Annals of Emergency Medicine

Use of Tandem Perimortem Cesarean Section and Open-Chest Cardiac Massage in the Resuscitation of Peripartum Cardiomyopathy Cardiac Arrest

Andrew J. Adan, MD, Abhinav Nafday, MD∗,anafday@med.umich.edu

Cardiac arrest and resuscitation of the pregnant woman at gestational term is rare. Depending on the circumstances of cardiac arrest and its timing, options are limited for allowing successful resuscitation of both mother and neonate. Herein, we describe the use of tandem perimortem cesarean section and thoracotomy for open-chest cardiac massage in a young woman with newly diagnosed peripartum cardiomyopathy. We used goal-directed resuscitation including diagnostic ultrasonography and capnography to assist in decision-making and successfully resuscitated both mother and neonate to hospital discharge without discernable long-term complications.

 

Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe—A Qualitative Study on the Decisionmaking Process of Emergency Department Providers

Presented at the American College of Emergency Physicians Scientific Assembly, October 2017, Washington, DC; and the Western Regional Conference of the Society for Academic Emergency Medicine, Stanford University, April 2017, Stanford, CA.

Bory Kea, MD, MCRa,∗,kea@ohsu.edu

 Study objective

Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation.

Methods

From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians’ attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians.

Results

Three broad domains emerged from our analyses. (1) Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2) Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3) Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors.

Conclusion

The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.

 

 

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