246 Abstracts

outcomes. Multiple linear regressions were performed to deter-mine relative delayed time ratios (DTRs) as determined by thenatural log of delay times for individual variables. The patientgroup consisted of 894 patients with a median age of 62 years;294 (32.9%) were female; and 653 (73.3%) were transferredfrom non-tertiary care facilities. The median time from arrivalto diagnosis was 4.3 h, and from diagnosis to surgery was4.3 h. The greatest relative predictors of delay to diagnosiswere transfer from outside facility (DTR 3.34; 95% confidenceinterval [CI] 2.38–4.69), fever (DTR 5.11; 95% CI 2.07–12.62), and normotension (DTR 2.45; 95% CI 1.80–3.33).Delays in time to diagnosis also occurred in female patients,patients who had undergone prior cardiac surgery, patientswith an electrocardiogram suggestive of myocardial ischemia,or patients with a normal chest radiograph (all p < 0.05). Patientswith typical symptoms (defined as posterior pain, abrupt pain,and worst pain ever) were diagnosed twice as quickly as othersin the cohort. Critically ill patients with hypotension, tampo-nade, pulse deficits, coma, or altered consciousness were alsodiagnosed sooner (all p < 0.05). Variables associated with thegreatest delay in time to surgery included race other than white(DTR 2.25; 95% CI 0.40–1.22), history of coronary arterybypass surgery (DTR 2.81; 95% CI 0.47–1.60), and time frompresentation to diagnosis (DTR 1.35; 95% CI 0.24–0.37).Patients with shock, cardiac tamponade, and diabetes mellituswent to surgery far more rapidly than others in the cohort(all p < 0.05).

[Omeed Saghafi, MD

Denver Health Medical Center, Denver, CO]

Comment: This study validates what the emergency physi-cian would suspect with respect to patients presenting withaortic dissection; when the diagnosis is self evident, delays totherapy are not an issue and when the presentation is atypical,delays become a problem. What was not clear, at least fromthis study, was whether such delays led to changes in outcomes.Nonetheless, the study findings serve as a reminder that aorticdissection maymimic other pathology and should be consideredwhen appropriate so as to minimize the possibility of delays.

, SADDLE PULMONARY EMBOLISM: IS IT AS BADAS IT LOOKS? A COMMUNITY HOSPITAL EXPERI-ENCE Sardi A, Gluskin K, Guttentag A, et al. Crit Care Med2011;39:2413–8.

The outcomes and clinical presentation for saddle pulmo-nary embolism (SPE) vary widely, and there is debate for theuse of thrombolytics or catheter thrombectomy based on rightheart dysfunction, measures seen on computed tomography an-giography (CTA) or cardiac enzyme elevation. In this study, tworadiologists retrospectively reviewed and evaluated for clot bur-den (CB) all CTAs coded for pulmonary embolism (PE) from allpatients at a single center from 2004 to 2009. All patient chartswere reviewed for echocardiography, treatments, and outcomes.SPE was found in 37 of 680 patients (5.4%), with a median ageof 60 years, of whom 41% were male and 83.7% were African-American. Of the 37, the most common comorbidities were un-derlying neurologic disease, recent surgery, smoking (all 24%),and malignancy (22%). Echocardiography was performed in 27patients (73%). Right heart enlargement and dysfunction oc-curred in 78%, and elevated pulmonary artery systolic pressurein 67%. The Qanadi scoring system for clot burden and pulmo-nary artery occlusion defines complete proximal obstructionwith a CB of 40 points; CTA demonstrated a high median scoreof 31 points. Therewere 2 deaths (5.4%), with CBs of 30 and 31,but the small number of deaths made it impossible to determinewhich characteristics were associated with mortality. The me-dian right-ventricle-to-left-ventricle diameter ratio was 1.39,and in those given thrombolytics it was 1.86 (p = 0.13), andthe median CB of those who received thrombolytics was 34,compared to 31. Inferior vena cava filters were placed in 46%.Unfractionated heparin was administered in 87%, low-molecu-lar-weight heparin in 11%, thrombolytics in 11%, and surgicalthrombectomy in 3%. Median length of hospital stay was 9days. Of the 4 patients who received thrombolytics, majorbleeds occurred in 2, one of which died of multi-organ failureon hospital day 13.

[Douglas Melzer, MD

Denver Health Medical Center, Denver, CO]

Comments: This small retrospective study demonstrated thatthe incidence of saddle pulmonary embolism was very low andthat when it did occur, it was almost always amenable to stan-dard therapy. This raises the question of when thrombolysis ormore invasive thrombectomy is really needed, especiallywhen 1 of the 2 patients receiving the former died in this cohort.It may be that SPE is not as life-threatening an entity as previ-ously believed. However, larger studies would have to be doneto verify this.