Evaluation of Syncope in the Emergency Department

Authors: Theodore Segarra, MD; Lee Grodin, MD; Taylor Conrad, MD; Raymond Beyda, MD
Editors: Michael C. Bond, MD FAAEM and Kelly Maurelus, MD
Originally Published: Common Sense January/February 2018

As syncope is a common yet nebulous complaint, evaluation of the patient with syncope presents a unique challenge. Syncope is defined as a brief loss of consciousness and postural tone with rapid return to baseline mentation. Yet, rather than having a single underlying cause, syncope itself is a syndrome with many potential etiologies. Some identified causes are arrhythmia, myocardial infarction (MI), cerebrovascular accident (CVA), hemorrhage, and pulmonary embolism (PE).[1] In this edition of RJR, we review the potential etiologies of syncope, the utility of risk stratification tools in the workup of syncope, and the prevalence of atypical causes of syncope.

Risk Management Monthly / Emergency Medicine - Case of the Month, February 2018

Seward v Metrolina Medical Associates (South Carolina) – A patient presented with shortness of breath and chest pressure after a lengthy airplane flight. He was accompanied by his wife. The chief complaint on the ED chart listed “cough and shortness of breath.” A chest x-ray was reported as negative for pneumonia, and the patient was discharged with a diagnosis of bronchitis. He died the following day. The autopsy listed pulmonary embolism as the cause of death. At the malpractice proceeding, the plaintiff’s attorney pointed out that the diagnosis was missed despite the presence of classic PE symptoms after a longplane flight. The defendant falsified the records after the fact (indicating that the patient had declined an ECG, reported productive cough, and had a negative calf exam for tenderness and swelling). The defendant claimed that this documentation was completed in the presence of the patient and his wife, but examination of the EHR showed that this documentation occurred after the diagnosis was known. The case was settled for $3 million.

The RMM panel notes that:

• In the age of electronic medical records, it’s easy to determine the timing of documentation. Be aware that juries are likely to come down hard on you if you are dishonest in your testimony.
• In Dr. Henry’s experience, he is unaware of a single case in which the defendant has prevailed after it is demonstrated that he/she has charted something that was not actually done or said something that was later found to be untrue.

2017-18 AAEM/RSA Medical Student Scholarship Winners Share Why They Are Choosing EM

Author: Tamathor Abughnaim
University of Illinois College of Medicine

RSA is proud to share the following essay from one of the 2017-2018 Medical Student Scholarship winners, Tamathor Abughnaim. We felt this essay best exemplified why she is choosing EM as a specialty. Congratulations, Tamathor!

2017-18 AAEM/RSA Medical Student Scholarship Winners Share Why They Are Choosing EM

Author: Michael Lauria
Dartmouth Geisel School of Medicine

RSA is proud to share the following essay from one of the 2017-2018 Medical Student Scholarship winners, Michael Lauria. We felt this essay best exemplified why he is choosing EM as a specialty. Congratulations, Michael!

Exhaustion had never felt so good. Many of the other details surrounding that rescue operation in the middle of the Iraqi desert were a blur, a shadowy haze of blood, twisted metal, and wind-driven dust. Just hours before, our combat search and rescue team had managed to triage, treat, and transport seven critically injured soldiers involved in a catastrophic helicopter crash. As the team sat back, relaxed, and watched the sun rise over the desert, I quietly reflected on the night's events. I realized that I truly loved being there to provide emergency medical care to those soldiers when they needed it most. Now, eight years later, I recognize that I want to dedicate my career as a physician to that same purpose.

The Opioid Epidemic: Where Are We Now?

Image Credit: Pixabay

Author: Aaron C. Tyagi, MD
Chair, RSA Social Media Committee
Originally Published: Common Sense January/February 2018

We have seen the rate of overdose mortality in general and mortality of overdoses related to opioids continue to rise.[1,2] As a society, we were slow to recognize this problem, for a number of reasons. Now it is incumbent upon us to respond appropriately and in a timely manner. But our opportunity in which to do that in is quickly shrinking. It seems the executive branch and President Trump have recognized this.[3] But let’s actually take closer look at what we’ve done and what we’re doing currently.

Drug overdose and opioid overdose continues to be a problem in the United States. According to a 2016 report by the CDC, of the 47,055 deaths from drug overdoses that occurred in 2014, 28,647 (60.9%) involved an opioid. The following year (2015), the number of deaths from overdoses rose to 52,404 with 33,091 (63.1%) from opioids.[4] We are constantly exposed to this in the ED. We (the ED and our EMS colleagues in the field) are the frontlines when these patients come in dead or near-dead and need to be resuscitated. We know first-hand the potentially devastating effects of these medications.

A Racing Heart and Seeing Stars: Pre-excitation and Syncope in a Young Adult

This post was peer reviewed.
Click to learn more.

Author: Eric Sulava, MD
Emergency Medicine Resident
Naval Medical Center Portsmouth
AAEM Education Committee

Author: Hannah Harris MD
Student Naval Flight Surgeon
Naval Aerospace Medical Institute

Author: Katrina Destree, MD
Staff Physician
Naval Medical Center Camp Lejeune

Chief Complaint
“My heart was racing and then everything went grey”

Maverick’s Fracture: Review of a Rare High-Impact Pediatric Elbow Fracture

This post was peer reviewed.
Click to learn more.

Author: Eric Sulava, MD
Emergency Medicine Resident
Naval Medical Center Portsmouth
AAEM Education Committee

Author: Katrina Destree, MD
Staff Physician
Naval Medical Center Camp Lejeune

I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.

The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Visceral Artery Aneurysms: An Unusual Case Report

This post was peer reviewed.
Click to learn more.

 









Author: Sara Bradley, MSII
Western University of Health Sciences
AAEM/RSA Education Committee 

Case Presentation

History and Physical
A 77-year-old obese Caucasian male presented to the emergency department (ED) with a sudden onset of lower chest and epigastric pain and collapse after lifting a heavy object while working on his ranch. Per his wife, the patient was a previously healthy and active individual who had recently lose fifty pounds with diet and exercise. The patient had a past medical history of gastroesophageal reflux disease (GERD), hyperlipidemia, diabetes, and hypertension. He was a smoker from age fifteen to sixty, stopping seventeen years ago. The patient also had a history of alcohol abuse, but had been sober since the mid-1970s. On arrival to the ED, the patient was alert, but somnolent, pale, and in moderate distress.