Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic d...
Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic dilatation, pericardial effusion or tamponade, and aortic valve regurgitation, warranting urgent definitive aortic imaging or transfer to expert centres(9). In particular, in the latter study "integration of[focused TTE] with D-dimer provided an exceptionally safe and fairly efficient rule-out criterion for AAS(acute aortic syndrome"(9).
I have no funding and no conflict of interest
References
(1) Greenslade JH., Sieben N., Parsonage WA
Factors influencing physicians' estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome
EMJ 2020;37:2-7
(2) Swan D., Hitchen S., Klok FA., Thachill J
The problem of underdiagnosis and overdiagnosis of pulmonary embolism
Thrombosis Research 2019;177:122-129
(3) Gimenez MR., Reiter M., Twerenbold R et al
Sex-specific chest pain characteristics in early diagnosis of acute myocardial infarction
JAMA Internal Medicine 2014;174:241-249
(4) Kukla P., Diugopolski R., Krupa E et al
How often pulmonary embolism mimics acute coronary syndrome?
Kardiologia Polska 2011;69:235-240
(5) Sandoval Y., Thgesen K
Myocardial infarction Type 2 and myocardial injury
Clinical Chemistry 2017;63:101-107
(6) Villablanca PA., Vlismas PP., Aleksandrovich T et al
Case report and systematic review of pulmonary embolism mimicking ST segment elevation myocardial infarction
Vascular 2019;27:90-97
(7) Amjad A., Ali A., Bashir A et al
Chest pain with raised troponin, ECG changes bu normal coronary arteries
BMJ case Reports 2014;doi:10.1136/bcr-2013-201975
(8) Yen K-H., Chang H-C
Massive pulmonary embolism with anterolateral ST segment elevation: electrocardiogram limitations and role of echocardiogram
Am J Emerg Med 2008;26:632.e1-632.e3
(9)Nazerian P., Mueller C., Vanni S et al
Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes
Eur Heart J 2019;40:1952-1960
PS please ignore my previous Rapid Response. This one is the definitive version
We were pleased to read the short report entitled: ‘Preparation for the next major incident: are we ready? A 12-year update’ by Mawhinney et al. (1). We were particularly interested to read the recommendations of the authors for improving knowledge of major incident protocol, as we have recently completed a Quality Improvement (QI) initiative at a central London hospital Emergency Department (ED), aiming to improve knowledge and awareness of major incident protocols.
We note that in your paper you assessed only doctors at registrar level. While we recognise the value of this approach, we adopted a slightly different methodology, by evaluating a single department but across staff groups; the importance of nurses, porters and security staff would be vital in transitioning to a major incident state.
We reviewed a trust Emergency Preparedness, Resilience and Response (EPRR) report that demonstrated, although the trust was broadly compliant with major incident guidelines, there was a suggestion training and awareness amongst staff could be improved.
We conducted a driver analysis to determine possible factors causing low levels of awareness of major incidents and methods of protocol access. This allowed us to optimise our understanding and target our interventions. Following this analysis we conducted baseline data collection and implemented two interventions: a poster campaign directing staff to both hard copies of the major incident...
We were pleased to read the short report entitled: ‘Preparation for the next major incident: are we ready? A 12-year update’ by Mawhinney et al. (1). We were particularly interested to read the recommendations of the authors for improving knowledge of major incident protocol, as we have recently completed a Quality Improvement (QI) initiative at a central London hospital Emergency Department (ED), aiming to improve knowledge and awareness of major incident protocols.
We note that in your paper you assessed only doctors at registrar level. While we recognise the value of this approach, we adopted a slightly different methodology, by evaluating a single department but across staff groups; the importance of nurses, porters and security staff would be vital in transitioning to a major incident state.
We reviewed a trust Emergency Preparedness, Resilience and Response (EPRR) report that demonstrated, although the trust was broadly compliant with major incident guidelines, there was a suggestion training and awareness amongst staff could be improved.
We conducted a driver analysis to determine possible factors causing low levels of awareness of major incidents and methods of protocol access. This allowed us to optimise our understanding and target our interventions. Following this analysis we conducted baseline data collection and implemented two interventions: a poster campaign directing staff to both hard copies of the major incident protocol as well as intranet based guidance; and a series of handover presentations.
From baseline to final collection, more staff in the ED were able to correctly define a major incident (58% to 94%); understand the role of major incident protocol (58% to 100%) as well as correctly locate the protocol quickly (63% to 100%). These interventions demonstrate how simple QI initiatives can significantly improve awareness, knowledge and understanding, for negligible cost.
As part of additional data we collected, we surveyed staff attitudes towards the importance of understanding major incident protocol as well as the number who had received formal training in major incidents. Only 67% had received formal training, and the format of this was variable. Some training was delivered at trust induction, some had attended simulation and disaster management courses.
We strongly endorse your recommendations to improve knowledge of major incident protocol, especially through the use of simulation and induction action cards as well as using virtual reality and other technology. Our cost effective interventions, and targeting of all stakeholders in the department would help to improve basic understanding of the need for and the role of the MIP, and would encourage staff to improve major incident protocol knowledge and event preparedness.
Reference: Mawhinney JA, Roscoe HW, Stannard GAJ, et al Preparation for the next major incident: are we ready? A 12-year update. Emergency Medicine Journal Published Online First: 12 August 2019
We thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.
Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.
We thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.
Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.
Ultimately we agree with Drs Gibson, Jones and Watkins in that our statement that RSI is commonly used by paramedics for stroke is not clear without qualification, but we hope they agree that RSI is indeed commonly used in unconscious stroke patients and in the emergency setting more broadly. If it is true that RSI is frequently used, and that there is a lack of high-quality evidence to support emergency intubation in stroke patients, then it is clear that a trial is needed.
Reference
1. Fouche PF, Stein C, Jennings PA, Boyle M, Bernard S, Smith K. Review article: Emergency endotracheal intubation in non-traumatic brain pathologies: A systematic review and meta-analysis. Emerg Med Australas 2019; 31(4): 533-41.
To the editor,
I read with interest the recent article by Allen et al, “Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England”1.
National Health Service (NHS) performance indicators are cited throughout Care Quality Commission (CQC) reports when rating emergency departments4-8. Given use of these data as justification for achieving a specific rating, it is reasonable for the authors and the wider acute medicine and healthcare communities to assume a relationship exists between improved ratings and improved performance. Allen et al found no such relationship on any of the 6 emergency department NHS performance indicators prior to CQC inspection and on the subsequent rating score. This finding expands the void of evidence to support the suggestion of improved emergency department performance after inspection and published ratings2.
Performance indicators such as those implemented by Allen et al and the CQC have evolved over the
last 2 decades as we attempt to “cross the quality chasm”. Time and presentation-based data points
such as time to assessment and treatment, time in department, unplanned re-presentations, left
before being seen etc. are easily measurable since the advent on electronic health records and patient
management systems. Their reflections in the tenets of the Institute of Medicine’s ideals of safety...
To the editor,
I read with interest the recent article by Allen et al, “Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England”1.
National Health Service (NHS) performance indicators are cited throughout Care Quality Commission (CQC) reports when rating emergency departments4-8. Given use of these data as justification for achieving a specific rating, it is reasonable for the authors and the wider acute medicine and healthcare communities to assume a relationship exists between improved ratings and improved performance. Allen et al found no such relationship on any of the 6 emergency department NHS performance indicators prior to CQC inspection and on the subsequent rating score. This finding expands the void of evidence to support the suggestion of improved emergency department performance after inspection and published ratings2.
Performance indicators such as those implemented by Allen et al and the CQC have evolved over the
last 2 decades as we attempt to “cross the quality chasm”. Time and presentation-based data points
such as time to assessment and treatment, time in department, unplanned re-presentations, left
before being seen etc. are easily measurable since the advent on electronic health records and patient
management systems. Their reflections in the tenets of the Institute of Medicine’s ideals of safety,
effectiveness, patient-centredness, timeliness, efficiency and equity are left profoundly wanting, however2,3, 14-16.
Although the authors were unable to link data for all level 1 emergency departments, the message to the CQC within this immense dataset should be loud and clear. Either the measures of quality utilised are invalid or the recommendations resulting from the rating derived are invalid. Given the increasing parliamentary scrutiny on this struggling behemoth, the author hopes that further analysis does not continue to demonstrate lack of efficacy of both assessment and implementation of change9-11.
Regulatory organisations such as CQC are becoming ever-more reliant on “intelligent data modelling”7,12,15. These programs utilise artificial intelligence and readily available datasets. It is reasonable to assume that status quo will remain when considering emergency department performance indicators, as these datapoints will continue to be generated at the click of a mouse at time of triage, treatment or discharge. Unfortunately, some hard truths must be considered by the CQC. These indicators may not be valid measures of quality, and neither may be inspection ratings. It is also possible that even if both performance indicators and inspections and ratings are valid forms of quality measurement, no relationship between the 2 in their current forms will ever exist. Lack of insight into this possibility is evident in that no piloting or testing occurred prior to the large-scale implementation of the CQC inspection program.
This article lays the foundation for addressing the dearth of evidence in performance indicators in the emergency department. I applaud the authors for shining a light on the lack of impact of Care Quality Commission inspections on emergency department performance and more importantly, for promoting the importance of inspecting the inspectors
1. Allen et al. Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England. Emerg Med J 2019;36:326–332. doi:10.1136/emermed-2018-207941
2. Flodgren et al. Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes. Cochrane Database Syst Rev 2011:CD008992.doi:10.1002/14651858.CD008992.pub2
3. Brubakk et al. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res 2015;15:280.doi:10.1186/s12913-015- 0933-x
4. NHS Digital. Provisional Accident and Emergency Quality Indicators - England. 2017 http://digital.nhs.uk/catalogue/PUB23839. Accessed July 19, 2019.
5. NHS Digital. Methodology for producing the A&E clinical quality indicator from provisional Hospital Episode Statistics (HES) data. 2016 https://files.digital.nhs.uk/publicationimport/pub23xxx/pub23839/prov-ae... january. Accessed July 19, 2019.
6. Care Quality Commission. How to get and re-use CQC information and data. 2016 http://www.cqc.org.uk/content/how-get-and-re-use-cqc-information-and-data. Accessed July 19, 2019.
7. Care Quality Commission. Inspection framework: NHS and independent acute hospitals. Core service: Urgent and emergency services. 2018 http://www.cqc.org.uk/sites/default/files/inspection-framework-acute-hos... emergency-services.pdf. Accessed July 19, 2019.
8. Care Quality Commission. Shaping the future. CQC’s strategy for 2016 to 2021. 2016 http://www.cqc.org.uk/sites/default/files/20160523_strategy_16- 21_strategy_final_web_01.pdf. Accessed July 19, 2019.
9. Iacobucci Gareth. CQC-style inspections don’t raise standards or improve patient safety, say RCGP members BMJ 2018; 363: k4216
10. Burton. What’s wrong with the CQC? Centre for Healthcare Reform. https://www.centreforwelfarereform.org/uploads/attachment/534/whats-wron... cqc.pdf. Accessed July 19, 2019.
11. Statement on BMA criticisms of CQC inspection regime. https://www.cqc.org.uk/news/stories/statement-bma-criticisms-cqc-inspect.... Accessed July 19, 2019.
12. Sorup et al. Evaluation of emergency department performance – a systematic review on recommended performance and quality-in-care measures. Scand J Trauma Resusc Emerg Med. 2013; 21: 62. Published online 2013 Aug 9. doi: 10.1186/1757-7241-21-62
13. Alberti G. Transforming emergency care in England. 2005. http://aace.org.uk/wp- content/uploads/2011/11/Transforming-Emergency-Care-in-England.pdf. Accessed July 19, 2019.
14. Alessandrini EA, Knapp J. Measuring quality in paediatric emergency care. Clin Ped Emerg Med. 2011;12(2):102–112. doi: 10.1016/j.cpem.2011.05.002.
15. Coleman P, Nicholl J. Consensus methods to identify a set of potential performance indicators for systems of emergency and urgent care. J Health Serv Res Policy. 2010; 15:12– 18. doi: 10.1258/jhsrp.2009.009096
16. The King’s Fund. Impact of the Care Quality Commission on provider performance: room for improvement? https://www.kingsfund.org.uk/publications/impact-cqc-provider- performance. Accessed July 19, 2019
As researchers with an interest in pre-hospital stroke care, we read this paper with interest, but also with some surprise at the authors’ assertion that ‘RSI is commonly used by paramedics in stroke’. On examining the cited studies and the authors’ own findings more closely, this statement is hard to justify. Although Meyer et al did indeed report that 55% of out-of-hospital haemorrhagic strokes received RSI, this actually refers to a retrospective chart review of 20 children, all of whom with a Glasgow Coma Scale ≤ 8 following acute haemorrhagic stroke from a cerebral arteriovenous malformation rupture. This small, selective paediatric sample cannot be held to be representative of all stroke patients who are conveyed to hospital by emergency medical services. The other study cited as evidence found that people with acute stroke form a substantial proportion (36.6%) of RSIs undertaken by paramedics (Fouche et al., 2017). Whilst stroke may be a common reason for paramedic RSI, it cannot therefore be inferred that paramedic RSI is common in stroke. The authors’ own findings bear this out: of their sample of nearly 44,000 stroke patients conveyed by the emergency medical services, only 2% had received paramedic RSI.
Whilst we congratulate the authors on their comprehensive analysis of this large dataset, it is important that readers do not gain the impression that paramedic RSI is frequently indicated and performed in pre-hospital stroke care.
As researchers with an interest in pre-hospital stroke care, we read this paper with interest, but also with some surprise at the authors’ assertion that ‘RSI is commonly used by paramedics in stroke’. On examining the cited studies and the authors’ own findings more closely, this statement is hard to justify. Although Meyer et al did indeed report that 55% of out-of-hospital haemorrhagic strokes received RSI, this actually refers to a retrospective chart review of 20 children, all of whom with a Glasgow Coma Scale ≤ 8 following acute haemorrhagic stroke from a cerebral arteriovenous malformation rupture. This small, selective paediatric sample cannot be held to be representative of all stroke patients who are conveyed to hospital by emergency medical services. The other study cited as evidence found that people with acute stroke form a substantial proportion (36.6%) of RSIs undertaken by paramedics (Fouche et al., 2017). Whilst stroke may be a common reason for paramedic RSI, it cannot therefore be inferred that paramedic RSI is common in stroke. The authors’ own findings bear this out: of their sample of nearly 44,000 stroke patients conveyed by the emergency medical services, only 2% had received paramedic RSI.
Whilst we congratulate the authors on their comprehensive analysis of this large dataset, it is important that readers do not gain the impression that paramedic RSI is frequently indicated and performed in pre-hospital stroke care.
Disclaimer: JG and CW are partly funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, North West Coast. The views expressed are those of the authors and not necessarily those of the NIHR, NHS, or Department of Health and Social Care.
Smith and Bongale correctly emphasise the importance of anatomical accuracy when examining the hand.[1] However their article requires correction. The muscle adductor pollicis longus (answer D in their question) does not exist. The abbreviation APL usually denotes abductor pollicis longus, a muscle of the forearm which contributes to abduction and extension of the thumb, and which runs alongside extensor pollicis brevis as it crosses the anterior (radial) border of the anatomical snuffbox. Adductor pollicis (shown in Figure 2 of the article) is an intrinsic muscle of the hand, and is not involved in thumb extension.
Hand injuries are common in Emergency Departments. Anatomical accuracy is essential when examining and describing these important presentations.
1. Smith E, Bongale S. Thumbs down: testing anatomy in the ED. Emerg Med J 2019;36:224-238.
Thank you for highlighting the need for correction in the article. The option D was meant to be spelt as Abductor pollicis longus (APL) instead of Adductor pollicis longus. Your elaboration on the anatomy of APL muscle will help readers understand our article better.
Dear Editor,
We have read the study published by Lipinski et al.(1) in which the authors observed that only a little percentage of patients with heart failure (HF) were monitored by a specific palliative care (PC) team. Also, this usually happened in the last two weeks of life. This suggests the need to identify earlier high-risk patients who can benefit from monitoring by a palliative care team (1).
In relation to this study, we would like to share our experience in a Spanish Emergency Department (ED). Our study included 143 patients with acute HF (AHF), mean age 82.5 (range 65-99) years old, of whom 69 (48.2%) were women. None of these patients were being monitored by a PC team before their admission in ED and only 8 (5.6%) were transferred to PC after the index visit. Out of 8 patients included in CP, 3 (37.5%) died within 30 days after visiting ED. Although our cohort had a lower 1-year mortality than the Canadian study (18.2% vs 27.0%), our findings confirm that older patients with AHF are not frequently followed-up by a PC team, although HF is known to be a disease with a progressive course which is associated with a significant morbidity and mortality, and a high consumption of socio-health resources (2). This may be due to the lack of awareness, among health professionals, that HF is a chronic disease with a poor 5-year prognosis, and the need of palliative care for older patients with HF in an earlier phase than the terminal care (3).
In conclusi...
Dear Editor,
We have read the study published by Lipinski et al.(1) in which the authors observed that only a little percentage of patients with heart failure (HF) were monitored by a specific palliative care (PC) team. Also, this usually happened in the last two weeks of life. This suggests the need to identify earlier high-risk patients who can benefit from monitoring by a palliative care team (1).
In relation to this study, we would like to share our experience in a Spanish Emergency Department (ED). Our study included 143 patients with acute HF (AHF), mean age 82.5 (range 65-99) years old, of whom 69 (48.2%) were women. None of these patients were being monitored by a PC team before their admission in ED and only 8 (5.6%) were transferred to PC after the index visit. Out of 8 patients included in CP, 3 (37.5%) died within 30 days after visiting ED. Although our cohort had a lower 1-year mortality than the Canadian study (18.2% vs 27.0%), our findings confirm that older patients with AHF are not frequently followed-up by a PC team, although HF is known to be a disease with a progressive course which is associated with a significant morbidity and mortality, and a high consumption of socio-health resources (2). This may be due to the lack of awareness, among health professionals, that HF is a chronic disease with a poor 5-year prognosis, and the need of palliative care for older patients with HF in an earlier phase than the terminal care (3).
In conclusion, we agree with Lipinski et al. that EDs are a magnificent scenario to identify patients with palliative needs and to activate the follow-up by specific teams, in order to improve patients’ welfare and quality of life and to avoid unnecessary readmissions and treatments (3). Thus, it seems important to evaluate the prognosis and to know the palliative care criteria to provide early support to these older patients with AHF (4,5).
REFERENCES
1. Lipinski M, Eagles D, Fischer LM, Lielniczuk L, Stiell AG. Heart failure and palliative care in the emergency department. Emerg Med J 2018;35:726-729.
2. Llorens P. Risk assessment in emergency department patients with acute heart failure: We need to reach beyond our clinical judgment. Emergencias. 2018;30:75-6.
3. McIlvennan CK, Allen LA. Palliative care in patients with heart failure. BMJ 2016;352:i1010
4. Martín-Sánchez FJ, Rodríguez-Adrada E, Vidan MT, Díez Villanueva P, Llopis García G, González Del Castillo J, et al. Impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure. Emergencias. 2018;30:149-55.
5. García-Gutiérrez S, Quintana López JM, Antón-Ladislao A, Gallardo Rebollal MS, Rilo Miranda I, Morillas Bueno M, et al. External validity of a prognostic score for acute heart failure based on the Epidemiology of Acute Heart Failure in Emergency Departments registry: the EAHFE-3D scale. Emergencias. 2018;30:84-90.
Failure to diagnose infective endocarditis(IE) as the underlying cause of embolic stroke merits recognition alongside failure to diagnose other subtypes of stroke,. The reason is that failure to recognise an infective basis for cerebral emboli precludes time-sensitive interventional strategies such as thrombectomy(1)(2) and, instead, exposes the patient to relatively contraindicated treatment options such as intravenous thrombolysis(IVT)(3)(4). One study compared outcomes from IVT in 222 patients(mean age 59) with IE-related stroke versus 134,048 subjects(mean age 69) with ischaemic stroke in the absence of IE. The rate of post-thrombolytic intracranial haemorrhage was significantly(P=0.006) higher in patients with IE-related stroke. The rate of favourable outcome was also significantly(P=0.01) lower in IE-related stroke(3). A high index of suspicion is required to diagnose IE-related stroke because both fever and heart murmurs are present in only a minority of IE patients at the time of presentation with stroke(4). For patients in whom a timely diagnosis of IE-related stroke is made thrombectomy appears to be a treatment option which generates a favourable outcome(1)(2).
For the sake of completeness one also ought to mention the potential for meningovascular syphilis to be overlooked in a patient presenting with stroke both in HIV positive(5) and in HIV-negative subjects(6). In both instances neither IVT nor thrombectomy will suffice. Definitive treatment o...
Failure to diagnose infective endocarditis(IE) as the underlying cause of embolic stroke merits recognition alongside failure to diagnose other subtypes of stroke,. The reason is that failure to recognise an infective basis for cerebral emboli precludes time-sensitive interventional strategies such as thrombectomy(1)(2) and, instead, exposes the patient to relatively contraindicated treatment options such as intravenous thrombolysis(IVT)(3)(4). One study compared outcomes from IVT in 222 patients(mean age 59) with IE-related stroke versus 134,048 subjects(mean age 69) with ischaemic stroke in the absence of IE. The rate of post-thrombolytic intracranial haemorrhage was significantly(P=0.006) higher in patients with IE-related stroke. The rate of favourable outcome was also significantly(P=0.01) lower in IE-related stroke(3). A high index of suspicion is required to diagnose IE-related stroke because both fever and heart murmurs are present in only a minority of IE patients at the time of presentation with stroke(4). For patients in whom a timely diagnosis of IE-related stroke is made thrombectomy appears to be a treatment option which generates a favourable outcome(1)(2).
For the sake of completeness one also ought to mention the potential for meningovascular syphilis to be overlooked in a patient presenting with stroke both in HIV positive(5) and in HIV-negative subjects(6). In both instances neither IVT nor thrombectomy will suffice. Definitive treatment of neurosyphilis will also be necessary.
References
(1) Asaithambi G., Adil MM., Qureshi AI
Thrombolysis for ischemic stroke associated with infective endocarditis
STROKE 2013;44:2917-2919
(2) Walker KA., Sampson JB., Skalabrin EJ., Majersik JJ
Clinical characteristics and thrombolytic outcomes of infective endocarditis-associated stroke
The Neurohospitalist 2012;2:87-91
(3)Kim J-M., Jeon J-S., Kim Y-W., Kang D-H., Hwang Y-H., Kim Y-S
forced suction thrombectomy of septic embolic middle cerebral artery occlusion due to infective endocarditis: an illustrative case and review of the literature
Neurointervention 2014;9:101-105
(4)Liang JJ., Bishi K., Anavekar
NS
Infective endocarditis complicated by acute ischemic stroke from septic embolus; Siccessful solitaire FR thrombectomy
Cardiol Res 2012;3:277-280
(5) Flood JM., Weinstock HS., Guroy ME., Bayne L., Simon RP., Bolan Gail
Neurosyphilis during the AIDS epidemic, San Francisco 1985-1992
The Journal of Infectious Diseases 1998;177:931-940
(6) Ghanem KG
Neurosyphilis: A hisorical perspective and review
CNS Neuroscince & Therapeutics doi:10.1111/j.1755-5949.2010.00183x
Thank you for your interesting article about hypothermia in the UK. I couldn't find reference in the case to the HM Coastguard cliff rescue operatives nor to HM Coastguard helicopter search and rescue service (Currently run by Bristow). Was there a reason for excluding these organisations or is there data included under the heading of another organisation? Thank you again,
Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic d...
Show MoreDear Editor,
We were pleased to read the short report entitled: ‘Preparation for the next major incident: are we ready? A 12-year update’ by Mawhinney et al. (1). We were particularly interested to read the recommendations of the authors for improving knowledge of major incident protocol, as we have recently completed a Quality Improvement (QI) initiative at a central London hospital Emergency Department (ED), aiming to improve knowledge and awareness of major incident protocols.
We note that in your paper you assessed only doctors at registrar level. While we recognise the value of this approach, we adopted a slightly different methodology, by evaluating a single department but across staff groups; the importance of nurses, porters and security staff would be vital in transitioning to a major incident state.
We reviewed a trust Emergency Preparedness, Resilience and Response (EPRR) report that demonstrated, although the trust was broadly compliant with major incident guidelines, there was a suggestion training and awareness amongst staff could be improved.
We conducted a driver analysis to determine possible factors causing low levels of awareness of major incidents and methods of protocol access. This allowed us to optimise our understanding and target our interventions. Following this analysis we conducted baseline data collection and implemented two interventions: a poster campaign directing staff to both hard copies of the major incident...
Show MoreWe thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.
Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.
Ultimately we agree with...
Show MoreTo the editor,
Show MoreI read with interest the recent article by Allen et al, “Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England”1.
National Health Service (NHS) performance indicators are cited throughout Care Quality Commission (CQC) reports when rating emergency departments4-8. Given use of these data as justification for achieving a specific rating, it is reasonable for the authors and the wider acute medicine and healthcare communities to assume a relationship exists between improved ratings and improved performance. Allen et al found no such relationship on any of the 6 emergency department NHS performance indicators prior to CQC inspection and on the subsequent rating score. This finding expands the void of evidence to support the suggestion of improved emergency department performance after inspection and published ratings2.
Performance indicators such as those implemented by Allen et al and the CQC have evolved over the
last 2 decades as we attempt to “cross the quality chasm”. Time and presentation-based data points
such as time to assessment and treatment, time in department, unplanned re-presentations, left
before being seen etc. are easily measurable since the advent on electronic health records and patient
management systems. Their reflections in the tenets of the Institute of Medicine’s ideals of safety...
As researchers with an interest in pre-hospital stroke care, we read this paper with interest, but also with some surprise at the authors’ assertion that ‘RSI is commonly used by paramedics in stroke’. On examining the cited studies and the authors’ own findings more closely, this statement is hard to justify. Although Meyer et al did indeed report that 55% of out-of-hospital haemorrhagic strokes received RSI, this actually refers to a retrospective chart review of 20 children, all of whom with a Glasgow Coma Scale ≤ 8 following acute haemorrhagic stroke from a cerebral arteriovenous malformation rupture. This small, selective paediatric sample cannot be held to be representative of all stroke patients who are conveyed to hospital by emergency medical services. The other study cited as evidence found that people with acute stroke form a substantial proportion (36.6%) of RSIs undertaken by paramedics (Fouche et al., 2017). Whilst stroke may be a common reason for paramedic RSI, it cannot therefore be inferred that paramedic RSI is common in stroke. The authors’ own findings bear this out: of their sample of nearly 44,000 stroke patients conveyed by the emergency medical services, only 2% had received paramedic RSI.
Whilst we congratulate the authors on their comprehensive analysis of this large dataset, it is important that readers do not gain the impression that paramedic RSI is frequently indicated and performed in pre-hospital stroke care.
Disclaimer: JG an...
Show MoreSmith and Bongale correctly emphasise the importance of anatomical accuracy when examining the hand.[1] However their article requires correction. The muscle adductor pollicis longus (answer D in their question) does not exist. The abbreviation APL usually denotes abductor pollicis longus, a muscle of the forearm which contributes to abduction and extension of the thumb, and which runs alongside extensor pollicis brevis as it crosses the anterior (radial) border of the anatomical snuffbox. Adductor pollicis (shown in Figure 2 of the article) is an intrinsic muscle of the hand, and is not involved in thumb extension.
Hand injuries are common in Emergency Departments. Anatomical accuracy is essential when examining and describing these important presentations.
1. Smith E, Bongale S. Thumbs down: testing anatomy in the ED. Emerg Med J 2019;36:224-238.
Dear Dr J Benger,
Thank you for highlighting the need for correction in the article. The option D was meant to be spelt as Abductor pollicis longus (APL) instead of Adductor pollicis longus. Your elaboration on the anatomy of APL muscle will help readers understand our article better.
Dear Editor,
Show MoreWe have read the study published by Lipinski et al.(1) in which the authors observed that only a little percentage of patients with heart failure (HF) were monitored by a specific palliative care (PC) team. Also, this usually happened in the last two weeks of life. This suggests the need to identify earlier high-risk patients who can benefit from monitoring by a palliative care team (1).
In relation to this study, we would like to share our experience in a Spanish Emergency Department (ED). Our study included 143 patients with acute HF (AHF), mean age 82.5 (range 65-99) years old, of whom 69 (48.2%) were women. None of these patients were being monitored by a PC team before their admission in ED and only 8 (5.6%) were transferred to PC after the index visit. Out of 8 patients included in CP, 3 (37.5%) died within 30 days after visiting ED. Although our cohort had a lower 1-year mortality than the Canadian study (18.2% vs 27.0%), our findings confirm that older patients with AHF are not frequently followed-up by a PC team, although HF is known to be a disease with a progressive course which is associated with a significant morbidity and mortality, and a high consumption of socio-health resources (2). This may be due to the lack of awareness, among health professionals, that HF is a chronic disease with a poor 5-year prognosis, and the need of palliative care for older patients with HF in an earlier phase than the terminal care (3).
In conclusi...
Failure to diagnose infective endocarditis(IE) as the underlying cause of embolic stroke merits recognition alongside failure to diagnose other subtypes of stroke,. The reason is that failure to recognise an infective basis for cerebral emboli precludes time-sensitive interventional strategies such as thrombectomy(1)(2) and, instead, exposes the patient to relatively contraindicated treatment options such as intravenous thrombolysis(IVT)(3)(4). One study compared outcomes from IVT in 222 patients(mean age 59) with IE-related stroke versus 134,048 subjects(mean age 69) with ischaemic stroke in the absence of IE. The rate of post-thrombolytic intracranial haemorrhage was significantly(P=0.006) higher in patients with IE-related stroke. The rate of favourable outcome was also significantly(P=0.01) lower in IE-related stroke(3). A high index of suspicion is required to diagnose IE-related stroke because both fever and heart murmurs are present in only a minority of IE patients at the time of presentation with stroke(4). For patients in whom a timely diagnosis of IE-related stroke is made thrombectomy appears to be a treatment option which generates a favourable outcome(1)(2).
Show MoreFor the sake of completeness one also ought to mention the potential for meningovascular syphilis to be overlooked in a patient presenting with stroke both in HIV positive(5) and in HIV-negative subjects(6). In both instances neither IVT nor thrombectomy will suffice. Definitive treatment o...
Dear Authors,
Thank you for your interesting article about hypothermia in the UK. I couldn't find reference in the case to the HM Coastguard cliff rescue operatives nor to HM Coastguard helicopter search and rescue service (Currently run by Bristow). Was there a reason for excluding these organisations or is there data included under the heading of another organisation? Thank you again,
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