Triage nurse prediction of hospital admission.

Introduction: Numerous factors affect patient flow in the emergency department. One important factor that has a negative impact on flow is ED patients waiting for an inpatient bed. It currently takes approximately 5 hours from triage to a request for an inpatient bed in our emergency department.

Patients who leave the emergency department without being seen.

Introduction: Patients who present to the ED for care and leave without being seen (LWBS) represent a significant problem. The objective of this study was to determine why patients LWBS, how long they perceived waiting versus actual time waited before leaving, and factors that might have prevented LWBS.

Methods: We conducted a prospective, scripted phone survey of all patients who left without being seen over a two-month period in 2006 at an ED with approximately 65,000 yearly visits.

Application of San Francisco Syncope Rule in elderly ED patients.

Objectives: The San Francisco Syncope Rule (SFSR) is a decision rule with the potential to identify patients at risk for serious outcomes within 7 days of the emergency department (ED) visit for syncope. The initial studies of the SFSR reported a high sensitivity and specificity for identifying patients, of all ages, with serious outcomes. Our objective was to determine if the SFSR can be safely and accurately applied to ED patients aged 65 and older with syncope or near-syncope.

Phantom shocks in patients with an implantable cardioverter defibrillator.

Phantom shock is the sensation of shock in the absence of an actual implantable cardioverter-defibrillator (ICD) discharge. The ICD is now the first-line therapy for patients with ventricular tachycardia and fibrillation. There has been a significant increase in the number of patients with an ICD and patients presenting to the Emergency Department (ED) after a shock for evaluation and device interrogation.

Nursing blood specimen collection techniques and hemolysis rates in an emergency department: analysis of venipuncture versus intravenous catheter collection techniques.

Introduction: Re-collection of hemolyzed blood specimens delays patient care in overcrowded emergency departments. Our emergency department was unable to meet a benchmark of a 2% hemolysis rate for the collection of blood samples. Our hypothesis was that hemolysis rates of blood specimens differ dependent on the blood collection technique by venipuncture or intravenous catheter draw.

Beta-blocker use in elderly ED patients with acute myocardial infarction.

Background: Despite the effectiveness of early beta-blocker (BB) use in reducing mortality in acute myocardial infarction (AMI), they remain underutilized in the emergency department (ED) management of AMI. The elderly, with higher AMI mortality, and women, may be particularly vulnerable to underutilization of BB.

Objective: To determine the effect of age and gender on BB use in AMI in the ED.

ECG manifestations of selected extracardiac diseases.

This article reviews the ECG manifestations of selected extracardiac diseases, including pulmonary embolism, pneumothorax, pulmonary hypertension, aortic dissection, central nervous system dis-ease, gastrointestinal disease, and sarcoidosis.

Out-of-hospital cardiac arrest locations in a rural community: where should we place AEDs?

Early defibrillation improves survival for patients suffering cardiac arrest from ventricular fibrillation (VF) or ventricular tachycardia (VT). Automated external defibrillators (AEDs) should be placed in locations in which there is a high incidence of out-of-hospital cardiac arrest (OOHCA). The study objective was to identify high-risk, rural locations that might benefit from AED placement.

Electrocardiographic manifestations: long QT Syndrome.

Long QT Syndrome is a cardiac disorder caused by an abnormal prolongation of the ventricular repolarization phase. The primary concern in this syndrome is the propensity towards polymorphic ventricular tachycardia and sudden cardiac death. This article presents several cases, highlighting the pathophysiology, clinical presentation, and management of this disorder.

Electrocardiographic manifestations: acute inferior wall myocardial infarction.

The 12-lead electrocardiogram (EKG) is an important tool in evaluating the patient with acute myocardial infarction (MI). Patients with acute inferior wall myocardial infarction (IWMI) represent a heterogeneous group in terms of morbidity, mortality, Emergency Department (ED) management, and site of occlusion in the culprit coronary artery. The standard 12-lead EKG, right-sided chest leads and posterior chest leads, in conjunction with clinical findings often provide the necessary information for the Emergency Physician (EP) to predict complications, morbidity and mortality.

Electrocardiographic manifestations: diagnosis of atrioventricular block in the Emergency Department.

Patients with bradycardia are commonly encountered by the Emergency Physician. Of the possible bradydysrhythmias, atrioventricular blocks (AVB) represent a significant portion of these presentations. In this article, we provide four illustrative cases of patients presenting to the Emergency Department (ED) with AVB.

Electrocardiographic manifestations: ventricular tachycardia.

Ventricular tachycardia is a serious rhythm disturbance that originates from any part of the myocardium or conduction system below the atrioventricular node. Ventricular tachycardia (VT) presents with a wide QRS complex and a rate greater than 120 beats/min. Ventricular tachycardia is frequently encountered as a complication of coronary artery disease or cardiomyopathy; furthermore, VT is also seen in patients with medication adverse effect or electrolyte disturbance.

Electrocardiographic manifestations: bundle branch blocks and fascicular blocks.

Intraventricular conduction block is the general name given to a varied group of electrocardiographic entities. All share a common finding of some degree of delay in ventricular activation; recognition of these blocks hinges upon analysis of the QRS complex, as well as the ST-T changes associated with them. Bundle branch block (right or left), and fascicular block (left anterior or left posterior) are all examples of intraventricular conduction block.

Electrocardiographic manifestations: wide complex tachycardia due to accessory pathway.

Tachycardia with a wide QRS complex is usually due to ventricular tachycardia (VT), supraventricular tachycardia (SVT) with aberrant intraventricular conduction, or an accessory pathway-mediated dysrhythmia. The most common type of accessory pathway causing a wide complex tachycardia is the atrioventricular bypass tract. Distinguishing the accessory pathway-mediated tachycardia from VT or SVT with aberrancy is often difficult, but has important clinical consequences.

Evaluation of emergency medicine resident death notification skills by direct observation.

Unlabelled: Emergency physicians commonly perform death notifications. Physician training in death notification has been limited. Resident physicians are rarely evaluated in their performance of death notifications.

Electrocardiographic manifestations: narrow QRS complex tachycardias.

Narrow QRS complex tachycardia is a common dysrhythmia in Emergency Medicine practice. Diagnosis and mechanism often can be made by 12-lead electrocardiographic (EKG) analysis but may subsequently require electrophysiologic testing. The clinical manifestations are varied and dependent upon heart rate, prior cardiac disease, and general physiologic status.

Electrocardiographic manifestations: right ventricular infarction.

The 12-lead electrocardiogram (EKG) is an essential tool when evaluating the Emergency Department (ED) patient with suspected cardiac ischemia. The standard EKG has limitations when evaluating "remote" areas of the heart such as the left posterior wall or right ventricular wall. Diagnosis of right ventricular infarction (RVI) in the presence of acute inferior wall myocardial infarction (MI) is made utilizing right-sided chest leads with high sensitivities and specificities.