Management of acute cholecystitis in patients on anti-thrombotic therapy: A single center experience.

Background: Acute cholecystitis in patients on anti-thrombotic therapy (ATT) presents a clinical dilemma at the intersection between conflicting guidelines, specifically between timing of early operative management (OM) versus time-to-reversal of certain ATT agents. With growing recognition that nonoperative management (NOM) is associated with considerable morbidity, and evidence in the literature that early OM in patients on ATT is safe, we reviewed our own practice to examine how we addressed these conflicting guidelines. Materials and methods: We performed a retrospective review of patients with acute cholecystitis between December 2017 and March 2022. Patients were classified as ATT or non-ATT; ATT patients were subdivided into anticoagulation (AC) and antiplatelet (AP) groups. Rates of OM were compared. Results: 502 patients with acute cholecystitis were identified, 464 non-ATT and 38 ATT. 30 ATT patients were on AC, 7 on AP, and 1 on both. Non-ATT patients were significantly more likely to receive OM at index presentation compared to those on ATT: 89.9 % vs 63.2 % (p < 0.05). Subgroup analysis of the ATT group showed AP patients were significantly less likely to receive OM compared to those on AC, 12.5 % vs 77 % (p < 0.05). Conclusions: At our institution, patients on ATT were significantly less likely to undergo OM for acute cholecystitis compared with non-ATT patients. Those on AC received OM significantly more than patients on AP. Further study is needed to better define the management of this growing population so that acute cholecystitis guidelines might address this issue in the future.

Double-dose external cardioversion for refractory unstable atrial fibrillation in the ED.

A 45-year-old man with dilated cardiomyopathy, atrial fibrillation, and hypertension presented to the emergency department with palpitations and shortness of breath for 2 days after running out of his medications. An electrocardiogram disclosed atrial fibrillation with rapid ventricular response. The patient was hemodynamically unstable and failed multiple cardioversion attempts up to 360 J. A second defibrillator was then attached and the patient successfully cardioverted once both defibrillators were set to their maximum levels, thus delivering a total of 720 J. Double-dose external cardioversion with 2 defibrillators is an important alternative method that the emergency physician should be aware of when treating refractory atrial fibrillation in the hemodynamically unstable patient.

Discrepancies in interpretation of ED body computed tomographic scans by radiology residents.

OBJECTIVE: In academic institutions, radiology residents are often relied on for providing preliminary reports of imaging studies done in the ED. We examined the prevalence of discrepant interpretations of body computed tomographic (CT) scans in our institution. METHODS: We conducted a retrospective study on a consecutive series of body CT scans at an urban ED. We compared the preliminary interpretation by radiology residents with the final interpretation by radiology attending physicians. An interpretation was characterized as having no discrepancy, minor discrepancy, or major discrepancy. A major discrepancy was defined as a discrepancy that resulted in a change in diagnosis, treatment, or disposition. RESULTS: Two hundred three body CT scans were identified during the study period. Of these CT scans, 20 had major discrepancies (10%), 40 had minor discrepancies (20%), and 143 had no discrepancy (70%). Major discrepancies included missed appendicitis, normal appendix, missed bowel obstruction, and missed colon cancer. Computed tomographic scans with abnormal findings were more likely to contain major discrepancies (relative risk = 6.0; 95% confidence interval = 1.8-2.0). CONCLUSION: Discrepancies between radiology residents and radiology attending physicians were common at our institution. Emergency department physicians should exercise caution when relying on residents' interpretation of body CT scans.

Who should be estimating a patient's weight in the emergency department?

OBJECTIVES: Medical personnel often need to estimate a patient's weight rapidly and accurately to administer pharmacologic agents whose dosages are based on weight. Inaccurate estimates of weight may result in administration of either subtherapeutic or, in other cases, toxic doses of medications. The hypothesis of this study was that the patient is a more accurate estimator of his or her own weight than the physician or nurse caring for him or her. METHODS: This was a prospective study in which adult patients presenting to an urban emergency department (ED) were examined for study eligibility. Patients unable to stand were excluded. The patient, physician, and nurse caring for the patients were independently asked to estimate the patients' weights. The patients were then weighed. RESULTS: A convenience sample of 458 patients were enrolled during a four-week period. The median measured (actual) weight was 172.5 lb. The best estimate of a patient's weight was made by the patient himself or herself: the median difference between patient estimates and actual weights was 0 lb (interquartile range [IQR] = -5 to 5). The physicians and nurses had larger underestimates: -5 lb (IQR = -22 to 12) and -6 lb (IQR = -22 to 10), respectively. Weight was estimated within 10% of actual weight by 90.6% of the patients, 50.4% of the physicians, and 49.6% of the nurses. CONCLUSIONS: When a patient is unable to be weighed, the patient's own weight estimate should be used. If neither is possible, the physician or nurse should estimate the patient's weight.