double jeopardy: risk in cardiology

Double Jeopardy: Risk in Cardiology

William Brady, MD, FACEP

Daniel J. Sullivan, MD, JD,FACEP

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Clinical Category % of Total Cases% of Total $$

IncurredAbdominal 20.88% 17.40%

Airway 2.20% 12.52%

Burn 1.10% 0.02%

Cardiac/Chest Pain 19.78% 34.25%

Diabetes 1.10% 0.25%

Eye 1.10% 0.01%

Fracture 5.49% 1.05%

Jail Case 1.10% 0.01%

Medication 2.20% 0.21%

Meningitis 2.20% 9.96%

Necrotizing Fasciitis 2.20% 2.31%

OB/GYN 2.20% 1.37%

Pediatric 9.89% 0.32%

Peripheral Vascular 1.10% 0.76%

Psychiatric 2.20% 0.06%

Respiratory 3.30% 1.10%

Spinal Cord 1.10% 1.58%

Stroke/SAH 5.49% 15.19%

Trauma 9.89% 0.87%

Wound 5.49% 0.75%

  100.01% 99.99%

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2000 - 2010 Closed Claims (N = 581)

Failure to Diagnose AMI via the ECG

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Chest Pain: Litigation Overview

Misinterpretation of the ECG Missed obvious changes of AMI Not recognizing serial changes Failure to order old ECG for comparison Failure to recognize the importance of the

non-specific ECG change

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Chest Pain: Litigation Overview

Misinterpretation of the ECG Missed obvious changes of AMI Not recognizing serial changes Failure to order old ECG for comparison Failure to recognize the importance of the

non-specific ECG change

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Initial ECG ECG just before admission

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Chest Pain: Litigation Overview

Misinterpretation of the ECG Missed obvious changes of AMI Not recognizing serial changes Failure to review the old ECG for comparison Failure to recognize the importance of the

non-specific ECG change

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Leads III & AVF at 11:30 PM

Leads III & AVF 5 months prior

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Chest Pain: Litigation Overview

Misinterpretation of the ECG Missed obvious changes of AMI Not recognizing serial changes Failure to order old ECG for comparison Failure to recognize the importance of the

non-specific ECG change

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Chest Pain: Litigation Overview

Failure to take and record a careful history Failure to recognize the “unusual” presentation Recognize the atypical presentation of ACS in

women Failure or delay in getting to intervention –

based on failure to meet national time guidelines

Lost Reperfusion Opportunities & Other ACS Misdiagnoses Due to ECG Misinterpretation

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Subtle Inferior STEMIConsidered to be BER ST segment elevation & reciprocal change not noted…thus, ECG diagnosis not made

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Subtle Inferior STEMIl ST segment elevation in leads III & AVFl Reciprocal change in leads I & AVL

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Acute Posterior Wall AMIAssumed ST depression in leads V2, V3, & V4 due to ischemia

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Acute Posterior Wall AMIHorizontal ST segment, large R wave, & upright T waves in leads V2-V4

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LBBB with ECG AMIMisinterpreted as “LBBB Pattern”

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LBBB with ECG AMIl Concordant ST elevation leads V5/V6l Concordant ST depression leads V2

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1124

• Prominent T wave• J point depression with ST segment depression• Lead aVR ST segment elevation• Leads V1-V4• Association with proximal LAD occlusion• High-risk pattern with rapid progression to STEMI

De Winter ECG FindingUnrecognized, high-risk Pattern

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1124

1247

De Winter ECG FindingUnrecognized, high-risk Pattern with Progression to STEMI

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62 year-old Female with Chest Pain

STEMIAnterior ST segment elevation with reciprocal change

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62 year-old Female with Chest Pain

& lead aVR ST segment elevation c/w LEFT MAIN CORONARY OCCLUSION

Ultimately, at PCI, near-complete LMCA occlusion noted

STEMIAnterior ST segment elevation with reciprocal change

Wide Complex Tachycardia

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ED Presentation

57 male with atrial fibrillation with BBB, MI, & DM Weakness & palpitations Exam – alert & distressed with BP 156/88 & P 177

IV, labs, & portable CXR

V lead

Aug 18 2016 1349 BED 47 936

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12-Lead ECG

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12-Lead ECG

• ED interpretation -- atrial fibrillation with RVR & bundle branch block; significant motion artifact noted

• Interventions -- IVF bolus 500 ml & diltiazem 20 mg IV

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Approximately 15 Minutes Later…

Rapid decompensation…no pulse

CPR initiated

Defibrillation

More CPR…

Ultimately ROSC

D/C with significant cognitive issues

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Outcome & Settlement Patient ultimately diagnosed with ventricular

tachycardia related to ischemic cardiomyopathy ICD placed Unable to return to pre-arrest lifestyle Suit filed against EP, EP’s group, & hospital

Alleged incomplete history Incorrect ECG interpretation Incorrect management Unable to find supporting opinion Case settled for undisclosed amount

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Another look at the ECG… Wide complex tachycardia Features suggestive

of VT 57-year-old male History of MI AV dissociation Positive concordancy

“Apparent” clinical stability incorrectly suggested SVT

V lead

Sept 21 2015 1349 BED 47 936

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Unresponsive & pulseless

Defibrillation…to Sinus Tachycardia with WPW Findings

12-lead ECG on presentation

23 year-old malePalpitationsAlert with “stable” vital signsInterpretation – atrial fibrillation

Diltiazem 20 mg IV

WPW Therapeutic Misadventure

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Wolff-Parkinson-White Syndrome Atrial Fibrillation 25% arrhythmias Loss of AVN “rate control” Irregular & very rapid rates Wide QRS – exaggerated delta wave Beat-to-beat QRS variation Potentially malignant

AP

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Outcome & Settlement

Patient diagnosed with WPW atrial fibrillation Unable to return to previous employment

Suit filed against EP & hospital Alleged incorrect ECG interpretation Alleged incorrect management Unable to find supporting defense EM expert Case settled for undisclosed amount

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Wide Complex Tachycardia

Aberrant SVT

AVNRT Sinus Tachycardia (BBB) WPW-Atrial Fibrillation Metabolic

Atrial Fibrillation (BBB) WPW-AV Reciprocating Toxicologic

Polymorphic Monomorphic

Torsade des Pointes

Ventricular Tachycardia

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Wide Complex Tachycardia…in the EDClassically Reported

SVT withAberrancy

VT

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Wide Complex Tachycardia…in the EDIn Reality

Chart Title

Non-VTTachycardia

Ventricular Tachycardia

Missed Diagnosis of Thoracic Aortic Dissection

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Aortic Dissection

Aortic dissection Tear within aortic wall Propagation of clot / possible rupture

Frequent associated events / disease states Hypertension n Sympathomimetic Ingestion Syphilis n Pregnancy Connective Tissue Disorders

(Marfan & Ehlers-Danlos) Race: Black > white Gender: Male > female Age: Average 53 yrs, range 30-70 yrs w/ peak

50-65 yrs

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Clinical Presentation

Pain (chest, back, pelvic, flank) not universally present

STEMI, particularly inferior Neurologic presentations

Focal symptoms & signs CVA Altered mental status

Syncope & “collapse” Dyspnea Hemoptysis Dysphagia Anxiety Premonitions of death

Consider aortic dissection if:• Patient > 35 years of age, • With chest / upper back

pain• Hypertensive• Other organ system

dysfunction

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Robust Literature Base…Problems with Diagnosis

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Factors in Cases of “Missed” Aortic Dissection

The Exam “Not ill enough” Vitals not unstable…except elevated BP

The Work-Up Over-reliance on normal chest radiography Over-reliance on negative d-dimer

The Diagnosis Did not consider alternative diagnosis

(ACS & M/S pain) The Patient

“My patient is too young” The History

Absence of abrupt onset of pain Absence of tearing pain

“I never considered it.!”

“The CXR was normal…”

“He wasn’t sick!”

“I thought it was ACS.”

“Inferior STEMI..!?!?”

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Case #1 Presentation

34 yo female evaluated for possible TAoD by PCP / PA

Fam Hx – Sister died with AoD MRI - Aortic cystic medical necrosis

PA did not know significance / did not discuss with MD

5 months later…more chest pain “sudden” To ED - R/O PE CXR-density lateral to aortic arch…CT / PA

negative 3 days later…continued pain…back to ED

• Dx not considered• Alternative Dx• Lack of understanding

of AoD & evaluation

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Case #1 Conclusion

In ED… Worsened chest & back pain…FHx of TAoD noted D/C’ed with outpatient arteriogram ordered

Died that night from TAoD with cardiac tamponade

Suit was filed…plaintiff claimed: Inadequate evaluation by PA No supervision of PA ED physician & hospital failed to diagnose TAoD

$650,000 settlement

• Dx not considered• Alternative Dx• Lack of understanding

of AoD & evaluation

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Case #2 Presentation

38 yo male – sharp chest pain for 1 hour Radiated to back…pain migrated while in ED First episode...no significant PMH Exam - Normal ECG, biomarkers, CXR – “negative” DX at D/C: Acute muscle spasm,

chest & back

• Dx not considered• Alternative Dx

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Case #2 Conclusion

Cardiac arrest next day

EMS to ED – not resuscitated

Cause of death TAD

Suit filed

Jury verdict against EP & hospital for $1.8 million

• Dx not considered• Alternative Dx

Long QT Syndrome

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Case # 1

15-year-old male was playing softball. While rounding the bases she experienced a

seizure-like episode. Neurologist diagnosed “heat stroke”. One year later she had several near fainting

spells. She presented to an ED, but had no work-up or diagnosis.

Two years after the initial episode, the mother demanded further evaluation and testing.

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Case # 1

An ECG was done that revealed QT prolongation. This was not mentioned to the mother and no treatment offered.

Four years after the initial episode as she was running bases, she felt a “seizure” coming on so she laid down on the ground.

She then lost consciousness and stopped breathing, and could not be resuscitated.

Suit filed for FTD long QT syndrome. Settled for $225,000.

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Case # 2

22-year-old female presented to the ED. She reported a history of seizures and

dizziness the day before which dropped her to her knees.

She was evaluated by a medical student and a resident who felt it was unlikely that she had a seizure as there had been no postictal period.

ECG was not ordered.

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Case # 2

She was bradycardic but was released with a diagnosis of vasovagal syndrome.

18 days later she was transported to the same ED by EMS.

In retrospect, the rhythm strip clearly suggested prolonged QT syndrome.

A resident again doubted a seizure and did not order an ECG. She was released.

Over the next 24 hours she felt a strange heartbeat and became fearful and anxious.

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Case # 2

The following day she presented to another ED where she was placed in a quiet room.

The physician gave her something for anxiety and discharged her home with a diagnosis of anxiety.

The next day she was found unresponsive, her father started CPR.

In the ED an ECG revealed prolonged QT syndrome.

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Case # 2

She was resuscitated but survived with severe brain damage due to anoxia.

The family sued and a jury returned a verdict of $16.5 million.

Family members were tested, and all have prolonged QT syndrome.

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LQTS Comments

The lawsuits often involve morbidity or mortality at an early age.

Consider dysrhythmias and conduction problems in patients with syncope or seizures.

Get an ECG on all patients with syncope. When evaluating the ECG, bring your focus to

the QT interval. Beware the Anchor diagnosis of anxiety. This failure to diagnose could follow you for a

long time!

Cardiac Arrest

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Cardiac Arrest

Outcome is poor Pre-hospital: 10% survival Hospital: 30% survival

Initial care not infrequently chaotic due to nature of presentation

Documentation frequently lacking in detail Combination of bad outcome + incomplete

documentation = high risk medicolegal issue

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