Prevalence and Significance of Renal Dysfunction Among Emergency Department Observation Patients With Chest Pain.

OBJECTIVES: Previous studies have demonstrated increased risk of acute coronary syndrome among patients with chest pain and renal dysfunction. The objective of this study was to investigate the impact of renal dysfunction on cardiac outcomes in patients with chest pain in an emergency department observation unit (EDOU). METHODS: We conducted a 5-year prospective evaluation of patients evaluated in the EDOU for chest pain. We collected baseline information and data from the emergency department visit, EDOU stay, inpatient admission, and the 30-day period after presentation to the emergency department. We calculated glomerular filtration rate (GFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. We stratified patients as having mild (GFR 60-89 mL/min per 1.73 m) or at least moderate (GFR <60) renal dysfunction. We evaluated the rate of major adverse cardiac events (MACE: myocardial infarction, stent, coronary artery bypass graft, and death). RESULTS: Of 1067 enrolled EDOU patients, the majority had at least mild renal dysfunction: 39% [95% confidence interval (95% CI): 36.1%-42%] had a GFR between 60 and 89, and 16% (95% CI: 14%-18.4%) had a GFR <60. MACE rates increased with decreasing GFR: 3.3% (95% CI: 2.1%-5.3%) for GFR ≥90, 7.3% (95% CI: 5.2%-10.2%) for GFR 60-89, and 9.1% (95% CI: 5.7%-14.3%) for GFR <60 (P = 0.005). In multivariate analysis, patients with at least mild renal dysfunction (GFR < 90) were at greater risk of MACE (P = 0.028). CONCLUSIONS: We noted a high prevalence of renal dysfunction among EDOU patients evaluated for chest pain. Even those with mild renal dysfunction demonstrated an increased risk of MACE. Clinicians may wish to consider renal dysfunction in selecting appropriate patients for EDOU placement.

Transesophageal echocardiography identification of aortic dissection during cardiac arrest and cessation of ECMO initiation.

Cardiac arrest is a challenging clinical presentation that emergency medicine providers often encounter. Aortic dissection is an uncommon etiology in all-comers presenting in cardiac arrest. The use of bedside point of care echocardiography to aid in resuscitative efforts is expanding, particularly with the increasing use of transesophageal echocardiography (TEE) by emergency medicine providers. Additionally, emergency department initiation of extracorporeal membrane oxygenation (ECMO) is a relatively newer development in emergency department practice. We report the case of a 64-year old male presenting to the emergency department in cardiac arrest with TEE identification of aortic dissection as the etiology resulting in discontinuation of ECMO initiation attempts.

Spontaneous pneumothorax resulting in tension physiology.

Spontaneous pneumothorax (SP) is a relatively common pathology in emergency medicine; however, scant information is published regarding SPs developing tension physiology in the literature. Risk factors for spontaneous pneumothorax include smoking, family history, and underlying lung disease such as chronic obstructive lung disease (COPD), cystic fibrosis, tuberculosis, among others. Treatment often involves conservative management, needle aspiration, catheter placement, or tube thoracostomy. Tension pneumothorax, however, is a life threatening condition requiring emergent intervention. Case reports have demonstrated large SPs with midline shift but without tension physiology as patients largely remained hemodynamically stable. We report the case of an 18-year-old male presenting to the Emergency Department (ED) with a SP that rapidly developed tension physiology with mediastinal shift and hypotension resolved by needle decompression and CT placement.