Assessing the Impact of a Pulmonary Embolism Response Team and Treatment Protocol on Patients Presenting With Acute Pulmonary Embolism.

BACKGROUND: Pulmonary embolism (PE) care has traditionally been fragmented. The newly introduced Pulmonary Embolism Response Team (PERT) model provides streamlined care based on expedient, multi-disciplinary decision-making. This study aimed to quantify the impact of PERT, as part of a hospital-wide PE treatment protocol, on clinical outcomes. METHODS: Consecutive adult patients with acute PE diagnosed via computed tomography pulmonary angiogram (CTPA) were included. The PERT and treatment protocol were introduced in January 2015. Patient characteristics, therapies, quality measures of CTPA reporting, and clinical outcomes of PE patients treated for 2 years before and after implementation of these changes were evaluated. Primary endpoints were median length of stay in intensive care (ICU) and survival to discharge. RESULTS: A total of 321 consecutive PE patients were enrolled, of which 154 (treated in 2013-2014) and 167 (2015-2016) patients formed the historical control and study groups, respectively. Implementation of the algorithm was associated with less variance in anticoagulation and improved reporting of right heart strain parameters on CTPA. The ICU stay was reduced from a median of 5 to 2 days (p < 0.01). Eligible massive PE patients receiving reperfusion increased from 30% to 92% (p = 0.01), with mean delay from diagnosis to reperfusion decreasing from 763 to 181 minutes (p < 0.01). Bleeding complications were not increased, but overall survival to discharge remained unchanged. CONCLUSIONS: Introducing a PERT and treatment protocol reduced ICU stay, enhanced quality measures, and improved access of massive PE patients to reperfusion therapies, without increasing bleeding complications or health care costs.

Early predictors for the diagnosis of liver abscess in the emergency department.

Diagnosing pyogenic liver abscess (PLA) in the emergency department (ED) is challenging due to its non-specific clinical presentation. We aim to identify predictors that aid in diagnosis of PLA in ED patients. This retrospective chart review included patients diagnosed with PLA in a tertiary hospital between January 2008 and December 2012. We compared the demographics, clinical characteristics, investigations and outcomes between patients with PLA diagnosed and missed in the ED. During the study period, 155 patients were admitted via the ED with a cause of death or discharge diagnosis of PLA. Mean age was 58.1 (standard deviation [SD] 15.8) years, with male predominance of 69.7%. There were 79.4% of patients with diagnosis of PLA missed in the ED. Fulfillment of SIRS criteria was associated with increased odds of diagnosing PLA in the ED (adjusted OR 3.20, 95% CI 1.03-9.92), while a higher SpO2/FiO2 ratio was associated with decreased odds of a timely ED diagnosis (adjusted OR 0.993, 95% CI 0.988-0.998). Missed ED diagnosis of PLA did not result in significant differences in mortality or treatment failure (p = 0.939), and median length of stay (11 days [IQR 8-16] vs. 11 days [IQR 7-17], p = 0.48). Non-fulfillment of the SIRS criteria and a higher SpO2/FiO2 ratio at ED presentation were associated with higher likelihood of missed diagnosis. Despite that, a missed diagnosis of PLA in the ED did not appear to affect outcomes.

Improvement in Door-to-Needle Time in Patients with Acute Ischemic Stroke via a Simple Stroke Activation Protocol.

BACKGROUND: In acute ischemic stroke (AIS), treatment with intravenous tissue-type plasminogen activator (IV-tPA) is time-sensitive. All stroke centers make continual efforts to reduce door-to-needle time (DNT) with varying success. We present the impact of modifications to our stroke activation protocol on DNT. METHODS: We included 404 consecutive patients with AIS receiving IV-tPA between January 2014 and December 2016. First changes in stroke activation protocol were made in March 2015 in the form of prenotification by paramedics, direct transfer from ambulance to computed tomography (CT) scanner, and rapid en route neurological assessment by an emergency physician and neurologist. In March 2016, a second amendment was made where a stroke nurse accompanied the patient to expedite various steps in the treatment pathway, including endovascular treatment in eligible cases. RESULTS: Both protocol amendments resulted in improvement in DNT and door-to-CT time from 84 ± 47 minutes before intervention to 69 ± 33 minutes after protocol amendment 1 to 59 ± 37 minutes after protocol amendment 2. In particular, the second amendment (144 patients) showed significant shortening of DNT compared with the 137 patients before (59 ± 37 minutes versus 69 ± 33 minutes, P = .020), with a higher percentage achieving the target of 60 minutes (68.1% versus 48.2%, P < .001). This finding was attributed to a reduction in both door-to-CT time and CT-to-needle time. This improvement remained consistent over subsequent months. CONCLUSIONS: The application of a simple systems-based, multidisciplinary stroke activation protocol may help in significant reduction in DNT. Encouraging increased patient ownership by stroke nurses appeared to be a promising approach for timely administration of definitive acute therapies.

Noninvasive Ventilation as a Temporizing Measure in Critical Fixed Central Airway Obstruction: A Case Report.

BACKGROUND: Critical central airway obstruction (CAO) requires emergent airway intervention, but current guidelines lack specific recommendations for airway management in the emergency department (ED) while awaiting rigid bronchoscopy. There are few reports of the use of noninvasive ventilation (NIV) in tracheomalacia, but its use as a temporizing treatment option in fixed, malignant CAO has not, to the best of our knowledge, been reported. CASE REPORT: An 84-year-old woman presented to the ED in respiratory distress, too breathless to speak and using her accessory muscles of respiration, with bilateral rhonchi throughout the lung fields. Point-of-care arterial blood gas revealed severe hypercapnia, and NIV was initiated to treat a presumed bronchitis with hypercapnic respiratory failure. Chest radiography revealed a paratracheal mass with tracheal deviation and compression. A diagnosis of critical CAO was made. While arranging for rigid bronchoscopic stenting, the patient was kept on NIV to good effect. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Recommendations for emergent treatment of life-threatening, critical CAO before bronchoscopic intervention are not well established. Furthermore, reports of NIV use in CAO are rare. We suggest that emergency physicians consider NIV as a temporizing measure for critical CAO while awaiting availability of bronchoscopy.

Management of dyspepsia-The role of the ED Observation unit to optimize patient outcomes.

BACKGROUND: Dyspepsia is a common complaint that can confer significant burden on one's quality of life and may also be associated with serious underlying conditions. The objective of this study was to determine if patients admitted to the emergency department observation unit (EDOU) for severe or persistent dyspepsia would have cost effective management in terms of investigations performed, length and cost of hospital stay. The secondary objective was to determine if any patient characteristics could predict a need for admission to the inpatient unit. METHODS: Retrospective chart reviews of patients admitted to the EDOU under the Dyspepsia protocol between January 2008 and August 2014 were conducted. Baseline demographics, investigations performed, outcomes related to EDOU stay, admission and 30-day re-presentation outcomes were recorded. RESULTS: A total of 1304 patients were included. Median length of stay was 1day. Cumulative bed-saved days were 38 per month. Two hundred eighteen (16.7%) patients required admission to the inpatient service for further management, while 533 (40.9%) and 313 (24.0%) patients underwent esophagogastroduodenoscopy and hepatobiliary ultrasonography, respectively. No major adverse events were attributed to the EDOU admissions or delays in treatment. No significant clinically relevant factors were associated with a need for admission from the EDOU to the inpatient unit. Median cost of the EDOU admission was approximately one-third that of a similar admission to the inpatient unit. CONCLUSION: The EDOU is an appropriate setting to facilitate investigations and treatment of patients with dyspepsia with considerable bed-saved days.

Impact of inpatient Care in Emergency Department on outcomes: a quasi-experimental cohort study.

BACKGROUND: Hospitals around the world are faced with the issue of boarders in emergency department (ED), patients marked for admission but with no available inpatient bed. Boarder status is known to be associated with delayed inpatient care and suboptimal outcomes. A new care delivery system was developed in our institution where boarders received full inpatient care from a designated medical team, acute medical team (AMT), while still residing at ED. The current study examines the impact of this AMT intervention on patient outcomes. METHODS: We conducted a retrospective quasi-experimental cohort study to analyze outcomes between the AMT intervention and conventional care in a 1250-bed acute care tertiary academic hospital in Singapore. Study participants included patients who received care from the AMT, a matched cohort of patients admitted directly to inpatient wards (non-AMT) and a sample of patients prior to the intervention (pre-AMT group). Primary outcomes were length of hospital stay (LOS), early discharges (within 24 h) and bed placement. Secondary outcomes included unplanned readmissions within 3 months, and patient's bill size. χ2- and Mann-Whitney U tests were used to test for differences between the cohorts on dichotomous and continuous variables respectively. RESULTS: The sample comprised of 2279 patients (1092 in AMT, 1027 in non-AMT, and 160 in pre-AMT groups). Higher rates of early discharge (without significant differences in the readmission rates) and shorter LOS were noted for the AMT patients. They were also more likely to be admitted into a ward allocated to their discipline and had lower bill size compared to non AMT patients. CONCLUSIONS: The AMT intervention improved patient outcomes and resource utilization. This model was noted to be sustainable and provides a potential solution for hospitals' ED boarders who face a gap in inpatient care during their crucial first few hours of admissions while waiting for an inpatient bed.

Neuropeptide Y associated with asthma in young adults.

OBJECTIVE: Neuropeptide Y, a widely circulating neurotransmitter, plays a pivotal role in energy balance, immunomodulation and asthma, and several NPY polymorphisms are promising genetic risk factors for asthma and obesity. We explored the associations of candidate NPY gene polymorphisms with prevalent asthma and its relationship with obesity in young adult asthma patients free of other chronic medical morbidity. METHODS: Five common gene variants of NPY (rs16147 (-399T/C), rs17149106 (-602G/T), rs16140 (+1000C/G), rs5573 (+1201A/G), rs5574 (+5327C/T)) previously validated to account for most of the NPY expression in vitro and in vivo were investigated in 126 physician-diagnosed asthma patients without other chronic medical morbidity and 182 healthy controls (21-35years). Plasma levels of NPY, adiponectin, and CRP were determined using ELISA, and IL-6 was measured by Luminex in a subgroup of 70 patients and 69 age- and sex-matched healthy controls. RESULTS: In logistic regression models controlling for gender and obesity, the CT genotype of rs5574 (OR=0.54, 95%CI: 0.30-0.89) and the GT genotype of rs17149106 (OR=5.58, 95%CI: 1.09-28.54) were significantly associated with asthma. No significant interaction between NPY SNP polymorphisms and obesity were detected. Plasma NPY level was correlated with adiponectin levels (p<0.05). Compared with the healthy controls, patients with asthma had higher BMI (p<0.001), adiponectin (p<0.05), IL-6 (p=0.001) and CRP (p<0.001), and lower NPY levels (p<0.01). CONCLUSIONS: The CT genotype of rs5574 and the GT genotype of rs17149106 are significantly associated with prevalent asthma.

Mapping clinical journeys of Asian patients presenting to the Emergency Department with syncope: Strict adoption of international guidelines does not reduce hospitalisations.

BACKGROUND: Limited data exists about management of syncope in Asia. The American College of Emergency Physicians (ACEP) and European Society of Cardiology (ESC) guidelines have defined the high-risk syncope patient. This study aims to determine the effectiveness of managing syncope in an Asian healthcare system and whether strict adherence of international guidelines would reduce hospitalizations. METHODS: Patients attending the Emergency Department of a Singaporean tertiary hospital with syncope were identified. Clinical journeys of all patients were meticulously mapped by interrogation of a comprehensive electronic medical record system and linkages with national datasets. Primary endpoint was hospitalization. Secondary endpoints were recurrent syncope within 1year and all-cause mortality. Expected admission rates based on application of ACEP/ESC guidelines were calculated. RESULTS: 638 patients (43.8±22.4years, 49.0% male) presented with syncope. 48.9% were hospitalized for 2.9±3.2days. Yields of common investigations ranged from 0 to 11.5% and no diagnosis was reached in 51.5% of patients. Diuretics use (HR 5.1, p=0.01) and prior hospitalization for syncope (HR 6.9, p<0.01) predicted recurrent syncope. Over 2.8 SD 0.3years of follow-up, 40 deaths occurred. 24 patients who died within 12months of presentation were admitted or had a firm diagnosis upon discharge. Application of guidelines did not significantly reduce hospitalisations, with limited agreement which patients warrant admission. (Actual 376, ACEP 354, ESC 391 admissions, p=NS). CONCLUSIONS: Unstructured management of syncope results in nearly half of patients being admitted and substantial healthcare expenditures, yet with limited diagnostic yield. Strict adoption of ACEP or ESC guidelines does not reduce admissions.

Early electroencephalography in patients with Emergency Room diagnoses of suspected new-onset seizures: Diagnostic yield and impact on clinical decision-making.

PURPOSE: To assess the utility of acute electroencephalography (EEG) performed in the emergency room (ER) and its impact on subsequent management of patients with new-onset seizures. Adults who recover fully in the ER following suspected isolated new-onset seizures are usually discharged to the neurology clinic for further review. An EEG at that stage may be normal. We sought to assess the feasibility and yield of early EEG in the ER setting, its impact on management. METHODS: A prospective study from January 2008 to January 2011 of patients diagnosed by ER physicians with uncomplicated suspected first episodes of unprovoked convulsive seizures. All patients underwent routine 30-min EEG in the ER prior to discharge and specialist review was arranged in the epilepsy clinic within 2 weeks of presentation. Management decisions were at the discretion of the treating neurologist. Seizure recurrence was assessed during a follow up period between 9 months and 3 years. RESULTS: 136 patients were included in the study (92 males). Mean age was 32 years (range 16-73). Forty had abnormal EEGs: 16 focal epileptiform discharges, 12 focal slowing, 10 generalized spike-wave discharges and 2 generalized slowing. Using multivariate analysis, those with abnormal EEG (51% vs 11%, p = 0.003) and abnormal MRI (53% vs 28%, p < 0.001) were more likely to be commenced on anticonvulsant therapy. Abnormal MRI (p = 0.001) was independently associated with a higher risk of recurrence. CONCLUSIONS: Following an ER diagnosis of new-onset uncomplicated seizure, early EEG had a high diagnostic yield. Abnormal EEG and abnormal MRI significantly contributed to decision-making regarding treatment at specialist review. Abnormal MRI was associated with significantly higher risks of subsequent seizures.

Obesity, asthma prevalence and IL-4: Roles of inflammatory cytokines, adiponectin and neuropeptide Y.

BACKGROUND: Obesity is associated with asthma risk and severity, but the underlying biological mechanisms are poorly understood. We hypothesized that cytokine markers of systemic inflammation, and adiponectin and neuropeptide Y (NPY) markers of immuno-modulating and neurohormonal regulation are involved in the obesity-asthma association. METHODS: We explored the relationships between body mass index (BMI), C-reactive protein (CRP), IL-6, TNF-α, adiponectin and NPY with asthma prevalence and IL-4 levels in 70 youth with asthma and 69 age- and gender-matched healthy controls using cross-sectional and longitudinal data. RESULTS: Mean BMI level was higher among patients with asthma than healthy controls (p < 0.001). In logistic regression models controlling for potential confounders, independent associations with asthma prevalence were found for obesity (p = 0.001), increasing tertiles of CRP (linear trend p < 0.001), IL-6 (linear trend p < 0.001) and lowest and highest tertiles of TNF-α (quadratic trend p < 0.05), increasing adiponectin (linear p = 0.022) and decreasing tertiles of NPY (linear trend p = 0.001). Among patients with asthma, NPY level was positively correlated with adiponectin (p < 0.05) and TNF-α (p < 0.05), and levels of NPY and IL-6 were significantly associated with IL-4 level at baseline and 1-year follow-up. CONCLUSIONS: The obesity-asthma association was not explained by systemic inflammation. Specifically, CRP, TNF-a, IL-6, NPY and adiponectin were independently associated with asthma prevalence. NPY and IL-6 were associated with IL-4 marker of allergic airway inflammation in asthma and should be further investigated as prognostic markers of asthma outcomes.

Not all unexplained hypoxia is pulmonary embolism.

Acute myocardial infarction is one of the conditions frequently managed in the emergency department. There are many complications associated with right ventricular infarction, and the incidence of right ventricular infarction associated with inferior myocardial infarction is as high as 51% based on electrocardiographic findings. We herein report the case of a 45-year-old Chinese man with inferior myocardial infarction complicated by right ventricular failure. He had hypoxaemia refractory to supplemental oxygen due to an acute right-to-left shunting through a patent foramen ovale (PFO). He underwent coronary angioplasty and closure of the PFO. It is crucial for the attending physician to consider the presence of a right-to-left shunt when there is persistent uncorrectable hypoxaemia despite maximal oxygen supplementation in the setting of right ventricular infarction, as there are clinical implications and certain clinical managing principles that should be applied.

Psychiatric comorbidities in Asian adolescent asthma patients and the contributions of neuroticism and perceived stress.

PURPOSE: Psychiatric comorbidity is reported to be common among adolescents with asthma, but little is known about its underlying psychological factors. OBJECTIVE: This study explored the profile of anxiety and depressive comorbidities among adolescents with well-controlled and poorly controlled asthma and the contribution of neuroticism and perceived stress. METHODS: The Revised Child Anxiety and Depression Scale, Neuroticism subscale of Big Five Inventory, Perceived Stress Scale, and Asthma Control Test were administered to 198 adolescents (aged 12-19 years) with well-controlled (n = 137) and poorly controlled asthma (n = 61) as well as 171 healthy neighborhood controls. RESULTS: Adolescents with poorly controlled asthma, compared with well-controlled asthma patients and healthy controls, had higher scores of depression (p = .006), panic attacks (p = .002), total anxiety (p = .038), and total internalizing symptoms (p = .017), after adjusting for gender, age, ethnicity, smoking status, and family housing type. Adolescents with asthma had higher neuroticism (p = .025), perceived stress (p = .022), and body mass index (p = .006) and lower self-rated health (p < .001) than healthy controls. No significant differences in psychiatric comorbidity scores were observed after accounting for differences in underlying psychological and physical factors. Among asthma patients, increased asthma control was associated with decreased scores of psychiatric comorbidity (p < .01), but the association was not significant after allowing for decreased neuroticism and perceived stress. CONCLUSIONS: The diagnosis of asthma and poor asthma control in adolescents is associated with excess psychiatric comorbidity, which is likely due to increased neuroticism and perceived stress.

IDSA/ATS minor criteria aid pre-intensive care unit resuscitation in severe community-acquired pneumonia.

The effect of employing severity scores to identify severe community-acquired pneumonia (SCAP) cases for early aggressive resuscitation is unknown. Optimising pre-intensive care unit (ICU) care may improve outcomes in patients at risk of SCAP. We conducted a before-and-after study of patients classified into control and intervention groups (January 2004 to December 2007 and January 2008 to December 2010, respectively). Our intervention was two-pronged, using the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) minor criteria to identify SCAP for aggressive emergency department resuscitation. Patients with SCAP, defined as those with three or more IDSA/ATS minor criteria, were targeted. Differences in mortality, triage and compliance with emergency department resuscitation were compared between the groups. The hospital mortality rate was lower in the intervention versus the control group (5.7% versus 23.8%, p<0.001). On multivariate analysis, the intervention group was associated with lower mortality (OR 0.24, 95% CI 0.09-0.67). ICU admission rates decreased from 52.9% to 38.6% (p=0.008) and inappropriately delayed ICU admissions decreased from 32.0% to 14.8% (p<0.001). There was increased compliance with the aggressive resuscitation protocol after the intervention. A combined intervention, using a pneumonia score to identify those at risk of SCAP early and an aggressive pre-ICU resuscitation protocol may reduce mortality and ICU admissions.

Validation of the San Francisco Syncope Rule in two hospital emergency departments in an Asian population.

OBJECTIVES: The objective was to externally validate the ability of the San Francisco Syncope Rule (SFSR) to accurately identify patients who will experience a 7-day serious clinical event in an Asian population. METHODS: This was a prospective cohort study, with a sample of adult patients with syncope and near-syncope enrolled. Patients 12 years old and below and patients with loss of consciousness after head trauma, a witnessed seizure, with known alcohol or illicit drug ingestion, and altered level of consciousness or persistent new neurologic deficits were excluded. The patients were evaluated for the presence of one or more of the five SFSR variables: shortness of breath, history of heart failure, hematocrit <30%, systolic blood pressure <90 mm Hg, and abnormal electrocardiogram (ECG). The patients were followed up by medical record review or telephone interview. Seven-day outcomes were death, arrhythmia, myocardial infarction, acute pulmonary edema, significant structural heart disease, pulmonary embolism, major cardiac procedure, stroke, subarachnoid hemorrhage, major bleeding, and anemia. RESULTS: A total of 1,250 patients from two centers were recruited. Fifty-six patients were excluded from primary analysis because of incomplete data (n = 55) and/or they were noncontactable for follow-up (n = 32). Of the 1,194 patients analyzed, 138 patients (11.6%) experienced adverse outcomes at 7 days. The rule performed with a sensitivity of 94.2% (95% confidence interval [CI] = 89.0% to 97.0%) and a specificity of 50.8% (95% CI = 47.7% to 53.8%). CONCLUSIONS: In this study, SFSR rule had a sensitivity of 94.2%. This suggests caution on the strict application of the rule to all patients presenting with syncope. It should only be used as an aide in clinical decision-making in this population.

Angiographic and platelet reactivity outcomes with prasugrel 60 mg pretreatment and clopidogrel 600 mg pretreatment in primary percutaneous coronary intervention.

Pretreatment with 60 mg of prasugrel is more effective than 300 mg of clopidogrel in reducing thrombotic complications with primary percutaneous coronary intervention (PCI). We compared angiographic outcomes and platelet reactivity between treatment with 60 mg of prasugrel and 600 mg of clopidogrel administered before primary PCI. In this single centre non-randomized study, 65 consecutive Asian patients with ST-elevation myocardial infarction (STEMI) received 60 mg of prasugrel before primary PCI. The pre- and post-PCI corrected thrombolysis in myocardial infarction frame count (CTFC) and the 8-h post-treatment platelet vasodilator-stimulated phosphoprotein (VASP) index was compared with a matched historical Asian STEMI cohort (n = 65) receiving 600 mg of clopidogrel pretreatment. Comparing the prasugrel and clopidogrel groups, the mean age was 54.1 ± 10.2 versus 55.5 ± 11.8 years, P = 0.238, and the mean body mass index was 24.6 ± 2.0 versus 24.7 ± 2.8 kg m(-2), P = 0.393. The mean pre-PCI CTFC was 82.1 ± 30.2 versus 86.1 ± 27.6, P = 0.045, and the mean post-PCI CTFC was 21.1 ± 13.9 versus 20.1 ± 9.2, P = 0.309. Pre-PCI coronary thrombi were visualised in 6.3 versus 18.1 %, P = 0.038. The median VASP index was 22.2 ± 24.5 versus 70.5 ± 17.5 %, P < 0.001, and high on-treatment platelet reactivity (VASP index > 50 %) was observed in 13.8 versus 84.3 %, P = 0.001. Rescue intracoronary glycoprotein inhibitors were administered to 29.7 versus 51.0 %, P = 0.018, respectively. Treatment with 60 mg of prasugrel before primary PCI was associated with lower platelet reactivity, a modest trend towards better pre-PCI angiographic outcomes, less pre-PCI coronary thrombi and less rescue glycoprotein inhibitor use compared with 600 mg of clopidogrel. The very high frequency of high on-clopidogrel platelet reactivity with 600 mg of clopidogrel in this Asian STEMI cohort deserves further study.

To study the effectiveness and safety of ketamine and midazolam procedural sedation in the incision and drainage of abscesses in the adult emergency department.

The objective of the report was to study the efficacy and safety of ketamine and midazolam combination in the procedural sedation of incision and drainage of abscesses in the adult emergency department (ED) patients. This prospective observational study enrolled patients aged 16-60 years (American Society of Anesthesiologists class I) requiring abscess drainage in an adult ED. Patients received 2 mg/kg of ketamine infusion over 5 min and midazolam 2-5 mg titrated to deep sedation according to Ramsay sedation scale. Primary outcome was patient satisfaction using pain score after procedure. Secondary outcomes included adverse effects, hemodynamics alterations and recovery time. Descriptive statistics were calculated using SPSS software. Fifteen patients were recruited. One patient was excluded because of difficulty with pain score interpretation. Seventy-nine percent were male patients. The mean age was 29. The mean size of abscess was 3.4 cm. The mean dose of midazolam was 3.2 mg. Eighty-six percent did not experience any pain for the procedure. Only two patients (14%) reported mild pain during the procedure. There were no significant adverse events or complications. Three patients had giddiness, two had vomiting and only one reported an unpleasant dream. The median systolic blood pressure and heart rate elevation were 30+/-5.1 mmHg and 12.5+/-3.2/min, respectively. The median time for blood pressure and pulse rate to return to baseline was 20+/-2.7 min. The use of ketamine and midazolam sedation is both well tolerated and effective for adults in the ED undergoing incision and drainage of abscesses. This study is limited by the small sample size.

NSAIDS-induced anaphylaxis precipitating acute coronary vasospasm.

We report a case of NSAID-induced anaphylaxis precipitating coronary artery vasospasm leading to myocardial infarction in the presence of normal coronaries. Furthermore, we have also discussed the possible mechanisms for this. Attending clinicians should be aware of this potential complication when treating anaphylaxis, especially in patients with known or presumed coronary artery disease.