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Introduction: Our objective was to examine gender, racial, and age differences in door-to-EKG time in patients diagnosed with non-cardiac chest pain., Methods: This was a prospective cohort study of adult patients with an explicitly stated chief complaint of chest pain at an urban, academic ED. Primary study outcome variable was time to initial EKG. Predictor variables included gender, race, and age., Results: The final sample consisted of 214 patients. The overall median time to EKG in this cohort of patients was 29 minutes. No difference in time to EKG was found between gender or racial category. Time to EKG was significantly greater for patients in age categories 18-39 and 40-59 when compared with subjects greater than 60 years old., Discussion: In this prospective cohort study of non-STEMI/ACS patients with a chief complaint of chest pain, there were no gender or racial disparities in door-to-EKG time.

Hypokalemia and hyperkalemia are electrolyte abnormalities that confront the emergency physician daily. The morbidity and mortality of these two conditions result from alterations in neuromuscular function and cardiac conduction, which if untreated may culminate in paralysis and cardiac arrest. This article outlines recognition and treatment of these potentially life-threatening conditions.

A 75-year-old woman presented with recurrent severe chest pain radiating to her back. The initial ECG was normal, and clinically an aortic dissection was suspected. The patient became hypotensive during a chest computed tomography scan with infusion, had subsequent repeated cardiac arrests, and died. Autopsy revealed a 1.5-cm polypoid lesion, a papillary fibroelastoma, on the aortic valve, which effectively occluded the ostium of the left coronary artery in a ball-valve effect. In addition, an embolic fragment of the tumor was found in the left anterior descending artery. This is the sixth reported case of angina and/or sudden death resulting from this lesion. Of the 75 cases reported in the literature, most are incidental necropsy findings, although neurologic emboli and outflow tract obstruction have been described.

Two patients who presented with acute paralysis of the lower extremities as an initial manifestation of aortic dissection are described. The first patient had transient chest pain followed by flaccid paralysis of her lower extremities and severe back pain. In the second patient, sudden paralysis of both legs developed without pain of any sort. The paraplegia completely resolved in a few minutes; however, chest and back pain later ensued. Both patients had a proximal (type I or A) aortic dissection. The first patient's entrance tear in the aortic intima was just above the aortic valve with antegrade propagation, whereas in the second patient, the entrance tear was at the aortic isthmus, with both antegrade and retrograde dissection. Acute cardiac tamponade resulted in sudden deterioration and death in both patients, before any therapeutic intervention could be entertained.

Pneumoencephalography, the usual method for demonstrating air within the sella turcica in empty sella syndrome (ESS), has been approached with reluctance by most physicians because of its technical difficulty and patient morbidity. For these reasons, neuroradiologists have investigated other contrast media in search of an ideal agent; metrizamide seems to be such an agent. Metrizamide is a nondissociable, water-soluble glucose amide containing three iodine molecules. This agent is miscible with CSF, and small recesses of the CSF-brain interface can be delineated with hypocycloidal tomography without performing cumbersome patient maneuvers to fill the cisterns. Furthermore, morbidity has been minimal, particularly with use of lower concentrations of metrizamide, allowed by the sensitivity of computerized tomographic (CT) scanning. Thus, at the present time, metrizamide cisternography (especially in conjunction with CT scanning) appears useful in evaluating an enlarged sella turcica, particularly when considering an entity such as ESS.

A case of severe ethylene glycol poisoning is presented, characterized by protracted delirium, coma, and delayed adult respiratory distress syndrome. This patient never demonstrated evidence of calcium oxalate crystalluria or renal insufficiency. Ethylene glycol intoxication should be considered in the patient who presents with an altered mental status, unexplained metabolic acidosis, and elevated anion and osmolal gaps with or without crystalluria. Early empiric ethanol therapy and consideration of dialysis are recommended for those patients with such a presentation without evidence of abnormal levels of ketones, lactate, salicylate, or ethanol. It is proposed that early ethanol therapy may prevent the formation of ethylene glycol metabolites to the extent that calcium oxalate crystalluria is not seen.