Introduction: ST-elevation myocardial infarction (STEMI) presenting to the ED is a significant health burden. The provision of IV morphine with doses titrated to provide comfort is recommended in the AHA STEMI Guidelines, yet there is limited evidence of safety in this setting. The primary objective of this study was to measure potential harm associated with the provision of IV morphine in STEMI patients presenting to the ED. Methods: This was a two centre retrospective chart review from an urban, inner city, academic ED with an annual census of 85,000 visits, and an affiliated community hospital with 35,000 annual visits. Consecutive patients from April 2009 to January 2015 presenting to the 2 EDs with a diagnosis of STEMI were identified in the ED database. Eight trained research assistants, blinded to the study hypothesis, used standardized data collection templates. The primary investigator double collected 20% of all data to ensure completeness and accuracy. Results: We included 311 patients with STEMI (124 received morphine [M]; 187 no morphine [nM]). The ages of the two groups were similar (mean 64 yrs [M] & 67 yrs [nM]; median 63 yrs [M] & 66 yrs [nM]; IQR 45-81 [M] and 45.5-86.5 [nM]); as were the proportion of female patients (21.0% [M] & 23.5% [nM]. The pre-STEMI Charlson comorbidity scores (mean 2.6), median time to first ECG (11 min [M] & 16 min [nM]), and mean time-to-needle for PCI (96.8 min [M] & 92.0 min [nM]) were similar between groups. The mean CCU length of stay (LOS) (9.3 days vs 6.3 days) and hospital LOS (7.4 days vs 4.6 days) were longer for patients receiving morphine than those not receiving morphine. Rates of congestive heart failure, acute kidney injury and cardiac arrest in hospital were unchanged between the groups. Unadjusted mortality was similar (10.5% [M] vs 13.3% [nM]) between groups. Binary logistic regression controlling for age, Charlson score, first and peak troponin values demonstrated an association between receiving morphine in the ED and an increased risk of death at 30 days (OR 8.1; 95% CI 7.1.-9.1). Conclusion: The provision of morphine to patients with STEMI in the ED may be associated with increased CCU and hospital LOS. When controlling for age, pre-STEMI Charlson score, first and peak troponin values, receiving morphine was associated with an increased risk of death at 30 days. Further research to elucidate this association is warranted.

Introduction: It is well established that a negative D-dimer will reliably rule out thromboembolism in selected low risk patients. Multiple modified D-dimer cutoffs have been suggested for older patients to improve diagnostic specificity. However, these approaches are better established for pulmonary embolism than for deep venous thrombosis (DVT). This study will evaluate the diagnostic performance of previously suggested D-dimer cutoffs for low risk DVT patients in the ED, and assess for a novel cutoff with improved performance. Methods: This health records review included patients >50 years with suspected DVT who were low-risk and had a D-dimer performed. Our analysis evaluated the diagnostic accuracy of D-dimer cutoffs of 500 and the age adjusted (age x 10) rule for patients >50 years; and 750, and 1,000 cutoffs for patients >60 years. 30-day outcome was a diagnosis of DVT. We also assessed the diagnostic accuracy for a novel cutoff (age x 12.5). Results: 1,000 patients (mean age 68 years; 59% female) were included. Of these, 110 patients (11%) were diagnosed with DVT. The conventional cutoff of <500 µg/L demonstrated a sensitivity of 99.1% (95% CI 95.0-99.9) and a specificity of 36.4% (95% CI 33.2-39.7). For patients >60 years, the absolute cutoffs of 750 and 1,000 showed sensitivity of 98.7% (95% CI, 92.9, 99.9), and the specificity increased to 48.6% (95% CI, 44.5-52.8%) and 62.1% (95% CI, 58.1-66.1%) respectively. For all study patients, age adjusted D-dimer demonstrated a sensitivity of 99.1% (95% CI 95.0-99.9) and a specificity of 51.2% (95% CI, 47.9-54.6). A novel age adjusted cutoff (age x 12.5) for patients >50, demonstrated a sensitivity of 97.3% (95% CI 92.2-99.4) and a specificity of 61.2% (95% CI 58.0-64.5). When compared to conventional cutoff, the age adjusted cutoffs (age x 10 and age x 12.5) would have resulted in an absolute decrease in further investigations of 13.1% and 22.2%, respectively, with false negative rates of 0.1% and 0.3%. Conclusion: Among older patients with suspected DVT and low clinical probability, the age adjusted D-dimer increases the proportion of patients among whom DVT can be ruled out. A novel cutoff (age x 12.5) demonstrated improved specificity. Future large scale prospective studies are needed to confirm this finding and to explore the cost savings of these approaches.

We present a rare case of a young patient with chest pain whose ascending thoracic aortic aneurysm (TAA) was detected by point-of-care ultrasound (POCUS) leading to a successful surgical repair. POCUS identified a moderate pericardial effusion and an associated severely dilated ascending aorta. In this context, it is important to rule out aortic rupture and aortic dissection. We also discuss the epidemiology, complications, and management of TAAs as well as the role of cardiac POCUS in the diagnosis of thoracic aneurysmal disease.

Herpes zoster, commonly called shingles, is a disease that results from the reactivation of varicella zoster virus. Local trauma has been reported as a precipitant for reactivation, but this condition is rarely seen localized to a fresh surgical incision. We present the case of a patient who developed shingles overlying the incision site of a recently buried central venous access port, illustrating the need to consider this diagnosis as a unique imposter of localized infection or reaction at sites of recent procedural trauma.

Introduction: Point of care ultrasonography (PoCUS) is an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown rule out certain shock etiologies, and improve diagnostic certainty, however evidence on benefit in the management of hypotensive patients is limited. We report the findings from our international multicenter RCT assessing the impact of a PoCUS protocol on diagnostic accuracy, as well as other key outcomes including mortality, which are reported elsewhere. Methods: Recruitment occurred at 4 North American and 3 Southern African sites. Screening at triage identified patients (SBP<100 mmHg or shock index >1) who were randomized to either PoCUS or control groups. Scans were performed by PoCUS-trained physicians. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. Final chart review was blinded to initial impressions and PoCUS findings. Categorical data was analyzed using Fishers two-tailed test. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. The perceived shock category changed more frequently in the PoCUS group 20/127 (15.7%) vs. control 7/125 (5.6%); RR 2.81 (95% CI 1.23 to 6.42; p=0.0134). There was no significant difference in change of diagnostic impression between groups PoCUS 39/123 (31.7%) vs control 34/124 (27.4%); RR 1.16 (95% CI 0.786 to 1.70; p=0.4879). There was no significant difference in the rate of correct category of shock between PoCUS (118/127; 93%) and control (113/122; 93%); RR 1.00 (95% CI 0.936 to 1.08; p=1.00), or for correct diagnosis; PoCUS 90/127 (70%) vs control 86/122 (70%); RR 0.987 (95% CI 0.671 to 1.45; p=1.00). Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We found that the use of PoCUS did change physicians’ perceived shock category. PoCUS did not improve diagnostic accuracy for category of shock or diagnosis.

Introduction: The “chain of survival” is a 5-link theoretical construct that has been central to cardiac arrest resuscitation for over 40 years. Although the role of each link has been extensively studied, little is known about the impact of performing the chain of survival in sequence. The purpose of this study was to estimate the proportion of out-of-hospital cardiac arrest (OHCA) responses by Emergency Medical Services (EMS) that had an intact chain of survival sequence response, and the effect of this on survival to hospital discharge. Methods: We conducted a prospective cohort study of adult (>age 20 years) OHCA patients using data collected between 2005-2007 by the Resuscitation Outcomes Consortium (ROC). ROC is a research network involving 10 research sites and 264 EMS agencies across North America. Using routinely collected data, we coded cases as receiving an intact or non-intact chain of survival sequence based on EMS cardio pulmonary resuscitation (CPR), rhythm analysis or defibrillation, epinephrine administration or endotracheal intubation, and transport to a hospital with an electrophysiology lab or percutaneous coronary intervention capability, contingent on the patient’s condition when EMS arrived. Multiple variable logistic regression was performed, adjusting for known (Utstein) survival predictors, to estimate the independent effect of intact chain of survival sequence on survival to hospital discharge. REB approval was obtained. Results: We enrolled12,821 OHCA cases, of which, 29.4% (n=3,773) had an intact chain of survival and 7.6% (n=972) survived to hospital discharge. Cases with an intact chain of survival were younger, and more likely to arrest in public, receive bystander CPR, occur in the USA and specific ROC sites, and had faster EMS response times. The adjusted odds ratio of survival to hospital discharge with an intact chain of survival sequence was 2.4 (95% CI: 2.1-2.8). A sensitivity analysis of 4,056 cases with known timing of endotracheal intubation found a similar adjusted odds ratio of 2.1 (95% CI: 1.6-2.8). Conclusion: Our results indicate that OCHA resuscitation with an intact chain of survival occurs in approximately 1/3 of cases, and results in over a two-fold increase in the odds of surviving to hospital discharge. Initiatives to improve EMS teamwork and increase the proportion of OHCA resuscitation with an intact chain of survival appear to be warranted.