The Accuracy of an Electronic Pulmonary Embolism Severity Index Auto-Populated from the Electronic Health Record: Setting the stage for computerized clinical decision support.

BACKGROUND: The Pulmonary Embolism (PE) Severity Index identifies emergency department (ED) patients with acute PE that can be safely managed without hospitalization. However, the Index comprises 11 weighted variables, complexity that can impede its integration into contextual workflow. OBJECTIVE: We designed a computerized version of the PE Severity Index (e-Index) to automatically extract the required variables from discrete fields in the electronic health record (EHR). We tested the e-Index on the study population to determine its accuracy compared with a gold standard generated by physician abstraction of the EHR on manual chart review. METHODS: This retrospective cohort study included adults with objectively-confirmed acute PE in four community EDs from 2010-2012. Outcomes included performance characteristics of the e-Index for individual values, the number of cases requiring physician editing, and the accuracy of the e-Index risk category (low vs. higher). RESULTS: For the 593 eligible patients, there were 6,523 values automatically extracted. Fifty one of these needed physician editing, yielding an accuracy at the value-level of 99.2% (95% confidence interval [CI], 99.0%-99.4%). Sensitivity was 96.9% (95% CI, 96.0%-97.9%) and specificity was 99.8% (95% CI, 99.7%-99.9%). The 51 corrected values were distributed among 47 cases: 43 cases required the correction of one variable and four cases required the correction of two. At the risk-category level, the e-Index had an accuracy of 96.8% (95% CI, 95.0%-98.0%), under-classifying 16 higher-risk cases (2.7%) and over-classifying 3 low-risk cases (0.5%). CONCLUSION: Our automated extraction of variables from the EHR for the e-Index demonstrates substantial accuracy, requiring a minimum of physician editing. This should increase user acceptability and implementation success of a computerized clinical decision support system built around the e-Index, and may serve as a model to automate other complex risk stratification instruments.

Epiploic appendagitis: a new diagnosis for the emergency physician. Two case reports and a review.

Two cases of epiploic appendagitis are presented. One was mistaken for acute appendicitis, the other for acute diverticulitis. In both cases, the correct diagnosis was made in the operating suite. With the aid of contemporary imaging modalities, however, the diagnosis of epiploic appendagitis need no longer hinge on the pathologic specimen but may be established by the emergency physician. As this disorder recently has been demonstrated to be predominantly self-limited, laparotomy no longer is considered necessary. Conservative management has been shown to be safe. The anatomy, pathophysiology, clinical presentation, radiologic evaluation, and emergency management of epiploic appendagitis are reviewed.

Slow infusion for the prevention of akathisia induced by prochlorperazine: a randomized controlled trial.

The utility of intravenous prochlorperazine (PCZ) in the treatment of nausea, vomiting, and headache may be limited by the akathisia that occurs frequently with the recommended 2-min infusion rate. We tested the hypothesis that decreasing the rate of PCZ infusion to 15 min reduces the incidence of akathisia at 1 hour. This double-blinded, randomized, controlled trial was conducted in the Emergency Department of an academic tertiary-care medical center with an annual census of 95,000 emergency patient visits. We enrolled a convenience sample of adult patients who received 10 mg i.v. PCZ for the treatment of nausea, vomiting, or headache. Subjects were randomized to receive either a 2-min infusion of PCZ (10 mg) followed by a 15-min infusion of saline, or a 2-min infusion of saline followed by a 15-min infusion of prochlorperazine. The incidence of akathisia at 1 hour was measured by using explicit diagnostic criteria. One hundred sixty patients were randomly enrolled into two groups, which were comparable with respect to age, gender, weight, and complaint. Akathisia developed in 31 of 84 patients (36.9%) who received the 2-min infusion of PCZ and in 18 of 76 patients (23.7%) who received the 15-min infusion of PCZ (p = 0.07), a 36% (95% CI, -5% to 61%) relative reduction. The delta from pre-infusion to postinfusion scores between the two groups was not significant (p = 0.19). We conclude that slowing the rate of PCZ infusion does not decrease akathisia.

Large-diameter suction system reduces oropharyngeal evacuation time.

Aspiration of vomitus is associated with significant morbidity and mortality. Standard suction equipment may be incapable of rapidly evacuating vomitus from the oropharynx. In this prospective, randomized, controlled bench trial, we compared a large-diameter suction system (5/8-inch open-bore suction tip and 3/4-inch tubing attached to a 1-inch pour spout) with two standard suction systems (small-diameter blunt-nosed and medium-diameter open-bore 1/4-inch suction tips connected to 1/4-inch tubing). Mean evacuation times from the mouth of a volunteer of 90 mL of water, activated charcoal, and Progresso vegetable soup were measured. All systems removed water within 3 s. With vegetable soup, however, both standard suction systems obstructed. Despite additional mechanical scooping with the standard suction wands, the large-diameter system significantly outperformed both standard systems, by 10 s with the soup and 40 s with the charcoal The reduction in oropharyngeal evacuation times of viscous and particulate material may have important clinical implications in the emergency management of the threatened airway.

Prochlorperazine induces akathisia in emergency patients.

STUDY OBJECTIVE: Prochlorperazine (PCZ), a commonly used antiemetic and analgesic agent, is known to cause akathisia. The incidence of akathisia after a single 10-mg dose of intravenous PCZ has not been prospectively evaluated. We determined the incidence and severity of PCZ-induced akathisia at 1 hour and the incidence of delayed akathisic symptoms at 48 hours. METHODS: This prospective controlled study evaluated a convenience sample of 140 adult patients at a 400-bed, academic, tertiary-care medical center with an annual emergency department census of 95,000 patient visits. One hundred patients who received intravenous PCZ for the treatment of severe headache or vomiting constituted the PCZ group. Forty patients receiving nonakathisic intravenous therapy (eg, saline solution or antibiotics) served as control subjects. Patients were excluded if they had preexisting motor disorders (eg, restless-leg syndrome or Parkinson's disease) or if they recently had received any medication with extrapyramidal, anticholinergic, sedative, or antiakathisic properties. All patients underwent an akathisia assessment before and 1 hour after receiving their respective intravenous medications. An established scale was used to detect the presence of akathisia and grade its severity as mild, moderate, or severe. The delayed development of akathisic symptoms within 48 hours also was measured in the PCZ group. RESULTS: Akathisia developed in 44 (44%) of the patients receiving PCZ within 1 hour (95% confidence interval, 34% to 54%). The akathisia was graded as mild, moderate, and severe in 14, 22, and 8 subjects, respectively. Delayed symptoms suggestive of akathisia developed in 3 other patients within 48 hours. None of the 40 control subjects developed akathisia. CONCLUSION: Single-dose intravenous PCZ frequently induced akathisia within 1 hour of administration. Acute akathisia was not observed in patients receiving intravenous saline solution or antibiotics. The delayed development of akathisia symptoms 48 hours after a single dose of intravenous PCZ was uncommon.

Outpatient treatment of deep venous thrombosis: a clinical care pathway managed by the emergency department.

STUDY OBJECTIVE: We evaluate the effectiveness and safety of an outpatient clinical care pathway for the initial treatment of acute proximal lower-extremity deep venous thrombosis (DVT) with low molecular weight heparin (LMWH) managed by the emergency department of 2 affiliated community hospitals. METHODS: This observational, retrospectively defined, population-based study with 39(1/2) months of preintervention analysis and 32(1/2) months of postintervention analysis was conducted in 2 suburban EDs of a large group model health maintenance organization. Our outpatient DVT clinical care pathway used careful patient selection and multidisciplinary follow-up. Ninety-six patients before the intervention and 178 patients after the intervention met eligibility criteria for the pathway. Adverse events during the first 2 weeks of treatment included symptomatic pulmonary embolism (PE), progressive DVT, minor and major bleeding, and death. RESULTS: Demographic and baseline clinical characteristics of the 2 groups were similar. Five (5.2%) of 96 preintervention subjects (95% confidence interval [CI] 2.4 to 8.1) developed adverse events compared with 5 (2.8%) of 178 postintervention subjects (95% CI 1.5 to 4.1; difference between groups 2.4%; P =.50). In each group, 1 (1.0% versus 0.6%) subject developed a PE, 2 (2.1% versus 1.1%) developed progressive symptoms of progressive DVT, and 2 (2.1% versus 1.1%) developed minor bleeding. Major bleeding occurred in 1 (1.0%) preintervention subject and no postintervention subjects. No patient in either cohort died. CONCLUSION: Managed by the ED, an outpatient DVT clinical care pathway using careful patient selection and an integrated multidisciplinary approach can provide a similar degree of effectiveness and safety as customary inpatient therapy.

Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial.

STUDY OBJECTIVES: The utility of intravenous prochlorperazine as an antiemetic agent and abortive therapy for headache may be limited by the frequent occurrence of akathisia, the distressing effects of which have been shown to disrupt patient care. We tested the hypothesis that adjuvant diphenhydramine reduces the incidence of akathisia induced by prochlorperazine. METHODS: This randomized, double-blind, placebo-controlled trial was conducted in the emergency department of an academic tertiary care medical center with an annual census of 95,000 emergency patient visits. We enrolled a convenience sample of 100 adult patients who received 10 mg of intravenous prochlorperazine for the treatment of nausea/vomiting or headache. Subjects were randomly assigned to receive a 2-minute infusion of prochlorperazine with either 50 mg of diphenhydramine or placebo. The incidence of akathisia at 1 hour was measured by using explicit diagnostic criteria. To measure the influence of treatment on sedation, the subjects noted, on a 100-mm visual analog scale, their degree of sedation before and after treatment. RESULTS: Akathisia developed in 18 (36%) of 50 subjects in the control group and in 7 (14%) of 50 subjects in the diphenhydramine group, a 61% relative reduction. The addition of adjunct diphenhydramine resulted in an absolute reduction of 22% in the incidence of akathisia (95% confidence interval [CI] 6% to 38%; P = .01). The odds ratio for akathisia with the use of adjuvant diphenhydramine was 0.39 (95% CI 0.18 to 0.85). Mean sedation scores increased 12 mm after infusion of prochlorperazine alone (95% CI 3 to 21 mm) compared with a 33-mm increase after infusion of prochlorperazine with adjuvant diphenhydramine (95% CI 24 to 42 mm). The 12-mm difference between the groups was statistically significant (95% CI 9 to 34 mm, P < .001). CONCLUSION: Adjuvant diphenhydramine reduces the incidence of akathisia induced by prochlorperazine and is associated with an increase in sedation.

The inadequacies of contemporary oropharyngeal suction.

Airway management is the highest priority in any resuscitation. Suction equipment capable of rapidly clearing the oropharynx is mandatory for airway management. Inadequate oropharyngeal suction with standard equipment may be associated with major complications in emergency airway management. We report cases that illustrate the inadequacies of standard suction equipment. Available oropharyngeal aspirators and their limitations are discussed. Recent advances in the field of oropharyngeal suction also are described.

Rapid reversal of life-threatening diltiazem-induced tetany with calcium chloride.

We describe a patient who developed tetany with sudden respiratory arrest after the infusion of intravenous diltiazem. The administration of calcium chloride rapidly resolved the patient's tetany with prompt recovery of respiratory function, averting the need for more aggressive airway management and ventilatory support. The emergency physician should be aware that life-threatening tetany may accompany the administration of intravenous diltiazem and that calcium chloride may be a rapid and effective remedy.

Carisoprodol-induced myoclonic encephalopathy.

CASE REPORT: A 39-year-old man ingested 35 g carisoprodol. He developed agitation, tachycardia, myoclonus, and coma. The blood carisoprodol was 71 micrograms/mL; the meprobamate was 26 micrograms/mL. DISCUSSION: Carisoprodol overdose is thought to induce simple central nervous system depression. This case demonstrates a severe overdose with symptoms more consistent with myoclonic encephalopathy. A review of cases presenting to the San Francisco Division of the California Poison Control System during 1997 suggests that carisoprodol is more commonly associated with agitation and bizarre movement disorders than the current literature suggests. The pharmacology and potential mechanisms of toxicity are discussed. CONCLUSION: Agitation, hypertonia, and a myoclonic encephalopathy may be seen with significant carisoprodol intoxication.