High-risk chief complaints I: chest pain--the big three

Thoracic aortic emergencies involving the aortic arch: An integrated cardiovascular surgical treatment approach

Thoracic aortic emergencies involving the aortic arch are potentially fatal conditions that require the entire surgical repertoire of conventional surgery, such as complete aortic arch replacement using the frozen-elephant-trunk technique, through hybrid procedures, to full surgical endovascular options with conventional or delivered/fenestrated stent-grafts. An interdisciplinary aortic team should choose the optimal treatment of the pathologies of the aortic arch, considering the morphology of the entire aorta, from the root to beyond the bifurcation, as well as the clinical comorbidities. The treatment goal is a complication-free postoperative result and lasting freedom from aortic reinterventions. Irrespective of the selected therapy method, patients should then be connected to a specialized aortic outpatient clinic. The aim of this review was to provide an overview of pathophysiology and current treatment options in emergencies of the thoracic aorta, also involving the aortic arch. We wanted to summarize the preoperative considerations, intraoperative settings, and strategies, as well the postoperative follow-up.

Relation of Community-Level Socioeconomic Status to Delayed Diagnosis of Acute Type A Aortic Dissection

Acute type A aortic dissection requires timely diagnosis and intervention. Previous studies have examined risk factors associated with delayed diagnosis; however, the effect of socioeconomic status (SES) has not been previously studied. Our study examined the impact of various SES measures on time to diagnosis. We examined time to diagnosis in consecutive cases of acute type A aortic dissection at a single institution. SES variables included race/ethnicity, Medicaid eligibility, and residence in a zip code with an increased Distressed Communities Index-an aggregate measure of community SES. Delayed diagnosis was defined as time to diagnosis in the upper quartile of the study population (>6.6 hours). A model predicting risk factors for delayed diagnosis was created using multivariable logistic regression. Our study included 124 patients with a median time to diagnosis of 3.36 hours (interquartile range [IQR] 1.83 to 6.63). A total of 92 patients were in the nondelayed cohort (median diagnosis time of 2.59 hours, IQR 1.49 to 4.18) and 32 patients were in the delayed cohort (median diagnosis time of 15.57 hours, IQR 9.34 to 28.75). In multivariable logistic regression, residence in a high-Distressed Communities Index zip code was associated with diagnostic delay (adjusted odds ratio [aOR] 5.108, p = 0.008). Patient age (aOR 0.944, p = 0.011), chest pain at presentation (aOR 0.099, p = 0.004), back pain at presentation (aOR 0.247, p = 0.012), evidence of malperfusion syndrome (aOR 0.040, p <0.001), history of hyperlipidemia (aOR 3.507, p = 0.026), and history of congestive heart failure (aOR 0.061, p = 0.036) were also significantly associated. In conclusion, our findings suggest community-level SES affects time to diagnosis in acute type A aortic dissection.

Pulmonary embolism initially misdiagnosed as perimyocarditis in a young patıent

Pulmonary embolism is a common cardiovascular emergency. In case of delayed diagnosis and treatment morbidity and mortality is high. In this report, we presented a case of pulmonary embolism without apparent risk factors, which was initially misdiagnosed as peri/myocarditis.

Transgastric Drainage for Esophageal Injuries: A Dynamic Strategy for a Heterogenous Patient Cohort

BACKGROUND

Esophageal injury is a rare but potentially lethal surgical emergency. It is associated with significant morbidity and mortality because of mediastinal contamination and difficulty of access. Surgery in such septic patients exacts a heavy physiological price, mandating consideration of more conservative measures. We review our experience with transgastric drainage for esophageal perforation and high-risk anastomotic dehiscence.

PATIENTS AND METHODS

A select cohort of patients presenting with esophageal perforation, or complex anastomotic leaks, over 10 years were considered for transgastric drainage (TGD). A modified 36F chest drainage tube was inserted by percutaneous endoscopic gastrostomy technique, either endoscopically or at open surgery, and a negative pressure (-10 cmH2O) was applied until the leak had sealed. Endpoints include, length of stay, restoration of gastrointestinal tract continuity and mortality.

RESULTS

Of 14 patients treated, 10 had perforations and 4 had complex anastomotic leaks. Ten patients had drainage alone, while 4 required concomitant operative intervention. The median duration of drain insertion for those treated with TGD alone was 19.5 days. Complete restoration of gastrointestinal tract continuity was achieved in all patients. There was no procedure-related morbidity or mortality.

CONCLUSION

These results show that TGD is a safe and effective management strategy. We advocate its use alone or as an adjunct to operative treatment for esophageal perforation or anastomotic leaks. This is the first report of completely endoscopic TGD for esophageal perforation.

Management of Boerhaave syndrome in Australasia: a retrospective case series and systematic review of the Australasian literature

BACKGROUND

Boerhaave syndrome is a rare and life-threatening condition characterized by a spontaneous transmural tear of the oesophagus. There remains wide variation in the condition's management with non-operative management (NOM) and surgery being the two main treatment strategies. The aim was to review the presentation, management and outcomes for patients treated for Boerhaave syndrome at our institution and to compare these data with that previously reported within the Australasian literature.

METHODS

A retrospective case series was performed for consecutive patients diagnosed with Boerhaave syndrome at our institution between January 2000 and January 2020. A systematic review of the Australasian literature was also performed.

RESULTS

In case series, 15 patients were included (n = 2 NOM, n = 13 operative). The most common operative technique was primary repair with intercostal drainage via thoracotomy. Major complications occurred in 11 (73%) patients. Median Comprehensive Complication Index was 53.4 (interquartile range: 50). There was a significantly lower Comprehensive Complication Index associated with primary repair when compared to oesophageal resection (P = 0.01). There was one death, in the operative management group. Median length of hospital stay was 33 days (interquartile range: 58). In systematic review, 11 articles were included; four case series and seven case reports. From these, 23 patients met inclusion criteria. The majority of patients (83%) were managed operatively, with only four undergoing NOM. Seven patients died, representing an overall mortality rate of 30%.

CONCLUSIONS

We provide an updated overview of the management of Boerhaave syndrome within Australasia. Aggressive operative management is associated with reasonable outcomes.

Defining High-risk Emergency Chief Complaints: Data-driven Triage for Low- and Middle-income Countries

OBJECTIVES

Emergency medicine in low- and middle-income countries (LMICs) is hindered by lack of research into patient outcomes. Chief complaints (CCs) are fundamental to emergency care but have only recently been uniquely codified for an LMIC setting in Uganda. It is not known whether CCs independently predict emergency unit patient outcomes.

METHODS

Patient data collected in a Ugandan emergency unit between 2009 and 2018 were randomized into validation and derivation data sets. A recursive partitioning algorithm stratified CCs by 3-day mortality risk in each group. The process was repeated in 10,000 bootstrap samples to create an averaged risk ranking. Based on this ranking, CCs were categorized as "high-risk" (>2× baseline mortality), "medium-risk" (between 2 and 0.5× baseline mortality), and "low-risk" (<0.5× baseline mortality). Risk categories were then included in a logistic regression model to determine if CCs independently predicted 3-day mortality.

RESULTS

Overall, the derivation data set included 21,953 individuals with 7,313 in the validation data set. In total, 43 complaints were categorized, and 12 CCs were identified as high-risk. When controlled for triage data including age, sex, HIV status, vital signs, level of consciousness, and number of complaints, high-risk CCs significantly increased 3-day mortality odds ratio (OR = 2.39, 95% confidence interval [CI] = 1.95 to 2.93, p < 0.001) while low-risk CCs significantly decreased 3-day mortality odds (OR = 0.16, 95% CI = 0.09 to 0.29, p < 0.001).

CONCLUSIONS

High-risk CCs were identified and found to predict increased 3-day mortality independent of vital signs and other data available at triage. This list can be used to expand local triage systems and inform emergency training programs. The methodology can be reproduced in other LMIC settings to reflect their local disease patterns.

Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis

Background

Emergency department (ED) triage is performed to prioritize care for patients with critical and time-sensitive illness. Triage errors create opportunity for increased morbidity and mortality. Here, we sought to measure the frequency of under- and over-triage of patients by nurses using the Emergency Severity Index (ESI) in Brazil and to identify factors independently associated with each.

Methods

This was a single-center retrospective cohort study. The accuracy of initial ESI score assignment was determined by comparison with a score entered at the close of each ED encounter by treating physicians with full knowledge of actual resource utilization, disposition, and acute outcomes. Chi-square analysis was used to validate this surrogate gold standard, via comparison of associations with disposition and clinical outcomes. Independent predictors of under- and over-triage were identified by multivariate logistic regression.

Results

Initial ESI-determined triage score was classified as inaccurate for 16,426 of 96,071 patient encounters. Under-triage was associated with a significantly higher rate of admission and critical outcome, while over-triage was associated with a lower rate of both. A number of factors identifiable at time of presentation including advanced age, bradycardia, tachycardia, hypoxia, hyperthermia, and several specific chief complaints (i.e., neurologic complaints, chest pain, shortness of breath) were identified as independent predictors of under-triage, while other chief complaints (i.e., hypertension and allergic complaints) were independent predictors of over-triage.

Conclusions

Despite rigorous and ongoing training of ESI users, a large number of patients in this cohort were under- or over-triaged. Advanced age, vital sign derangements, and specific chief complaints—all subject to limited guidance by the ESI algorithm—were particularly under-appreciated.

Acute ischemic stroke what is hidden behind?

Acute aortic dissection (AAD) is a rare and potentially fatal disease. The classic presentation is sudden and severe pain in the chest, back, or abdomen, described as tearing or ripping pain radiating to the interscapular region. Cerebral ischemic complications occur in 18-30% of aortic dissections and patients may present to the emergency department (ED) with isolated focal neurology and no chest pain. In AAD patients, presenting with stroke and subsequently thrombolized, a 71% mortality rate has been reported in patients receiving recombinant tissue plasminogen activator (r-TPA). We present a case of a 58-year-old male patient that presented to ED with sudden onset of headache and left-sided hemiparesis, computed tomography (CT) demonstrated an ischemic stroke of the right middle cerebral artery. When the question of whether to start r-TPA or mechanical thrombectomy was discussed, a cardiac point-of-care ultrasound was performed in ED and showed a type A aortic dissection; immediately a CT aortic angiogram was performed and confirmed the diagnosis. The patient was taken to theater and had a favorable outcome. <Learning objective: Acute aortic dissection (AAD) may present as acute ischemic stroke with no chest pain. In patients with acute ischemic stroke with an unclear etiology point-of-care ultrasound (POCUS), cardiac, and aortic ultrasound are important rapidly to diagnose AAD and avoid the deleterious effect of thrombolysis. This case supports the feasibility of emergency physicians performing POCUS assessments for AAD.>.

Vascular Causes of Syncope: An Emergency Medicine Review

BACKGROUND

Syncope is a common emergency department (ED) complaint, accounting for 2% of visits annually. A wide variety of etiologies can result in syncope, and vascular causes may be deadly.

OBJECTIVE

This review evaluates vascular causes of syncope and their evaluation and management in the ED.

DISCUSSION

Syncope is defined by a brief loss of consciousness with loss of postural tone and complete, spontaneous recovery without medical intervention. Causes include cardiac, vasovagal, orthostatic, neurologic, medication-related, and idiopathic, and most cases of syncope will not receive a specific diagnosis pertaining to the cause. Emergency physicians are most concerned with life-threatening causes such as dysrhythmia and obstruction, and electrocardiogram is a primary means of evaluation. However, vascular etiologies can result in patient morbidity and mortality. These conditions include pulmonary embolism, subclavian steal, aortic dissection, cerebrovascular disease, intracerebral hemorrhage, carotid/vertebral dissection, and abdominal aortic aneurysm. A focused history and physical examination can assist emergency physicians in determining the need for further testing and management.

CONCLUSIONS

Syncope is common and may be the result of a deadly condition. The emergency physician, through history and physical examination, can determine the need for further evaluation and resuscitation of these patients, with consideration of vascular etiologies of syncope.

Boerhaave syndrome - case report

CONTEXT:

Boerhaave syndrome consists of spontaneous longitudinal transmural rupture of the esophagus, usually in its distal part. It generally develops during or after persistent vomiting as a consequence of a sudden increase in intraluminal pressure in the esophagus. It is extremely rare in clinical practice. In 50% of the cases, it is manifested by Mackler's triad: vomiting, lower thoracic pain and subcutaneous emphysema. Hematemesis is an uncommon yet challenging presentation of Boerhaave's syndrome. Compared with ruptures of other parts of the digestive tract, spontaneous rupture is characterized by a higher mortality rate.

CASE REPORT:

This paper presents a 64-year-old female patient whose vomit was black four days before examination and became bloody on the day of the examination. Her symptoms included epigastric pain and suffocation. Physical examination showed hypotension, tachycardia, dyspnea and a swollen and painful abdomen. Auscultation showed lateral crackling sounds on inspiration. Ultrasound examination showed a distended stomach filled with fluid. Over 1000 ml of fresh blood was extracted by means of nasogastric suction. Esophagogastroduodenoscopy was discontinued immediately upon entering the proximal esophagus, where a large amount of fresh blood was observed. The patient was sent for emergency abdominal surgery, during which she died. An autopsy established a diagnosis of Boerhaave syndrome and ulceration in the duodenal bulb.

CONCLUSION:

Boerhaave syndrome should be considered in all cases with a combination of gastrointestinal symptoms (especially epigastric pain and vomiting) and pulmonary signs and symptoms (especially suffocation).

Oesophageal rupture masquerading as STEMI

A 67-year-old man presented to the emergency department, with acute onset of chest pain. Based on ECG changes suggestive of ST elevation myocardial infarction (STEMI), he was taken emergently to the cardiac catheterisation laboratory for coronary angiography. There he was found to have only non-obstructive coronary disease. Subsequent physical examination and review of his chest radiograph revealed subcutaneous emphysema, and CT scan revealed a distal oesophageal rupture and pneumomediastinum. After stabilisation in the intensive care unit (ICU), he was taken to the operating room for thoracotomy, chest tube placement and stenting of his oesophagus. He survived the incident and, after several weeks of ICU stay, recovered to a large extent. His case highlights the importance of considering oesophageal rupture in the differential diagnosis for acute onset of chest pain.

Spontaneous resolution of iatrogenic dissection of the left main coronary artery extending to the thoracic and abdominal aorta

Iatrogenic coronary artery dissection extending to the ascending aorta is a rare complication of percutaneous coronary interventions. Coronary stent implantation is usually sufficient to control the injury. In this report we describe an unusual case of spontaneous resolution of both left main coronary artery and aortic wall dissection. The patient was not operated on due to the location of the initial tear in the distal part of the left main coronary artery. Moreover, in computed tomography (CT) thrombus formation in the false lumen of the dissected aorta was seen. The in-hospital course was uneventful. The last follow-up CT showed complete resolution of dissection.

Early recognition of acute thoracic aortic dissection and aneurysm

BACKGROUND

Thoracic aortic dissection (TAD) and aneurysm (TAA) are rare but catastrophic. Prompt recognition of TAD/TAA and differentiation from acute coronary syndrome (ACS) is difficult yet crucial. Earlier identification of TAA/TAD based upon routine emergency department screening is necessary.

METHODS

A retrospective analysis of patients that presented with acute thoracic complaints to the ED from January 2007 through June 2012 was performed. Cases of TAA/TAD were compared to an equal number of controls which consisted of patients with the diagnosis of ACS. Demographics, physical findings, EKG, and the results of laboratory and radiological imaging were compared. P-value of > 0.05 was considered statistically significant.

RESULTS

In total, 136 patients were identified with TAA/TAD, 0.36% of patients that presented with chest complaints. Compared to ACS patients, TAA/TAD group was older (68.9 vs. 63.2 years), less likely to be diabetic (13% vs 32%), less likely to complain of chest pain (47% vs 85%) and head and neck pain (4% vs 17%). The pain for the TAA/TAD group was less likely characterized as tight/heavy in nature (5% vs 37%). TAA/TAD patients were also less likely to experience shortness of breath (42% vs. 51%), palpitations (2% vs 9%) and dizziness (2% vs 13%) and had a greater incidence of focal lower extremity neurological deficits (6% vs 1%), bradycardia (15% vs. 5%) and tachypnea (53% vs. 22%). On multivariate analysis, increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction were independent predictors of ACS.

CONCLUSIONS

Increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction can be used to differentiate acute coronary syndromes from thoracic aortic dissections/aneurysms.

Inferior myocardial infarction secondary to aortic dissection associated with bicuspid aortic valve

Aortic dissection (AD) is a life-threatening condition and may present with symptoms which mimic myocardial infarction, leading to misdiagnosis and inappropriate use of anticoagulant and thrombolytic therapy. A 40-year-old woman with no prior history presented in our emergency department with sudden chest pain. Electrocardiography (ECG) showed a ST-segment elevation in leads II, III and avF, suggesting an acute inferior myocardial infarction. The patient was given anticoagulation and antiplatelet treatment. Coronary angiography, transthoracic echocardiography and computed tomography were performed. The patient was diagnosed with DeBakey I aortic dissection extending from ascending aorta to iliac artery, and associated with bicuspid aortic valve.Surgical treatments with a replacement of the ascending aorta, aortic valve replacement and coronary artery bypass grafting were successfully performed. Early imaging examination, if possible, might assist the diagnosis and guide the management of this disease. The condition of myocardial infarction secondary to aortic dissection is discussed.

Shifting up cutoff value of d-dimer in the evaluation of pulmonary embolism: a viable option? Possible risks and benefits

Objectives. To evaluate the viability of the possibility to use a higher D-dimer value than the one used today in the clinical algorithms evaluating patients suspected to have pulmonary embolism. Methods. A retrospective analysis of 300 serial patients for whom D-dimer values were taken during a 10 month period in the emergency room of a tertiary medical center. Results. Our analysis showed that it may be safe and cost effective to use a D-dimer value of 900 ng/ml rather than the value of 500 ng/ml accepted today, with sensitivity of 94.4%. In younger patients [under 40 years] the sensitivity reached was even higher-100%. Conclusions. Raising cutoff values of D-dimer in screening for pulmonary embolism seems a viable option. There may be a place for "tailoring" cutoff values according individual patient characteristics, such as according age groups. More studies of the subject are warranted.

Emergency bedside ultrasound diagnosis of sub-massive acute pulmonary embolism: a case of the McConnell sign

Introduction

This is a case of a healthy 61-year-old man with acute onset of dyspnea and atrial flutter where bedside emergency ultrasound was used to identify a classic echocardiographic finding called the “McConnell sign”. The clinical presentation and this echocardiographic finding led to the presumptive diagnosis of acute pulmonary embolism.

Materials and methods

This is a case report and brief review of the literature.

Conclusion

Bedside echocardiography has important diagnostic value in the evaluation of suspected acute pulmonary embolism. Findings, such as the McConnell sign are relatively quick and easy to identify at the bedside and could provide valuable information to rapidly guide management decisions when further research defines its role in emergent bedside ultrasound.