Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel.

Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.

Prevalence of Trauma-Induced Hypocalcemia in the Prehospital Setting.

BACKGROUND: Recent data published by the Special Operations community suggest the Lethal Triad of Trauma should be changed to the Lethal Diamond, to include coagulopathy, acidosis, hypothermia, and hypocalcemia. The purpose of this study is to determine the prevalence of trauma-induced hypocalcemia in level I and II trauma patients. METHODS: This is a retrospective cohort study conducted at a level I trauma center and Special Operations Combat Medic (SOCM) training site. Adult patients were identified via trauma services registry from September 2021 to April 2022. Patients who received blood products prior to emergency department (ED) arrival were excluded from the study. Ionized calcium levels were utilized in this study. RESULTS: Of the 408 patients screened, 370 were included in the final analysis of this cohort. Hypocalcemia was noted in 189 (51%) patients, with severe hypocalcemia identified in two (<1%) patients. Thirty-two (11.2%) patients had elevated international normalized ratio (INR), 34 (23%) patients had pH <7.36, 21 (8%) patients had elevated lactic acid, and 9 (2.5%) patients had a temperature of <35°C. CONCLUSION: Hypocalcemia was prevalent in half of the trauma patients in this cohort. The administration of a calcium supplement empirically in trauma patients from the prehospital environment and prior to blood transfusion is not recommended until further data prove it beneficial.

Left atrial volume measurement with automated border detection by 3-dimensional echocardiography: comparison with Magnetic Resonance Imaging.

OBJECTIVE: Left atrial size is an important marker for adverse cardiovascular events. There is general consensus that left atrial volume index (LAVI) is the best measurement of size. The current LAVI measurement techniques are laborious. Semi-automated measurement with a 3-dimensional echocardiography (3DE) system may be a practical clinical alternative to measure LAVI, but it has not been adequately evaluated against Magnetic Resonance Imaging (MRI) gold standard. The aim of this study was to compare the accuracy of a commercially available 3D algorithm for measurement of LAVI against LAVI obtained from MRI and Area Length Method (ALM). DESIGN: In 27 consecutive subjects referred for cardiac MRI (age 54 +/- 13 years, 63% male), LAVI was measured using 3 imaging modalities: 3DE, ALM, MRI and the results were correlated. ALM was measured using standard American Society of Echocardiography guidelines. The time required to measure LAVI by 3DE and ALM were compared. RESULTS: There was a significant correlation in systolic and diastolic LA volumes and left atrial ejection fraction between 3DE and MRI (r = 0.86 for systole, r = 0.76 for diastole, r = 0.88 for ejection fraction, P < 0.0001 for all). There was also significant correlation of diastolic volumes between 3DE and ALM (r = 0.77, P < 0.0001). The time to obtain LAVI was shorter using 3DE versus ALM (56 +/- 8 vs 135 +/- 55 seconds, P < 0.0001). CONCLUSION: Three-dimensional echocardiography with semiautomatic border detection is a practical alternative for obtaining the left atrial volume in a time-efficient manner compared to the current standard.

Use of saline contrast echo timing to distinguish intracardiac and extracardiac shunts: failure of the 3- to 5-beat rule.

Patent foramen ovale (PFO) is thought to be associated with cryptogenic stroke and migraine headache. Saline contrast echocardiography (SCE) is the gold standard for identifying the presence of right-to-left shunt, whether from PFO or pulmonary arteriovenous malformation (PAVM). The timing of left heart contrast entry during SCE is used to distinguish a PFO from a PAVM, a method that is not as specific as previously thought. In this report, we describe a patient with a SCE demonstrating the early appearance of left heart bubbles during good effort Valsalva injections that is ultimately proven to be due to a PAVM. The case illustrates the limited specificity of left heart contrast timing during SCE as the sole criteria for differentiating intracardiac and extracardiac shunts.

Small- and moderate-size right-to-left shunts identified by saline contrast echocardiography are normal and unrelated to migraine headache.

BACKGROUND: We suspected, based on clinical experience, that the prevalence of both intracardiac and pulmonary arteriovenous malformations (PAVMs) is higher than previously reported in a healthy population when using modern ultrasound technology combined with a rigorous saline contrast echocardiogram (SCE) protocol. We hypothesized the prevalence of right-to-left shunts (RLSs) would be so high when using this sensitive technique that there would be no significant association of RLS with migraine headache. METHODS: We recruited 104 healthy volunteers to undergo an SCE followed by completion of a migraine questionnaire. The SCEs were meticulously graded for shunt size and location based on left-sided heart contrast quantity and timing. The migraine headache questionnaire was graded by a neurologist blinded to SCE results. RESULTS: One hundred four subjects underwent the study protocol. We found 71% of subjects exhibited evidence of RLS. Patent foramen ovale (PFO) was identified in 40 (38%), PAVM was identified in 29 (28%), and five subjects had evidence of both (5%). Based on questionnaires, 42 (40%) of the subjects had migraine headache (29% with aura). There was no significant association of migraine headache with PFO (OR, 0.59; 95% CI, 0.16-2.12; P = .54) or PAVM (OR, 0.8; 95% CI, 0.34-1.9; P = .67), although only 13 (13%) of the subjects had evidence of large RLS. CONCLUSIONS: When using modern ultrasound technology combined with a rigorous SCE technique, the majority of healthy subjects demonstrate some degree of RLS. PAVM in an otherwise healthy population is common. Small- and moderate-size RLSs do not appear to be significantly associated with migraine headache.

A critical review of patent foramen ovale detection using saline contrast echocardiography: when bubbles lie.

Saline and indocyanine green dye were the first agents noted to produce a contrast effect when injected peripherally during M-mode echocardiographic imaging, although it was subsequently found that almost any type of injected solution would have this effect. These first-generation contrast agents were limited to opacification of right heart structures, and they prompted subsequent development of agents that traverse pulmonary circulation. Although opacification limited to right heart structures is considered a limitation of these first-generation agents, this is an advantage when attempting to identify the presence of right-to-left shunt. First-generation air contrast is considered the gold standard for identification of patent foramen ovale (PFO). However, PFO investigators have used varying criteria to define abnormal contrast studies. There are also multiple mechanisms by which saline contrast studies may produce both false-positive and false-negative results for presence of PFO. There is mounting experimental evidence that PFO is associated with cerebral ischemia and migraine headache, with a resulting evolution of devices for percutaneous closure of these shunts. Echocardiographic physicians must be aware of potential pitfalls of the air contrast technique to avoid exposing patients to unnecessary risk of closure devices, and missing the potential benefit of shunt closure in appropriately selected patients.

Transesophageal echocardiography and stroke.

Only coronary artery disease and cancer kill more people than stroke in the United States. Transesophageal echocardiography (TEE) is a semi-invasive ultrasound cardiac imaging technique that provides superior anatomic detail as well as functional information. Searching for a cause of cerebral ischemia is the most common indication for TEE in cardiac ultrasound laboratories. Although TEE is not superior to transthoracic imaging for identifying all sources of cardiac embolism, its ability to more sensitively detect atrial septal aneurysm, patent foramen ovale, and aortic atheroma has been well described in recent years. Care must be exercised in using TEE to identify suspected cardiac sources of embolism, as potential etiologies described in the literature are not equally established by rigorous clinical trials. Confidence level in cause and effect for any cardiac pathology identified must be factored into therapeutic decisions.