained frequently during periods of hypothermia, even if renal function appears stable, in order to avoid supratherapeutic vancomycin levels and associated adverse reactions.

Letter by Mark et al Regarding Article, “Implementation of the Fifth Link of the Chain of Survival Concept for Out-of-Hospital Cardiac Arrest”

To the Editor: We applaud Tagami et al1 for reporting their experience in caring for survivors of out-of-hospital cardiac arrest following the implementation of a regionalized postarrest system of care to deliver the fifth link of the chain of survival. The authors’ interrupted time series study suggests an improved rate of favorable neurological outcomes among survivors after regionalization of care. However, we question their assertion that regionalization of care, as opposed to overall improved postresuscitation care (the “fifth link”), was instrumental in improving outcomes. The authors note that following implementation of the program, there were higher rates of both return of spontaneous circulation (ROSC) and admission …

CorrespondenceIn response to

nized bias might have existed. Nationwide survey will be necessary to evaluate the true impact of H1N1 influenza pandemic on EMS system. However, it is likely that H1N1 influenza pandemic did not have a great impact on supply and demand of EMS system. H5N1 influenza virus is another concern, although we should be careful in applying the results of this study to predicting its influence on the EMS. There are considerable differences in the virulence between the 2 types of influenza viruses.