Sandy Schneider, MD, FACEP
ACEP Associate Executive Director, Practice, Policy and Academic Affairs

ACEP would like to provide you with very brief synopses of the latest articles in Annals of Emergency Medicine. Some of these have not appeared in print. These synopses are not meant to be thorough analyses of the articles, simply brief introductions. Before incorporating into your practice, you should read the entire articles and interpret them for your specific patient population. 


Title: ECG predictors of cardiac arrhythmias in older adults with syncope
Authors: Nishijima DK, Lin AL, Weiss RE, et al

This paper looks at elderly patients with syncope. About 5% of such patients had a serious arrhythmia in the ED. Another 3% had a serious arrhythmia within 30 days. Several ECG abnormalities were associated with increased risk including abnormal rhythm, multiple PVCs, short PR, first degree AVB, LBBB, and Q/ST/T segment abnormalities consistent with ischemia.


Title: Measurement under the Microscope: High Variability and Limited Construct Validity in ED Patient Experience Scores
Authors: Pines JM, Penninti P, Alfaraj S, et al

Many of our institutions use patient satisfaction scores to evaluate their emergency physicians. This paper demonstrates what most of us know. The authors looked at patient satisfaction scores from 2012-15 across 42 facilities and 242 physicians. There is wide variability in an individual’s scores from month to month making individual values problematic. There was less variation in the facility scores from month to month.


Title: Change in Lactate Levels after Hemodialysis in Patients with End-Stage Renal Disease
Authors: Hourmozdi JJ, Gill J, Markin A, et al.
And the editorial
Title: Lactate Levels in Patients Receiving Hemodialysis: A Confounder in the Assessment of Infected Patients
Authors: Puskarich MA, Jones AE.

This paper and the accompanying editorial discuss the issue of elevated lactate in patients in patients with end stage renal disease on regular hemodialysis. They found routine elevation of lactate to 1.8 on average. This can create confusion when assessing such a patient for sepsis where a lactate of 2 is the CMS threshold for sepsis. Of note, none of the patients without infection had a lactate over 4. A lactate of 4 or above should raise strong suspicion in such patients.


Title: Outpatient Management of Emergency Department Patients with Acute Pulmonary Embolism: Variation, Patient Characteristics and Outcomes
Authors list: Vinson DF, Ballard DW, Huang J, et al.

Many of us have started discharging stable patients with small PE home from the ED. This paper examines a group of 2,387 patients with proven PE, 179 were discharged home (7.5%). The percentage of patients discharged home varied by institution from 0% to 14.3%. Patients who arrived by ambulance or had abnormal vital signs, syncope or pre-syncope, DVT, positive troponins or large proximal emboli were less likely to be discharged from the ED. Only a small percentage of patients (<10%) returned to the ED with PE related issues. Hemorrhage and recurrent VTE were uncommon and similar to the group that was hospitalized. Because these patients tended to be less ill, there was lower mortality in the discharged group.


Title: A Systematic Review and Meta-analysis of the Management and Outcomes of Isolated Skull Fractures in Children
Authors: Bressan S, Marchetto L, Lyons TW et al.

This is a meta analysis of children with isolated skull fractures. The paper supports that practice that asymptomatic children with isolated skull fractures can be safely managed as outpatients if there are no other clinical concerns.


Title: Impact of Automated Prescription Drug Monitoring Program Queries on Emergency Department Opioid Prescribing
Authors: Sun BC, Charlesworth CJ, Lupulescu-Mann N, et al.

This study reviewed over 1 M visits and showed that accessing a prescription monitoring data system did not change the number of opioid prescriptions written in the ED.