Mel Herbert

Failure to Agree on the Electrocardiographic Diagnosis of Ventricular Tachycardia

STUDY OBJECTIVE To determine the extent of interobserver agreement in the ECG diagnosis of ventricular tachycardia (VT) by using a four-step algorithm and three observers. METHODS Simulated emergency department setting from records of an urban university teaching hospital. All ECGs taken in the ED during a 2-year period that showed a QRS duration of more than 120 msec and a heart rate faster than 110 beats per minute were reviewed. ECGs were categorized as demonstrating sinus rhythm (SR), irregular broad-complex tachycardia (I-BCT), or regular broad-complex tachycardia (BCT). Copies of the BCT ECGs and short clinical histories were given to each of three emergency physicians, who used a published, four-step algorithm (the Brugada algorithm) to categorize the BCT ECGs as indicating VT, indicating supraventricular tachycardia with aberrancy (SVT-A), or indeterminate. Interobserver agreement was assessed with the K-statistic. RESULTS The records contained 178 ECGs, 88 of which were SR, 63 I-BCT, and 27 BCT. The 27 BCT ECGs were selected for review. The emergency physicians disagreed with each other 22% of the time in differentiating VT from SVT-A (K = .58). CONCLUSION Application of the algorithm to actual clinical practice in the ED would probably result in the misdiagnosis of a substantial minority of patients having BCT, with potentially serious adverse consequences.

Myth: Parenteral ketorolac provides more effective analgesia than oral ibuprofen

Acute pain is an extremely common presenting symptom to the emergency department (ED), making it imperative that emergency physicians provide adequate, safe and cost-effective analgesia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often first-line treatments for moderate to severe pain. Physicians can choose between intramuscular (IM) or intravenous (IV) ketorolac and an oral NSAID. The mechanism of action (reversible inhibition of prostaglandin synthesis at the level of cyclooxygenase) is identical irrespective of the route the medication is given. Despite the similar pharmacodynamics, many physicians believe that parenteral ketorolac is more efficacious, despite a greater cost and a more invasive route of administration. To investigate this myth (i.e., that parenteral ketorolac provides greater analgesic effect than an oral NSAID), we conducted a review of the literature, with specific focus on ibuprofen as the prototypical — and least expensive — oral NSAID.

Myth: Interpretation of a single ammonia level in patients with chronic liver disease can confirm or rule out hepatic encephalopathy

Although the exact pathophysiology of hepatic encephalopathy (HE) is not fully understood, for more than a century ammonia has been thought to play a critical role. However, the interpretation and utility of ammonia levels in patients with chronic liver disease (CLD) presenting with HE has been a long-standing source of confusion. It is a common belief in the emergency department and on the wards that a single elevated ammonia level in a patient with CLD can confirm the diagnosis of HE, and a normal level essentially rules it out. This confusion stems from the fact that early studies showed a correlation between degree of encephalopathy and the ammonia level, but numerous subsequent studies have shown that severely encephalopathic patients often have normal ammonia levels. This paper reviews the published literature on ammonia levels in patients with CLD in an attempt to clarify its value as a clinical decision-making tool in patients with suspected HE.

Adenosine in Wide-Complex Tachycardia

The use of adenosine as a therapeutic and diagnostic tool in wide-complex tachycardia is suggested in the current Advanced Cardiac Life Support (ACLS) guidelines. The ACLS guidelines are now 4 years old, and new information on the safety and efficiency of adenosine in wide-complex tachycardia is available. We review the ACLS recommendations in light of the current available literature. In general, the ACLS recommendations remain reasonable with some important caveats.

Trust Me, This Is the Worst “Acne” of Your Life!

ANNALS CASE A 55-year-old woman presented to the emergency department (ED) with a 2-week history of a pruritic rash and progressive weakness. The eruption, first affecting the abdomen, appeared 9 days after initiation of vancomycin and cefepime (Figure 1). The patient had a temperature of 38.4 C (101.1 F) and a pulse rate of 160 beats/min. Physical examination revealed diffuse, edematous, erythematous plaques with overlying pustules and isolated bullae (Figure 2). The oral mucosa was not involved. Laboratory investigation identified an elevated lactate level of 6.4 mmol/L and leukocytosis of 28.9 10^9/L. To paraphrase Indiana Jones.rashes, why did it have to be rashes? When you take a look at these images, the rash is pretty impressive, and the patient sounds sick. A decision to admit this patient is probably the easy part. Butwhat’s your working diagnosis and what should you do next? Is this purpura fulminans in evolution or some autoimmune reaction? Do you give empiric antibiotics? Do you give empiric corticosteroids? Read on.

Penetrating Neck Injury: What’s In and What’s Out?

Editor’s note: Annals has partnered with Hippo Education and EM:RAP, enabling our readers without subscriptions to Hippo EM Board Review or EM:RAP to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and Hippo Education, EM:RAP or its authors.

A Clinical Decision Rule for Thoracolumbar Spine Imaging in Blunt Trauma

Editor’s Note: Annals has partnered with Hippo Education and EM:RAP, enabling our readers without subscriptions to Hippo EM Board Review or EM:RAP to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and Hippo Education, EM:RAP, or its authors.

Chest Pain Bounce-Back: Posterior Sternoclavicular Dislocation

Editor’s note: Annals has partnered with Hippo Education and EM:RAP, enabling our readers without subscriptions to Hippo EM Board Review or EM:RAP to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and Hippo Education, EM:RAP or its authors.

Pyoderma Gangrenosum: An Inside Job.

Editor’s note: Annals has partnered with EM:RAP, enabling our readers without subscriptions to the EM:RAP service to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and EM:RAP or its authors.

Why Does Your Dandruff Smell Like Urine

ANNALS CASE A 26-year-old man with hypertension and end-stage renal disease (ESRD) presents to the emergency department (ED) with worsening shortness of breath developing during the past 2 weeks. He is visibly dyspneic and has difficulty speaking. He is alert but is slow to respond to questions. He reports that he stopped attending dialysis approximately 3 weeks ago because of fear that the dialysis staff was “stealing” his blood. On physical examination, white flaky material is noted on the patient’s scalp (Figure). The blood urea nitrogen (BUN) level is 249 mg/dL.