Revisiting "Excited Delirium": Does the Diagnosis Reflect and Promote Racial Bias?

INTRODUCTION: "Excited delirium" (ExD) is purported to represent a certain type of agitated state that can lead to unexpected death. The 2009 "White Paper Report on Excited Delirium Syndrome," authored by the American College of Emergency Medicine (ACEP) Excited Delirium Task Force, continues to play a pivotal role in defining ExD. Since that report was produced, there has been an increasing appreciation that the label has been applied more often to Black people. METHODS: Our aim was to analyze the language of the 2009 report, the role of potential stereotypes, and the mechanisms that may potentially encourage bias. RESULTS: Our evaluation of the diagnostic criteria for ExD proposed in the 2009 report shows that it relies on persistent racial stereotypes: eg, unusual strength, decreased sensitivity to pain, and bizarre behavior. Research indicates that use of such stereotypes could encourage biased diagnosis and treatment. CONCLUSION: We suggest that the emergency medicine community avoid use of the concept ExD and that ACEP withdraw implicit or explicit support of the report.

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STUDY OBJECTIVE: Ventricular paced rhythm is thought to obscure the electrocardiographic diagnosis of acute coronary occlusion myocardial infarction. Our primary aim was to compare the sensitivity of the modified Sgarbossa criteria (MSC) to that of the original Sgarbossa criteria for the diagnosis of occlusion myocardial infarction in patients with ventricular paced rhythm. METHODS: In this retrospective case-control investigation, we studied adult patients with ventricular paced rhythm and symptoms of acute coronary syndrome who presented in an emergency manner to 16 international cardiac referral centers between January 2008 and January 2018. The occlusion myocardial infarction group was defined angiographically as thrombolysis in myocardial infarction grade 0 to 1 flow or angiographic evidence of coronary thrombosis and peak cardiac troponin I ≥10.0 ng/mL or troponin T ≥1.0 ng/mL. There were 2 control groups: the "non-occlusion myocardial infarction-angio" group consisted of patients who underwent coronary angiography for presumed type I myocardial infarction but did not meet the definition of occlusion myocardial infarction; the "no occlusion myocardial infarction" control group consisted of randomly selected emergency department patients without occlusion myocardial infarction. RESULTS: There were 59 occlusion myocardial infarction, 90 non-occlusion myocardial infarction-angio, and 102 no occlusion myocardial infarction subjects (mean age, 72.0 years; 168 [66.9%] men). For the diagnosis of occlusion myocardial infarction, the MSC were more sensitive than the original Sgarbossa criteria (sensitivity 81% [95% confidence interval [CI] 69 to 90] versus 56% [95% CI 42 to 69]). Adding concordant ST-depression in V4 to V6 to the MSC yielded 86% (95% CI 75 to 94) sensitivity. For the no occlusion myocardial infarction control group of ED patients, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 96% (95% CI 90 to 99) versus 97% (95% CI 92 to 99); negative likelihood ratio (LR) 0.19 (95% CI 0.11 to 0.33) versus 0.45 (95% CI 0.34 to 0.65); and positive LR 21 (95% CI 7.9 to 55) versus 19 (95% CI 6.1 to 59). For the non-occlusion myocardial infarction-angio control group, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 84% (95% CI 76 to 91) versus 90% (95% CI 82 to 95); negative LR 0.22 (95% CI 0.13 to 0.38) versus 0.49 (95% CI 0.35 to 0.66); and positive LR 5.2 (95% CI 3.2 to 8.6) versus 5.6 (95% CI 2.9 to 11). CONCLUSION: For the diagnosis of occlusion myocardial infarction in the presence of ventricular paced rhythm, the MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm.

A deep neural network for 12-lead electrocardiogram interpretation outperforms a conventional algorithm, and its physician overread, in the diagnosis of atrial fibrillation.

BACKGROUND: Automated electrocardiogram (ECG) interpretations may be erroneous, and lead to erroneous overreads, including for atrial fibrillation (AF). We compared the accuracy of the first version of a new deep neural network 12-Lead ECG algorithm (Cardiologs®) to the conventional Veritas algorithm in interpretation of AF. METHODS: 24,123 consecutive 12-lead ECGs recorded over 6 months were interpreted by 1) the Veritas® algorithm, 2) physicians who overread Veritas® (Veritas®â€¯+ physician), and 3) Cardiologs® algorithm. We randomly selected 500 out of 858 ECGs with a diagnosis of AF according to either algorithm, then compared the algorithms' interpretations, and Veritas®â€¯+ physician, with expert interpretation. To assess sensitivity for AF, we analyzed a separate database of 1473 randomly selected ECGs interpreted by both algorithms and by blinded experts. RESULTS: Among the 500 ECGs selected, 399 had a final classification of AF; 101 (20.2%) had ≥1 false positive automated interpretation. Accuracy of Cardiologs® (91.2%; CI: 82.4-94.4) was higher than Veritas® (80.2%; CI: 76.5-83.5) (p < 0.0001), and equal to Veritas®â€¯+ physician (90.0%, CI:87.1-92.3) (p = 0.12). When Veritas® was incorrect, accuracy of Veritas®â€¯+ physician was only 62% (CI 52-71); among those ECGs, Cardiologs® accuracy was 90% (CI: 82-94; p < 0.0001). The second database had 39 AF cases; sensitivity was 92% vs. 87% (p = 0.46) and specificity was 99.5% vs. 98.7% (p = 0.03) for Cardiologs® and Veritas® respectively. CONCLUSION: Cardiologs® 12-lead ECG algorithm improves the interpretation of atrial fibrillation.

Distinctive ECG patterns in healthy black adults.

Six ECG patterns are found more frequently in healthy black adults than in whites. These patterns are presumably benign, but also may resemble those of malignant disease. 1) Healthy black adults show higher QRS voltage, and more often meet ECG criteria for left ventricular hypertrophy (LVH). Associated repolarization abnormalities can produce ST segment elevation (STE) that resembles ST elevation MI (STEMI). 2) The pattern of benign anterior STE, seen often in males, is more common in black subjects. Similar to LVH, this pattern may falsely suggest STEMI. 3) Both early repolarization (ER) and benign inferolateral STE are more common in black patients. Although they may convey a higher risk of fatal arrhythmias or cardiac death in white populations, it does not appear that black subjects with these patterns show a similar risk. 4) The persistent juvenile T wave inversion pattern shows asymmetric T wave inversion (TWI) in V1-V4, without ST segment deviations. It is most common in black females, and is considered benign. However, this pattern can also resemble the anterior TWI of arrhythmogenic right ventricular cardiomyopathy (ARVC). 5) A pattern of anterior TWI with associated J point elevation is a common finding in the black population, especially athletes. It could suggest hypertrophic cardiomyopathy, but can be presumed to be a benign finding in black athletes, when TWI is limited to V1-V4 and preceded by J point elevation. 6) TWI in the lateral precordial leads, usually associated with end-QRS slurring or notches is seen much more often in apparently healthy black subjects than white subjects. Unlike the anterior TWI pattern, however, it cannot be presumed benign. In conclusion, awareness of these ECG patterns may help to avoid unnecessary diagnostic or therapeutic interventions, but also encourage appropriate investigations.

A deep neural network learning algorithm outperforms a conventional algorithm for emergency department electrocardiogram interpretation.

BACKGROUND: Cardiologs® has developed the first electrocardiogram (ECG) algorithm that uses a deep neural network (DNN) for full 12­lead ECG analysis, including rhythm, QRS and ST-T-U waves. We compared the accuracy of the first version of Cardiologs® DNN algorithm to the Mortara/Veritas® conventional algorithm in emergency department (ED) ECGs. METHODS: Individual ECG diagnoses were prospectively mapped to one of 16 pre-specified groups of ECG diagnoses, which were further classified as "major" ECG abnormality or not. Automated interpretations were compared to blinded experts'. The primary outcome was the performance of the algorithms in finding at least one "major" abnormality. The secondary outcome was the proportion of all ECGs for which all groups were identified, with no false negative or false positive groups ("accurate ECG interpretation"). Additionally, we measured sensitivity and positive predictive value (PPV) for any abnormal group. RESULTS: Cardiologs® vs. Veritas® accuracy for finding a major abnormality was 92.2% vs. 87.2% (p < 0.0001), with comparable sensitivity (88.7% vs. 92.0%, p = 0.086), improved specificity (94.0% vs. 84.7%, p < 0.0001) and improved positive predictive value (PPV 88.2% vs. 75.4%, p < 0.0001). Cardiologs® had accurate ECG interpretation for 72.0% (95% CI: 69.6-74.2) of ECGs vs. 59.8% (57.3-62.3) for Veritas® (P < 0.0001). Sensitivity for any abnormal group for Cardiologs® and Veritas®, respectively, was 69.6% (95CI 66.7-72.3) vs. 68.3% (95CI 65.3-71.1) (NS). Positive Predictive Value was 74.0% (71.1-76.7) for Cardiologs® vs. 56.5% (53.7-59.3) for Veritas® (P < 0.0001). CONCLUSION: Cardiologs' DNN was more accurate and specific in identifying ECGs with at least one major abnormal group. It had a significantly higher rate of accurate ECG interpretation, with similar sensitivity and higher PPV.

Misplacing V1 and V2 can have clinical consequences.

The precordial electrocardiogram (ECG) leads V1 and V2 are often misplaced. Such misplacement usually involves placing these leads too high on the chest. The resulting ECG may generate erroneous ECG patterns: e.g. incomplete right bundle branch block, anterior T wave inversion, septal Q waves, ST-segment elevation. These features may falsely suggest acute or old cardiac ischemia, pulmonary embolism, or a type-2 Brugada pattern. On rare occasion, conversely, high placement of V1 and V2 may reveal a true type-1 Brugada pattern. The emergency clinician needs to be aware of the possibility of lead misplacement, and should know how to suspect it based on unusual P wave morphology in V1 and V2.

New Insights Into the Use of the 12-Lead Electrocardiogram for Diagnosing Acute Myocardial Infarction in the Emergency Department.

The 12-lead electrocardiogram (ECG) remains the most immediately accessible and widely used initial diagnostic tool for guiding management in patients with suspected myocardial infarction (MI). Although the development of high-sensitivity cardiac troponin assays has improved the rule-in and rule-out and risk stratification of acute MI without ST elevation, the immediate management of the subset of acute MI with acute coronary occlusion depends on integrating clinical presentation and ECG findings. Careful interpretation of the ECG might yield subtle features suggestive of ischemia that might facilitate more rapid triage of patients with subtle acute coronary occlusion or, conversely, in identification of ST-elevation MI mimics (pseudo ST-elevation MI patterns). Our goal in this review article is to consider recent advances in the use of the ECG to diagnose coronary occlusion MIs, including the application of rules that allow MI to be diagnosed on the basis of atypical ECG manifestations. Such rules include the modified Sgarbossa criteria allowing identification of acute MI in left bundle branch block or ventricular pacing, the 3- and 4-variable formula to differentiate normal ST elevation (formerly called early repolarization) from subtle ECG signs of left anterior descending coronary artery occlusion, the differentiation of ST elevation of left ventricular aneurysm from that of acute anterior MI, and the use of lead aVL in the recognition of inferior MI. Improved use of the ECG is essential to improving the diagnosis and appropriate early management of acute coronary occlusion MIs, which will lead to improved outcomes for patients who present with acute coronary syndrome.

Proximal RCA occlusion producing anterior ST segment elevation, Q waves, and T wave inversion.

An ST segment elevation myocardial infarction (STEMI) that produces anterior ST segment elevation (STE) is typically caused by acute occlusion of the left anterior descending (LAD) artery. Anterior STE, however, may also be caused by acute occlusion of either the proximal right coronary artery (RCA) or the right ventricular marginal branch (RVB). It has been thought that, in contrast to occlusions of the LAD, proximal RCA/RVB occlusion rarely causes Q waves in the right precordial leads. We present a case where a proximal RCA occlusion produced not only anterior STE, but also anterior T wave inversions and anterior Q waves.

The Role of Early Focused Cardiac Ultrasound in a Not-So-Typical Presentation of Takotsubo Cardiomyopathy: A Case Report.

BACKGROUND: Focused cardiac ultrasound (FoCUS) can be extremely helpful in identifying unexpected diagnoses that can significantly alter treatment options. The diagnosis of Takotsubo cardiomyopathy (TCM) may be difficult to identify. CASE REPORT: We describe a 47-year-old woman who presented to the emergency department (ED) with atypical features of TCM. Her clinical features included being a premenopausal woman with mild chest pain with a lack of identifiable emotional or physical stressors or significant electrocardiographic changes. Initial findings on FoCUS were consistent with TCM, with these findings replicated on repeat bedside echo performed in the ED by the cardiology fellow. A subsequent comprehensive echo showed marked improvement of the TCM pattern within 24 hours. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: TCM may present in younger women or men, without obvious preceding physical or emotional stressors and with nonspecific ECG findings. FoCUS performed in the ED may suggest a diagnosis of TCM in patients with chest pain or dyspnea of uncertain etiology. The performance of FoCUS, as highlighted by this case report, can lead to timely intervention and follow-up of a variety of cardiac conditions.

Hemorrhagic Pericardial Cyst Diagnosis Accelerated by Emergency Physician Echocardiography: A Case Report.

BACKGROUND: The differential diagnosis for chest pain in the emergency department is broad and includes both benign and life-threatening conditions-with pericardial cyst as a rare example. Emergency physician-performed point-of-care focused cardiac ultrasound (FOCUS) is increasingly recognized as a useful modality in the evaluation of patients with chest pain. CASE REPORT: We report a case of hemorrhagic pericardial cyst in a young woman presenting with chest pain in which findings on FOCUS contradicted findings on chest x-ray study and thus, accelerated diagnosis and definitive treatment. We also comment on epidemiology, pathophysiology, clinical presentation, diagnosis, and management of this uncommon, potentially fatal cause of chest pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report aims to bring an uncommon case to the attention of emergency providers and emphasize the importance of facility with FOCUS. Although definitive diagnosis and management were not accomplished at the bedside in this case, an abnormal finding on FOCUS prompted further investigation and timely treatment.

Low-Pressure Pericardial Tamponade: Case Report and Review of the Literature.

BACKGROUND: Focused cardiac ultrasound (FoCUS) is accurate for determining the presence of a pericardial effusion. Using FoCUS to evaluate for pericardial tamponade, however, is more involved. Many experts teach that tamponade is unlikely if the inferior vena cava (IVC) shows respiratory variation and is not distended. CASE REPORT: A 53-year-old woman presented to the emergency department (ED) with severe orthostatic hypotension, exertional dyspnea, and hypoxia. The evaluation did not reveal an acute cardiopulmonary etiology, but FoCUS demonstrated a pericardial effusion, with several signs consistent with tamponade. The IVC, however, was not distended. She was believed to be hypovolemic, but fluid therapy provided minimal benefit. The patient's condition improved only after aspiration of the effusion. The patient's presentation was likely a "low-pressure" pericardial tamponade. Patients with this subset of tamponade often do not have significant venous congestion, but urgent pericardial aspiration is still indicated. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pericardial tamponade may not manifest with IVC plethora on ultrasound. Patients with low-pressure tamponade do not present with the most florid signs of tamponade, but they nonetheless fulfill diagnostic criteria for tamponade. If a non-plethoric IVC is used to rule out tamponade, the clinician risks delaying comprehensive echocardiography or other tests. Furthermore, the potential for deterioration to frank shock could be discounted, with inappropriate disposition and monitoring.

Terminal QRS distortion is present in anterior myocardial infarction but absent in early repolarization.

BACKGROUND: Early repolarization (ER) and acute left anterior descending artery occlusion (LADO) may be difficult to distinguish. Terminal QRS distortion (TQRSD), defined by the absence of both an S wave and J wave in either of leads V2 or V3, is often present in anterior ST-segment elevation myocardial infarction. We hypothesized that this finding would always be absent in ER. METHODS: This was a retrospective analysis of electrocardiograms (ECGs) of consecutive patients who presented to the emergency department with ischemic symptoms and had a cardiologist interpretation of "benign ER" on the initial emergency department ECG. All ECGs were scrutinized for the presence of an S wave and a J wave in leads V2 and V3. Differences in S-wave amplitudes between complexes with and without J waves were analyzed using nonparametric Mann-Whitney testing and confidence intervals around a proportion. RESULTS: One hundred seventy-one patients were identified with benign ER. Zero of 171 had TQRSD (specificity for LADO, 100%; 95% confidence interval, 97.8-100). In lead V2, S waves were absent in only 1 of 171 ECGs; however, in that ECG, a J wave measuring 0.5 mm was present. In lead V3, S waves were absent in 16 ECGs, but all of these ECGs had J waves. When J waves were absent in leads V2 or V3, the corresponding S waves were deeper than S waves in QRS complexes with J waves. CONCLUSION: Terminal QRS distortion was never observed in benign ER. Based on previous studies indicating the presence of TQRSD in LADO, it was, thus, 100% specific to LADO when the differential diagnosis was acute myocardial infarction vs ER.

T-wave inversions on ECG as primary manifestation of Hashimoto's disease.

A middle-aged Hispanic woman presented to the emergency department (ED) reporting of acute new onset pressure-like chest pain developed at rest. It was radiated to the right arm and associated with malaise. Initial ECG demonstrated T-wave inversions (TWIs) in all anterior and lateral leads. Electrolytes, serial cardiac troponin and D-dimer were all normal. Comprehensive transthoracic echocardiogram and nuclear stress test did not reveal a cardiac cause of her symptoms.Serum thyroid-stimulating hormone was markedly elevated (207 mIU/L) and free thyroxine was low (FT4 0.07 ng/dL), consistent with severe primary hypothyroidism. Thyroperoxidase (TPO) antibodies were positive. Therapy with levothyroxine was started. No other cause of the TWIs was identified. A repeat ECG obtained 8 weeks later showed partial resolution of the TWIs. Our observations indicate that Hashimoto's disease is the most likely primary cause of this patient's extensive and profound TWI, which improved after thyroid replacement therapy.

Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature.

OBJECTIVES: The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors. METHODS: The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes. RESULTS: Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, "unintentional manipulation," falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study. CONCLUSIONS: Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable.

"Persistent Juvenile" T-Wave Pattern May Not Be Persistent: Case Series and Literature Review.

BACKGROUND: T-wave inversions (TWI) can signify serious pathology, but may also represent a benign variant. One such variant has been termed the "persistent juvenile" T-wave pattern (PJTWP). It is characterized by TWI in the right precordium, and has been understood to represent an arrested stage of the normal electrocardiographic evolution from childhood. CASE REPORT: A series of four African-American (AA) women, ages 20 to 43 years, presented to the Emergency Department, and were found to have right precordial TWI that was absent on prior electrocardiograms. The diagnostic evaluation did not reveal acute cardiopulmonary causes for these new TWIs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The "persistent" juvenile pattern may not be actually persistent in the individual patient. In an appropriate patient, such as a young AA woman, where acute cardiopulmonary disease has been reasonably ruled out, the finding of new right precordial TWI should not preclude the diagnosis of PJTWP.

McConnell's Sign Is Not Specific for Pulmonary Embolism: Case Report and Review of the Literature.

BACKGROUND: McConnell's sign (right ventricular [RV] free wall hypokinesis with apical sparing on echocardiography) is often described as very specific for the diagnosis of pulmonary embolism (PE). We present the case of a patient who, despite manifesting a classic McConnell's sign, was not found to have a PE. CASE REPORT: A 58-year-old woman presented to the emergency department with a cough, dyspnea, and leg swelling. A bedside focused cardiac ultrasound revealed hypokinesis of the RV free wall, with apical sparing, in the apical four-chamber view. A computed tomography angiogram for PE was negative. Ultrasounds of both lower extremities were negative for deep venous thrombosis, and a D-dimer was only marginally elevated. The patient was ultimately diagnosed with pulmonary hypertension due to chronic obstructive pulmonary disease and systemic lupus erythematosus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware that McConnell's sign is not completely specific for acute right heart strain from PE.