American Journal of Emergency Medicine 2015

Treatment

1. Stromberg PE, Burt MH, Rose SR et al. Airway compromise in children exposed to single-use laundry detergent pods: a poison center observational case series. Am J Emerg Med. 2015 Mar;33(3):349-51. doi: 10.1016/j.ajem.2014.11.044. Epub 2014
Dec 3.

CONCLUSIONS: Exposure to laundry detergent pods (LDP) can cause significant toxicity, particularly in infants and toddlers. Compared to traditional detergents, clinicians should be aware of the potential for airway compromise following exposure to LDP. PMID: 25592250

Comments: The concentrated form of detergent in LDPs puts younger patients at risk.  Only 9 children were hospitalized in this query of poison center data, but 6 out of the 9 were intubated. Take these ingestions seriously and strongly consider admission of any child with LDP ingestion.

 

2. Wares CM, Heffner AC, Ward SL et al. ED prognostication of comatose cardiac arrest patients undergoing therapeutic hypothermia is unreliable. Am J Emerg Med. 2015 Jun;33(6):802-6. doi: 10.1016/j.ajem.2014.12.033. Epub 2015 Feb 26.

CONCLUSIONS: Physicians poorly prognosticate both survival and neurologic outcome in comatose OHCA patients undergoing TH. Premature prognostication in the ED is unreliable and should be avoided. PMID: 25858162

Comments: Prognostication after cardiac arrest is difficult but becomes clearer over the hospital course.  How good are we in the ED at predicting survival and neurological outcome in cardiac arrest patients with ROSC started on TH?  We are poor at predicting who will live (AUC 0.74), but we are awful at predicting neurological outcome (sensitivity 0.44; AUC 0.55).  This matters because we should avoid having an optimistic conversation with families after a successful resuscitation.  We would be more accurate if we flipped a coin when predicting neurological outcome.

 

Diagnostic

1. Mark DG, Kene MV, Offerman SR et al. Validation of cerebrospinal fluid findings in aneurysmal subarachnoid hemorrhage. Am J Emerg Med. 2015 Sep;33(9):1249-52. doi: 10.1016/j.ajem.2015.05.012. Epub 2015 May 15.

CONCLUSIONS: All patients in this case series of patients with aSAH had either a CSF RBC count greater than 2000 × 10(6)/L or visible CSF xanthochromia, increasing the likelihood that this proposed cutoff strategy may safely identify patients who warrant further investigation for an aneurysmal cause of subarachnoid hemorrhage. PMID: 26022754

Comments: What we learn is that patients with aneurysmal SAH all had >2000 RBCs and/or xanthochromia in this study (100% sensitivity).  My question is if I have a patient with a good history and negative CT in which I proceed with LP and have 1000 RBCs, will I feel comfortable not pursuing further SAH workup?


2. Bischof JE, Worrall C, Thompson P et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2015 Oct 3. pii: S0735-6757(15)00818-9. doi:10.1016/j.ajem.2015.09.035. [Epub ahead of print]

CONCLUSION: When there is inferior ST-segment elevation, the presence of any ST depression in lead aVL is highly sensitive for coronary occlusion in inferior myocardial infarction and very specific for differentiating inferior myocardial infarction from pericarditis. PMID: 26542793

CommentsDr. Smith's ECG blog is outstanding.  Here is a publication for which he is the senior author.  It may be difficult to tell if ST elevation in the inferior leads is pericarditis or STEMI.  Lead aVL can help you decide.  All patients with confirmed inferior STEMI in this cohort had at least some ST depression in aVL.


3. Lardaro T, Self WH, Barrett TW. Thirty-day mortality in ED patients with new onset atrial fibrillation and actively treated cancer. Am J Emerg Med. 2015 Oct;33(10):1483-8. doi: 10.1016/j.ajem.2015.07.033. Epub 2015 Jul 21.

CONCLUSIONS: Among ED patients with new-onset AF, active cancer appears to be associated with 11-fold increased odds of 30-day mortality; new-onset AF may represent progressive organ dysfunction leading to an increased risk of short-term mortality in patients with cancer. PMID: 26283615

Comments: Some patients with new onset atrial fibrillation may be treated and discharged home.  This study suggests patients with an active malignancy are not in that category.  Atrial fibrillation is a marker for declining health in patients with active cancer.  Odds ratio for death in 30 days was 10.8.  (Great work, Thomas!)

 

4. Klein LR, Shroff GR, Beeman W et al. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm. Am J Emerg Med. 2015 Jun;33(6):786-90. doi: 10.1016/j.ajem.2015.03.044. Epub 2015 Mar 27.

CONCLUSIONS: When patients present to the emergency department with ischemic symptoms and the differential diagnosis for STE on the ECG is AMI vs LVA, these 2 ECG rules may be helpful in differentiating these 2 pathologies. Both rules are highly sensitive and accurate in predicting AMI vs left ventricular aneurysm (LVA). PMID: 25862248

Comments: The first rule is: if the sum of the T wave amplitudes in V1-V4/sum of QRS amplitudes in V1-V4 > 0.22, this is concerning for STEMI rather than LVA.  Sensitivity for this rule was 91.5%.  Rule 2 states: if any lead in V1-V4 has a T wave amplitude to QRS amplitude ratio > 0.36, STEMI is likely rather than LVA.  This rule was also 91,5% sensitive.

Review

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Clinical Prediction Rules

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