Joel T. Levis

Radial artery pseudoaneurysm formation after cat bite to the wrist.

Pseudoaneurysms may occur in the groin after catheterization of the femoral artery but may also occur in arteriovenous shunting for dialysis after placement of indwelling catheters or after direct trauma to an artery. We report a unique cause of radial artery pseudoaneurysm at the wrist related to a cat bite sustained by an elderly woman. The patient underwent successful operative repair of the aneurysm, with ligation of the radial artery.

Acute Myocardial Infarction due to Coronary Artery Embolism in a Patient with a Tissue Aortic Valve Replacement

Acute occlusive embolism to the coronary arteries resulting in acute myocardial infarction (AMI) is an uncommon occurrence. Although cases of patients with mechanical prosthetic heart valves resulting in this phenomenon have been reported in the setting of inadequate anticoagulation, reported cases resulting years after tissue aortic valve replacement (AVR) are rare. We report the case of a 50-year-old man who underwent a tissue AVR four years earlier and presented to the Emergency Department (ED) with an ST-segment elevation myocardial infarction. ED door-to-balloon time was delayed (at 115 minutes) because of pre-existing left bundle branch block on electrocardiogram. Emergent coronary angiography demonstrated complete occlusion of the left anterior descending coronary artery by a coronary embolus. The patient was successfully treated with percutaneous transluminal coronary angioplasty and aspiration thrombectomy, and subsequently underwent a transesophageal echocardiogram demonstrating thrombus on the tissue aortic valve prosthesis. This case demonstrates that coronary embolism resulting in AMI, while rare, can occur in patients years after tissue AVR surgery.

Factors Contributing to Door-to-Balloon Times of ≤90 Minutes in 97% of Patients with ST-Elevation Myocardial Infarction: Our One-Year Experience with a Heart Alert Protocol.

CONTEXT Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) can significantly reduce mortality and morbidity, although its effectiveness may be limited by delays in delivery. In March 2008, our hospital implemented a Heart Alert protocol to rapidly identify and treat patients with STEMI presenting to our Emergency Department (ED) with PCI, using strategies previously described to reduce door-to-balloon times. Before the Heart Alert protocol start date, patients with STEMI presenting to our ED were treated with thrombolysis. OBJECTIVE We evaluated data from patients with STEMI after one year of use of our Heart Alert protocol to determine protocol success on the basis of the percentage of patients for whom the recommended door-to-balloon times of ≤90 minutes were met. We examined factors involved in implementation of the protocol that contributed to these results. DESIGN We conducted a retrospective data and chart review for patients in the ED with STEMI who underwent PCI after a Heart Alert protocol activation between March 17, 2008, and March 17, 2009. RESULTS During the study period, our staff met the recommended door-to-balloon time of ≤90 minutes (mean door-to-balloon time, 57.3 ± 17.6 minutes) for 70 of 72 patients (97%) presenting to our ED with STEMI. Sixty-five of the 72 patients (90.3%) survived to hospital discharge. CONCLUSION Initiation of a Heart Alert protocol at our hospital resulted in achievement of door-to-balloon times of ≤90 minutes for 97% of patients with STEMI. This achievement was obtained through careful preparation, training, and interdepartmental collaboration and occurred despite immediate conversion from a previous thrombolytic protocol.

ECG Diagnosis: Hypokalemia

The earliest electrocardiogram (ECG) change associated with hypokalemia is a decrease in the T-wave amplitude.1 As potassium levels decline further, ST-segment depression and T-wave inversions are seen, while the PR interval can be prolonged along with an increase in the amplitude of the P wave.1 The U wave is described as a positive deflection after the T wave, often best seen in the mid-precordial leads (eg, V2 and V3). When the U wave exceeds the T-wave amplitude, the serum potassium level is < 3 mEq/L.2 In severe hypokalemia, T- and U-wave fusion with giant U waves masking the smaller preceding T waves becomes apparent on the ECG.1,2 A pseudo-prolonged QT interval may be seen, which is actually the QU interval with an absent T wave.1 Severe hypokalemia can also cause a variety of tachyarrhythmias, including ventricular tachycardia/fibrillation and rarely atrioventricular block.3 Treatment of hypokalemia involves parenteral and oral potassium supplementation, as well as identification and treatment of the underlying cause.1 Figure 1 12-lead ECG from a 21-year-old man with syncope, generalized weakness, and severe hypokalemia (serum potassium 1.6 mEq/L). Figure 2 12-lead ECG from same patient following oral and intravenous potassium replacement (serum potassium 2.5 mEq/L).

Dermatologic Diagnosis: Leukocytoclastic Vasculitis.

Leukocytoclastic vasculitis (LCV), also termed hypersensitivity vasculitis, is a small-vessel vasculitis. The skin is the organ most commonly involved in LCV. Typical presentation is a painful, burning rash predominantly in the lower extremities. The most common skin manifestation is palpable purpura. Other skin manifestations include maculopapular rash, bullae, papules, plaques, nodules, ulcers, and livedo reticularis.

Intracranial hemorrhage after prehospital administration of intramuscular epinephrine

BACKGROUND The administration of epinephrine by the intramuscular route can be life-saving in cases of anaphylaxis or severe allergic reactions. However, the use of this drug can lead to a rapid rise in blood pressure, which theoretically could lead to deleterious effects in patients of any age, with elderly patients at greatest risk. OBJECTIVES To present a rare case of intracranial hemorrhage potentially resulting from the administration of intramuscular epinephrine in an elderly patient with an allergic reaction. CASE REPORT We present a case report of a 65-year-old woman who developed an intracranial hemorrhage after a single, therapeutic, intramuscular dose of epinephrine for a wasp sting to the tongue. The patient underwent successful craniotomy with evacuation of the intracranial hematoma. CONCLUSIONS In circumstances where the severity of the allergic reaction remains unclear (lack of airway compromise, cardiovascular collapse, or true anaphylaxis), careful consideration of the potential risks of intramuscular epinephrine, such as a rapid rise in blood pressure leading to intracranial hemorrhage, should be undertaken when using this medication in elderly patients.

ECG diagnosis: apical hypertrophic cardiomyopathy.

Apical hypertrophic cardiomyopathy (HCM) is an atypical phenotype of nonobstructive HCM with an indistinguishable histology.1 In Japan this apical variant constitutes approximately 25% of patients with HCM, although it is uncommon in other parts of the world, accounting for only 2% of patients with HCM.1 The electrocardiogram in apical HCM typically shows repolarization changes and giant (>10 mm), inverted T waves in the anterolateral leads (particularly in leads V4 and V5).2,3 Transthoracic echocardiography is the initial test of choice in making the diagnosis. Patients with apical HCM can present with chest pain, dyspnea, palpitations, or syncope.1 Patients with this condition may remain asymptomatic, with the condition detected by chance as a result of an abnormal electrocardiogram.3 In general, the condition carries a benign prognosis, although complications including ventricular tachycardia, atrial fibrillation, apical myocardial infarction, and apical aneurysm can occur in rare instances.1

ECG Diagnosis: Flecainide Toxicity

Flecainide acetate is a Vaughn-Williams class IC antiarrhythmic and a sodium channel blocking agent used mainly for the treatment of supraventricular dysrhythmias.1 Adverse cardiac effects include moderate negative inotropic action and depression of all major conduction pathways.2 With increasing concentration, flecainides action on conduction pathways is manifested on electrocardiogram as an increased PR interval and QRS duration. Toxicity is suggested when a 50% increase in QRS duration (0.18 sec) or 30% prolongation in PR interval (0.26 sec) occurs. The QTc interval can also be prolonged in cases of flecainide overdose.3 Treatment of acute flecainide overdose includes administration of activated charcoal (for patient presenting early in course of ingestion), administration of sodium bicarbonate (reverses action of sodium channel blockade), pressors (eg, dobutamine) for profound hypotension, and transthoracic or transvenous pacing.1,4 Figure 1 12-lead Electrocardiogram from a 46-year-old woman with flecainide toxicity. Figure 2 12-lead Electrocardiogram from same patient obtained 24 hours later.

ECG Diagnosis: Right Ventricular Myocardial Infarction

Approximately 25% to 50% of cases of inferior wall myocardial infarction are associated with a right ventricular myocardial infarction (RVMI).1 In a large meta-analysis, the presence of RVMI was associated with a 2.6-fold increased risk of mortality as well as an increase in ventricular arrhythmias, high-grade atrioventricular block, and mechanical complications.2 The hemodynamic syndrome associated with RVMI includes hypotension, elevated venous pressures, and shock without evidence of congestive heart failure.3 The standard 12-lead electrocardiogram (ECG) provides information on the left ventricle but yields limited information on the right side of the heart. Leads V1 and V2 on the standard ECG provide only a partial view of the right ventricle free wall. The ECG findings suggestive of RVMI on the standard 12-lead ECG include ST elevation in leads II, III, and aVF with reciprocal ST depression in the lateral leads. Characteristically in RVMI, the ST elevation in lead III is greater than in lead II, and the ST elevation in lead aVF is greater than the ST depression in lead V2. Right-sided precordial leads are critical to the evaluation of suspected RVMI. Using right-sided precordial leads, STsegment elevation in lead V4R ≥ 1.0 mm is diagnostic of RVMI.4 The ECG finding of ST elevation in lead V4R for diagnosis of RVMI has 100% sensitivity, 87% specificity, and 92% predictive accuracy.4,5 Right precordial ST-segment elevation is a transient event that may be absent in up to half of patients with RVMI 12 hours after the onset of pain.6,7 ST-segment elevation in right-sided precordial leads, especially in V4R, correlates with reduced right ventricle ejection fraction and is associated with major complications and inhospital mortality.6-8 In RVMI, the resulting elevated right ventricle volume and right ventricle enddiastolic pressure displace the septum toward the volume-deprived left ventricle, further limiting left ventricle filling. Hence, once the diagnosis of RVMI is established, one must be careful to avoid diuretics, beta-adrenergic blockers, morphine, and nitrates because they

Ready or not: Does household preparedness prevent absenteeism among emergency department staff during a disaster?

INTRODUCTION During major disasters, hospitals experience varied levels of absenteeism among healthcare workers (HCWs) in the immediate response period. Loss of critical hospital personnel, including Emergency Department (ED) staff, during this time can negatively impact a facilitys ability to effectively treat large numbers of ill and injured patients. Prior studies have examined factors contributing to HCW ability and willingness to report for duty during a disaster. The purpose of this study was to determine if the degree of readiness of ED personnel, as measured by household preparedness, is associated with predicted likelihood of reporting for duty. Additionally, the authors sought to elucidate other factors associated with absenteeism among ED staff during a disaster. METHODS ED staff of five hospitals participated in this survey-based study, answering questions regarding demographic information, past disaster experience, household disaster preparedness (using a novel,15-point scale), and likelihood of reporting to work during various categories of disaster. The primary outcome was personal predicted likelihood of reporting for duty following a disaster. RESULTS A total of 399 subjects participated in the study. ED staffs were most likely to report for duty in the setting of an earthquake (95 percent) or other natural disaster, followed by an epidemic (90 percent) and were less likely to report for work during a biological, chemical, or a nuclear event (63 percent). Degree of household preparedness was determined to have no association with an ED HCWs predicted likelihood of reporting for duty. Factors associated with predicted absenteeism varied based on type of disaster and included having dependents in the home, female gender, past disaster relief experience, having a spouse or domestic partner, and not owning pets. Having dependents in the home was associated with predicted absenteeism for all disaster types (OR 0.30-0.66). However, when stratified by gender, the presence of dependents at home was only a significantly associated with predicted absenteeism among women as opposed to men (OR 0.07-0.59 versus OR 0.41-1.02). DISCUSSION Personal household preparedness, while an admirable goal, appears to have no effect on predicted absenteeism among ED staff following a disaster. Having responsibilities for dependents is the most consistent factor associated with predicted absenteeism among female staff. Hospital and ED disaster planners should consider focusing preparedness efforts less toward household preparedness for staff and instead concentrate on addressing dependent care needs in addition to professional preparedness.