POCUS for Diastolic Dysfunction: A Review of the Literature.

Emergency and critical care physicians frequently encounter patients presenting with dyspnea and normal left ventricular systolic function who may benefit from early diastolic evaluation to determine acute patient management. The current American Society of Echocardiography Guidelines approach to diastolic evaluation is often impractical for point of care ultrasound (POCUS) evaluation, and few studies have evaluated the potential use of a simplified approach. This article reviews the literature on the use of a simplified diastolic evaluation to assist in determining acute patient management.

An odontoid fracture and vertebral artery injury in fast-track.

While CT scans without IV contrast are obtained commonly to evaluate vertebral injuries, CT angiography scans should be considered whenever a fracture site approaches known vasculature.

Evaluation of Spodick's Sign and Other Electrocardiographic Findings as Indicators of STEMI and Pericarditis.

BACKGROUND: Patients with ST elevation on electrocardiogram (ECG) could have ST elevation myocardial infarction (STEMI) or pericarditis. Spodick's sign, a downsloping of the ECG baseline (the T-P segment), has been described, but not validated, as a sign of pericarditis. OBJECTIVE: This study estimates the frequency of Spodick's sign and other findings in patients diagnosed with STEMI and those with pericarditis. METHODS: In this retrospective review, we selected charts that met prospective definitions of STEMI (cases) and pericarditis (controls). We excluded patients whose ECGs lacked ST elevation. An authority on electrocardiography reviewed all ECGs, noting the presence or absence of Spodick's sign, ST depression (in leads besides V1 and aVR), PR depression, greater ST elevation in lead III than in lead II (III > II), abrupt take-off of ST segment (the RT checkmark sign), and upward or horizontal ST convexity. We quantified strength of association using odds ratio (OR) with 95% confidence interval (CI). RESULTS: One hundred and sixty-five patients met criteria for STEMI and 42 met those for pericarditis. Spodick's sign occurred in 5% of patients with STEMI (95% CI 3-10%) and 29% of patients with pericarditis (95% CI 16-45%). All other findings statistically distinguished STEMI from pericarditis, but ST depression (OR 31), III > II (OR 21), and absence of PR depression (OR 12) had the greatest OR values. CONCLUSIONS: Spodick's sign is statistically associated with pericarditis, but it is seen in 5% of patients with STEMI. Among other findings, ST depression, III > II, and absence of PR depression were the most discriminating.

A Diagnosis of Adult-Onset Still's Disease after Multiple Urgent Care Visits.

A 34-year-old man with recent treatment and resolution of community-acquired pneumonia presents to the emergency department with protracted fever, rash, and sore throat. Sustained fever and greater than two-fold increase in leukocytosis despite appropriate antibiotic therapy prompted hospital admission for infectious disease and rheumatologic evaluations which ultimately revealed adult-onset Still's disease, a rare autoinflammatory disorder with potentially life-threatening complications.

The Approach to the Patient with Hematuria.

Hematuria is common; whether gross or microscopic, it is incumbent on emergency providers to consider life-threatening and benign processes when evaluating these patients. Most workup is driven by a focused history and physical, including laboratory studies and diagnostic imaging. The cause originates in the genitourinary tract and, as long as the patient remains stable, they can be discharged with close outpatient follow-up. The importance of this cannot be stressed enough because hematuria, especially in the elderly, frequently signals the presence of urologic malignancy. In addition, the workup occasionally yields a nongenitourinary tract cause, and these patients often require emergent management.

Spontaneous Intracranial and Lumbar Subdural Hematoma Presenting as Vaginal Pain.

BACKGROUND: Spontaneous spinal and intracranial subdural hematomas are rarely reported, especially occurring simultaneously. Anticoagulation use has been associated with spontaneous hemorrhages. Prompt diagnosis is required to prevent permanent neurological sequelae. In this case report, we describe a spontaneous spinal and intracranial subdural hematoma in a woman taking warfarin and initially presenting with severe vaginal pain. CASE REPORT: A 42-year-old woman who had a history of mechanical valve replacement and was therefore taking warfarin, came to an emergency department for relief of severe vaginal pain. Mild concurrent lumbar pain increased concern about spinal pathology, so magnetic resonance imaging of her spine was performed. It revealed a subdural hematoma extending from L1-S1 with arachnoiditis, which suggested intracranial pathology, though the patient had no complaint of a headache. Computed tomography of her brain demonstrated a large right subdural hemorrhage with midline shift. Subsequent imaging revealed no aneurysm or source of the intracranial bleeding. We concluded that the patient experienced spontaneous anticoagulation-related intracranial hemorrhage resulting in lumbar subdural hematoma and arachnoiditis with referred vaginal pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pelvic, vaginal, or perineal pain may be the presenting symptom in patients with lower spinal pathology. It is important to consider causes other than gynecological ones in the differential diagnosis of these patients, as well as to be cognizant of the relationship between spinal and intracranial subdural hemorrhages. In patients with back pain or radiating lumbar pain, especially coupled with neurological effects, clinicians should consider spinal subdural hemorrhage and arachnoiditis to expedite imaging studies and treatment of these rare entities.

48-year-old Man with Fevers, Chest Pain, and a History of Substance Abuse.

A 48-year-old male with a history of intravenous (IV) drug use presented to the emergency department (ED) for an area of mild pain and erythema on his chest. He was then triaged to the urgent care, or fast track, area of the ED. He was well appearing with normal lab findings and vital signs, but his workup revealed mediastinitis with osteomyelitis of the manubrium and clavicles, a surgical emergency. His treatment course included IV antibiotics and operative intervention with thoracic surgery. The patient looked too good to be sick, yet he had a life-threatening infection.

Cardiogenic Shock.

Cardiogenic shock (CS) is a physiologic state in which cardiac pump function is inadequate to perfuse the tissues. If CS is not rapidly recognized and treated, tissue hypoperfusion can quickly lead to organ dysfunction and patient death. Evaluation of patients with suspected CS should include an electrocardiogram, chest radiograph, laboratory studies, and bedside echocardiogram. Initial resuscitation is directed toward restoring cardiac output and tissue perfusion. Mechanical circulatory support is indicated for patients with CS who do not respond to pharmacologic therapy. Ultimately, these patients should undergo emergent reperfusion therapy with either percutaneous coronary intervention or coronary artery bypass grafting.

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain.

Less than half of patients with a chest pain history indicative of acute coronary syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. The physician must dissect the ECG for elusive, but perilous, characteristics that are often missed by machine analysis. ST depression is interpreted and often suggestive of ischemia; however, when exclusive to leads V1-V3 with concomitant tall R waves and upright T waves, a posterior infarction should first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR should raise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECG findings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographic findings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precede an inferior myocardial infarction. Similarly, something as ordinary as an upright and tall T wave or a biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, should give pause and merit careful inspection since misinterpretation occurs in 20-40% of misdiagnosed myocardial infarctions.

Augmenting Function for Infarction from Infection: Impella 2.5 for Ischemic Cardiogenic Shock Complicating Sepsis.

Cardiac dysfunction is a common complication of sepsis in individuals with preexisting coronary disease and portends a poor prognosis when progressing to ischemic cardiogenic shock. In this setting, maximal medical therapy in isolation is often inadequate to maintain cardiac output for patients who are poor candidates for immediate revascularization. Furthermore, the use of vasopressors and inotropes increases myocardial demand and may lead to further injury. Percutaneous ventricular assist devices provide a viable option for management of severe shock with multiorgan failure. The Impella is one of several novel mechanical support systems that can effectively augment cardiac output while reducing myocardial demand and serve as a bridge to recovery from severe hemodynamic compromise. This case report describes the successful utilization of the Impella 2.5 in a patient with baseline profound anemia and coronary artery disease (CAD) presenting in combined distributive and cardiogenic shock associated with a type 2 myocardial infarction complicating sepsis.

Cardiovascular Catastrophes in the Obstetric Population.

Pregnancy is a complex and dynamic physiologic state, in which the needs of the mother and fetus must achieve a fine balance with one another. Some of the most dreaded and deadly complications that can arise during this period affect the cardiovascular system are hypertensive emergencies (including preeclampsia and eclampsia), acute coronary syndrome, peripartum cardiomyopathy, dysrhythmias, dissection, thromboembolism, and cardiac arrest. This review provides emergency physicians, obstetricians, intensivists, and other health care providers with the most recent information on the diagnosis and management of these deadly cardiovascular complications of pregnancy.

Gender-specific research for emergency diagnosis and management of ischemic heart disease: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup.

Coronary artery disease (CAD) is the most common cause of death for both men and women. However, over the years, emergency physicians, cardiologists, and other health care practitioners have observed varying outcomes in men and women with symptomatic CAD. Women in general are 10 to 15 years older than men when they develop CAD, but suffer worse postinfarction outcomes compared to age-matched men. This article was developed by the cardiovascular workgroup at the 2014 Academic Emergency Medicine (AEM) consensus conference to identify sex- and gender-specific gaps in the key themes and research questions related to emergency cardiac ischemia care. The workgroup had diverse stakeholder representation from emergency medicine, cardiology, critical care, nursing, emergency medical services, patients, and major policy-makers in government, academia, and patient care. We implemented the nominal group technique to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in-person meetings, and Web-based surveys between June 2013 and May 2014. Through three rounds of nomination and refinement, followed by an in-person meeting on May 13, 2014, we achieved consensus on five priority themes and 30 research questions. The overarching themes were as follows: 1) the full spectrum of sex-specific risk as well as presentation of cardiac ischemia may not be captured by our standard definition of CAD and needs to incorporate other forms of ischemic heart disease (IHD); 2) diagnosis is further challenged by sex/gender differences in presentation and variable sensitivity of cardiac biomarkers, imaging, and risk scores; 3) sex-specific pathophysiology of cardiac ischemia extends beyond conventional obstructive CAD to include other causes such as microvascular dysfunction, takotsubo, and coronary artery dissection, better recognized as IHD; 4) treatment and prognosis are influenced by sex-specific variations in biology, as well as patient-provider communication; and 5) the changing definitions of pathophysiology call for looking beyond conventionally defined cardiovascular outcomes to patient-centered outcomes. These emergency care priorities should guide future clinical and basic science research and extramural funding in an area that greatly influences patient outcomes.

Hyperthyroidism and thyrotoxicosis.

Hyperthyroidism and thyrotoxicosis are hypermetabolic conditions that cause significant morbidity and mortality. The diagnosis can be difficult because symptoms can mimic many other disease states leading to inaccurate or untimely diagnoses and management. Thyroid storm is the most severe form of thyrotoxicosis, hallmarked by altered sensorium, and, if untreated, is associated with significant mortality. Thyroid storm should be considered in the differential of any patient presenting with altered mental status. The emergency medicine physician who can rapidly recognize thyrotoxicosis, identify the precipitating event, appropriately and comprehensively begin medical management, and facilitate disposition will undoubtedly save a life.

Cooling the fire: resuscitated sudden death.

Care of the patient with return of spontaneous circulation following sudden cardiac death is complex and challenging. A systematic and comprehensive approach can increase the chances of meaningful recovery of the postarrest patient. This article focuses on a systematic approach to the postarrest patient, which includes optimizing oxygenation and ventilation, maintaining adequate perfusion pressure, monitoring oxygen delivery, initiating and maintaining therapeutic hypothermia, and identifying patients appropriate for emergent cardiac catheterization. Using this approach, providers treating the postarrest patient can maximize the chance that a patient walks out of the hospital neurologically intact.