The electrocardiographic differential diagnosis of ST segment depression.
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Adult↗
Biomedical subjects
A D Perron
Publications and source records attributed to A D Perron.
Onset seizures independently predict poor outcome after subarachnoid hemorrhage.
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Decerebrate State↗
Electrocardiographic diagnosis of acute myocardial infarction.
The widely recognized benefits of early diagnosis and treatment of acute myocardial infarction (AMI) have only emphasized the importance of emergency physician (EP) competence in electrocardiographic interpretation. As such, the EP must be an expert in the interpretation of the electrocardiogram (ECG) in the emergency department chest pain center patient. The ECG is a powerful clinical tool used in the evaluation of patients, assisting in making the diagnosis of AMI and other syndromes, selecting appropriate therapies (including thrombolysis and primary angioplasty), securing the location of an adequate inpatient disposition, and predicting the risk of cardiovascular complications and death. This article will discuss the appropriate uses of the ECG in the patient with possible or confirmed AMI and review the typical electrocardiographic findings of AMI, diagnostically confounding patterns, mimickers of infarction, and new techniques.
Arrhythmias, Cardiac↗
Cause of ST segment abnormality in ED chest pain patients.
The objective of this study was to determine the electrocardiographic diagnoses of chest pain patients with ST segment elevation (STE) on the 12-lead electrocardiogram (ECG). This study was a retrospective ECG review of adult chest pain patients in a university hospital emergency department (ED) over a 3-month period (January 1, 1996 to March 31, 1996). STE was determined if the ST segment was elevated >/=1 mm in the limb leads and >/=2 mm in the precordial leads in at least two anatomically contiguous leads. Results showed 902 patients who met entry criteria and of whom 202 (22.4%) had STE. Thirty-one (15%) patients had STE acute myocardial infarction (AMI) as the final hospital diagnosis which caused the STE; 171 (85%) patients with STE had non-AMI diagnosis responsible for the ST segment elevation, including left ventricular hypertrophy (LVH) 51 (25%), left bundle branch block (LBBB) 31 (15%), benign early repolarization (BER) 25 (12%), right bundle branch block 10 (5%), nonspecific bundle branch block 10 (5%), left ventricular aneurysm 5 (3%), acute pericarditis 2 (1%), ventricular paced rhythm 2 (1%), and undefined ST segment elevation 35 (17%). Forty-four patients had AMI as the final diagnosis of whom 31 showed STE on presentation to the ED. In 2 of 31 (6%) cases of STE AMI, the ST segment waveform was atypical for acute infarction. We concluded that AMI is not the most common cause of STE in ED chest pain patients. LVH is most often responsible for electrocardiographic STE followed by AMI and LBBB which occur at equal frequencies.
Adult↗
Administration of atropine in the setting of acute myocardial infarction: potentiation of the ischemic process?
Atropine has also been suggested to potentially worsen the ischemic situation in patients who are in the midst of acute coronary ischemia. We report the case of a female patient with ischemic chest pain and third degree atrioventricular block who developed acute myocardial infarction (AMI) immediately after atropine administration. The use of atropine in this instance remains a reasonable option and should be strongly considered-despite this apparent complication. Undoubtedly in some cases, acute ischemia is intensified by hypoperfusion attributable to vagally mediated bradyarrhythmia; atropine is the antidote for such situations. An awareness of this potential adverse reaction coupled with a prudent selection of candidates for atropine therapy will show the risk/benefit ratio in each individual patient and, therefore, guide the clinician.
Acute Disease↗
Orthopedic pitfalls in the ED: Lisfranc fracture-dislocation.
Lisfranc fracture-dislocation of the foot is an injury that carries a high incidence of chronic pain and disability. Its emergency department presentation can be subtle, and more frequent than previously believed. This review article examines the clinical presentation, historical factors, diagnostic techniques, and management options applicable to the emergency practitioner.
Adult↗
Paroxysmal supraventricular tachycardia: outcome after ED care.
The objective of this study was to investigate the outcome and rate of symptomatic recurrence of paroxysmal supraventricular tachycardia (PSVT) in an emergency department (ED) patient population, after ED management and disposition. A retrospective descriptive review of ED records and state death registry was performed. The study took place at a University hospital ED with 60,000 annual patient volume. The subjects were all patients presenting to the ED in PSVT from January 1993 to December 1996. One hundred eleven patients met entry criteria. The mean age was 53 years, 49% were men, and 51% were women. EMS was used by 47 (42%) patients. Ten of these patients who used the EMS system had an unstable event in the prehospital setting. Eleven patients had unstable events once in the ED. ED therapy given (with number of successes in parentheses) included: Adenosine 48 (41), vagal maneuvers 44 (22), calcium channel blockers 22 (14), beta-blockers 10 (4), and electrical cardioversion 5 (1). Twenty-six patients (23%) spontaneously converted to normal sinus rhythm (NSR). Seventy-nine (71%) patients were discharged from the ED. Mean age for this group was 49 years, and the mean ED stay for this group was 3.8 hours. Three patients (4%) in this group had a recurrence of their SVT after discharge. These patients all had recurrence within 24 hours, and none had an unstable event associated with their recurrence. Thirty-two (29%) patients were admitted to the hospital, with 3 (9%) going to a monitored floor, and 29 (91%) going to an intensive care unit. Mean age for this group was 65 years. Twenty-one of these 32 admitted patients (65%) required continued in-hospital therapy once admitted for their arrhythmia. Six of the 32 admitted patients (19%) had recurrent PSVT in the hospital, with 1 episode of instability. Recurrence of PSVT was more likely to occur among those admitted (P <.05), in older patients (P<.01), and in those with a history of cardiovascular disease (P <.01). No deaths were recorded in either group. Most patients with PSVT can be safely discharged from the ED after short-term observation if therapy produces prompt conversion to NSR. PSVT recurrence is relatively uncommon and usually occurs within 24 hours of ED presentation. PSVT recurrence occurs more often in the elderly and in those with established cardiac disease.
Aged↗
Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand.
Closed tendon injuries of the hand are frequently seen in the emergency department. Unlike open tendon injuries, however, these injuries are often missed on initial presentation. Early recognition and treatment can decrease the pain, dysfunction, and long-term sequelae associated with these injuries. This review article examines the clinical presentation, historical factors, diagnostic techniques, and management options applicable to the emergency practitioner. Injuries discussed include rupture of the flexor digitorum profundus, mallet finger, central slip rupture, extensor hood rupture, and ulnar collateral ligament injury.
Emergency Service, Hospital↗
Orthopedic pitfalls in the ED: lunate and perilunate injuries.
Occult dislocations at and around the lunate can accompany wrist trauma. When left unrecognized and untreated, these injuries lead to a high incidence of long-term functional disability and chronic pain. Emergency medicine practitioners need to be vigilant for both lunate and perilunate dislocations. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.
Accidental Falls↗
Electrocardiographic ST segment depression.
Traditionally, ST segment depression has been associated with acute coronary syndromes; this electrocardiographic pattern may also be found in patients with nonischemic events, such as left bundle branch block (LBBB), left ventricular hypertrophy (LVH), and those with therapeutic digitalis levels. Using the ECG as an adjunct in distinguishing those patients with acute coronary syndromes from those with more "benign," nonacute causes of STSD will obviously lead to divergent treatment and management plans. The following cases illustrate the use the ECG in patients presenting with chest pain and electrocardiographic ST segment depression attributable to an ACS, LVH, LBBB, or digitalis.
Bundle-Branch Block↗
Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracture-dislocation.
Occult dislocations at the wrist and elbow frequently accompany forearm fractures. When left unrecognized and untreated, these injuries lead to a high incidence of long-term functional disability and chronic pain. Emergency medicine practitioners need to be vigilant for both Galeazzi (distal radius fracture with radioulnar joint disruption), and Monteggia (proximal ulna fracture with radial head dislocation) fracture-dislocations. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.
Accidental Falls↗
Atrioventricular dissociation.
Atrioventricular (AV) dissociation is an electrocardiographic syndrome; a descriptive term for a variety of conditions of abnormal cardiac conduction which all feature independent function of the atria and ventricles. AV dissociation can be subclassified as AV dissociation by default (an independent ventricular pacemaker responds to slowing of the dominant atrial pacemaker) versus AV dissociation by usurpation (acceleration of a latent pacemaker takes control of cardiac conduction by exceeding the intrinsic atrial rate). Inclusion of third degree AV block (complete heart block) as a manifestation of AV dissociation is controversial, yet is functionally appealing in that this disorder also features independent activity of the atria and ventricles.
Aged↗
Orthopedic pitfalls in the ED: scaphoid fracture.
Wrist injuries are frequently encountered in the emergency department. When a patient presents with such an injury, the possibility of scaphoid fracture must be at the top of the differential for the emergency practitioner. Unfortunately, these injuries can be missed on first presentation, as they are frequently radiographically occult. When left unrecognized and untreated, these injuries lead to a high incidence of long-term functional disability and chronic pain. The emergency physician needs to be vigilant for scaphoid fracture and be aggressive in both its diagnosis and treatment to avoid this practice pitfall. This review examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician.
Accidental Falls↗
Commodio cordis: an underappreciated cause of sudden cardiac death in young patients: assessment and management in the ED.
Commotio cordis is the condition of sudden cardiac death or near sudden cardiac death after blunt, low-impact chest wall trauma in the absence of structural cardiac abnormality. Ventricular fibrillation is the most commonly reported induced arrhythmia in commotio cordis. Blunt impact injury to the chest with a baseball is the most common mechanism. Survival rates for commotio cordis are low, even with prompt CPR and defibrillation.
Adolescent↗
Orthopedic pitfalls in the ED: acute compartment syndrome.
Acute compartment syndrome is a rare but potentially disastrous complication of orthopedic injury to the extremities. Compartment syndrome occurs when the circulation and function of muscle within a closed fascial space are compromised by increased pressure within that space. Early diagnosis and treatment is crucial to prevent the devastating complications of this condition. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.
Adult↗
The paced electrocardiogram: issues for the emergency physician.
Since the first introduction of implantable pacemaker approximately 50 years ago, these devices have become increasingly more common and more complex. It is estimated that there are approximately 1 million patients with implanted pacemakers in the United States and, with an aging population, the number of pacemakers is certain to increase. This review focuses on basics of pacemaker function as well as the common rhythm disturbance issues and other clinical syndromes that the emergency physician is likely to encounter.
Electrocardiography↗
Prominent R wave in lead V1: electrocardiographic differential diagnosis.
Tall lead V1 (tall RV1), defined as an R/S ratio equal to or greater than 1, is not an infrequent occurrence in emergency department patients. This electrocardiographic finding exists as a normal variant in only 1% of patients. Physicians should therefore be familiar with the differential diagnosis for this important QRS configuration. The electrocardiographic entities which can present with this finding include right bundle branch block, left ventricular ectopy, right ventricular hypertrophy, acute right ventricular dilation (acute right heart strain), type a Wolff-Parkinson-White syndrome, posterior myocardial infarction, hypertrophic cardiomyopathy, progressive muscular dystrophy, dextrocardia, misplaced precordial leads, and normal variant. Various cases are presented to highlight the different causes of the tall RV1.
Adult↗
The "swallowed" endotracheal tube.
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Adult↗