Cardiology clinics
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Acute heart failure and cardiogenic pulmonary edema is a common cause of respiratory distress among patients presenting to the emergency department. The emergency department is frequently the primary entry point into the health care system for these patients and is the site of initial stabilization, evaluation, and management of the patient. Emergency physicians, alongside cardiologists, play a critical role as these patients are treated in the emergency department and transferred to the cardiac ICU. The approach to the critically ill patient who has heart failure should be multidisciplinary and involve the emergency physician and the cardiologist who will care for the patient.
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Failure to diagnose patients who have acute coronary syndromes (ACSs)-either acute myocardial infarction (AMI) or unstable angina pectoris (UAP)-who present to the emergency department (ED) remains a serious public health issue. Better understanding of the pathophysiology of coronary artery disease has allowed the adoption of a unifying hypothesis for the cause of ACSs: the conversion of a stable atherosclerotic lesion to a plaque rupture with thrombosis. Thus, physicians have come to appreciate UAP and AMI as parts of a continuum of ACSs. This article reviews the state of the art regarding the diagnosis of ACSs in the emergency setting and suggests reasons why missed diagnosis continues to occur, albeit infrequently.
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Medical errors in the care of patients who present with acute coronary syndrome (ACS)include errors in emergency department (ED) triage, such as the decision to send home a patient who presents with ACS or to hospitalize a patient who does not have ACS to the cardiac care unit (CCU), and errors in treatment, such as the failure to promptly use reperfusion therapy for patients who present with ST-elevation acute myocardial infarction(AMI). ECG-based acute cardiac ischemia time-insensitive predictive instrument(ACI-TIPI) and thrombolytic predictive instruments (TPIs), with a linked TIPI information system (TIPI-IS), provide real-time, concurrent, and retrospective decision support tools and feedback for the prevention of medical errors in the care of patients who present with ACS. In real-time, ACI-TIPI probabilities printed on the ECG header for the ED physician, provide an additional piece of information for triage decision making, and the ACI-TIPI Risk Management form reduces liability risk by prompting consideration and documentation of key clinical factors in the diagnosis of ACI. ⋯ Concurrent flagging by TIPI-IS uses electronically acquired ECG and hospital data to provide concurrent alerts about potential misdiagnosis or mis-triage of patients with ACS. Retrospectively TIPI-IS-based feedback reports allow performance improvement. These examples of information technology tools integrated into ECG equipment already used in hospitals to deliver patient care demonstrate the potential to adapt other existing equipment or other patient care activities to enhance patient safety and error reduction.
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Acute decompensated heart failure (ADHF) is a complex disease of epidemic proportions. In the United States, it accounts for more than 1 million hospitalizations annually,and heart failure represents the single greatest cost to the Centers for Medicaid and Medicare Studies. Half of the annual costs are estimated to be the result of hospitalization. ⋯ Validated protocols have demonstrated that in ADHF, intensive short-term therapeutic, diagnostic, and educational protocols result in a marked improvement in hospitalization rates, while at the same time decreasing costs. New risk stratification data can aid in the identification of the appropriate candidate. The observation unit now represents a nonhospitalization disposition option for patients presenting to the emergency department with ADHF.viii CO
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Patency of the foramen ovale is a risk factor for DCS in SCUBA divers, even if they adhere to the currently accepted and used decompression tables. The primary cause of DCS, however, is the nitrogen bubble, not the PFO. There are a number of techniques any diver can use to minimize the occurrence of nitrogen bubbles after a dive. ⋯ In the meantime, PFO remains a reason for caution. Whether all divers should be screened for PFOis an ongoing discussion [50] in view of methodologic and practical issues outlined in this article. Any definitive recommendations can be made only after a careful, prospective evaluation of the real relative risk for DCS and long-term cerebral damage.