The initial ECG (figure 1A) demonstrates a regularly irregular rhythm at approximately 80bpm. There is a profound first-degree atrioventricular(AV) block with a PR interval of over 400ms. There is monomorphic ventricular ectopy in a right bundle branch pattern. The baseline QRS complexes are narrow.
Abnormal cardiac conduction in a septic patient: incidental finding or cause for concern? Read More
Both hyper and hypovolaemia have been associated with poor outcomes. Assessment of fluid responsiveness is challenging in the acute medical patient, due to time constraints, limited evidence and quite often the lack of accurate assessment tools on the Acute Medicine Unit (AMU). This article explains how focused echo assessment is quick and easy to use for this purpose on the acute medical take and highlights key principles to bear in mind when assessing for hypovolaemia and whether to administer fluid therapy. The increasing familiarity with focused echo such as Focused Intensive Care Echocardiography (FICE) and Point Of Care Ultrasound (POCUS) makes extension of these skill sets to assess for fluid responsiveness a relatively straightforward next step for acute physicians.
Deep vein thrombosis (DVT) is an important cause of short-term mortality and long-term morbidity. Among the different presentations of DVT, thrombus in the iliofemoral veins may be considered the severest form. Although anticoagulation is the mainstay of the management of iliofemoral thrombosis, despite adequate anticoagulant treatment, complications including post-thrombotic syndrome is not uncommon. The latter is often overlooked but can cause considerable morbidity to the affected individuals. Preventing this condition remains a challenge but recent clinical trials of catheter directed thrombolysis and elasticated compression stockings provide some advance in this context. In this article, with the aid of a clinical case, we review the particular considerations to take into account when managing patients with an iliofemoral DVT.
Iliofemoral deep vein thrombosis and the problem of post-thrombotic syndrome Read More
A 64-year-old male presents to the emergency department in acute respiratory distress. He gives a limited history of progressive shortness of breath of one week’s duration and several episodes of sudden unexplained syncope. There was no history of chest pain, palpitations or localising symptoms of infection. He takes no regular medications.
Abnormal cardiac conduction in a septic patient: incidental finding or cause for concern? Read More
Abstract
Olanzapine is an antipsychotic drug used in psychiatric diseases. At high doses it exhibits cardiovascular and neurological sideeffects in particular. Lipid emulsion therapy for the removal of medication from plasma in high-dose lipophilic drug use has recently become very widespread. In the light of current literature, this report discusses the successful treatment of a patient within 4 hrs of olanzapine overdose as an attempted suicide, who presented with agitation and clouded consciousness
Successful intravenous lipid emulsion therapy: Olanzapine intoxication Read More
Abstract
Treatment of human immunodeficiency virus(HIV) in cancer patients improves outcomes and reduces transmission of this oncogenic virus. HIV testing rates of cancer patients are similar to the general population (15-40%), despite the association with cancer. Our aim was to increase HIV screening in the Emergency Department(ED) of a comprehensive cancer center through a quality initiative. Testing increased significantly during the intervention (p<0.001; 0.15/day to 2.69/day). Seropositive HIV rate was 1.4% (12/852), with incidence of 0.3%. All patients were linked to care. Incident cases were between 36 and 55 years of age. Barriers encountered included confusion regarding the need for written consent for HIV testing, failure to consider ordering the test, and concerns regarding linkage to care.
Routine HIV Screening in Cancer Patients in the Emergency Department Read More
Abstract
Readmissions are treated as adverse events in many healthcare systems. Causes can be physiological deterioration or breakdown of social support systems.
We investigated data from a European multi-centre study of readmissions for changes in vital signs between index admission and readmission. Data sets were graded according to the National Early Warning Score (NEWS).
Of 487 patients in whom NEWS could be calculated on discharge and again on re-admission, 39.6% had worse vital signs with a NEWS score difference ≥ 2 points while only 7.6% had improved by ≥ 2 points. Changes in individual vital signs of 20% or more were most common in respiratory rate and heart rate.
Monitoring of respiratory rate and pulse rate post-discharge might predict some deteriorations.
Abstract
The aims of this retrospective cohort study were to retrieve characteristics and outcomes of older (65+) medical patients who are directly admitted to ICU from the ED and to compare these with those admitted to ICU from a ward.
Of 1396 patients, 21 (1.5%) were directly admitted to ICU and 54 (3.9%) after a delay. Blood pressure was lower and respiratory rate higher in the direct than in the delayed group. The direct group had lower mortality (28-day: 19.0 vs.
38.9%, p=0.14; 1-year: 42.9 vs. 66.7%; p=0.06), shorter length-of-stay and returned more frequently to independent living than the delayed group.
Only a fraction of older patients are admitted to ICU; directly admitted patients tend to have better outcomes.
Direct and delayed admissions to ICU in older medical patients Read More
Abstract
Time and resource constraints have often led to the use of assessment records as discharge communications from acute and emergency departments. However, whether this addresses the primary care needs has not been demonstrated. This study examined the optimal structure that can impart key discharge information effectively using feedback from general practitioners (GP). We implemented an electronic assessment template that focused on the most relevant headings. Prespecified process measures were examined and qualitative thematic analysis of free-text comments from GP surveys were conducted to optimise the document. Our findings suggest that the structure of a discharge summary can influence the quality of information, users’ compliance and readers’ perceptions of the length of the letter.
Abstract
Background: There is an increased influx of patients needing admission. Introducing an acute medical unit (AMU) may increase the admission capacity without increasing the total number of beds.
Methods: Data collected during the first four years after implementation of an AMU in an academic tertiary care center in Amsterdam were analyzed.
Results: A 24 bed unit was realized. The total number of admissions increased in the first year with 977 (16%), with an additional 4.1% increase after 2 years with stabilization thereafter. The length of stay decreased, the absolute number of refusals declined, the number of readmissions remained unchanged.
Conclusion: Introduction of AMUs in overcrowded services could be beneficial in improving the strain on the acute healthcare systems
Results on patient flow of implementing an Acute Medical Unit Read More