Gabriel Blecher

Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates.

OBJECTIVE It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion. METHODS This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. Predictive variables were incorporated into the multivariate model to calculate adjusted odds ratios (ORs) associated with successful cardioversion. RESULTS A total of 634 patients underwent attempted cardioversion: 428 electrical, 354 chemical, and 148 both. Adjusted ORs for factors associated with successful electrical cardioversion were use of rate control medication, 0.39 (95% confidence interval [CI] 0.21-0.74); rhythm control medication, 0.28 (95% CI 0.15-0.53); and CHADS₂ score > 0, 0.43 (95% CI 0.15-0.83). ORs for factors associated with successful chemical cardioversion were use of rate control medication, 1.29 (95% CI 0.82-2.03); female sex, 2.37 (95% CI 1.50-3.72); and use of procainamide, 2.32 (95% CI 1.43-3.74). CONCLUSION We demonstrated reduced successful electrical cardioversion of RAFF when patients were pretreated with either rate or rhythm control medication. Although rate control medication was not associated with increased success of chemical cardioversion, use of procainamide was. Slowing the ventricular rate prior to cardioversion should be avoided.

RESPECT-ED: Rates of pulmonary emboli (PE) and sub-segmental PE with modern computed tomographic pulmonary angiograms in emergency departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates

Introduction Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4–10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. Aims To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. Methods A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. Results Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8–15.4%; range 9.3–25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1–58.2%) and SSPE 8.8% (CI: 7.1–10.5%) of positive scans. CTPA usage (0.2–1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. Discussion/ Conclusions We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5–3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

Survival in Out-of-hospital Rapid Sequence Intubation of Non-Traumatic Brain Pathologies

Abstract Introduction: Rapid sequence intubation (RSI) is not only used in traumatic brain injuries in the out-of-hospital setting, but also for non-traumatic brain pathologies (NTBP) such as brain tumors, meningitis, encephalitis, hypoxic/anoxic brain injury, stroke, arteriovenous malformations, tumors, aneurysms, brain hemorrhage, as well as brain injury due to diabetes, seizures and toxicity, metabolic conditions, and alcohol and drug overdose. Previous research suggests that RSI is common in non-traumatic coma, but with an unknown prevalence of NTBP in those that receive RSI. If NTBP is common and if brain trauma RSI evidence is not valid for NTBP then a sizable proportion of NTBP receive this treatment without evidence of benefit. This study calculated the out-of-hospital NTBP prevalence in patients that had received RSI and explored factors that predicted survival. Methods: A retrospective cohort study based on data collected from an ambulance service and seven hospitals based in Melbourne, Australia. Non-traumatic brain pathologies were defined using ICD10-AM codes for the calculation of NTBP prevalence. Logistic regression modelled out-of-hospital predictors of survival to hospital discharge after adjustment for comorbidities. Results: The seven participating hospitals treated 2,277 patients that received paramedic RSI for all illnesses and indications from January 1, 2008 to December 31, 2015, with survival data available for 1,940 (85%). Of the 1,940, 1,125 (58%) patients had at least one hospital-diagnosed NTBP. Sixty-nine percent all of NTBP survived to hospital discharge, compared to 65% for traumatic intracranial injury. Strokes were the most common and had poor survival to discharge (37%) compared to the second most common NTBP toxicity/toxic encephalopathy that had very high survival (98%). No out-of-hospital clinical intervention or prehospital time interval predicted survival. Factors that did predict survival include Glasgow Coma Scale (GCS), duration of mechanical ventilation, age, ICU length of stay, and comorbidities. Conclusions: Non-traumatic brain pathologies are seven times more prevalent than traumatic brain injuries in patients that underwent out-of-hospital RSI in Victoria, Australia. Since the mechanisms through which RSI impacts mortality might differ between traumatic brain injuries and NTBP, and given that NTBP is very prevalent, it follows that the use of RSI in NTBP could be unsupported.

Introduction of a new imaging guideline for suspected renal colic in the ED reduces CT urography utilisation

Background Patients presenting to the ED with suspected renal colic are frequently imaged with CT urography (CTU), which rarely alters diagnosis or management. To reduce use of CTU in this population, we instigated a new imaging and management guideline in our ED. Methods This was a quasi-experimental prospective study, whereby a new guideline was commenced at the intervention site (Monash Medical Centre) and the existing guideline continued at the control site (Dandenong Hospital). The new guideline promotes focused ultrasound for diagnosing renal colic and restricts CT to those with poor response to analgesia or ‘red flags’. A consecutive series of patients with suspected renal colic were prospectively enrolled and outcomes compared between the sites. The primary outcome was CTU utilisation and secondary outcomes were radiation exposure, stone rate on CTU, admission, ED length of stay and rates of urological intervention and returns to ED at 4-week follow-up. Results Preintervention CTU rates were 76.7% at Monash and 72.1% at Dandenong. 324 patients were enrolled; 148 at Monash and 176 at Dandenong. Median age 47 years vs 49 years, males 76.4% vs 66.5% and medianSex, Timing, Origin, Nausea, Erythrocytes (STONE) score 10 vs 10 for Monash and Dandenong, respectively. CTU was performed in 54.1% vs 75.0% (p<0.001), median radiation exposure 2.8 vs 4.0 mSv (p<0.001) and urological intervention occurred in 16.4% vs 15.7% for Monash and Dandenong, respectively. Conclusions We found that use of CTU for renal colic was significantly reduced by introduction of a guideline promoting ultrasound and encouraging selective CTU. Although intervention rates were similar between the two sites, further prospective study is needed to ensure other patient-centred outcomes do not differ.

Predictors for urologic intervention and alternate diagnoses in people having computed tomography urography for suspected renal colic

The majority of ureteric calculi pass spontaneously and are uncomplicated, yet use of computed tomography urography (CTU) has increased in recent years. This study describes a cohort of ED patients undergoing CTU for renal colic and assesses the predictors of urologic intervention.

Collaborative model for training and credentialing point-of-care ultrasound: 6-year experience and quality outcomes

Point‐of‐care ultrasound (PoCUS) is a rapidly growing area, providing physicians with a valuable diagnostic tool for patient assessment. This paper describes a collaborative model, utilising radiology department ultrasound expertise, to train and credential physicians in PoCUS. A 6‐year experience of the implementation and outcomes of the programme established within the emergency departments of a large, multi‐campus hospital network are presented.

Konjac flour noodles associated with gastric outlet obstruction: CASE LETTER

Dear Editor, A 61 year old non-Indigenous Australian woman presented to an ED with a 10 day history of upper abdominal bloating, post-prandial pain and vomiting. Her medical history included a hysterectomy and varicose vein surgery. She was a non-smoker and consumed occasional alcohol. She took no regular medications and had a latex sensitivity. Physical examination revealed a soft but tender distended abdomen with a large irregular palpable mass extending from the left upper quadrant into the right lower quadrant. A succussion splash was audible. An abdominal computed tomography (CT) scan (Fig. 1) demonstrated a massively distended stomach, containing food matter, which had compressed the fourth section of the duodenum. Blood tests including haematology, electrolytes, renal and liver function tests were unremarkable. The patient was admitted to hospital for further investigations and a nasogastric tube was inserted, but only drained a small amount of fluid. Gastroscopy performed 48 h later revealed a normal oesophagus and a large soft mass of undigested vegetable matter in the stomach completely obstructing the lumen (Fig. 2). The scope was carefully ‘tunnelled’ through the bezoar until the pylorus was reached. The scope could then be passed well into the distal duodenum. No other obstructing lesions were seen and the duodenal lumen was empty. The bezoar was partially broken up with the scope tip and a snare and flushed into the duodenum. The whole bezoar could not be evacuated. The nasogastric tube was re-inserted. Proton pump inhibitors (started on admission) were ceased and the patient was allowed clear fluids over the next few days. When gastroscopy was repeated 4 days later the bezoar was almost completely gone. The patient gradually returned to a normal diet and was discharged home. After the gastroscopy, when questioned about her dietary intake, the patient recalled eating a whole pack of Konjac flour noodles a day prior to the onset of her symptoms. The patient reported no other food intake that day and no other food intake post-ingestion of the noodles, prior to her symptoms commencing. Konjac is a root vegetable from Asia (Amorphophallus konjac). It is currently being used as a dietary supplement in Australia. Claims have been made that Konjac and its extract (glucomannan/food additive E425) are able to assist with weight loss and lower cholesterol and blood sugar levels. Konjac is extremely hydroscopic and glucomannan expands 12–17-fold on contact with water or hydrochloric acid solution. It is marketed as a dieting tool as it expands in the stomach on contact with fluids, delaying gastric emptying and creating satiety while contributing very few calories. Glucomannan containing dieting pills have been associated with oesophageal obstruction. A case series of nine patients was reported in Australia in 1986. In 2002, glucomannan was associated with a series of choking deaths and has been banned in confectionary in Australia, Europe and the USA. Australia now has ready-made meal products (including noodles) containing Konjac flour available in many local shops. The noodle associated with this gastric outlet bezoar and obstruction was made from 5% Konjac flour and water. We wish to raise concern that the Konjac noodle product may cause gastric outlet obstruction by expanding once in the stomach. If it is clinically suspected, we recommend general anaesthetic for the gastroscopy to help clear the bezoar.

Windsock in the heart

Dear Editor, A 47-year-old woman with a history of untreated hypertension presented via ambulance to the ED with 2 h of central chest pain. Initial electrocardiography demonstrated inferior ST elevation and prehospital activation of the cardiac catherisation laboratory was initiated. On arrival to the ED, she developed an evolving rightsided hemiplegia with reducing conscious state and subsequent pulmonary oedema. She was emergently intubated and a BELS scan performed. This demonstrated an abnormal aortic valve with severe aortic regurgitation and independently mobile, parallel echogenicities arising from the aortic annulus and prolapsing into the left ventricular outflow tract during diastole, similar to the appearance of a ‘windsock’ (Fig. 1a). No clear dissection plane was noted in the ascending aorta. Sonographer-performed transthoracic echocardiography (TTE) confirmed these findings and immediate computed tomography (CT) demonstrated an extensive aortic dissection (AoDx) arising at the aortic annulus extending into the head and neck vessels as well in a retrograde direction to both coronary ostia. She was transferred for urgent operative intervention and intra-operative trans-oesophageal echocardiography was consistent with BELS assessment (Fig. 1b,c). Visual evaluation of the aorta confirmed a transverse AoDx above the annulus with prolapsing intimal tissue across the aortic valve. The aortic valve itself was structurally normal. The dissection was repaired with a 28 mm Dacron graft with complete resolution of aortic regurgitation. AoDx is often misdiagnosed due to its varied clinical presentation. Traditional diagnosis requires CT, but TTE does have a place for the bedside assessment of AoDx. BELS is fast becoming an important tool within emergency medicine that can facilitate rapid diagnosis of life-threatening conditions including AoDx. The incidence of type A AoDx is approximately 30 cases per million people per annum. Left to run its natural course, AoDx has an initial mortality rate of about 1% per hour with around 50% of patients dead after 3 days, rising to almost 80% mortality after 2 weeks. Differential diagnoses that involve the aortic root that could mimic a windsock is rupture of the sinus of Valsalva or complete destruction of the aortic valve leaflets due to endocarditis resulting in multiple leaflet prolapse. Little information exists in the literature about the use of BELS in AoDx. This may reflect clinician inexperience due to varied presentation and diagnostic assessment of AoDx, as well as the infrequency of this disease process. Comprehensive TTE has a sensitivity approaching

Correction: RESPECT-ED: Rates of Pulmonary Emboli (PE) and sub-segmental PE with modern computed tomographic pulmonary angiograms in emergency departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates (PLoS ONE (2016) 11:12 (e0166483) DOI: 10.1371/journal.pone.0166483)

[This corrects the article DOI: 10.1371/journal.pone.0166483.].

ABC: Don't forget to clear the airway!

Dear Editor, A 52-year-old man presented to the ED with a 1 day history of increasing neck pain, dysphagia and odynophagia. The pain had worsened during the day and he had not eaten since waking. Initially he was able to drink water, but his dysphagia progressed so he was unable to swallow liquids or clear his saliva. On presentation, he gave a history of unintentional i.v. opiate overdose the night before. He reported that CPR was performed and an ambulance was called. The resuscitation included administration of i.m. naloxone and placement of an oropharyngeal airway with bag and mask ventilation until the patient regained consciousness. There was a period of observation by the paramedics and the patient refused transfer to hospital; in the case of an unintentional overdose, the patient has the right to refuse hospitalisation. The patient awoke the next morning with neck pain, which he attributed to trauma of the oropharyngeal airway. On examination, his vital signs were normal and he was afebrile. There was no obvious oedema or palpable neck masses, but there was generalised tenderness. His tongue, palate and posterior pharyngeal wall showed no signs of oedema or trauma. His upper left tooth was missing, but this was from an old injury many years ago. Chest was clear on auscultation. Swallowing was very painful. A CXR showed no acute chest pathology, but there was a strange metallic shape at his tracheal notch (Fig. 1). This prompted neck X-rays to be done, but in the meantime, the patient gave additional history of a partial dental plate for his missing front tooth. He was unsure where his denture was, but assumed it was lost among the activity of the night before. Antero-posterior and lateral neck X-rays showed a dental plate impacted in his upper oesophagus and airway (Fig. 2). There was no radiological sign of pneumomediastinum and his vital signs remained stable in the ED. The ENT surgeons were consulted to remove the dental plate, which was done successfully in theatre via endoscopy without surgical complication. He remained an inpatient for 1 day. Swallowed or inhaled full or partial dentures are a documented complication. They account for 11–18% of ingested foreign bodies. Most scenarios are accidental inhalation, inhalation during anaesthetic induction or during generalised seizures. This presents a diagnostic challenge, as patients often cannot give a history of swallowing their dentures. A high clinical suspicion is needed, with common presenting symptoms being dysphagia and odynophagia. Imaging of swallowed or inhaled dentures may be difficult as many dentures are made from radiolucent polymethylacrylate. Many dentures with clasps, wire retainers or metallic components will be radiopaque. Another important X-ray finding to look for is pneumomediastinum. Figure 1. CXR showing metallic object at tracheal notch.