Impact of COVID-19 on emergency department management of stroke and STEMI. A narrative review.

The novel coronavirus of 2019 (COVID-19) has resulted in a global pandemic; COVID-19 has resulted in significant challenges in the delivery of healthcare, including emergency management of multiple diagnoses, such as stroke and ST-segment myocardial infarction (STEMI). The aim of this study was to identify the impacts of the COVID-19 pandemic on emergency department care of stroke and STEMI patients. In this study a review of the available literature was performed using pre-defined search terms, inclusion criteria, and exclusion criteria. Our analysis, using a narrative review format, indicates that there was not a significant change in time required for key interventions for stroke and STEMI emergent management, including imaging (door-to-CT), tPA administration (door-to-needle), angiographic reperfusion (door-to-puncture), and percutaneous coronary intervention (door-to-balloon). Potential future areas of investigation include how emergency department (ED) stroke and STEMI care has adapted in response to different COVID-19 variants and stages of the pandemic, as well as identifying strategies used by EDs that were successful in providing effective emergency care in the face of the pandemic.

Electrocardiographic features of Wolff-Parkinson-White syndrome.

Wolff-Parkinson-White syndrome is not uncommon in the emergency department. Its early recognition and initial treatment allows rapid restoration to sinus rhythm. Prompt referral to cardiology is essential for risk stratification through electrophysiological studies.

Electrocardiographic artefact mimicking arrhythmic change on the ECG.

Artefact on electrocardiograms is a source of potential misdiagnosis and may lead to patients' receiving unnecessary treatments. This article present two cases that illustrate this problem, and will briefly look at known internal and external causes of artefact.

The paced electrocardiogram: issues for the emergency physician.

Since the first introduction of implantable pacemaker approximately 50 years ago, these devices have become increasingly more common and more complex. It is estimated that there are approximately 1 million patients with implanted pacemakers in the United States and, with an aging population, the number of pacemakers is certain to increase. This review focuses on basics of pacemaker function as well as the common rhythm disturbance issues and other clinical syndromes that the emergency physician is likely to encounter.

Orthopedic pitfalls in the ED: vascular injury associated with knee dislocation.

Tibial femoral knee dislocation is a severe injury, with a real potential for limb-threatening vascular compromise, primarily caused by injury to the popliteal artery. When unrecognized or inadequately evaluated and treated, these injuries often lead to a high incidence of morbidity and potential limb loss. Emergency medicine practitioners should be vigilant for vascular injury associated with knee dislocation. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.

Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment.

UNLABELLED: Acute myocardial infarction (AMI) is one of many causes of ST-segment elevation (STE) in emergency department (ED) chest pain (CP) patients. The morphology of STE may assist in the correct determination of its cause, with concave patterns in non-AMI syndromes and non-concave waveforms in AMI. OBJECTIVES: To determine the impact of STE morphologic analysis on AMI diagnosis and the ability of this technique to separate AMI from non-infarction causes of STE. METHODS: The electrocardiograms (ECGs) of consecutive ED adult CP patients (with three serial troponin I determinations) were interpreted in two-step fashion by six attending emergency physicians (EPs): 1) the determination of STE by three EPs followed by 2) STE morphologic analysis (either concave or non-concave) in those patients with STE. The impact of STE morphology analysis was investigated in the identification of AMI and non-AMI causes of STE. Acute myocardial infarction was diagnosed by abnormal serum troponin I values (>0.1 mg/dL) followed by a rise and fall of the serum marker; STE diagnoses of non-AMI causes were determined by medical record review. Interobserver reliability concerning STE morphology was determined. Study inclusion criteria included at least three troponin values performed in serial fashion no more frequently than every three hours, initial ED ECG, ED diagnosis, and final hospital diagnosis. RESULTS: Five hundred ninety-nine CP patients were entered in the study, with 171 (29%) individuals having STE on their ECGs. Of the 171 patients who had STE, 56 had AMI, 50 had unstable angina pectoris (USAP), and 65 had non-coronary final diagnoses. Forty-nine patients had non-concave STE, 46 with AMI and three with USAP; no patient with a non-coronary diagnosis had a non-concave STE morphology. The sensitivity and specificity of the non-concave STE morphology for AMI diagnoses were 77% and 97%, respectively; the positive and negative predictive values for non-concave morphology in AMI diagnoses were 94% and 88%, respectively. Interobserver reliability in the STE morphology determination revealed a kappa coefficient of 0.87. CONCLUSIONS: A non-concave STE morphology is frequently encountered in AMI patients. While the sensitivity of this pattern for AMI diagnosis is not particularly helpful, the presence of this finding in adult ED chest pain patients with STE strongly suggests AMI. This technique produces consistent results among these EPs.

Electrocardiographic manifestations: pulmonary embolism.

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.

The quick confusion scale in the ED: comparison with the mini-mental state examination.

The Quick Confusion Scale (QCS) is a 6-item battery of questions focusing on orientation, memory, and concentration weighted to yield a top score of 15. Analysis of the QCS compared with the Mini-Mental State Examination (MMSE) is needed to determine if the QCS is a valid marker of cognitive mental status. The MMSE and the QCS were administered to a convenience sample of 205 patients presenting to the emergency department. Exclusions included head trauma, multisystem trauma, Glasgow Coma Scale less than 15, non-English speaking, education level less than 8 years, contact or droplet isolation, acute illness, or incomplete data for reasons such as restricted patient access. Mean scores were 24.8(SD = 4.7; range 2-30) on the MMSE and 11.89 (SD = 3.5; range 0-15) on the QCS. QCS scores were significantly correlated (r = .783) with MMSE scores. The QCS appears comparable with the MMSE and is quicker to administer.

Prominent R wave in lead V1: electrocardiographic differential diagnosis.

Tall lead V1 (tall RV1), defined as an R/S ratio equal to or greater than 1, is not an infrequent occurrence in emergency department patients. This electrocardiographic finding exists as a normal variant in only 1% of patients. Physicians should therefore be familiar with the differential diagnosis for this important QRS configuration. The electrocardiographic entities which can present with this finding include right bundle branch block, left ventricular ectopy, right ventricular hypertrophy, acute right ventricular dilation (acute right heart strain), type a Wolff-Parkinson-White syndrome, posterior myocardial infarction, hypertrophic cardiomyopathy, progressive muscular dystrophy, dextrocardia, misplaced precordial leads, and normal variant. Various cases are presented to highlight the different causes of the tall RV1.

Electrocardiographic manifestations of pulmonary embolism.

The electrocardiogram (ECG) may be entirely normal in the patient with pulmonary embolism (P/E); alternatively, any number of rhythm and/or morphologic abnormalities may be observed in such a patient. The abnormal ECG may deviate from the norm with alterations in rhythm, in conduction, in axis of the QRS complex, and in the morphology of the P wave, QRS complex, and ST segment/T wave. The electrocardiographic findings associated with PE are numerous, including arrhythmias (sinus tachycardia, atrial flutter, atrial fibrillation, atrial tachycardia, and atrial premature contractions), nonspecific ST segment/T wave changes, T wave inversions in the right precordial leads, rightward QRS complex axis shift and other axis changes, S1Q3 or S1Q3T3 pattern, right bundle branch block, and acute cor pulomnale. This review focuses on the ECG and the various abnormalities seen in the patient with PE.

Commodio cordis: an underappreciated cause of sudden cardiac death in young patients: assessment and management in the ED.

Commotio cordis is the condition of sudden cardiac death or near sudden cardiac death after blunt, low-impact chest wall trauma in the absence of structural cardiac abnormality. Ventricular fibrillation is the most commonly reported induced arrhythmia in commotio cordis. Blunt impact injury to the chest with a baseball is the most common mechanism. Survival rates for commotio cordis are low, even with prompt CPR and defibrillation.

Orthopedic pitfalls in the ED: acute compartment syndrome.

Acute compartment syndrome is a rare but potentially disastrous complication of orthopedic injury to the extremities. Compartment syndrome occurs when the circulation and function of muscle within a closed fascial space are compromised by increased pressure within that space. Early diagnosis and treatment is crucial to prevent the devastating complications of this condition. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.

Principles of stress fracture management. The whys and hows of an increasingly common injury.

As the patient population becomes more involved with athletics, informally or in an organized fashion, risk of stress fracture increases. Rapid and safe recovery is best ensured with early diagnosis and expedient conservative therapy. A history of progressive pain, initially with exertion and ultimately at rest, suggests the diagnosis. Plain radiographs often do not reveal fractures, and specialized studies, such as bone scanning, SPECT, or MRI, may be necessary to confirm the diagnosis. Simple rest with progressive reintroduction of activity is the treatment of choice for most stress fractures.

Electrocardiographic ST segment depression.

Traditionally, ST segment depression has been associated with acute coronary syndromes; this electrocardiographic pattern may also be found in patients with nonischemic events, such as left bundle branch block (LBBB), left ventricular hypertrophy (LVH), and those with therapeutic digitalis levels. Using the ECG as an adjunct in distinguishing those patients with acute coronary syndromes from those with more "benign," nonacute causes of STSD will obviously lead to divergent treatment and management plans. The following cases illustrate the use the ECG in patients presenting with chest pain and electrocardiographic ST segment depression attributable to an ACS, LVH, LBBB, or digitalis.

Orthopedic pitfalls in the ED: scaphoid fracture.

Wrist injuries are frequently encountered in the emergency department. When a patient presents with such an injury, the possibility of scaphoid fracture must be at the top of the differential for the emergency practitioner. Unfortunately, these injuries can be missed on first presentation, as they are frequently radiographically occult. When left unrecognized and untreated, these injuries lead to a high incidence of long-term functional disability and chronic pain. The emergency physician needs to be vigilant for scaphoid fracture and be aggressive in both its diagnosis and treatment to avoid this practice pitfall. This review examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician.

Electrocardiographic manifestations: acute posterior wall myocardial infarction.

Posterior myocardial infarction (PMI) refers to infarction of the posterior wall of the left ventricle. Although often associated with inferior and lateral myocardial infarctions, detection of acute PMI is difficult because the standard 12-lead electrocardiogram does not adequately image the posterior wall of the left ventricle. We review the findings on 12-lead electrocardiogram with PMI, as well as discuss the utility of additional electrocardiographic leads in the diagnosis of PMI.

Electrocardiographic diagnosis of acute myocardial infarction.

The widely recognized benefits of early diagnosis and treatment of acute myocardial infarction (AMI) have only emphasized the importance of emergency physician (EP) competence in electrocardiographic interpretation. As such, the EP must be an expert in the interpretation of the electrocardiogram (ECG) in the emergency department chest pain center patient. The ECG is a powerful clinical tool used in the evaluation of patients, assisting in making the diagnosis of AMI and other syndromes, selecting appropriate therapies (including thrombolysis and primary angioplasty), securing the location of an adequate inpatient disposition, and predicting the risk of cardiovascular complications and death. This article will discuss the appropriate uses of the ECG in the patient with possible or confirmed AMI and review the typical electrocardiographic findings of AMI, diagnostically confounding patterns, mimickers of infarction, and new techniques.