False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series.

INTRODUCTION: The use of transcutaneous pacing (TCP) for unstable bradycardia has a class 2B recommendation from the American Heart Association. Prior studies have not adequately described the frequency or possible causes of treatment failure. EMS clinicians and leaders have reported false electrical capture as a potential cause. In this study, we aimed to describe the frequency of true electrical capture, documented verification of mechanical capture, and its association with systolic blood pressure (SBP) and survival. METHODS: This was a retrospective study of patients treated by an urban, hospital-based EMS network comprising two EMS agencies between March 2021 and March 2023. Inclusion criteria were adults with a heart rate of <60 bpm and attempted TCP. Variables included: initial electrocardiogram rhythm, SBP, current applied, neurological status at discharge, and diagnosis. The primary outcome was true electrical capture, defined as the presence of a visible wide QRS and T wave. This enabled calculation of false electrical capture. Additional outcomes included change in SBP and neurological status at discharge. RESULTS: 19 of the 23 (82.6%) patients who underwent TCP had false electrical capture despite all 23 having documented mechanical capture by palpated pulse. For patients with true electrical capture, the median change in SBP was +40 mmHg (IQR = 24.25, range= -12 to +49 mmHg). For patients with false electrical capture, the median change in SBP was -1 mmHg (IQR = 58.50, range= -90 to +23 mmHg). Median current for patients with true electrical capture was 95 mA (IQR = 13.75, range = 85-110) versus 70 mA (IQR = 30, range = 55-160) in those with false electrical capture. 16 (69.6%) had outcome data available. Patients with true electrical capture and outcome data (n = 2) survived to admission but only one survived to discharge with good functional capacity. Of 14 with false electrical capture and outcome data, 10 (71.4%) survived to admission; none survived to discharge with functional capacity. CONCLUSIONS: These findings suggest a high proportion of patients undergoing TCP are at risk of false electrical capture despite a recorded palpable pulse. While our analysis is limited to a single EMS network, these data raise concerns regarding the incidence of prehospital false electrical capture. Further research is warranted to calculate the incidence of false electrical capture and evaluate mitigation strategies.

Reliability of Electronic Health Records in Recording Veterans' Tobacco Use Status.

INTRODUCTION: The prevalence of tobacco use in the Veteran population and among Veterans Health Administration patients remains high, resulting in significant health and economic consequences. This problem has generated many tobacco research studies and clinical interventions, which often rely upon tobacco use status data previously recorded in electronic health records (EHR). Therefore, the consistency and reliability of these data are critical. The Veterans Health Administration uses an extensive EHR system where tobacco use status can be documented either as free text (FT) or as health factors (HF). The current literature assessing the reliability of HF and FT data is limited. This analysis evaluated the agreement between HF and FT tobacco use status data. MATERIALS AND METHODS: This retrospective study included Veterans who underwent coronary revascularization and had tobacco use statuses recorded as both HF and FT. These statuses were categorized as "Current," "Former," or "Never." The closest recorded status to the index date (date of revascularization procedure) for each subject in both datasets was chosen, and Cohen's kappa statistic was calculated to measure the agreement between HF and FT. Implausible tobacco use status changes within each dataset were quantified to assess trustworthiness. Agreement between HF and FT data was first measured for all subjects (n = 1,095), which included those who had implausible status changes in either dataset and then measured again for subjects (n = 770) without any implausible status changes in either dataset. This study was exempt from institutional review board review. RESULTS: Overall, 14.3% and 17.7% of all subjects had implausible tobacco use status changes in HF and FT data, respectively. For all subjects (n = 1,095), including those with implausible data, there was "moderate" agreement between HF and FT data (kappa = 0.49; 95% CI, 0.44-0.53). For subjects without implausible data (n = 770), the strength of agreement between HF and FT data was "good" (kappa = 0.64; 95% CI, 0.59-0.69). CONCLUSIONS: Agreement between HF and FT data that document the tobacco use statuses of Veterans varied because of implausible data. HF data had fewer implausible tobacco use statuses, but FT data were recorded more frequently. Although HF and FT data can be reasonably relied upon to determine the tobacco use statuses of Veterans, researchers and clinicians must be aware of implausible data and consider methods to overcome this limitation. Future studies should investigate the ways of improving the consistency of EHR documentation by health care providers and benchmark HF and FT data against a gold standard like biochemical verification to determine accuracy.

Ventricular Fibrillation in an Afebrile COVID-19 Patient Presenting With Transient Type-I Brugada Pattern.

COVID-19 has been associated with an increased risk of both atrial and ventricular arrhythmias. Brugada syndrome (BrS), an inherited sodium channelopathy presenting with a characteristic ECG morphology, confers a baseline risk of ventricular arrhythmias such as ventricular fibrillation (VF), especially during febrile illnesses. However, mimics of BrS, termed Brugada phenocopies (BrP), have been noted in association with fever, electrolyte abnormalities, and toxidromes outside of viral illness. Such presentations manifest the same ECG pattern, the type-I Brugada pattern (type-I BP). Thus, the acute stage of an illness such as COVID-19, when accompanied by a first-time presentation of type-I BP, may not result in a certain diagnosis of BrS versus BrP. Thus, expert recommendations are to anticipate arrhythmia regardless of the presumed diagnosis. Here we demonstrate the importance of these guidelines and a novel report of VF in the setting of a transient type-I BP in afebrile COVID-19. We discuss the potential factors which may have triggered VF, the presentation of isolated "coved" ST elevation in V1, and the difficulty of BrS versus BrP diagnosis in acute illness. In summary, a SARS-CoV-2 positive 65-year-old male without significant cardiac history for BrS presented with type-I BP after two days of shortness of breath. Hypoxemia, hyperkalemia, hyperglycemia, elevated inflammatory markers, and acute kidney injury were present. After treatment, his ECG normalized; however, aborted VF occurred days later while afebrile and normokalemic. Follow-up ECG again revealed a type-I BP, which also became more apparent during an episode of bradycardia, a classic finding in BrS. This case suggests that there is room for larger studies to determine the prevalence and outcomes when type-I BP presents in acute COVID-19. When possible, genetic data should be obtained to confirm BrS, a notable limitation in our case. Regardless, it corroborates guideline-directed clinical management, with heightened vigilance for arrhythmia in such patients until full recovery.