J Emerg Med
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McKesson's InterQual criteria are widely used in hospitals to determine if patients should be classified as observation or inpatient status, but the accuracy of the criteria is unknown. ⋯ In older adults with syncope, those who met InterQual criteria for inpatient status had longer LOS compared with those who did not; however, the accuracy of the criteria to predict length of stay over 2 days is poor, with a sensitivity of 60% and a specificity of 48%. Future research should identify criteria to improve LOS prediction.
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Venous thoracic outlet syndrome (VTOS) results from compression and thrombosis of the axillosubclavian vein. In primary effort thrombosis, a subtype of VTOS, chronic repetitive compression injury of the axillosubclavian vein leads to scarring, stenosis, and eventually, thrombosis. This is a rare manifestation of an upper extremity deep vein thrombosis. ⋯ A 23-year-old male student without significant past medical history presented to our Emergency Department with a complaint of intermittent swelling and discoloration of his upper right arm. His symptoms had been present for the past year and had worsened over the past few weeks. Swelling was associated with overhead use of the arm. There is no family history of clotting disorders. A computed tomography angiogram of the chest with upper extremity runoff showed findings consistent with VTOS. The patient was discharged with an urgent referral to Vascular Surgery. Within 2 weeks, he underwent multiple surgical procedures and was initiated on anticoagulation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VTOS usually presents in patients who do not have commonly recognized prothrombotic risk factors. Emergency physicians should include this diagnosis in their differential because good functional outcomes rely on early diagnosis and prompt initiation of treatment. In addition, emergency physicians must refer these patients to vascular surgeons, as most will require surgical management.
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Flecainide is a class Ic antidysrhythmic agent used to prevent and treat both ventricular and supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, and Wolff-Parkinson-White syndrome. Flecainide can cause serious side effects, including cardiac arrest, dysrhythmias, and heart failure. Despite its growing use, the presenting signs and symptoms of flecainide toxicity are not familiar to most clinicians. In particular, our patient's particular presentation of acute kidney injury (AKI) resulting in flecainide accumulation is high risk for missed diagnosis in the emergency department. ⋯ A 58-year-old woman presented with altered mental status and hypoxia that was later found to be secondary to sepsis. Medical history was notable for atrial fibrillation, for which she was on flecainide. Laboratory results were notable for hypokalemia and an AKI. Her wide complex tachycardia on admission was ultimately attributed to flecainide toxicity in the setting of AKI. Six days after presentation, it was found that her flecainide level was in the toxic range at 2.02 μg/mL (normal range 0.20-1.00 μg/mL, toxic >1.50 μg/mL). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Flecainide intoxication is rare but serious due to the potential for cardiogenic shock. Its diagnosis can be difficult, as the flecainide serum level may take days to result. This case demonstrates the necessity of keeping flecainide toxicity on the physician's differential for patients who are taking the drug, as well as what electrocardiogram findings suggest it as the etiology. Treatment can be lifesaving if initiated promptly.