Jennifer V. Pope

Multicenter Study of Central Venous Oxygen Saturation (ScvO2) as a Predictor of Mortality in Patients With Sepsis

STUDY OBJECTIVE Abnormal (both low and high) central venous saturation (ScvO(2)) is associated with increased mortality in emergency department (ED) patients with suspected sepsis. METHODS This was a secondary analysis of 4 prospectively collected registries of ED patients treated with early goal-directed therapy-based sepsis resuscitation protocols from 4 urban tertiary care hospitals. Inclusion criteria were sepsis, hypoperfusion defined by systolic blood pressure less than 90 mm Hg or lactate level greater than or equal to 4 mmol/L, and early goal-directed therapy treatment. ScvO(2) levels were stratified into 3 groups: hypoxia (ScvO(2) <70%); normoxia (ScvO(2) 71% to 89%); and hyperoxia (ScvO(2) 90% to 100%). The primary exposures were initial ScvO(2) and maximum ScvO(2) achieved, with the primary outcome as inhospital mortality. Multivariate analysis was performed. RESULTS There were 619 patients who met criteria and were included. For the maximum ScvO(2), compared with the mortality rate in the normoxia group of 96 of 465 (21%; 95% confidence interval [CI] 17% to 25%), both the hypoxia mortality rate, 25 of 62 (40%; 95% CI 29% to 53%) and hyperoxia mortality rate, 31 of 92 (34%; 95% CI 25% to 44%) were significantly higher, which remained significant in a multivariate modeling. When the initial ScvO(2) measurement was analyzed in a multivariate model, only hyperoxia was significantly higher. CONCLUSION The maximum ScvO(2) value achieved in the ED (both abnormally low and high) was associated with increased mortality. In multivariate analysis for initial ScvO(2), the hyperoxia group was associated with increased mortality, but not the hypoxia group. This study suggests that future research aimed at targeting methods to normalize high ScvO(2) values by therapies that improve microcirculatory flow or mitochondrial dysfunction may be warranted.

Klebsiella Pneumoniae Liver Abscess: An Emerging Problem in North America

BACKGROUND Before the 1980s, Escherichia coli was the most common cause of pyogenic liver abscess, but more recently, Klebsiella pneumoniae has emerged as the most common organism in the United States and Taiwan. OBJECTIVE Our goal is to present a case of K. pneumoniae liver abscess (KLA) and review the risk factors, presenting symptoms, complications, and treatment of this disease that is emerging in North America. CASE REPORT We present a patient who was found to have KLA complicated by bacteremia and sepsis. CONCLUSIONS Initially described in the Asian literature, KLA is an emerging problem in North America. We present this case to increase awareness among emergency physicians of the diagnosis, risk factors, potential complications-including bacteremia and disseminated infection-and treatment.

Avoiding Misdiagnosis in Patients with Neurological Emergencies

Approximately 5% of patients presenting to emergency departments have neurological symptoms. The most common symptoms or diagnoses include headache, dizziness, back pain, weakness, and seizure disorder. Little is known about the actual misdiagnosis of these patients, which can have disastrous consequences for both the patients and the physicians. This paper reviews the existing literature about the misdiagnosis of neurological emergencies and analyzes the reason behind the misdiagnosis by specific presenting complaint. Our goal is to help emergency physicians and other providers reduce diagnostic error, understand how these errors are made, and improve patient care.

Favorable response to analgesics does not predict a benign etiology of headache.

Background.— Distinguishing between primary and secondary headaches (HAs) is essential for the safe and effective management of patients with HA. A favorable response to analgesics may be observed with both classes of HAs and therefore is not a good predictor of who needs further evaluation.

PRACTICING EMERGENCY PHYSICIANS REPORT PERFORMING WELL ON MOST EMERGENCY MEDICINE MILESTONES

BACKGROUND The Accreditation Council for Graduate Medical Educations Next Accreditation System endorsed specialty-specific milestones as the foundation of an outcomes-based resident evaluation process. These milestones represent five competency levels (entry level to expert), and graduating residents will be expected to meet Level 4 on all 23 milestones. Limited validation data on these milestones exist. It is unclear if higher levels represent true competencies of practicing emergency medicine (EM) attendings. OBJECTIVE Our aim was to examine how practicing EM attendings in academic and community settings self-evaluate on the new EM milestones. METHODS An electronic self-evaluation survey outlining 9 of the 23 EM milestones was sent to a sample of practicing EM attendings in academic and community settings. Attendings were asked to identify which level was appropriate for them. RESULTS Seventy-nine attendings were surveyed, with an 89% response rate. Sixty-one percent were academic. Twenty-three percent (95% confidence interval [CI] 20%-27%) of all responses were Levels 1, 2, or 3; 38% (95% CI 34%-42%) were Level 4; and 39% (95% CI 35%-43%) were Level 5. Seventy-seven percent of attendings found themselves to be Level 4 or 5 in eight of nine milestones. Only 47% found themselves to be Level 4 or 5 in ultrasound skills (p = 0.0001). CONCLUSIONS Although a majority of EM attendings reported meeting Level 4 milestones, many felt they did not meet Level 4 criteria. Attendings report less perceived competence in ultrasound skills than other milestones. It is unclear if self-assessments reflect the true competency of practicing attendings. The study design can be useful to define the accuracy, precision, and validity of milestones for any medical field.

Types of diagnostic errors in neurological emergencies in the emergency department

Abstract Background: Neurological emergencies often pose diagnostic challenges for emergency physicians because these patients often present with atypical symptoms and standard imaging tests are imperfect. Misdiagnosis occurs due to a variety of errors. These can be classified as knowledge gaps, cognitive errors, and systems-based errors. The goal of this study was to describe these errors through review of quality assurance (QA) records. Methods: This was a retrospective pilot study of patients with neurological emergency diagnoses that were missed or delayed at one urban, tertiary academic emergency department. Cases meeting inclusion criteria were identified through review of QA records. Three emergency physicians independently reviewed each case and determined the type of error that led to the misdiagnosis. Proportions, confidence intervals, and a reliability coefficient were calculated. Results: During the study period, 1168 cases were reviewed. Forty-two cases were found to include a neurological misdiagnosis and twenty-nine were determined to be the result of an error. The distribution of error types was as follows: knowledge gap 45.2% (95% CI 29.2, 62.2), cognitive error 29.0% (95% CI 15.9, 46.8), and systems-based error 25.8% (95% CI 13.5, 43.5). Cerebellar strokes were the most common type of stroke misdiagnosed, accounting for 27.3% of missed strokes. Conclusions: All three error types contributed to the misdiagnosis of neurological emergencies. Misdiagnosis of cerebellar lesions and erroneous radiology resident interpretations of neuroimaging were the most common mistakes. Understanding the types of errors may enable emergency physicians to develop possible solutions and avoid them in the future.

Catatonia in the Emergency Department

Dr. Katherine Kroll: Today’s case is that of a 21-yearold man with a history of psychosis and moderate mental retardation who presented to the Emergency Department (ED) with a chief complaint of ‘‘Mental Status Change.’’ He was transferred on a section 12 from an outside hospital ED to our ED for evaluation of disorganized behavior, self-dialoguing, and odd behavior. On initial evaluation, the patient was able to give only limited history. Although he answered simple and direct questions appropriately, he gave very limited information to open-ended questioning, mainly with oneor two-word answers. He did endorse increased frequency of hearing voices telling him to put a penis in his mouth. He denied depressed mood as well as any suicidal or homicidal ideation. His review of systems was negative, denying any recent fever, chills, vomiting, diarrhea, headache, vision changes, numbness, tingling, weakness, or abnormal gait. Dr. Jennifer Pope: Based on this initial history, concern is raised for a psychiatric illness. In this setting, where the patient is reluctant or unable to give additional history, it can be helpful to acquire additional corroborating history from family members, friends, and previous health care providers. Were there any friends or family members available to provide collateral information? Dr. K. Kroll: The remainder of the history was obtained from the patient’s mother and stepfather. They reported that the patient began to deteriorate around age 17 years, after two close friends died suddenly. He became more introverted, was expelled from school, and