George L. Higgins

Effect of Bedside Ultrasonography on the Certainty of Physician Clinical Decisionmaking for Septic Patients in the Emergency Department

STUDY OBJECTIVE Sepsis protocols promote aggressive patient management, including invasive procedures. After the provision of point-of-care ultrasonographic markers of volume status and cardiac function, we seek to evaluate changes in emergency physician clinical decisionmaking and physician assessments about the clinical utility of the point-of-care ultrasonographic data when caring for adult sepsis patients. METHODS For this prospective before-and-after study, patients with suspected sepsis received point-of-care ultrasonography to determine cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility. Physician reports of treatment plans, presumed causes of observed vital sign abnormalities, and degree of certainty were compared before and after knowledge of point-of-care ultrasonographic findings. The clinical utility of point-of-care ultrasonographic data was also evaluated. RESULTS Seventy-four adult sepsis patients were enrolled: 27 (37%) sepsis, 30 (40%) severe sepsis, 16 (22%) septic shock, and 1 (1%) systemic inflammatory response syndrome. After receipt of point-of-care ultrasonographic data, physicians altered the presumed primary cause of vital sign abnormalities in 12 cases (17% [95% confidence interval {CI} 8% to 25%]) and procedural intervention plans in 20 cases (27% [95% CI 17% to 37%]). Overall treatment plans were changed in 39 cases (53% [95% CI 41% to 64%]). Certainty increased in 47 (71%) cases and decreased in 19 (29%). Measured on a 100-mm visual analog scale, the mean clinical utility score was 65 mm (SD 29; 95% CI 58 to 72), with usefulness reported in all cases. CONCLUSION Emergency physicians found point-of-care ultrasonographic data about cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility to be clinically useful in treating adult patients with sepsis. Increased certainty followed acquisition of point-of-care ultrasonographic data in most instances. Point-of-care ultrasonography appears to be a useful modality in evaluating and treating adult sepsis patients.

Pediatric poisoning from over-the-counter imidazoline-containing products

We present two instructive cases of imidazoline poisoning in young children. Imidazoline decongestants, readily available in numerous non-prescription preparations, can rapidly produce toxicity from oral ingestion and topical application. Signs and symptoms depend on whether peripheral or central alpha 2-adrenergic receptor stimulation predominates. Timely diagnosis depends on a high index of suspicion and careful questioning about the availability of these over-the-counter products. Standard toxicologic management will prevent significant morbidity. No specific antidote exists.

Body surface mapping vs 12-lead electrocardiography to detect ST-elevation myocardial infarction

A prospective, multicenter trial was conducted in patients with nontraumatic chest pain in 4 hospitals to determine whether an 80-lead body surface map electrocardiogram system (80-lead BSM ECG) improves detection of ST-segment elevation in acute myocardial infarction (STEMI) compared with a standard 12-lead electrocardiogram (ECG) in an emergency department (ED) setting. A trained ED or cardiology staff member (technician or nurse) recorded a 12-lead ECG and 80-lead BSM ECG from each subject at initial presentation. Serial biomarkers (total creatine kinase [CK], CK-MB, and/or troponin) were obtained according to individual hospital practice. Of the 647 patients evaluated, 589 had available biomarkers results. Eighty-lead BSM ECG improved detection of biomarker-confirmed STEMI compared with the 12-lead ECG for CK-MB-defined STEMI (100% vs 72.7%, P = .031; n = 364) or troponin-defined STEMI (92.9% vs 60.7%, P = .022; n = 225). Specificity for STEMI was high (range, 94.9%-97.1%) with no significant difference between 80-lead BSM ECG and 12-lead ECG. Right ventricular involvement complicating inferior STEMI was detected by 80-lead BSM ECG in 2 (22%) of 9 patients with CK-MB-defined MI and in 2 (22%) of 9 patients with troponin-defined MI. The infarct location missed most commonly on 12-lead ECG but detected by 80-lead BSM ECG was inferoposterior MI. We conclude that BSM using 80-lead BSM ECG is more sensitive for detection of STEMI than 12-lead ECG, while retaining similar specificity.

Spontaneous Peripartum Coronary Artery Dissection Presentation and Outcome

Objective: The objective of this study was to determine whether spontaneous peripartum coronary artery dissection (SPCAD) is a cause of acute myocardial infarction in women. Methods: Patients with SPCAD reported in the recent literature were analyzed to elucidate the clinically relevant characteristics of this condition. Results: Forty-seven cases of SPCAD are described. Patient characteristics include the following: mean age, 33.5 ± 5.2 years; gravity, 2.7 (95% confidence interval, 1.8–3.5); mean gestational age if prepartum, 32.5 ± 4.2 weeks (range, 23–36 weeks); and mean onset if postpartum, 22.9 ± 26.1 days (range, 3–90 days). Only 17 patients (36%) reported a cardiac risk factor, with the most frequent being smoking. All presented with characteristic ischemic pain; 25% of patients were hemodynamically unstable; and 81% of initial electrocardiograms demonstrated ST-elevation myocardial infarctions. The left coronary artery system was involved 81% of the time. Thirty percent of patients were managed conservatively or with thrombolytic therapy, whereas 34% received emergent percutaneous cardiac intervention and 36% required bypass surgery. There were no maternal deaths. Long-term follow-up revealed good cardiac function in the majority of patients, although 3 women required heart transplantation. Conclusions: SPCAD can occur weeks before or after delivery and should be considered in women presenting during the peripartum period with acute chest pain.

Intussusception in traditional pediatric, nontraditional pediatric, and adult patients

STUDY OBJECTIVES We sought to determine the rate of intussusception in 3 age groups (traditional pediatric-age [T], nontraditional pediatric-age [N], and adult-age [A]) and to compare group characteristics. METHODS We conducted a retrospective records review for patients discharged with diagnosis of intussusception between October 1999 and June 2008. RESULTS Ninety-five cases of intussusception were diagnosed as follows: 61 T (64%), 12 N (13%), and 22 A (23%). Bloody stool was more common in T patients (P = .016). Air contrast enema (36%) and ultrasound (33%) were the most common diagnostic tests in T, whereas computed tomography was most common in N (83%) and A (68%) patients. Bowel resection occurred more often in older (T) patients (P = .001). The most frequent causative pathologic conditions were adenitis (T), Peutz-Jeghers polyp (N), and carcinoma (A) and prior gastric bypass in 10 A patients. CONCLUSIONS The incidence of intussusception is substantially higher in nontraditional age groups than previously reported. Symptoms, management strategies, and causative pathologic conditions varied with age. All adults with intussusception require definitive diagnostic testing to determine the cause, given the concerning list of possibilities we observed.

Red Blood Cell Transfusion: Experience in a Rural Aeromedical Transport Service

INTRODUCTION The administration of blood products to critically ill patients can be life-saving, but is not without risk. During helicopter transport, confined work space, communication challenges, distractions of multi-tasking, and patient clinical challenges increase the potential for error. This paper describes the in-flight red blood cell transfusion practice of a rural aeromedical transport service (AMTS) with respect to whether (1) transfusion following an established protocol can be safely and effectively performed, and (2) patients who receive transfusions demonstrate evidence of improvement in condition. METHODS A two-year retrospective review of the in-flight transfusion experience of a single-system AMTS servicing a rural state was conducted. Data elements recorded contemporaneously for each transfusion were analyzed, and included hematocrit and hemodynamic status before and after transfusion. Compliance with an established transfusion protocol was determined through structured review by a multidisciplinary quality review committee. RESULTS During the study, 2,566 missions were flown with 45 subjects (1.7%) receiving in-flight transfusion. Seventeen (38%) of these transports were scene-to-facility and 28 (62%) were inter-facility. Mean bedside and in-flight times were 22 minutes (range 3-109 minutes) and 24 minutes (range 8-76 minutes), respectively. The most common conditions requiring transfusion were trauma (71%), cardiovascular (13%) and gastrointestinal (11%). An average of 2.4 liters (L) of crystalloid was administered pre-transfusion. The mean transfusion was 1.4 units of packed red blood cells. The percentages of subjects with pre- and post-transfusion systolic blood pressures of <90 mmHg were 71% and 29%, respectively. The pre- and post-transfusion mean arterial pressures were 62 mmHg and 82 mmHg, respectively. The pre- and post- transfusion mean hematocrit levels were 17.8% and 30.4%, respectively. At the receiving institution, 9% of subjects died in the Emergency Department, 18% received additional transfusion within 30 minutes of arrival, 36% went directly to the operating room, and 36% were directly admitted to intensive care. Thirty-one percent of subjects died prior to hospital discharge. There were no protocol violations or reported high-risk provider blood exposure incidents or transfusion complications. All transfusions were categorized as appropriate. CONCLUSIONS In this rural AMTS, transfusion was an infrequent, likely life-saving, and potentially high-risk emergent therapy. Strict compliance with an established transfusion protocol resulted in appropriate and effective decisions, and transfusion proved to be a safe in-flight procedure for both patients and providers.

Expediting the early hospital care of the adult patient with nontraumatic chest pain: Impact of a modified ED triage protocol

A prospective study that compared a traditional emergency department (ED) triage protocol with an expedited protocol was conducted to determine if minimizing the subjectivity of nursing triage would result in more efficient management of adult patients presenting with nontraumatic chest pain. The traditional protocol triaged 382 patients into 1 of 5 categories of acuity. The expedited study group (418 patients) were triaged as usual but subsequently were treated as if they were triage category 1 or 2 (medical evaluation within 15 minutes of arrival). Traditional triage led to 40% of acute myocardial infarction (AMI) patients being triaged into inappropriately low-acuity categories. The expedited protocol resulted in significant improvement in the following intervals: ED arrival to triage, triage to cubicle, ED arrival to cubicle, ED arrival to electrocardiogram (ECG) ordered, ED arrival to ECG available, ED arrival to physician evaluation, and ED arrival to decision to thrombolyse. Study patients with non-AMI cardiac chest pain and AMI cardiac chest pain were evaluated by a physician an average of 12 minutes and 8 minutes after ED arrival, respectively. Delays in interdepartmental processes, such as ECG-technician responsiveness, thrombolysis protocol fulfillment and thrombolytic agent delivery, negated benefits derived from improvements in internal processes. Effective coordination of the numerous processes involved in the initial ED management of adult patients with nontraumatic chest pain is required to make thrombolytic therapy for AMI within 30 minutes of patient arrival a routinely achievable goal.

C OMPARISON OF E XTRACTION D EVICES FOR THE R EMOVAL OF S UPRAGLOTTIC F OREIGN B ODIES

Objective. By using a porcine model, the efficacy of various extraction devices for airway foreign body removal was examined. Methods. The upper airways of euthanized swine were occluded with a rubber ball, glass marble, or grape. A Magill forceps, a spongestick forceps, and a nasal trumpet attached to suction were used by test subjects for foreign body removal. Extraction success and time were recorded for each removal attempt. Satisfaction scores were recorded for each foreign body and device combination. Results. Seven paramedics, seven residents, and seven attending physicians participated. A total of 189 attempts were analyzed. Success rates for foreign body extraction with Magill and spongestick forceps were similar, with both devices superior to nasal trumpet (98% and 97% vs. 83%, respectively, p < 0.001). For successful ball removal attempts, the mean extraction time with spongestick forceps was less than those for both Magill forceps and nasal trumpet: 12.4 (95% confidence interval [CI], 10–14.7) versus 23.4 (95% CI, 16.3–30.3) and 21.2 (95% CI, 14.2–28.3) seconds, respectively. For marble removal, the mean extraction time with spongestick forceps also was less than Magill forceps and nasal trumpet: 10.8 (95% CI, 8.7–12.8) versus 18.4 (95% CI, 12.8 to 23.8) and 16.7 (95% CI, 12.6–20.8) seconds, respectively. For grape removal, the mean extraction times with both spongestick and Magill forceps were less than that of nasal trumpet: 11.8 (95% CI, 7.1 to 16.4) and 8.1 (95% CI, 6.8–9.4) versus 15.6 (95% CI 10–21.2) seconds, respectively. Subjects preferred the spongestick forceps for removal of the glass and rubber ball to the Magill forceps and nasal trumpet. Conclusion. In this porcine model, the SF appeared to be the most efficient and preferred device for extracting the type of airway foreign body that is associated with fatal asphyxiation.

Cardiac myxoma as a mimic: a diagnostic challenge.

OBJECTIVE Patients with occult, undiagnosed cardiac myxomas (CM) often present with acute complications that mimic other, more common, conditions. We describe two recently encountered patients who classically demonstrate this phenomenon and report the results of an integrative review of CM cases to define the characteristics of such patients. METHODS A comprehensive 20-year review of reported cases that described patient-specific data of CM was performed. Using a standardized tool, the following elements were collected: age; gender; presenting symptoms and signs; diagnostic and management approaches; and outcomes. RESULTS One hundred twenty-six cases of CM were identified. The mean patient age was 47.5 years (range, 6-90). Seventy (56%) were women. The most common mimic conditions initially being considered were cardiac complications, including acutely decompensated heart failure, myocardial infarction, dysrhythmia and sudden death (46%); systemic embolization, including cutaneous infarction and pulmonary embolism (23%); central nervous system embolization, including transient ischemic attack and acute stroke syndrome (22%); and constitutional conditions, such as fever, myalgia, arthralgia, fatigue, and myxoma infections (17%). Echocardiography proved to be a readily available and accurate diagnostic test. The majority of reported patients experienced full recoveries after surgical intervention. CONCLUSIONS CM is a rare but potentially life-threatening condition. Symptoms and signs relating to CM mimic other, more common conditions, resulting in diagnostic delay. Echocardiography can quickly and accurately diagnose CM and timely surgical intervention is curative. Clinician awareness of this condition, in a suggestive clinical context, will increase the likelihood of optimal patient outcome.

A Case of Superior Vena Cava Syndrome Demonstrating Pemberton Sign

1079 pulse oximetry 98% on 2 L of oxygen. Examination revealed symmetric, plethoric edema of the face and neck (Figure 1A), bilateral serosanguinous chemosis, right arm edema, and a positive Pemberton sign (exaggeration of edema and flushing with placement of the patient’s arms overhead) (Figure 1B). Chest computed tomographic (CT) imaging revealed effacement of the superior vena cava (SVC) by a mediastinal mass, as well as catheter-associated thrombus involving the SVC and internal jugular vein. An enlarged cystic liver was