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Biomedical subjects

Richard A Harrigan

Publications and source records attributed to Richard A Harrigan.

18 recordsLinked to original sources
PubMed2006

Evaluation and treatment of patients with severely elevated blood pressure in academic emergency departments: a multicenter study.

STUDY OBJECTIVE: Current guidelines advise that emergency department (ED) patients with severely elevated blood pressure be evaluated for acute target organ damage, have their medical regimen adjusted, and be instructed to follow up promptly for reassessment. We examine factors associated with performance of recommended treatment of patients with severely elevated blood pressure. METHODS: Observational study performed during 1 week at 4 urban, academic EDs. Severely elevated blood pressure was defined as systolic blood pressure greater than or equal to 180 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on at least 1 measurement. ED staff were blinded to the study purpose. Demographics, presenting complaints, vital signs, tests ordered, medications administered, disposition, and discharge instructions were recorded, and associations were tested in bivariate analyses. RESULTS: Severely elevated blood pressure was noted in 423 patients. Serum chemistry was obtained in 73% of patients, ECG in 53% of patients, chest radiograph in 46% of patients, urinalysis in 43% of patients, and funduscopy documented in 36% of patients. All studies were performed in 6% of patients and were associated with complaints of dyspnea (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.1 to 8.7) and chest pain (OR 3.0; 95% CI 1.2 to 7.6). Oral antihypertensives were administered to 36% of patients and were associated with blood pressure-related complaints (OR 2.0 [1.2 to 3.3]), patient-suspected severely elevated blood pressure (OR 5.6, 95% CI 2.0 to 15.3), and being uninsured (OR 2.0; 95% CI 1.2 to 3.3). Intravenous antihypertensives were given to 4% of patients, associated only with chest pain (OR 3.2; 95% CI 1.1 to 9.5). Modification of antihypertensive regimen was documented in 19% of discharged patients and associated with patient-suspected severely elevated blood pressure (OR 5.5; 95% CI 2.5 to 12.2) and being uninsured (OR 1.8; 95% CI 1.1 to 2.9). CONCLUSION: The majority of ED patients with severely elevated blood pressure do not receive the evaluation, medical regimen modification, and discharge instructions advised by current guidelines. Further study is necessary to determine whether these recommendations are appropriate in this setting.

Academic Medical Centers↗
PubMed2006

Peripheral venous cutdown.

Timely establishment of vascular access is a critical component of the care of the acutely ill or injured patient. Peripheral venous cutdown, once a mainstay in the care of the severely traumatized patient, has progressively lost favor since the introduction of the Seldinger technique of central venous line placement. In fact, recent editions of the Advanced Trauma Life Support (ATLS) text refer to saphenous venous cutdown as an optional skill to be taught at the discretion of the instructor. In certain patients, percutaneous vascular access may be impossible to achieve or result in unacceptable time delays. In these situations, the ability to rapidly and proficiently perform peripheral venous cutdown techniques may prove invaluable and potentially lifesaving. This article reviews the anatomy of the most common sites used for peripheral venous cutdown, peripheral venous cutdown techniques, and the complications associated with peripheral venous cutdown.

Catheterization↗
PubMed2005

Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients.

A number of cardiopulmonary and neurological symptoms are presumed to be associated with hypertension. We examined the prevalence of these symptoms in ED patients with elevated blood pressure (BP) and studied the relationship between symptom prevalence and BP value. We enrolled consecutive adult ED patients with sustained BP elevation (systolic BP>or=140 mm Hg, diastolic BP>or=90 mm Hg). BP values were categorized according to Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure, 6th Report criteria. Elevated BP was noted in 551 (29%) of 1908 patients. Unprompted complaints of hypertension-associated symptoms were noted in 26%, and there was no association between BP category and complaints other than dyspnea. Symptom interviews were conducted in 294 (56%) patients; 68% of this subset noted >or=1 current hypertension-associated symptom with no relationship between symptom prevalence and BP category. We conclude that symptoms putatively associated with hypertension are common among ED patients with elevated BP, and their prevalence appears unrelated to BP value.

Adult↗
PubMed2005

ECG patterns confounding the ECG diagnosis of acute coronary syndrome: left bundle branch block, right ventricular paced rhythms, and left ventricular hypertrophy.

The ECG has limitations in the evaluation of the chest-pain patient, including the presence of confounding ECG patterns; the ECG patterns that confound the diagnosis of acute myocardial infarction(AMI) include left bundle branch block (LBBB), ventricular paced rhythms (VPR), and left ventricular hypertrophy (LVH). These patterns produce new ST-segment/T-wave abnormalities, which are the new normal findings in these patients and may lead the clinician astray in two distinct instances: (1) diagnosing ECG change related to acute coronary syndromes (ACS) when the abnormality results solely from the confounding pattern; and (2) not acknowledging the confounding nature of these ECG patterns in the evaluation of potential ACS, thereby placing excessive diagnostic confidence in the ECG. This article highlights the diagnostic dilemma encountered in these confounding ECG patterns; the discussion focuses on the expected ECG abnormalities in these patients and the findings seen in ACS.

Bundle-Branch Block↗
PubMed2005

Elevated blood pressure in urban emergency department patients.

OBJECTIVES: There has been little systematic study of emergency department (ED) patients with elevated blood pressure (BP) values. The authors sought to characterize ED patients with elevated BP values, assess presenting symptoms, and determine the prevalence of elevated BP after discharge. METHODS: This was a cross-sectional study performed in four academic EDs. Adults presenting with systolic BP >or=140 mm Hg or diastolic BP >or=90 mm Hg were enrolled over a one-week equivalent period. Demographics, medical history, and symptoms were obtained by chart abstraction and structured interview. A random patient subset underwent a three-week follow-up interview. BP measurements were staged, using Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) criteria, according to the greatest value noted in the ED. RESULTS: A total of 1,396 patients were enrolled. Stage 1 BP values were noted in 44.3%, stage 2 in 25.3%, and stage 3 in 30.3%. African American patients more frequently had stage 2 and 3 BP values than other ethnic groups. BP measurements were repeated in 61.1% of patients and were the same or greater in 51.3% of patients. Dyspnea was associated with greater BP values. Among the 63.9% of patients who were interviewed, 52.7% were not being treated for hypertension, and 42.1% of those with hypertension had recently missed a medication dose. Follow-up was obtained in 74.7% of those targeted. A visit to a medical practitioner since discharge was reported by 63.2%; of these, 26.1% reported that their BP remained elevated. CONCLUSIONS: Elevated BP is common among ED patients. African American patients are more likely than those of other ethnic groups to have greater BP values. The ED visit may be a good opportunity to identify patients with unrecognized or poorly controlled hypertension.

Black or African American↗
PubMed2004

Orthopedic pitfalls in the ED: Achilles tendon rupture.

Achilles tendon rupture is a relatively uncommon occurrence in a general ED population. The history can be subtle, and physical findings may not be clear-cut. Prompt diagnosis and treatment of these injuries, however, is important to improved clinical outcome. The emergency physician needs to remain vigilant for this diagnosis to avoid this orthopedic pitfall. This review article examines the clinical presentation, diagnostic technique, and management options applicable to the emergency physician in the treatment of Achilles tendon rupture.

Achilles Tendon↗
PubMed2004

Electrocardiographic manifestations: diagnosis of atrioventricular block in the Emergency Department.

Patients with bradycardia are commonly encountered by the Emergency Physician. Of the possible bradydysrhythmias, atrioventricular blocks (AVB) represent a significant portion of these presentations. In this article, we provide four illustrative cases of patients presenting to the Emergency Department (ED) with AVB. We review the various types of AV block dysrhythmias (1st, 2nd, and 3rd degrees) and their underlying etiologies. This discussion also focuses on the presentation, clinical considerations, management and acute treatment of AVB dysrhythmias in the emergent setting.

Aged↗
PubMed2004

Emergency evaluation and treatment of priapism.

Priapism is a fairly uncommon presentation to the Emergency Department, but when it does present, it represents a true urologic emergency. Prompt treatment will decrease the risk of permanent sequelae including impotence. Treatment should be based on etiology and follow an organized approach. Various cases will arise when conservative management will not remedy the priapism and more aggressive measures will be needed, particularly if emergent urological consultation is not available. This article reviews the causes of priapism and systematically reviews techniques and procedures used to manage and treat priapism.

Adrenergic alpha-Agonists↗
PubMed2004

Nasal foreign body removal.

Patients with nasal foreign bodies often present to the Emergency Department (ED) for removal. In most cases, successful removal can be performed by the Emergency Physician (EP) using a variety of simple techniques. The EP should be familiar with multiple procedural techniques as a significant number of patients will require multiple attempts and techniques for removal of the nasal foreign body. This article reviews the more common techniques for removal, and provides specific technical tips, indications and contraindications for each technique.

Catheterization↗
PubMed2004

Electrocardiographic manifestations: acute inferior wall myocardial infarction.

The 12-lead electrocardiogram (EKG) is an important tool in evaluating the patient with acute myocardial infarction (MI). Patients with acute inferior wall myocardial infarction (IWMI) represent a heterogeneous group in terms of morbidity, mortality, Emergency Department (ED) management, and site of occlusion in the culprit coronary artery. The standard 12-lead EKG, right-sided chest leads and posterior chest leads, in conjunction with clinical findings often provide the necessary information for the Emergency Physician (EP) to predict complications, morbidity and mortality. IWMI patients may have associated right ventricular infarction (RVI) or lateral and posterior wall extension. Each of these entities is associated with specific hemodynamic abnormalities and increased mortality. In addition, various atrioventricular (AV) blocks are commonly associated with IWMI. This article presents several cases of IWMI with EKGs and a discussion of EKG interpretation in the setting of IWMI.

Aged↗
PubMed2004

Electrocardiographic manifestations: electrolyte abnormalities.

Because myocyte depolarization and repolarization depend on intra- and extracellular shifts in ion gradients, abnormal serum electrolyte levels can have profound effects on cardiac conduction and the electrocardiogram (EKG). Changes in extracellular potassium, calcium, and magnesium levels can change myocyte membrane potential gradients and alter the cardiac action potential. These changes can result in incidental findings on the 12-lead EKG or precipitate potentially life-threatening dysrhythmias. We will review the major electrocardiographic findings associated with abnormalities of the major cationic contributors to cardiac conduction-potassium, calcium and magnesium.

Adult↗
PubMed2004

Anterior shoulder dislocations: beyond traction-countertraction.

The shoulder is the most commonly dislocated large joint presenting to American Emergency Departments (ED). Anterior dislocations account for the great majority of these dislocations. Most anterior shoulder dislocations can be reduced in the ED using a variety of reduction techniques. The traction-countertraction technique is quite familiar to most Emergency Physicians, however, many other effective methods of reduction have been described. No method has proven 100% successful, and occasionally multiple attempts using different techniques are required to effect reduction. This article reviews some of the other techniques used to reduce anterior shoulder dislocations, variations reported on these techniques, and their success rates, advantages, and disadvantages.

Emergency Medical Services↗
PubMed2004

Electrocardiographic manifestations: long QT Syndrome.

Long QT Syndrome is a cardiac disorder caused by an abnormal prolongation of the ventricular repolarization phase. The primary concern in this syndrome is the propensity towards polymorphic ventricular tachycardia and sudden cardiac death. This article presents several cases, highlighting the pathophysiology, clinical presentation, and management of this disorder.

Adolescent↗
PubMed2003

Electrocardiographic manifestations: bundle branch blocks and fascicular blocks.

Intraventricular conduction block is the general name given to a varied group of electrocardiographic entities. All share a common finding of some degree of delay in ventricular activation; recognition of these blocks hinges upon analysis of the QRS complex, as well as the ST-T changes associated with them. Bundle branch block (right or left), and fascicular block (left anterior or left posterior) are all examples of intraventricular conduction block. Causation of intraventricular conduction block may be cardiac or noncardiac; early recognition of the etiology may be of clinical importance. This article reviews the basic anatomy and physiology related to intraventricular conduction blocks, and then examines each in terms of electrocardiographic definition and clinical correlation.

Bundle-Branch Block↗
PubMed2003

Electrocardiographic manifestations: ventricular tachycardia.

Ventricular tachycardia is a serious rhythm disturbance that originates from any part of the myocardium or conduction system below the atrioventricular node. Ventricular tachycardia (VT) presents with a wide QRS complex and a rate greater than 120 beats/min. Ventricular tachycardia is frequently encountered as a complication of coronary artery disease or cardiomyopathy; furthermore, VT is also seen in patients with medication adverse effect or electrolyte disturbance. Ventricular tachycardia presents electrocardiographically in several forms, including monomorphic and polymorphic VT. As is true in most Emergency Department presentations, the Emergency Physician must approach the dysrhythmic patient from an undifferentiated perspective, in this instance, the wide complex tachycardia (WCT) scenario. The electrocardiographic differential diagnosis of WCT classically includes VT and supraventricular tachycardia with aberrant intra-ventricular conduction. This article will review the electrocardiographic presentations encountered in patients with ventricular tachycardia.

Aged↗