Sepsis in Special Populations.

Sepsis is recognized by the presence of physiologic and laboratory changes that reflect the inflammatory response to infection on cellular and systemic levels. Comorbid conditions, such as cirrhosis, end-stage renal disease, and obesity, alter patients' susceptibility to infection and their response to it once present. Baseline changes in vital signs and chronic medications often mask clues to the severity of illness. The physiologic, hematologic, and biochemical adjustments that accompany pregnancy and the puerperium introduce similar challenges. Emergency providers must remain vigilant for subtle alterations in the expected baseline for these conditions to arrive at appropriate management decisions.

Emergency department focused bedside echocardiography in massive pulmonary embolism.

BACKGROUND: Massive pulmonary embolism (PE) is a common consideration in unstable patients presenting to the emergency department (ED) with chest pain, dyspnea, or cardiac arrest. It is a potentially lethal condition necessitating prompt recognition and aggressive management. Conventional diagnostic modalities in the ED, including chest computed tomography angiography and ventilation-perfusion scanning, require the unstable patient to leave the department, and raise concerns over renal injury. Several case reports document findings of massive PE on echocardiography performed in the ED; however, none was performed, interpreted, and acted upon in the form of thrombolytic therapy by an emergency physician without the additional benefit of a cardiologist's interpretation or a confirmatory imaging study. OBJECTIVE: We present a case that illustrates the utility of ED focused bedside echocardiography in suspected massive PE and briefly review direct and indirect ultrasound findings of acute PE. CASE REPORT: A case of massive PE in a 61-year-old woman is reported. In this patient with marked dyspnea, progressive hemodynamic instability, and contraindications to definitive imaging, ED focused bedside echocardiography provided valuable information that strongly suggested the diagnosis and led to alteplase administration. To our knowledge, this case represents the first report of thrombolytic therapy administration for acute massive PE based solely on clinical presentation and an emergency physician-performed bedside echocardiogram. CONCLUSION: In the hands of an experienced emergency physician ultrasonographer, ED focused bedside echocardiography provides a safe, rapid, and non-invasive diagnostic adjunct for evaluation of the patient suspected of having massive PE.

Electrocardiographic differential diagnosis of narrow QRS complex tachycardia: an ED-oriented algorithmic approach.

The differentiation of narrow complex tachycardias is a common diagnostic conundrum encountered by emergency physicians. Although a number of published algorithms are available to assist the clinician in evaluating features of the 12-lead electrocardiogram (ECG), many of these are too cumbersome, requiring multiple decisions and introducing treatment suggestions within the diagnostic framework. To optimize the diagnosis of the narrow complex tachycardia, we propose 3 separate algorithms tailored to address varying levels of available clinical information. The static algorithm depends only on the 12-lead ECG without the benefit of historical data or diagnostic interventions. The comparative algorithm requires a baseline ECG to which the presenting ECG is compared. The dynamic algorithm encourages the clinician to take advantage of diagnostic maneuvers to further elucidate the tachycardia mechanism. Each of these algorithms requires the clinician to answer either "yes" or "no" for each criterion and does not include treatment recommendations.

Impact of the 12-lead electrocardiogram on ED evaluation and management.

STUDY OBJECTIVE: This study was conducted to assess the impact (diagnostic, therapeutic, and disposition) of the 12-lead electrocardiogram (ECG) on emergency department (ED) patient evaluation and management. METHODS: This project was a prospective study of a convenience sample of 304 ED patients undergoing ECG analysis during their evaluation in the ED of a level 1 trauma center. The data collection for this study was divided into 4 parts. In part I, the treating physicians determined the specific reasons for ECG analysis; categories include complaint-based (eg, chest pain), syndrome-based (eg, overdose/poisoning), and system-based (eg, "requested by consult"). In part II, all treating physicians were surveyed before ECG interpretation regarding the future diagnostic, therapeutic, and disposition plans for the patient based only on history and physical examination. Their comments were recorded on a standardized data sheet. In part III, the physicians were surveyed after their interpretation of the ECG as to whether the results could suggest any further diagnostic information (eg, normal vs abnormal), or provide enough information for the patient care plan to be altered. In part IV of the study period, alterations to the original diagnostic, therapeutic, and disposition plans made by information provided by the ECG were obtained from the treating physician. RESULTS: A total of 304 patients underwent ECG examination and were used for data analysis. The average age of patients, of which 48% were men, was 60 years. The most common complaints that prompted electrocardiographic evaluation were chest pain and dyspnea. The most common reason an ECG was ordered was nursing staff protocol. Physicians determined that they were able to make a diagnosis based primarily on ECG in 33 (10.9%) cases. The total number of ECGs that were determined to be normal was 95 (31.3%), 7 (2.3%) of which allowed a rule-out diagnosis; 209 (68.7%) of total ECGs were determined to be abnormal, 72 (23.6%) of which were considered "of diagnostic significance." In 96 (31.6%) cases of electrocardiographic interpretation, alterations were made to the diagnostic, therapeutic, or disposition plans because of the information provided by the ECG. CONCLUSIONS: The ECG provides clinical information that frequently alters the management plan.

Disagreement between transport team and ED staff regarding the prehospital assessment of air medically evacuated scene patients.

STUDY OBJECTIVE: To determine the rate of disagreement in assessment of significant illness or injury between air medical transport team assessment and emergency department (ED) diagnosis in patients transferred from the scene of an incident to the ED. METHODS: Retrospective analysis was performed on 84 patients transported by medical flight teams from an accident scene to an ED. RESULTS: Results show transport team assessment concurred with ED diagnosis 96.7% of the time; most of the differences in assessment were overassessments by the transport team. Assessment differences occurred most often for abdominal injuries and least often for head injuries. Underassessment occurred most often for spinal cord injuries. CONCLUSIONS: Despite the numerous difficulties involved in patient assessment, data show that the transport teams accurately evaluated patients in most instances. Disagreements in assessment of injury/illness most often were overassessments.