Atrial flutter with flecainide-induced 1:1 conduction at a rate <200bpm at rest: a case report

Background Class IC antiarrhythmic drug flecainide is commonly used in the management of atrial arrhythmias and in particular atrial fibrillation (AF). Although previously reported as a potential complication, atrial flutter (AFL) with 1:1 atrioventricular conduction is rare, with only few cases reported so far, most of which related to physical activity. In all previous reported cases, 1:1 conduction resulted in ventricular rates of more than 200 b.p.m. Case Summary We report the case of a 60 year old woman, who presented to our local emergency department with palpitations related to acute onset AF. The patient developed symptomatic 1:1 AFL with a rate of 192 b.p.m., shortly after administration of intravenous flecainide, which spontaneously converted back to AF and subsequently to sinus rhythm, with further administration of amiodarone and beta blocker. Discussion The case raises awareness of this rare but potentially life threatening complication to those using flecainide for pharmacological cardioversion of AF. QRS complex widening can be seen in the context of very rapid ventricular rates, posing additional diagnostic challenge, especially with rates of less than 200 b.p.m. Prescribing an AV nodal blocking agent, such as a beta-blocker, together with flecainide reduces significantly the risk of 1:1 conduction and should always be considered.

The impact of the COVID-19 pandemic on referrals to liaison psychiatry services at University Hospital Hairmyres, NHS Lanarkshire

AimsThe COVID-19 pandemic has led to sweeping public health restrictions with predictable impact on mental health. In Scotland, lockdown measures during the first wave of the pandemic commenced on 23rd March 2020 and only began to ease after 29th May 2020. The aim of this study was to evaluate the impact of the first wave of the COVID-19 pandemic on the number and type of referrals made to the adult psychiatric liaison nursing service (PLNS) at University Hospital Hairmyres, NHS Lanarkshire.MethodWe collated all of the archived referrals made by our local emergency department to the PLNS at University Hospital Hairmyres for adults (aged 18–65 years) during the period of the first COVID-19 national lockdown (April-July 2020) and the corresponding period one-year prior (April-July 2019) to analyse differences in referral numbers and demographics. Additionally, for referrals made during 2020, we conducted a qualitative review of electronic records to determine the reason for referral, contributory stressors to presentation, and in particular any effect from COVID-19.ResultA total of 549 referrals were made over the study period, with 320 in 2019 and 229 in 2020, a decrease of almost 30%. In 2019, referrals fell each month from April (n = 89) to July (n = 74), while this trend was reversed in 2020, rising from April (n = 45) to near-usual levels by July (n = 68). Compared to baseline, referrals in April 2020 were for a higher proportion of men (62.2%). On qualitative analysis, 26 records (11.3%) could not be found. Otherwise, the most common reasons for referral were suicidal ideation (43.3%) and/or deliberate self-harm (39.9%). Many patients presented with comorbid substance misuse (54.2%) and the majority were not known to community services (64.5%). COVID-19 was implicated in 48 referrals (23.6%), but only 2 of these arose as a direct result of infection.ConclusionWe have observed clear differences in the pattern of referrals made to the adult PLNS during the first COVID-19 national lockdown. COVID-19 was implicated in a minority of referrals, but most were related to secondary effects of lockdown restrictions rather than COVID-19 infection. Possible reasons for fewer referrals during this time could be non-presentation through fears of contracting COVID-19 or altruistic avoidance of putting “pressure on the NHS”. Further studies would be insightful; in particular, equivalent analysis of contacts with community services; and qualitative patient perspectives regarding reasons for non-presentation during this time.

Metronidazole, an Uncommon Cause of Dizziness and Ataxia in the Emergency Department: A Case Report

Introduction: Metronidazole, a nitroimidazole antibiotic, is a well-known antibacterial and antiprotozoal agent that is generally well tolerated without many serious side effects. Most adverse reactions affect the gastrointestinal or genitourinary system, but the central nervous system may also be afflicted. In addition to headache and dizziness, cerebellar dysfunction can occur with metronidazole use. Case Report: We discuss the clinical presentation and imaging findings of metronidazole-induced encephalopathy in a 12-year-old male. The patient had a history of Crohn’s disease and chronic Clostridium difficile infection for which he had received metronidazole for approximately 75 days prior to arrival to a local emergency department (ED). He presented with five days of progressive vertigo, nausea, vomiting, and ataxia. Subsequent magnetic resonance imaging showed symmetric hyperintense dentate nuclei lesions, characteristic of metronidazole-induced encephalopathy. The patient’s symptoms improved rapidly after cessation of metronidazole, and his symptoms had completely resolved by discharge on hospital day two. Conclusion: Metronidazole-induced encephalopathy is a rare cause of vertigo and ataxia that can lead to permanent sequela if not identified and treated promptly. Thus, it is important for physicians to keep this diagnosis in mind when evaluating patients on metronidazole who present to the ED with new neurologic complaints.

Psychiatry NCHD referrals to the local emergency department in the context of an in-house primary care service

Objectives. Patients with psychiatric illness are at increased risk of developing non-psychiatric medical illnesses. There have been positive reports regarding the integration of primary care services into mental health facilities. Here, we evaluate the appropriateness of psychiatry non-consultant hospital doctors (NCHD) transfers to the local emergency department (ED) in the context of an in-house primary care service. Methods. We reviewed the inpatient transfers from St Patrick’s University Hospital (SPUH) to the local ED at St James’ Hospital (SJH) from 1 January 2016 to 31 December 2017. We used inpatient admission to SJH as our primary marker of an appropriate transfer. Results. 246 inpatients were transferred from SPUH to the SJH ED for medical review in the years 2016 and 2017. 27 (11%) of these were referred to the ED by the primary care service. 51% of those referred were admitted with similar rates of admission for both general practitioner (n = 27, 54% admitted) and NCHD initiated referrals (n = 219, 51% admitted). Acute neurological illness, concern regarding a cardiac illness, and deliberate self-harm were the most common reasons for referral. Conclusion. Our primary finding is that, of those transferred to ED by either primary care or a psychiatry NCHD, a similar proportion was judged to be in need of inpatient admission. This indicates that as a group, psychiatry NCHD assessment of acuity and need for transfer was similar to that of their colleagues in primary care.

LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway)

Background: Atrial fibrillation (AF) is a risk for stroke. The Canadian Cardiovascular Society advises patients who are CHADS65 positive should be started on oral anticoagulation (OAC). Our local emergency department (ED) review showed that only 16% of CHADS65 positive patients were started on OAC and that 2% of our patients were diagnosed with stroke within 90 days. We implemented a new pathway for initiation of OAC in the ED (the SAFE pathway). Aim Statement: We report the effectiveness and safety of the SAFE pathway for initiation of OAC in patients treated for AF in the ED. Measures & Design: A multidisciplinary group of physicians and pharmacist developed the SAFE pathway for patients who are discharged home from the ED with a diagnosis of AF. Step 1: contraindications to OAC, Step 2: CHADS65 score, Step 3: OAC dosing if indicated. The pathway triggers referral to AF clinic, family physician letter and follow up call from the ED pharmacist. Patients are followed for 90 days by a structured medical record review and a structured telephone interview. We record persistence with OAC, stroke, TIA, systemic arterial embolism and major bleeding (ISTH criteria). Patient outcomes are fed back to the treating ED physician. Evaluation/ Results: The SAFE pathway was introduced in two EDs in June 2018. In total, 177 patients have had the pathway applied. The median age was 70 (interquartile range (IQR) 61-78), 48% male, median CHADS2 score 2 (IQR 0-2). 19/177 patients (11%) had a contraindication to initiating OAC. 122 patients (69%) had no contraindication to OAC and were CHADS65 positive. Of these 122 patients, 109 were given a prescription for OAC (96 the correct dose, 9 too high a dose and 4 too low a dose). 6 patients declined OAC and the physician did not want to start OAC for 7 patients. 73/122 were contacted by phone at 90 days, 15 could not be reached and 34 have not completed 90 days of follow up since their ED visit. Of the 73 who were reached by phone after 90 days, 65 were still taking an anticoagulant. To date, 1 patient who declined OAC (CHADS2 score of 2) had a stroke within 90 days and one patient prescribed OAC had a gastrointestinal bleed. Discussion/Impact: The SAFE pathway appears safe and effective although we continue to evaluate and improve the process.

Impact of cannabis mass gathering events on mental health and health service utilization

BackgroundThe Canadian government has legalized and regulated access to cannabis as of October 2018. In this context, there is a need to analyze data that may provide insights on the effects of increased accessibility and tolerance for cannabis use. One source of data is the phenomenon known as “4/20”, a decades-old yearly mass gathering event supporting the legalization of cannabis. These events offer naturalistic epidemiologic data to ascertain specific impacts of cannabis consumption in a context of increased tolerance on health service utilization. Our study assessed the association between cannabis mass gathering events and health service utilization related to mental illness and substance use disorders at the nearest local emergency department.MethodsEmergency department service utilization data (2005-2015) was used. The sample analyzed consists of emergency department visits due to mental and substance use disorders. A multiple linear regression model was used to predict the number of daily visits with year, month, day of the week, and day of income assistance distribution as independent variables. Daily residuals were averaged, and residuals for the days with the highest number of visits were compared with the mean residual number of visits. Also, correlation of number of visits with attendance to mass gathering events was explored.ResultsThe residual number of visits for mental health and substance use disorder was the highest on April 20th 2015 (n=51.0, z-score=11.0, p<0.001), and on days associated with subsequent cannabis mass gathering events. Moreover, this number of visits is positively correlated with the number of attendees at the “4/20” event (Pearson’s correlation coefficient: 0.76, 95% CI: 0.19 to 0.956, p=0.002), and increased over time.ConclusionCannabis mass gathering events were associated with an increased number of emergency visits for patients with mental health and substance use diagnoses at the nearest local emergency department. In the context of legalization and regulation of cannabis use, these specific gatherings will not necessarily be discontinued. Indeed, as per news reports the recent post-legalization “4/20” drew tens of thousands of people in Vancouver. Also, in the new context other non-specific mass gatherings may also lead to foreseeable episodic surges in ER utilization. In light of this and from a public health perspective, services need to be prepared to care for predictably larger numbers of people suffering cannabis intoxication during mass gatherings, as well as to make provisions to provide all other services that are regularly needed for other emergency conditions. Also, educational campaigns about responsible use during these events will become particularly important, as well as offering on-site support, triage and basic services. This will allow for specific care to be provided in a non-stigmatizing manner, proportional to need, and without overcrowding general emergency services.

Unexpected death secondary to streptococcus salivarius endocarditis

A 51-year old male with a medical history of chronic ethanol and tobacco use was complaining of difficulty breathing and was driven to the local emergency department where he was noted to be in respiratory distress. The decedent had not seen a physician in over ten years. The decedent was undergoing an ultrasound to evaluate for a lower extremity deep venous thrombosis when he arrested. He was unable to be resuscitated. An autopsy was performed. The external examination revealed numerous petechial type hemorrhages of the skin with prominence of the arms and lower legs. Internal examination revealed cardiomegaly (heart weight 720 grams) with left ventricular hypertrophy and prominent endocarditis of the mitral and aortic valves. Infarcts were noted involving the right kidney and the spleen. A postmortem blood culture grew Streptococcus salivarius in both the aerobic and anaerobic culture bottles.