Delayed Symptomatic Pulmonary Embolism Secondary to Bone Cement After Percutaneous Vertebroplasty.

BACKGROUND: Percutaneous vertebroplasty (PVP) is a common procedure performed on patients suffering from osteoporotic compression fractures. Complications of the bone cement escaping both locally as well as systemically into pulmonary circulation leading to pulmonary embolism (PE) have been reported in ≤26% of patients. CASE REPORT: A 57-year-old woman presented to the emergency department with complaints of chest pain, fever, and cough. The patient had a history of an outpatient PVP from compression fractures of T5 and T7 performed 25 days before her presentation. She was in moderate respiratory distress and placed on bilateral positive airway pressure with improvement of her respiratory status. Laboratory results were remarkable for an elevated D-dimer, normal B-type natriuretic peptide, and decreased pH on venous blood gas. Pulmonary computed tomography angiography demonstrated bone cement PE in both the left lower lobe and a right middle lobe pulmonary artery. She was admitted to the hospital with improvement of her respiratory status with supportive treatment only. She was discharged after a 4-day hospital stay but died unexpectedly in her sleep 38 days after discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PVP is a common procedure that carries a risk of PE from bone cement embolization. Most of these events occur during the procedure, making the diagnosis obvious. However, delayed presentations from weeks to years have been reported. The emergency physician should consider bone cement embolization in the differential diagnosis in any patient with chest pain and shortness of breath that also has a history of PVP.

Are You Applying to More Than One Specialty?

Although the majority of U.S. medical students predominantly apply to only one specialty, some apply to more than one. When it comes to emergency medicine (EM), applicants may apply to additional specialties due to several reasons: being international medical graduates as well as their inability to make a decision regarding the choice of specialty, fear from the growing competitiveness of EM, or the desire to stay in a specific geographic area. Accordingly, in this article we aim to guide medical students through the process of applying to more than one specialty, including using the Electronic Residency Application Service application, writing a personal statement, getting letters of recommendation, and an Early Match. Moreover, we elaborate on the effect of applying to more than one specialty on a student's application to a residency in EM.

Impact of frailty and anticoagulation status on readmission and mortality rates following falls in patients over 80.

Falls are the leading cause of trauma-related mortality in geriatric patients. We hypothesized that frailty and anticoagulation status are risk factors for readmission and mortality following falls in patients >80 years. A retrospective review was performed on patients over 80 years old who presented to our level 1 trauma center for a fall and underwent a computed tomography of the head between January 2014 and January 2016. Frailty was assessed via the Rockwood Frailty Score. Clinical outcomes were death, readmission, recurrent falls, and delayed intracranial hemorrhage. Of 803 fall-related encounters, 173 patients over 80 years old were identified for inclusion. The 30-day readmission rate was 17.5% and was associated with an increased 6-month mortality (P = 0.01). One-year and 2-year mortality rates were 28% and 47%, respectively. Frailty was the strongest predictor of 6-month and overall mortality (P < 0.01). Anticoagulation status did not significantly influence these outcomes. The recurrent fall rate was 21%, and delayed intracranial hemorrhage did not occur in this study. Mortality of octogenarians after a fall is most influenced by patient frailty. Acknowledgment of frailty, risk of recurrent falls, and increased mortality should direct goals of care for geriatric trauma patients.

Delayed Onset of Atrial Fibrillation and Ventricular Tachycardia after an Automobile Lightning Strike.

BACKGROUND: Lightning strike is a rare medical emergency. The primary cause of death in lightning strike victims is immediate cardiac arrest. The mortality rate from lightning exposure can be as high as 30%, with up to 70% of patients left with significant morbidity. CASE REPORT: An 86-year-old male was struck by lightning while driving his vehicle and crashed. On initial emergency medical services evaluation, he was asymptomatic with normal vital signs. During his transport, he lost consciousness several times and was found to be in atrial fibrillation with intermittent runs of ventricular tachycardia during the unconscious periods. In the emergency department, atrial fibrillation persisted and he experienced additional episodes of ventricular tachycardia. He was treated with i.v. amiodarone and admitted to cardiovascular intensive care unit, where he converted to a normal sinus rhythm on the amiodarone drip. He was discharged home without rhythm-control medications and did not have further episodes of dysrhythmias on follow-up visits. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Lightning strikes are one of the most common injuries suffered from natural phenomenon, and short-term mortality ordinarily depends on the cardiac effects. This case demonstrates that the cardiac effects can be multiple, delayed, and recurrent, which compels the emergency physician to be vigilant in the initial evaluation and ongoing observation of patients with lightning injuries.

Ambulatory cardiac monitoring for discharged emergency department patients with possible cardiac arrhythmias.

INTRODUCTION: Many emergency department (ED) patients have symptoms that may be attributed to arrhythmias, necessitating outpatient ambulatory cardiac monitoring. Consensus is lacking on the optimal duration of monitoring. We describe the use of a novel device applied at ED discharge that provides continuous prolonged cardiac monitoring. METHODS: We enrolled discharged adult ED patients with symptoms of possible cardiac arrhythmia. A novel, single use continuous recording patch (Zio®Patch) was applied at ED discharge. Patients wore the device for up to 14 days or until they had symptoms to trigger an event. They then returned the device by mail for interpretation. Significant arrhythmias are defined as: ventricular tachycardia (VT) ≥4 beats, supraventricular tachycardia (SVT) ≥4 beats, atrial fibrillation, ≥3 second pause, 2nd degree Mobitz II, 3rd degree AV Block, or symptomatic bradycardia. RESULTS: There were 174 patients were enrolled and all mailed back their devices. The average age was 52.2 (± 21.0) years, and 55% were female. The most common indications for device placement were palpitations 44.8%, syncope 24.1% and dizziness 6.3%. Eighty-three patients (47.7%) had ≥1 arrhythmias and 17 (9.8%) were symptomatic at the time of their arrhythmia. Median time to first arrhythmia was 1.0 days (IQR 0.2-2.8) and median time to first symptomatic arrhythmia was 1.5 days (IQR 0.4-6.7). 93 (53.4%) of symptomatic patients did not have any arrhythmia during their triggered events. The overall diagnostic yield was 63.2% CONCLUSION: The Zio®Patch cardiac monitoring device can efficiently characterize symptomatic patients without significant arrhythmia and has a higher diagnostic yield for arrhythmias than traditional 24-48 hour Holter monitoring. It allows for longer term monitoring up to 14 days.

A prospective study of the impact of multiple patient transports on care provided during aeromedical transport.

OBJECTIVES: The purpose of the current study was to determine reasons for multiple-patient transports using a helicopter emergency medical services (HEMS) and to observe for any negative impact on patient care caused by the presence of the second patient. METHODS: The study was a prospective observational study of all two-patient trauma transports (doubles) over a 12-month period, from January 2004 through December 2004. The authors selected a sample of 20% of single-patient transports (singles) from the same time period for comparison. Flight crews completed a study form after the flight. Information requested included Glasgow Coma Scale (GCS) score, Revised Trauma Score (RTS), and negative impact on care of the primary patient caused by transporting the secondary patient. Data were analyzed using Mann-Whitney rank test and descriptive statistics. RESULTS: There were a total of 59 double-trauma transports. A total of 269 single-trauma transports were identified for comparison. Although there was no statistically significant difference in GCS score or RTS (single vs. primary double), doubles never included the most severely injured trauma patients. The secondary patients from the doubles were the least severely injured. There were nine patients in whom the crew felt there was a negative impact from the second patient. Need for trauma center evaluation of the second patient and distance of transport were common reasons for double transports. CONCLUSIONS: Patients transported as doubles do not include the most severely injured trauma patients. In only a small percentage of doubles did the second patient have a perceived impact on care of the primary patient.