Faculty Bibliography

OBJECTIVE:To determine whether a checklist of possible etiologies for syncope provided alongside ECGs helps Emergency Medicine (EM) residents identify ECG patterns more accurately than with ECGs alone. METHODS:We developed a test of ten ECGs with syncope-related pathology from ECG Wave-Maven. We reviewed the literature and used expert consensus to develop a checklist of syncope-related pathologies commonly seen and diagnosed on ECGs. We randomized residents from three New York EM residency programs to interpret ECGs with or without a checklist embedded into the test. RESULTS:We randomized 165 residents and received completed tests from 100 (60%). Of those who responded, 39% were interns, 23% PGY2s, and 38% were PGY3s or PGY4s. We found no significant difference in overall test scores between those who read ECGs with a checklist and those who read ECGs alone. In post-hoc analysis, residents given a checklist of syncoperelated etiologies were significantly more likely to recognize Brugada (96% vs. 78%, p = 0.007), long QT (86% vs. 68%, p = 0.03) and heart block (100% vs 78%, p = 0.003) as compared to those without a checklist. Those with a checklist were more likely to overread normal ECGs (72% vs 35%, p = 0.0001) compared to those without a checklist, finding pathology where there was none. CONCLUSION:Using a checklist with common syncope-related pathology when interpreting an ECG for a patient with clinical scenario of syncope may improve residents' ability to recognize some clinically important pathologies; however it could lead to increased interpretation and suspicion of pathology that is not present.

Objective: Hyperthermia is a life-threatening complication of agitated delirium, and a potential consequence of sympathomimetic, anticholinergic, or oxidative phosphorylation uncoupling xenobiotics. Failure to promptly cool a hyperthermic patient leads to morbid sequelae, including rhabdomyolysis, acute kidney injury, ischemic hepatitis (shock liver), disseminated intravascular coagulation, and possibly death. The primary objective of this study is to assess one Poison Control Center's (PCC) experience with hyperthermic patients, specifically as it relates to the use of ice or water bath treatment. Secondary objectives include characterizing mortality rate, ambient temperatures at the time of presentation, and initial laboratory abnormalities.
Method(s): This is a retrospective analysis of data from a single PCC from 2014 to 2019. A structured query language search (SQL) of Toxicall

INTRODUCTION/BACKGROUND:The goals of this study are to describe clinical characteristics and risk factors for metabolic acidosis with hyperlactatemia in emergency department (ED) patients with acute metformin overdose. METHODS:This was a secondary analysis of data from a retrospective observational cohort of adult ED patients presenting with acute drug overdose at two tertiary care hospitals over 5 years. The primary outcomes were: (1) hyperlactatemia, defined as a lactate concentration ≥ 2 mmol/L at any point during hospital admission and, (2) metformin associated lactic acidosis (MALA), defined as a lactate concentration ≥ 5 mmol/L and pH <7.35 at any point during hospital admission. RESULTS:We screened 3739 acute overdoses; 2872 met eligibility, 56 self-reported metformin overdose (57% female, mean age 55.8). Of these, 39 had measured lactate values. There was a high incidence of hyperlactatemia (56.4%); MALA was less frequent (17.9%). There were no deaths. Low serum bicarbonate was an independent clinical risk factor for hyperlactatemia (adjusted p < 0.05). Acetaminophen co-exposure was an independent clinical risk factor for MALA (OR 24.40, 95% CI 1.6-376.4). CONCLUSIONS:In ED patients with acute metformin overdose, initial hyperlactatemia is common but MALA is unusual. Acetaminophen co-exposure is a novel independent risk factor for the occurrence of MALA that deserves further investigation.

Objective: Beta-adrenergic antagonists (BAAs) and calcium channel blockers (CCBs) negatively affect chronotropy and inotropy and are administered for many indications. The frequency of adverse reactions when BAAs and CCBs are administered concomitantly is infrequently described [1]. We reviewed the incidence of hemodynamic instability in patients in whom both a BAA and CCB were administered within a pharmacologically relevant time period.
Method(s): This was a quality improvement initiative in emergency department (ED) patients, performed at an urban, tertiary care hospital network from 1 October 2016 to 30 September 2018. Adult patients (>=18 years) who received both an intravenous BAA and CCB (in either order) within 6 hours were included. Primary outcomes were the incidence of bradycardia (heart rate <60 bpm) or hypotension (systolic blood pressure <90mmHg) after administration of the second medication. Secondary outcomes were associated diastolic blood pressure changes and administratively assigned primary and secondary diagnoses.
Result(s): Overall 56 ED patients met inclusion criteria. The median time between medication administration was 110 minutes for the cohort. The median decrease in pulse was 42 bpm. The median decrease in systolic blood pressure was 26mmHg, and the median diastolic blood pressure decrease was 11mmHg. According to the prespecified endpoints, 8.9% developed bradycardia, 8.9% developed systolic hypotension, and 17.9% developed either complication. These complications occurred at median times after second medication administration of 36 minutes for bradycardia and 10 minutes for hypotension. The most common diagnosis in patients who received concomitant BAA and CCB administration was atrial fibrillation (n= 39). All patients who developed bradycardia had atrial fibrillation (n= 4) or atrial flutter (n= 1). All patients who developed hypotension had atrial fibrillation (n= 5).
Conclusion(s): Despite a lack of published data, the administration of both BAAs and CCBs within 6 hours can cause significant hypotension and bradycardia in emergency department patients. Avoidance of concurrent administration of these medication classes or assurance of antidotal availability or pretreatment (i.e. with calcium salts) should be strongly encouraged

Objective: Aggressive gastric emptying is often withheld in poisoning due to concerns over safety and efficacy. Despite this, endoscopy performed by emergency medicine physicians demonstrates significant retention of residual drug products many hours after ingestion [1]. Decedents may also demonstrate significant drug retention [2]. We developed a novel video technique in an attempt to improve the safety, efficacy, and completeness of orogastric lavage.
Method(s): Using SolidWorksTM (Dassault Systems, Waltham, MA, 2018), we designed and produced a special Y-adapter with a polylactic acid medium using a 3D Printer (Monoprice, Rancho Cucamonga, CA, 2018) to permit side hole insertion of a disposable AmbuR aScopeTM three intubating bronchoscope (Columbia, MD, 2018) into a standard 40 Fr orogastric lavage tube (OGT). This allowed bronchoscope placement into the orogastric tube (OGT) with an air-tight seal and the ability to visualize through a distal side port. To simulate overdose, 50 pills (acetaminophen 500 mg/diphenhydramine 25mg tablet) were placed into the mannequin stomach with 200 mL of tap water. The mannequin was positioned in the left lateral decubitus position; the apparatus was assembled; and gastric lavage was accomplished with 2 L of tap water.
Result(s): We were able to easily visualize tube passage and placement into the stomach to an appropriate depth, appreciating an initially cloudy solution with numerous pill fragments. The adapted system then permitted lavage under constant bronchoscope visualization. Gastric contents were easily ascertained through the distal ports, and the stomach could be evaluated to the pylorus to exclude bezoars or remaining pill fragments. After lavage, a clear solution with no remaining evidence of pill slurry was evident. After extensive lavage, using the bronchoscope, only a small amount of pill fragments were visualized in the fundus.
Conclusion(s): This study demonstrates a proof of concept, linking visualization with OGT placement and active lavage. If these findings can be confirmed in vivo, our novel device may help clarify the indications, improve the safety and efficacy, and define the endpoints of orogastric lavage

Background: Alcoholic ketoacidosis (AKA) is a metabolic derangement caused by poor nutritional status and an altered oxidation-reduction state in patients with alcohol use disorder (AUD). During starvation, fatty acids undergo beta-oxidation, with resulting ketone and ketone-like byproducts causing both an elevated osmolar gap and an elevated anion gap metabolic acidosis. Ingestion of toxic alcohols (TAs), such as methanol or ethylene glycol, also produces an elevated osmolar gap, and subsequently an elevated anion gap metabolic acidosis. It is difficult to distinguish AKA from TA ingestion clinically, many hospitals do not provide timely serum TA concentrations, and the cost of unnecessary fomepizole and/or hemodialysis is significant. The aim of this study is to identify risk factors suggestive of AKA when TA ingestion is the primary alternative differential diagnosis. We hypothesize that a positive ethanol concentration will be predictive of the diagnosis of AKA.
Method(s): This is a retrospective analysis of data from a single Poison Control Center (PCC) from 2000 to 2019. A structured query language search (SQL) of Toxicall

OBJECTIVE:Although the ε4 allele of the apolipoprotein E (APOE) genotype is a known risk factor for Alzheimer's dementia (AD), prior findings on whether it is also a risk factor for mild cognitive impairment (MCI) have been inconsistent. We tested two contrasting explanations: (a) an ε4-AD specificity hypothesis, and (b) a measurement insensitivity hypothesis. METHOD/METHODS:The frequency of the ε4 allele was investigated in older adults (mean age > 70) with various types of cognitive impairment (including MCI) and various types of dementia (including AD) with the aging, demographics, and memory study (ADAMS) of the National Institute on Aging's Health and Retirement Study (HRS). The ADAMS controls sources of Type I and Type II error that are posited in the ε4-AD specificity hypothesis and the measurement insensitivity hypothesis, and it is the only nationally representative data set on aging and cognitive impairment. RESULTS:ε4 was a reliable predictor of MCI, with a frequency of 32% in MCI subjects versus 20% in healthy control subjects. This link was specific to MCI because ε4 was not a risk factor for other forms of cognitive impairment without dementia. CONCLUSIONS:The results support the measurement insensitivity hypothesis rather than the ε4-AD specificity hypothesis and are consistent with recent research showing modest reductions in cognitive performance among normal functioning ε4 carriers.