Review of cardiology failure to diagnose cases in emergency medicine.

1. Double Jeopardy:
Risk in Cardiology
William Brady, MD, FACEP
Daniel J. Sullivan, MD, JD,FACEP

2. 2
Clinical Category % of Total Cases
% of Total $$
Incurred
Abdominal 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%

3. 3
2000 - 2010 Closed Claims (N = 581)

4. Failure to Diagnose AMI
via the ECG

5. 5
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

6. 6

7. 7

8. 8
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

9. 9
Initial ECG ECG just before admission

10. 10
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

11. 11
Leads III & AVF
at 11:30 PM
Leads III & AVF
5 months prior

12. 12
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

13. 13

14. 14

15. 15

16. 16
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

17. Lost Reperfusion Opportunities
& Other ACS Misdiagnoses Due
to ECG Misinterpretation

18. 18
Subtle Inferior STEMI
Considered to be BER ST segment elevation & reciprocal
change not noted…thus, ECG diagnosis not made

19. 19
Subtle Inferior STEMI
l ST segment elevation in leads III & AVF
l Reciprocal change in leads I & AVL

20. 20
Acute Posterior Wall AMI
Assumed ST depression in leads V2, V3, & V4 due to ischemia

21. 21
Acute Posterior Wall AMI
Horizontal ST segment, large R wave, & upright T waves in
leads V2-V4

22. 22
LBBB with ECG AMI
Misinterpreted as “LBBB Pattern”

23. 23
LBBB with ECG AMI
l Concordant ST elevation leads V5/V6
l Concordant ST depression leads V2

24. 24
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 Finding
Unrecognized, high-risk Pattern

25. 25
1124
1247
De Winter ECG Finding
Unrecognized, high-risk Pattern with Progression to STEMI

26. 26
62 year-old Female with Chest Pain
STEMI
Anterior ST segment elevation with reciprocal change

27. 27
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
STEMI
Anterior ST segment elevation with reciprocal change

28. Wide Complex Tachycardia

29. 29
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

30. 30
12-Lead ECG

31. 31
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

32. 32
Approximately 15 Minutes Later…
 Rapid decompensation…no pulse
 CPR initiated
 Defibrillation
 More CPR…
 Ultimately ROSC
 D/C with significant cognitive issues

33. 33
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

34. 34
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

35. 35
Unresponsive & pulseless
Defibrillation…
to Sinus Tachycardia with WPW Findings
12-lead ECG on presentation
23 year-old male
Palpitations
Alert with “stable” vital signs
Interpretation – atrial fibrillation
Diltiazem 20 mg IV
WPW Therapeutic
Misadventure

36. 36
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

37. 37
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

38. 38
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

39. 39
Wide Complex Tachycardia…in the ED
Classically Reported
SVT with
Aberrancy
VT

40. 40
Wide Complex Tachycardia…in the ED
In Reality
Non-VT
Tachycardia
Ventricular
Tachycardia

41. Missed Diagnosis of Thoracic
Aortic Dissection

42. 43
Aortic Dissection
 Aortic dissection
 Tear within aortic wall
 Propagation of clot / possible rupture
 Frequent associated events / disease states
 Hypertension  Sympathomimetic Ingestion
 Syphilis  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

43. 44
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

44. 45
Robust Literature Base…Problems with
Diagnosis

45. 51
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

46. 52
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

47. 53
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

48. 54
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

49. 55
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

50. Long QT Syndrome

51. 57
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.

52. 58
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.

53. 59
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.

54. 60
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.

55. 61
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.

56. 62
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.

57. 63

58. 64
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!

59. Cardiac Arrest

60. 66
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

61. THANK YOU