Study Objective: The 12-lead electrocardiogram (ECG) is an important tool in the stratification of emergency department (ED) patients with chest pain. Lead aVR is often ignored when interpreting an ECG. Prior studies have shown that ST segment deviation in aVR(devAVR) is associated with worse outcomes, including increased mortality at one year, and impaired coronary reperfusion in patients who have undergone recanalization of a vessel following a myocardial infarction. The objective of this study is to determine the importance of devAVR in ED patients with chest pain and a non-STEMI ECG. Methods: A retrospective chart review and ECG analysis of consecutive ED patients who were admitted with the diagnosis of chest pain at a 75,000 visit community hospital over a 3-month period in 2012. Patients in the study were classifide into 2 groups based on the presence or absence of devAVR. ST segment deviation was measured to the nearest 0.05 mV. ST segment deviation was considered significant if > 0.05 mV. Charts for the index admission were reviewed for cardiac endpoints (coronary artery bypass graft surgery (CABG), coronary artery stent placement, or elevated troponin). Exclusion criteria were <18 years of age, left bundle branch block, ST elevation MI, and paced cardiac rhythm. Statistical analysis included the sensitivity, specificity, and predictive values of devAVR for the end points described. Results: There were 124 chest pain patients admitted through the ED with 17 excluded. 12 of the 107 subjects had devAVR, (11.2%, 95%CI 6.4-18.7). 9 of the 107 subjects had a cardiac endpoint, 8.4% (95%CI 4.3-15.4). 3 of the 9 subjects with a cardiac endpoint had ST elevation in aVR with a sensitivity of 33%, (95%CI 12.1-64.6) and specificity 90.8%, (95%CI 83.5-95.1). Positive predictive value was 25% (95%CI 8.9-53.2) and negative predictive value was 93.7% (CI 86.9-97.1). Conclusion: ST segment deviation in lead aVR in non-STEMI chest pain patients, while not common, is a fairly specific predictor of several critical outcomes, namely the patient receiving a coronary artery stent, CABG surgery or developing a NSTEMI. The emergency physician should examine lead aVR carefully for ST segment deviation in chest pain patients with a non-diagnostic ECG.

Introduction: Numerous factors affect patient flow in the emergency department. One important factor that has a negative impact on flow is ED patients waiting for an inpatient bed. It currently takes approximately 5 hours from triage to a request for an inpatient bed in our emergency department. Knowledge of patients requiring admission early in their ED evaluation could speed up the process of securing a bed. The objective of this study was to determine if an ED triage nurse (TRN) can determine at triage if a patient will be admitted to an inpatient unit. A secondary objective was to measure the confidence of the TRN prediction.Methods: A prospective, non-consecutive study was conducted during an 18-day period in 2010 in a community hospital emergency department treating 76,000 patients. Experienced TRNs were trained in the evaluation tool. Immediately after the initial TRN evaluation, a determination was made in writing by the TRN regarding the likelihood of hospital admission and level of confidence in this decision. Patients who did not enter the emergency department through triage (ambulance) or were younger than 18 years were excluded.Results: A total of 3514 patients approached triage. Of these patients, 1866 were eligible for the study and 1164 (62%) were enrolled. We excluded 25 subjects because of missing data, resulting in 1139 subjects. Missed subjects had the same baseline characteristics. A total of 287 (25.2%) hospital admissions occurred. TRN predicted 217 admissions, with a sensitivity of 75.6% (95% confidence interval [CI] 71.3-79.5) and a specificity of 84.5% (95% CI 83.1-85.8). The TRN reported being extremely confident in the prediction 50.1% of the time. In these cases, the TRN demonstrated an admission sensitivity of 81.6% (95% CI 76.5-85.8) and specificity of 93.1% (95% CI 91.8-94.3).Conclusions: The TRN demonstrated a high sensitivity and specificity in admission prediction at triage and could potentially save many hours in requesting an inpatient bed. This increased efficiency could result in a more rapid ED throughput and decreased ED boarding.

Study ObjectiveUpper gastrointestinal bleeds commonly present to the emergency department (ED), and account for 300,000 yearly US hospital admissions at a cost of $2.5 billion per year. Many upper gastrointestinal bleeding patients are at low risk for serious complications and could be managed in an outpatient setting. There are no validated US guidelines to aid the emergency physician in determining which patients can be safely discharged from the ED. The United Kingdom (UK) has developed a scoring system, the Glasgow-Blatchford bleeding score (GBS), which accurately predicts which patients are low-risk for 7-day complications and can have an outpatient evaluation. The objective of this study is to evaluate the usefulness of the GBS in determining if admitted low-risk ED patients with upper gastrointestinal bleeding experience serious adverse events.MethodsWe conducted a retrospective chart review of adult patients admitted to the hospital from the ED with upper gastrointestinal bleeding over a 3-year period. Charts were selected using ICD-9 code for GI bleed. Subjects with a GBS of zero (low-risk) were evaluated for complications. A GBS of zero was assigned if BUN<18.2, hemoglobin ≥13.0(male) or ≥12.0 (female), systolic blood pressure ≥110, pulse<100, the patient had no complaints of melena or syncope, and had no history of hepatic disease or congestive heart failure. A serious adverse event was defined as endoscopic treatment, blood transfusion, or surgery. The setting was a 76,000 visit ED community hospital with an emergency medicine residency program.ResultsFive hundred sixty-seven presentations of upper gastrointestinal bleeding were screened. Four hundred sixty-four of these patients were admitted to the hospital with a diagnosis of upper gastrointestinal bleeding. Twenty-one (4.5%, 95% CI: 3.0-6.8%) of these were low-risk (GBS score of 0). Nine of the 21 patients underwent UGI endoscopy in the hospital. Serious adverse events were as follows: 0 blood transfusions, 0 surgeries, and 1 endoscopic treatment (hemorrhagic gastric polyp banded), 4.8%, (95%CI: 0.1-26.5).ConclusionVery few (4.5%) of our low-risk upper gastrointestinal bleeding patients were admitted to the hospital. Of the 21 low-risk patients admitted, only 1 had an adverse event (4.8%). The GBS may not be applicable to the US health care system, due to the already low percent of low-risk upper gastrointestinal bleeding patients admitted. The reason might be more stringent admission criteria and the rapid availability of outpatient endoscopy. More low-risk patients need to be followed to determine safety of outpatient management. Study ObjectiveUpper gastrointestinal bleeds commonly present to the emergency department (ED), and account for 300,000 yearly US hospital admissions at a cost of $2.5 billion per year. Many upper gastrointestinal bleeding patients are at low risk for serious complications and could be managed in an outpatient setting. There are no validated US guidelines to aid the emergency physician in determining which patients can be safely discharged from the ED. The United Kingdom (UK) has developed a scoring system, the Glasgow-Blatchford bleeding score (GBS), which accurately predicts which patients are low-risk for 7-day complications and can have an outpatient evaluation. The objective of this study is to evaluate the usefulness of the GBS in determining if admitted low-risk ED patients with upper gastrointestinal bleeding experience serious adverse events. Upper gastrointestinal bleeds commonly present to the emergency department (ED), and account for 300,000 yearly US hospital admissions at a cost of $2.5 billion per year. Many upper gastrointestinal bleeding patients are at low risk for serious complications and could be managed in an outpatient setting. There are no validated US guidelines to aid the emergency physician in determining which patients can be safely discharged from the ED. The United Kingdom (UK) has developed a scoring system, the Glasgow-Blatchford bleeding score (GBS), which accurately predicts which patients are low-risk for 7-day complications and can have an outpatient evaluation. The objective of this study is to evaluate the usefulness of the GBS in determining if admitted low-risk ED patients with upper gastrointestinal bleeding experience serious adverse events. MethodsWe conducted a retrospective chart review of adult patients admitted to the hospital from the ED with upper gastrointestinal bleeding over a 3-year period. Charts were selected using ICD-9 code for GI bleed. Subjects with a GBS of zero (low-risk) were evaluated for complications. A GBS of zero was assigned if BUN<18.2, hemoglobin ≥13.0(male) or ≥12.0 (female), systolic blood pressure ≥110, pulse<100, the patient had no complaints of melena or syncope, and had no history of hepatic disease or congestive heart failure. A serious adverse event was defined as endoscopic treatment, blood transfusion, or surgery. The setting was a 76,000 visit ED community hospital with an emergency medicine residency program. We conducted a retrospective chart review of adult patients admitted to the hospital from the ED with upper gastrointestinal bleeding over a 3-year period. Charts were selected using ICD-9 code for GI bleed. Subjects with a GBS of zero (low-risk) were evaluated for complications. A GBS of zero was assigned if BUN<18.2, hemoglobin ≥13.0(male) or ≥12.0 (female), systolic blood pressure ≥110, pulse<100, the patient had no complaints of melena or syncope, and had no history of hepatic disease or congestive heart failure. A serious adverse event was defined as endoscopic treatment, blood transfusion, or surgery. The setting was a 76,000 visit ED community hospital with an emergency medicine residency program. ResultsFive hundred sixty-seven presentations of upper gastrointestinal bleeding were screened. Four hundred sixty-four of these patients were admitted to the hospital with a diagnosis of upper gastrointestinal bleeding. Twenty-one (4.5%, 95% CI: 3.0-6.8%) of these were low-risk (GBS score of 0). Nine of the 21 patients underwent UGI endoscopy in the hospital. Serious adverse events were as follows: 0 blood transfusions, 0 surgeries, and 1 endoscopic treatment (hemorrhagic gastric polyp banded), 4.8%, (95%CI: 0.1-26.5). Five hundred sixty-seven presentations of upper gastrointestinal bleeding were screened. Four hundred sixty-four of these patients were admitted to the hospital with a diagnosis of upper gastrointestinal bleeding. Twenty-one (4.5%, 95% CI: 3.0-6.8%) of these were low-risk (GBS score of 0). Nine of the 21 patients underwent UGI endoscopy in the hospital. Serious adverse events were as follows: 0 blood transfusions, 0 surgeries, and 1 endoscopic treatment (hemorrhagic gastric polyp banded), 4.8%, (95%CI: 0.1-26.5). ConclusionVery few (4.5%) of our low-risk upper gastrointestinal bleeding patients were admitted to the hospital. Of the 21 low-risk patients admitted, only 1 had an adverse event (4.8%). The GBS may not be applicable to the US health care system, due to the already low percent of low-risk upper gastrointestinal bleeding patients admitted. The reason might be more stringent admission criteria and the rapid availability of outpatient endoscopy. More low-risk patients need to be followed to determine safety of outpatient management. Very few (4.5%) of our low-risk upper gastrointestinal bleeding patients were admitted to the hospital. Of the 21 low-risk patients admitted, only 1 had an adverse event (4.8%). The GBS may not be applicable to the US health care system, due to the already low percent of low-risk upper gastrointestinal bleeding patients admitted. The reason might be more stringent admission criteria and the rapid availability of outpatient endoscopy. More low-risk patients need to be followed to determine safety of outpatient management.

Phantom shock is the sensation of shock in the absence of an actual implantable cardioverter-defibrillator (ICD) discharge. The ICD is now the first–line therapy for patients with ventricular tachycardia and fibrillation. There has been a significant increase in the number of patients with an ICD and patients presenting to the Emergency Department (ED) after a shock for evaluation and device interrogation. Phantom shock is more likely to be nocturnal in the first 6 months after implantation, and patients are more likely to be clinically depressed and have higher levels of anxiety. There is no specific treatment. We report 3 patients who presented to the ED with the sensation of ICD discharges, however, on device interrogation had no shocks and no dysrhythmias.

Introduction: Patients who present to the ED for care and leave without being seen (LWBS) represent a significant problem. The objective of this study was to determine why patients LWBS, how long they perceived waiting versus actual time waited before leaving, and factors that might have prevented LWBS.Methods: We conducted a prospective, scripted phone survey of all patients who left without being seen over a two-month period in 2006 at an ED with approximately 65,000 yearly visits. Outcome measures were number leaving, ability to obtain care after leaving, reason for leaving, would they return to this ED, perceived and actual time waited, number with a primary physician, and factors associated with leaving.Results: One-hundred and twenty-seven of 11,147 total patients (1.1%) patients left without being seen. Seventy-two (56.7%) were interviewed within 8 days. Eighty-four and seven-tenths percent stated they had a primary physician. The mean age was 29.9 years, and 44.4% were male. The patient-reported mean time waited before leaving was 73.2 minutes while the actual mean time waited was 70.4 minutes. The reasons for leaving were the length of wait (76.7%), the problem resolved (12.3%), and for other reasons (11.0%). During the week after leaving the ED, 56.3% were able to obtain medical care. Sixty-five percent would seek future emergency care at this ED, 15.3% would not, and 19.7% would possibly return. During the wait, patients wanted information, lab tests/X-rays, and analgesics.Discussion: Most would return for future ED care. Most had a physician and were able to obtain care elsewhere. Reduced LWBS might be accomplished by triage testing, communication and attention to pain.

Introduction: Re-collection of hemolyzed blood specimens delays patient care in overcrowded emergency departments. Our emergency department was unable to meet a benchmark of a 2% hemolysis rate for the collection of blood samples. Our hypothesis was that hemolysis rates of blood specimens differ dependent on the blood collection technique by venipuncture or intravenous catheter draw.Methods: A prospective, cross-over study of blood collection techniques in a 64,000 annual visit, community teaching hospital emergency department was conducted. Eleven experienced registered nurses with more than 2 years' ED experience completed a standardized phlebotomy retraining session. Registered nurses were randomly assigned to collect samples via intravenous catheters or venipuncture. After nurses collected 70 samples, they then collected samples via the other method. A standardized data collection form was completed. Blood samples were processed and assessed for hemolysis using standard procedures by laboratory technicians who were blinded to the collection method.Results: A total of 853 valid samples were collected; 355 samples (41.6%) were drawn via venipuncture and 498 samples (58.4%) were drawn through an intravennus catheter. Of these, 28 intravenous catheter samples (5.6%) were found to be hemolyzed, whereas only 1 venipuncture sample (0.3%) was hemolyzed. This finding was significant (x(2) < 0.001).Discussion: Experienced ED nurses can reduce the number of hemolyzed specimens by collecting via venipuncture instead of through intravenous catheters. This practice should be considered as standard of care in the ED setting. Limitations: Total samples by nurse were affected by EMS patients arriving with existing intravenous lines, and nurse schedules affected total samples per nurse.

Objective: Nausea and vomiting is a common complaint of ED patients. Most previous studies of nausea and vomiting involve post-operative and oncology patients. The objective is to compare the efficacy of usual (4mg) and low (2mg) dose ondansetron and 10mg metoclopramide in relief of nausea and vomiting in ED patients. Methods: This is a prospective, randomized, double-blind study of adult ED patients with nausea and at least 1 episode of vomiting within 12 hours of presentation in a 65,000 visit ED teaching hospital. A validated 100mm visual analog nausea scale (VAS) was used prior to medication and 30 minutes post-treatment. Patients also rated their nausea post-treatment on a subjective scale. All patients received at least 500cc of saline IV. End points were complete relief of nausea, significant reduction of initial VAS, subjective change in nausea and adverse events. Analysis by ANOVA and Kruskal-Wallis. Results: 132 patients were enrolled over a 12 month period in 2005-2006. Initial VAS scores were similar with a mean of 66.4mm. All 3 groups had a significant and similar reduction in VAS with a mean final VAS score of 33.6 mm, p< 0.0001. There was no difference between the groups (power=0.87). 55.3% obtained >50% relief and 18.2% obtained complete relief, with no difference between groups. More nausea was experienced by 7.6% in the post-treatment odansetron groups and none in the metoclopramide group. None of the patients had an adverse reaction, 95% CI 0.0 – 2.2%. Conclusions: Low and usual dose odansetron and metoclopramide are efficacious in ED patients with nausea and vomiting without significant difference between the drugs. No adverse events occurred with either drug. Significant cost savings with similar efficacy would occur by using low-dose odansetron or metoclopramide in ED patients with nausea and vomiting. Reprinted with permission from Elsevier Inc. Acad Emerg Med 2007;14(Suppl):S16.

Objectives: The San Francisco Syncope Rule (SFSR) is a decision rule with the potential to identify patients at risk for serious outcomes within 7 days of the emergency department (ED) visit for syncope. The initial studies of the SFSR reported a high sensitivity and specificity for identifying patients, of all ages, with serious outcomes. Our objective was to determine if the SFSR can be safely and accurately applied to ED patients aged 65 and older with syncope or near-syncope.Methods: A retrospective review of ED patients aged 65 years and older with syncope or near-syncope between January 2000 and August 2001 was performed. Charts were reviewed for evidence of SFSR risks for the ED visit and serious outcomes within 7 days of the ED visit.Results: Of 773 subjects identified as having syncope or near-syncope, 517 subjects were included. There were 98 patients with serious outcomes. Twenty-three patients who were negative on SFSR had serious outcomes. The sensitivity and specificity of the SFSR were 76.5% (95% confidence interval [CI], 66.7%-84.3%) and 36.8% (95% CI, 32.2%-41.6%), respectively. The negative and positive predictive values were 87.0% (95% CI, 80.9%-91.4%) and 22.1% (95% CI, 17.8%-26.9%), respectively.Conclusions: in our cohort of elderly ED patients, the SFSR had a lower sensitivity and specificity. The SFSR may not be applicable to the elderly ED population. Future prospective validation is necessary before application to the ED elderly population. (C) 2008 Elsevier Inc. All rights reserved.

Early initiation of reperfusion therapy remains the cornerstone of successful management for ST-elevation myocardial infarction (STEMI). Rapid restoration of coronary blood flow relies on prompt recognition of the typical ST-segment elevation on a 12-lead electrocardiogram (ECG)—a surrogate for coronary occlusion or critical stenosis—allowing timely activation of the STEMI protocol cascade, with a major positive impact in mortality and clinical outcomes. However, atypical, very high risk ECG patterns—known as “STEMI equivalents”—are present in 10% to 25% of patients with ongoing myocardial ischemia in need of urgent primary percutaneous coronary intervention. Though briefly mentioned in the current recommendations, structured clinical data on those specific ECG presentations are lacking. By thoroughly searching MEDLINE and EMBASE we conducted a structured review of non-STEMI, albeit very high risk, ECG patterns of acute coronary syndrome, often associated with coronary occlusion or critical stenosis. After screening 997 studies, we identified the following distinct “STEMI equivalent” ECG patterns: Wellens’ syndrome, de Winter sign, hyperacute T waves, left bundle branch block—including paced rhythm—and right bundle branch block. For each pattern, a brief summary of the existing evidence, together with the sensitivity, specificity, and positive predictive value—whenever available—are presented. In conclusion, prompt recognition of “STEMI equivalent” ECG patterns is crucial for every physician or paramedic dealing with acute coronary syndrome patients in the emergency department or the prehospital setting, as misinterpretation of those high risk presentations can lead to reperfusion delays and worse outcomes.

Long QT Syndrome is a cardiac disorder caused by an abnormal prolongation of the ventricular repolarization phase. The primary concern in this syndrome is the propensity towards polymorphic ventricular tachycardia and sudden cardiac death. This article presents several cases, highlighting the pathophysiology, clinical presentation, and management of this disorder.

The 12-lead electrocardiogram (EKG) is an important tool in evaluating the patient with acute myocardial infarction (MI). Patients with acute inferior wall myocardial infarction (IWMI) represent a heterogeneous group in terms of morbidity, mortality, Emergency Department (ED) management, and site of occlusion in the culprit coronary artery. The standard 12-lead EKG, right-sided chest leads and posterior chest leads, in conjunction with clinical findings often provide the necessary information for the Emergency Physician (EP) to predict complications, morbidity and mortality. IWMI patients may have associated right ventricular infarction (RVI) or lateral and posterior wall extension. Each of these entities is associated with specific hemodynamic abnormalities and increased mortality. In addition, various atrioventricular (AV) blocks are commonly associated with IWMI. This article presents several cases of IWMI with EKGs and a discussion of EKG interpretation in the setting of IWMI.

Patients with bradycardia are commonly encountered by the Emergency Physician. Of the possible bradydysrhythmias, atrioventricular blocks (AVB) represent a significant portion of these presentations. In this article, we provide four illustrative cases of patients presenting to the Emergency Department (ED) with AVB. We review the various types of AV block dysrhythmias (1st, 2nd, and 3rd degrees) and their underlying etiologies. This discussion also focuses on the presentation, clinical considerations, management and acute treatment of AVB dysrhythmias in the emergent setting.

The 12-lead electrocardiogram (EKG) is an essential tool when evaluating the Emergency Department (ED) patient with suspected cardiac ischemia. The standard EKG has limitations when evaluating "remote" areas of the heart such as the left posterior wall or right ventricular wall. Diagnosis of right ventricular infarction (RVI) in the presence of acute inferior wall myocardial infarction (MI) is made utilizing right-sided chest leads with high sensitivities and specificities. RVI is a serious ED problem because morbidity and mortality is higher in acute MIs associated with RVI.

Toxicity from the digitalis family of cardiac glycoside medications remains common. Successful treatment depends on early recognition; however, the diagnosis of potentially life-threatening toxicity remains difficult because the clinical presentation is often nonspecific and subtle. The hallmark of cardiac toxicity is increased automaticity coupled with concomitant conduction delay. Though no single dysrhythmia is always present, certain aberrations such as frequent premature ventricular beats, bradydysrhythmias, paroxysmal atrial tachycardia with block, junctional tachycardia, and bidirectional ventricular tachycardia are common. Treatment depends on the clinical condition rather than serum drug level. Management varies from temporary withdrawal of the medication to administration of digoxin-specific Fab fragments for life-threatening cardiovascular compromise.

The electrocardiographic findings associated with pulmonary embolism have been well described in the medical literature for over 50 years. These abnormalities include changes in rhythm, QRS axis, and morphology, particularly in the QRS and T waves. Such findings may reflect hemodynamic changes, such as right heart strain, as well as myocardial ischemia associated with the disease. Although certain findings may correlate with the severity of pulmonary embolism, the overall utility of the electrocardiogram is limited due to the variable presence, frequency, and transient nature of most of the abnormalities associated with the disease.

Previous uncontrolled, nonrandomized trials suggest that magnesium sulfate (MgSO4) is effective in the treatment of headache. The objective of this study was to determine the efficacy of MgSO4 vs. prochlorperazine in emergency department (ED) patients with acute headache. Patients presenting to the ED with a chief complaint of headache who met study criteria were enrolled. Each patient rated pain on a visual analog scale before and 30 min after a randomized study drug infusion. Thirty-six similar patients were enrolled. There was complete or partial pain relief in 90% of the prochlorperazine group and 56% of the MgSO4 group, a statistically significant difference. Prochlorperazine caused significantly fewer side effects, and none of the patients required additional medication during the study period. It was determined that intravenous prochlorperazine is highly effective in the treatment of headache and magnesium is moderately effective. Response to MgSO4 was unrelated to serum Mg level.

The 12-lead electrocardiogram (EKG), a powerful tool used in evaluating the chest pain patient, has its shortcomings. One such failing is encountered in a patient with one of the following electrocardiographic patterns: left bundle branch block (LBBB), ventricular paced rhythm (VPR), and left ventricular hypertrophy (LVH). These patterns reduce the ability of the EKG to detect acute coronary ischemic change and acute myocardial infarction (AMI). Several strategies are available to assist in the correct interpretation of these complicated electrocardiographic patterns, including a knowledge of the ST segment-T wave changes associated with these confounding patterns, performance of serial EKGs, and comparison with previous EKGs if available. This article suggests guidelines and interpretive tools for diagnosing AMI on EKG in patients with these confounding patterns.