Joshua J. Oliver

An end-user's guide to the HEART score and pathway

Background: Chest pain accounts for a significant percentage of emergency department (ED) presentations. The HEART score and pathway have demonstrated an ability to appropriately risk stratify and discharge from the ED a significant proportion of patients. Objective: This review evaluates vital components of the HEART score and pathway, while discussing important considerations for current and future use. Discussion: Chest pain is a common ED presentation, and several conditions associated with chest pain result in patient morbidity and mortality. One major disease is acute coronary syndrome (ACS). Despite the fear associated with this disease, it accounts for a minority of patients with chest pain in the ED. Emergency physicians rarely miss myocardial infarction (MI) or ACS, with miss rates < 1%. Many have sought a score and pathway that allow physicians to safely and reliably risk stratify patients. The HEART score and pathway have revolutionized chest pain evaluation, as they can risk stratify a significant number of patients accurately into separate categories based on history, electrocardiogram (ECG), troponin, age, and risk factors while displaying high sensitivity for MACE. Several intricacies must be considered in the use of this score including risk factors, ECG, troponin, age, history, gestalt, follow up, borderline score, and shared decision making. The HEART pathway can supplement clinician decision making. Conclusions: Appropriate use of the HEART pathway reliably risk stratifies patients. Physicians must consider several key components when utilizing the HEART pathway, and future directions may incorporate other patient factors.

An analysis of casualties presenting to military emergency departments in Iraq and Afghanistan

Background: During the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting. Methods: We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016. Results: During this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X‐ray (79.9%) was the most frequently performed imaging study. Conclusions: US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, administered blood products, and obtained diagnostic imaging studies.

Anatomy of the Eye

The eye is a complex organ. The emergency physician may be tasked with managing various ophthalmologic emergencies. A basic understanding of the specific structures of the eye can help recognize and manage the differentials of the eye. This applies to both medical and traumatic pathologies. This chapter delves into the anatomy of the eye, focusing on highlighting the different structures that are highly relevant to the emergency medicine differential diagnosis.

Treatment of Mal de Debarquement Syndrome in a Deployed Environment

We report the case of a 26-year-old Caucasian female with persistent sensations of forward and reverse movement with spontaneous onset. This worsened over 4 wk. The patient reported an episode of these symptoms 5 mo prior, which lasted for 3 mo before improving. Our case details the treatment of Mal de Debarquement syndrome, or Disembarkment Syndrome, in a deployed military environment. Mal de Debarquement was a term originally coined to describe the persistent sensation of rocking back and forth after disembarking a boat and returning to land. This is normal, and usually only lasts for minutes to hours. When it persists, it is called Mal de Debarquement Syndrome. The onset frequently coincides with travel and most commonly by boat, however it can also occur spontaneously as in this case. Currently, there are three different treatment options. The first involves medications that are often sedating. The second uses magnetic resonance imaging at high frequency to stimulate the areas of the brain thought to be involved. The third option is a form of physical therapy termed re-adaptation of the vestibular ocular reflex. As we were in a deployed military environment the first two options were unsafe and unavailable respectively. We employed an improvised version of re-adaptation of the vestibular ocular reflex. The patient demonstrated a 50% reduction in symptoms following 1 wk of treatment and as a result was safely able to complete her deployment.

Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study

BACKGROUND Chest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful. OBJECTIVE To compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway). METHODS We conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts. RESULTS The admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7-68.2%), vs. 48.3% (95% CI 43.7-53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7-21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33-0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE. CONCLUSIONS The HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial

Study Objective We compare aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access. Methods In a randomized, blinded, placebo‐controlled trial, we enrolled a convenience sample of adults presenting to an urban tertiary care ED with chief complaints including nausea or vomiting. We randomized subjects to 1 of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0‐ to 100‐mm visual analog scale from enrollment to 30 minutes postintervention. Secondary outcomes included receipt of rescue antiemetic medications and adverse events. Results We enrolled 122 subjects, of whom 120 (98.3%) completed the study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41 received inhaled saline solution placebo and oral ondansetron. The mean decrease in nausea visual analog scale score in each arm was 30 mm (95% confidence interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. The proportions of subjects who received rescue antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95% CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were no adverse events. Conclusion Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone.

A HEART Pathway pitfall in an admitted patient: A case report

&NA; This paper discusses a possible weakness of the HEART Pathway specific to patients identified as high risk, requiring admission for inpatient risk stratification. Emergency Department (ED) crowding is at an all‐time high and the possibility that many of these patients will board in the ED for a period of time before they are transported to an inpatient ward is becoming more likely. Given troponins peak at 6 h after the initial cardiac injury, it is plausible an initial troponin could still remain negative upon arrival. Extending the HEART Pathway to include a 3‐hour delta troponin for admitted patients boarded in the emergency department may help alert the patients inpatient team of those requiring more aggressive evaluations or more timely interventions. The case discussed herein highlights the course of a patient who was admitted to a medicine floor for chest pain along the HEART Pathway. After remaining in the ED for 3 h following admission a second troponin was drawn that resulted in the diagnosis of a non‐ST segment myocardial infarction. The patient then received further management in the ED and a change in admission to the Cardiac Care Unit instead of the medicine floor. The patient ultimately received a Coronary Artery Bypass Graft during admission. If the patient had not had the second troponin while in the ED this care would have been delayed.

Delayed Migration and Perforation of the Jugular Vein by a Peripherally Inserted Central Catheter

We report a case of peripherally inserted central catheter (PICC) migration and perforation of the left internal jugular vein in a home health setting in an 80-year-old female. A left sided PICC was placed for treatment of diverticulitis following hospital discharge. She complained of sudden onset left sided neck pain immediately after starting an infusion of vancomycin. In the emergency department the injury was identified by portable chest radiograph and computed tomography of her neck. Following removal of the line, she had an uneventful course. Emergency physicians should be aware of this possible PICC line complication.

Optimizing Military Human Subjects Protection and Research Productivity: The Role of Institutional Memory.

responding promptly through conversation. While we see little benefit in the proposal to prioritize grant funded research, we are in support of many of Freed and colleagues’ proposals. We have proposed some feasible suggestions for consideration that are admittedly more logistically complex and would require greater, but reasonable, resources. We welcome the dialogue that Freed and colleagues have opened and we too look forward to improvements in the efficiency of the military IRB system.