Heart rate and heart rate variability in emergency medicine.

BACKGROUND: Tachycardia may be indicative of mental stress, which in turn can decrease performance, reduce information processing capacity, and hinder memory recall. The objective of this study is to examine heart rate trends present among emergency medicine trainees over a standard emergency room shift to measure the frequency and severity of stress experienced while on shift. METHODS: We assessed heart rate in emergency medicine residents using the Empatica E4 device, a mobile wrist-worn physiological monitor. The 31 consenting residents received training in wearing the monitor and uploading the data during a typical critical care shift. Data was deindividualized, compiled, and analyzed with descriptive statistics using Microsoft Excel. RESULTS: Data collected from 31 critical care shifts illustrated that the mean range in HR was 53.9-162.7 bpm per shift and the overall range in HR across all shifts was 49-202.7 bpm. There was a mean of 10.2 peaks in the 120-129.9 bpm range, 11.3 peaks within 130-159.9 bpm, and 1.06 peaks above 160 bpm per shift. The mean length of time that HR rose above 130 bpm was 660.6 s per shift. Only 2 of the 31 shifts examined did not have any accelerations above 130 bpm. CONCLUSIONS: Continuous monitoring of HR in emergency medicine residents during standard critical care shifts using a wrist-worn device found marked elevations suggestive of episodic tachycardia.

Acute Pancreatitis: What's the Score?

BACKGROUND: Acute pancreatitis (AP) is a common presentation in the emergency department (ED). Severity of pancreatitis is an important consideration for ED clinicians making admission judgments. Validated scoring systems can be a helpful tool in this process. OBJECTIVE: The aim of this review is to give a general outline on the subject of AP and compare different criteria used to predict severity of disease for use in the ED. DISCUSSION: This review updates the classifications and scoring systems for AP and the relevant parameters of each. This article assesses past and current scoring systems for AP, including Ranson criteria, Glasgow criteria, Acute Physiology and Chronic Health Evaluation II (APACHE II), computed tomography imaging scoring systems, Bedside Index of Severity in Acute Pancreatitis (BISAP) score, Panc 3, Harmless Acute Pancreatitis Score (HAPS), and the Japanese Severity Score. This article also describes the potential use of single variable predictors. Finally, this article discusses risk factors for early readmission, an outcome pertinent to emergency physicians. These parameters may be used to risk-stratify patients presenting to the ED into mild, moderate, and severe pancreatitis for determination of appropriate disposition. CONCLUSION: Rapid, reliable, and validated means of predicting patient outcome from rapid clinical assessment are of value to the emergency physician. Scoring systems such as BISAP, HAPS, and single-variable predictors may assist in decision-making due to their simplicity of use and applicability within the first 24 h.

A targeted, conventional assay, emergency department HIV testing program integrated with existing clinical procedures.

OBJECTIVE: Various HIV testing models have been described, but widespread implementation has lagged. We describe a clinical HIV testing program notable for its use of conventional (nonrapid) assays, native hospital personnel, and an electronic system to aid targeted patient selection. METHODS: Clinical HIV testing program records and hospital emergency department (ED) and laboratory records were reviewed and linked for the period from January 2007 until November 5, 2008. RESULTS: There were 103,475 visits to the ED, for which 1,258 (1.2%) resulted in HIV testing, and 54 (4.3%) were positive for HIV antibody. Result notification was successful for 52 (96%) individuals with positive test results. After reporting to the health department, it was determined that 28 (2.2%) individuals had received a new diagnosis, of whom 89% were linked with care. Mean baseline CD4 counts for new diagnoses for periods 1 through 3, respectively, were (1) unavailable, (2) 138 cells/µL (95% confidence interval [CI] 34 to 242 cells/µL), and (3) 222 cells/µL (95% CI 119 to 325 cells/µL). Overall, mean calculated to be 180 cells/µL (95% CI 16 to 345 cells/µL). CONCLUSION: This ED HIV testing model successfully expanded new patient identification, result notification, and linkage to care. Although this effort falls short of Centers for Disease Control and Prevention recommendations, the model can be implemented widely without external funding for parallel staffing or rapid assays.

Social media guidelines and best practices: recommendations from the Council of Residency Directors Social Media Task Force.

Social media has become a staple of everyday life among over one billion people worldwide. A social networking presence has become a hallmark of vibrant and transparent communications. It has quickly become the preferred method of communication and information sharing. It offers the ability for various entities, especially residency programs, to create an attractive internet presence and "brand" the program. Social media, while having significant potential for communication and knowledge transfer, carries with it legal, ethical, personal, and professional risks. Implementation of a social networking presence must be deliberate, transparent, and optimize potential benefits while minimizing risks. This is especially true with residency programs. The power of social media as a communication, education, and recruiting tool is undeniable. Yet the pitfalls of misuse can be disastrous, including violations in patient confidentiality, violations of privacy, and recruiting misconduct. These guidelines were developed to provide emergency medicine residency programs leadership with guidance and best practices in the appropriate use and regulation of social media, but are applicable to all residency programs that wish to establish a social media presence.

Cardiac arrest from postpartum spontaneous coronary artery dissection.

We present the case of a 32-year-old woman who presented to the emergency department with a witnessed cardiac arrest. She was otherwise healthy with no cardiac risk factors and had undergone an uneventful repeated cesarean section 3 days priorly. The patient underwent defibrillation, out of ventricular fibrillation to a perfusing sinus rhythm, and was taken to the catheterization laboratory where coronary angiography findings showed spontaneous dissection of the left anterior descending artery. The patient received a total of 6 stents during her hospital stay and was eventually discharged in good condition. Spontaneous coronary artery dissection is a rare entity with a predilection for pregnant or postpartum women. Early diagnosis and treatment are key for survival, and when identified early, mortality rate is reduced.