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Evaluation and outcomes of patients with palpitations
The Journal of Emergency Medicine
32%). ST elevation or depression was found significantly more often in men than in women. Men were more likely to have lactate dehydrogenase isoenzymes and creatine kinase-MB levels evaluated and were more likely to receive an emergency cardiology consult, nitroglycerin, aspirin, heparin, and thrombolytic agents. Women were more likely to receive controlled substances and anxiolytics. After treatment in the ED, 11 men (7.6%) and 4 women (2.4%) were admitted to the intensive care unit, and 35 men (24%) and 29 women (17.5%) to the cardiac step-down unit. Of all patients, 14 men (9.7%) and 4 women (2.4%) had a discharge diagnosis of myocardial infarction. The authors conclude that, although coronary artery disease is the number one causeof mortality in women, those with new-onset chest pain who present with similar symptoms as men are approached, diagnosed, and treated less aggressively than are men. [Christy M. Rosa, MD] Editor’s comment: Women also had IO fewer MIS in this study, and twice as many presented with pleuritic pain. Historical features that may have led to a change in management were not analyzed.
cl EVALUATION AND OUTCOMES OF PATIENTS WITH PALPITATIONS. Weber BE, Kapoor WN. Am J Med. 1996;100:138-48. This prospective cohort study examines the etiologies and recurrence rates of palpitations and the outcomes of patients with palpitations. One hundred ninety patients presenting with the chief complaint of palpitations were enrolled, and I-yr follow up was obtained in 96% of the patients. An etiology of palpitations was determined in 84% of the patients: 43% were cardiac, 31% psychiatric, and 10% were grouped as “miscellaneous” (medication, illicit drugs, stimulants, thyrotoxicosis). The etiology was not determined in 16% of the patients. Thirty-five percent of the etiologies were determined solely by history, physical examination, and electrocardiogram. Laboratory data contributed to only 3% of the etiologies. The 1-yr mortality rate was 1.6% and the I -yr stroke rate was 1.1%. Patients experienced recurrent palpitations within the first year in 75% of the cases. [Greg W. Lampe, MD] Editor’s comment: Psychiatric illness accounts for the etiology in approximately one-third of the patients. The short-term prognosis of patients with palpitations is excellent. with low rates of death and stroke at 1 yr, but with a high rate of recurrence.
cl TICK PARALYSIS-WASHINGTON, 1995. MMWR. 1996;45( 16):325-7 Tick paralysis is one of the eight most common tick-borne diseases and can mimic other neuromuscular disorders. A 2-yr-old girl presented to a local emergency department with symptoms of unsteady gait, difficulty standing, and reluctance to walk. She had no other recent history. Physical
examination revealed a decreased ability to stand, truncal and extremity weakness, and diminished reflexes. After admission, a nurse noted an engorged tick by her ear. Within 7 h of removal of the tick, strength had itnproved and the patient made a complete recovery. Tick paralysis is caused by the introduction of neurotoxin from several species of tick and causes a symmetric paralysis. It is most common in the Rocky Mountain states and the northwest. Most cases are reported in girls under the age of 10 in the months of April-June. The disease can be fatal if the tick is not found prior to the progression to respiratory failure. The tick should be removed carefully, ensuring that the mouth parts are not left imbedded in the skin. Prevention includes use of skin repellents and examination for the presence of ticks aftct. [Edward A Walton. MD ] outdoor exposure. Editor’s comment: The risk is greatest in rural areas,and in many cases a careful examination must he performed to reveal the tick.
0 A DOUBLE-BLIND CLlNICAL TRIAL COMPARING WORLD HEALTH ORGANIZATION ORAL REHYDRATION SOLUTION WITH A REDUCED OSMOLARITY SOLUTTON CONTAINING EQUAL AMOUNTS OF SODIUM AND GLUCOSE. Santosham M, Fayad I, Zikri MA, et al. J Pediatr. 1996: 12X:45-51. The World Health Organization (WHO) has for many years recommended oral rehydration solution IORS) for treatment of acute diarrhea in children. Concern has risen. however. that the ORS can cause hypernatremia: thus, this study examined the efficacy of reduced osmolarity ORS in Egyptian children treated for diarrhea. In this randomized. double-blind study, 190boys aged l-24 months were treated either with standard ORS (311 mmol/L) or reduced osmolarity ORS (245 mmol/L). Those treated with reduced osmolarity ORS had 36% lower mean stool output and significantly less risk of vomiting during the rehydration phase. During the maintenance phase, oral intake, stooi output. urine output, and weight gain were similar in the two groups. Treatment failure rate (the need for intravenous fluids ) was significantly higher in children given WHO ORS. Although sodium levels at 24 h were significantly lower in those receiving reduced osmolarity ORS, these children did not have a higher risk of developing hyponatremia. Overall, the reduced osmolarity ORS has a role in treatment of acute diarrhea as less stool output and vomiting occurs. and patients are less likely to need intravenous treatment. Editor’s comment: This reduced osmolarity solution may prove to be useful if these findings are confirmed in thih country.
0 INJURIES TO CHILDREN RELATED TO SHOPPING CARTS. Smith GA. Dietrich AM, Garcia CT. et al. Pediatrics. 1996;97: 161-5. The authors report their experience with 62 children treated for shopping cart injuries over ;I 15-month period
32%). ST elevation or depression was found significantly more often in men than in women. Men were more likely to have lactate dehydrogenase isoenzymes and creatine kinase-MB levels evaluated and were more likely to receive an emergency cardiology consult, nitroglycerin, aspirin, heparin, and thrombolytic agents. Women were more likely to receive controlled substances and anxiolytics. After treatment in the ED, 11 men (7.6%) and 4 women (2.4%) were admitted to the intensive care unit, and 35 men (24%) and 29 women (17.5%) to the cardiac step-down unit. Of all patients, 14 men (9.7%) and 4 women (2.4%) had a discharge diagnosis of myocardial infarction. The authors conclude that, although coronary artery disease is the number one causeof mortality in women, those with new-onset chest pain who present with similar symptoms as men are approached, diagnosed, and treated less aggressively than are men. [Christy M. Rosa, MD] Editor’s comment: Women also had IO fewer MIS in this study, and twice as many presented with pleuritic pain. Historical features that may have led to a change in management were not analyzed.
cl EVALUATION AND OUTCOMES OF PATIENTS WITH PALPITATIONS. Weber BE, Kapoor WN. Am J Med. 1996;100:138-48. This prospective cohort study examines the etiologies and recurrence rates of palpitations and the outcomes of patients with palpitations. One hundred ninety patients presenting with the chief complaint of palpitations were enrolled, and I-yr follow up was obtained in 96% of the patients. An etiology of palpitations was determined in 84% of the patients: 43% were cardiac, 31% psychiatric, and 10% were grouped as “miscellaneous” (medication, illicit drugs, stimulants, thyrotoxicosis). The etiology was not determined in 16% of the patients. Thirty-five percent of the etiologies were determined solely by history, physical examination, and electrocardiogram. Laboratory data contributed to only 3% of the etiologies. The 1-yr mortality rate was 1.6% and the I -yr stroke rate was 1.1%. Patients experienced recurrent palpitations within the first year in 75% of the cases. [Greg W. Lampe, MD] Editor’s comment: Psychiatric illness accounts for the etiology in approximately one-third of the patients. The short-term prognosis of patients with palpitations is excellent. with low rates of death and stroke at 1 yr, but with a high rate of recurrence.
cl TICK PARALYSIS-WASHINGTON, 1995. MMWR. 1996;45( 16):325-7 Tick paralysis is one of the eight most common tick-borne diseases and can mimic other neuromuscular disorders. A 2-yr-old girl presented to a local emergency department with symptoms of unsteady gait, difficulty standing, and reluctance to walk. She had no other recent history. Physical
examination revealed a decreased ability to stand, truncal and extremity weakness, and diminished reflexes. After admission, a nurse noted an engorged tick by her ear. Within 7 h of removal of the tick, strength had itnproved and the patient made a complete recovery. Tick paralysis is caused by the introduction of neurotoxin from several species of tick and causes a symmetric paralysis. It is most common in the Rocky Mountain states and the northwest. Most cases are reported in girls under the age of 10 in the months of April-June. The disease can be fatal if the tick is not found prior to the progression to respiratory failure. The tick should be removed carefully, ensuring that the mouth parts are not left imbedded in the skin. Prevention includes use of skin repellents and examination for the presence of ticks aftct. [Edward A Walton. MD ] outdoor exposure. Editor’s comment: The risk is greatest in rural areas,and in many cases a careful examination must he performed to reveal the tick.
0 A DOUBLE-BLIND CLlNICAL TRIAL COMPARING WORLD HEALTH ORGANIZATION ORAL REHYDRATION SOLUTION WITH A REDUCED OSMOLARITY SOLUTTON CONTAINING EQUAL AMOUNTS OF SODIUM AND GLUCOSE. Santosham M, Fayad I, Zikri MA, et al. J Pediatr. 1996: 12X:45-51. The World Health Organization (WHO) has for many years recommended oral rehydration solution IORS) for treatment of acute diarrhea in children. Concern has risen. however. that the ORS can cause hypernatremia: thus, this study examined the efficacy of reduced osmolarity ORS in Egyptian children treated for diarrhea. In this randomized. double-blind study, 190boys aged l-24 months were treated either with standard ORS (311 mmol/L) or reduced osmolarity ORS (245 mmol/L). Those treated with reduced osmolarity ORS had 36% lower mean stool output and significantly less risk of vomiting during the rehydration phase. During the maintenance phase, oral intake, stooi output. urine output, and weight gain were similar in the two groups. Treatment failure rate (the need for intravenous fluids ) was significantly higher in children given WHO ORS. Although sodium levels at 24 h were significantly lower in those receiving reduced osmolarity ORS, these children did not have a higher risk of developing hyponatremia. Overall, the reduced osmolarity ORS has a role in treatment of acute diarrhea as less stool output and vomiting occurs. and patients are less likely to need intravenous treatment. Editor’s comment: This reduced osmolarity solution may prove to be useful if these findings are confirmed in thih country.
0 INJURIES TO CHILDREN RELATED TO SHOPPING CARTS. Smith GA. Dietrich AM, Garcia CT. et al. Pediatrics. 1996;97: 161-5. The authors report their experience with 62 children treated for shopping cart injuries over ;I 15-month period