Palpable Pulse Research Articles

Confounding factors leading to misdiagnosing ventricular tachycardia as supraventricular in the emergency room

Studies conducted during the last 50 years have proposed electrocardiographic criteria and algorithms to determine if a wide QRS tachycardia is ventricular or supraventricular in origin. Sustained ventricular tachycardia is an uncommon reason for consultation in the emergency room. The latter and the complexity of available electrocardiographic diagnostic criteria and algorithms result in frequent misdiagnoses. Good hemodynamic tolerance of tachycardia in the supine position does not exclude its ventricular origin. Although rare, ventricular tachycardia in patients with and without structural heart disease may show a QRS duration <120 ms. Interruption of tachycardia by coughing, carotid sinus massage, Valsalva maneuver, or following the infusion of adenosine or verapamil should not discard the ventricular origin of the arrhythmia. In patients with regular, uniform, sustained broad QRS tachycardia, the presence of structural heart disease or A-V dissociation strongly suggest its ventricular origin. Occasionally, ventricular tachycardia can present with AV dissociation without this being evident on the 12-lead ECG. Cardiac auscultation, examination of the jugular venous pulse, and arterial pulse palpation provide additional clues for identifying A-V dissociation during tachycardia. This paper does not review the electrocardiographic criteria for categorizing tachycardia as ventricular but rather why emergency physicians misdiagnose these patients.

Validation of the Ischaemia Severity Scale (ISS) Based on Non-Invasive Vascular Assessments (SEWSS) for Predicting Outcomes of Diabetic Foot Attack.

Assessment of ischaemia severity includes a variety of measures, such as pedal pulse palpation, the ankle/brachial index (ABI), and the toe/brachial index (TBI), but there is a lack of consensus regarding which ischaemia scale is the most effective for determining outcome prognosis. The purpose of this study is to validate the application of the ischaemia severity scale (ISS) in the effective prediction of wound healing, amputations, and mortality for diabetic foot wounds (DFW). This prospective study included 235 consecutive patients graded according to the Saint Elian Wound Score System (SEWSS). The ISS is part of this system, with patients being scored as non-ischaemic (0) or having mild (1), moderate (2), or severe (3) ischaemia. Age, diabetes duration in years, and ulcer size were found to be associated with a longer mean ischaemia of increasing severity. A trend of reduction in the pulse palpation rates (70.4%, 50%, 8.5% to 0%; p &lt; 0.01), ABI (1.1 ± 0.1, 0.86 ± 0.3, 0.68 ± 0.2, 0.47 ± 0.2, p &lt; 0.01), TBI average values (0.90 ± 0.35, 0.62 ± 0.52, 0.50 ± 0.33, 0.10 ± 0.42, p &lt; 0.01), wound healing success (88.7%, 57.7%, 40.7%, 12.9%; p &lt; 0.01), and delay in weeks (Kaplan-Meier: log-rank 44.2, p &lt; 0.01) was observed with increasing values of the ISS (0, 1, 2, and 3). The odds ratio for adverse outcomes increased for each additional level of ischaemia severity. Thus, we demonstrate that the ISS is useful in effectively predicting adverse outcomes for DFW.

A Universal Device to Convert a Continuous Flow Assist Device to a Pulsatile Flow Device to Simulate Normal Blood Flow and Pressure Patterns.

Continuous follow assist devices (CFAD) are the most commonly used mechanical circulatory support devices. Compared to Pulsatile flow assist devices (PFAD), CFADs deliver a non-physiologic type of flow, which might contribute to complications related to lack of pulsatility in these devices. Moreover, lack of pulsatility complicates the clinical management of these patients who often present with good perfusion but with no palpable pulse and none or a negligible pulse pressure on blood pressure measurement. Presented here is a concept of a universal converter device that can be added inline other CFADs to convert the flow from continuous to pulsatile, simulating a normal flow and pressure pattern. After initial implantation and stabilization with a CFAD, adding this converter might potentially provide the benefits of pulsatile physiologic flow. The device is made of 2 components connected in parallel, working in tandem in user determined cycles. The continuous flow through a specifically positioned openings create a smooth conversion to a pulsatile flow. This device can convert a continuous flow to a physiologic pulsatile flow to achieve a native-like flow pattern and potentially prevent some CFAD complications. This paper presents the concept of pulsatility generation and simulation for other assist devices. Such a device can be a universal add-on or a supplemental option for CFADs.

Safety and Feasibility of Retrograde Recanalization of Radial Artery Occlusion in Patients with Need for Repeated Wrist Procedures

AIM: The purpose of the study was to present a new technique of retrograde recanalization of radial artery (RA) occlusion (RAO) in patients with need for repeated wrist access percutaneous angiographic procedures. MATERIALS AND METHODS: During a 10-year period from March 2011–May 2021, 53 000 patients were referred for percutaneous coronary intervention (PCI) in a high-volume transradial center. RAO on angiography was documented in 1165 patients. Retrograde recanalization of RAO was attempted in 70 patients. The selected patients were with multiple previous bilateral wrist interventions (n = 3–9). Ipsilateral ulnar artery was usually rudimented or occluded and contralateral wrist approach could not be used. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and procedural success of retrograde recanalization of RAO. Visual analog scale (VAS) score forearm pain assessment was performed after procedure. Technique: All patients had palpable pulse distal of previous puncture site due to collaterals from ipsilateral ulnar and interosseous artery. The RA was punctured with an inner metallic needle with a plastic cannula. Using retrograde radial angiography performed by injecting contrast through the plastic cannula, the occluded segment was visualized and crossed with different types of hydrophilic chronic total occlusion guide wires. After sheath insertion, balloon dilatation of the occluded RA segment, successful catheterization, and/or percutaneous coronary intervention was performed. Final RA angiography was performed on all patients. RESULTS: Successful retrograde opening of RAO was achieved in 65 out of 70 patients (92%). PCI was performed in 56% of patients through the opened RAO and 5 patients underwent CAS. Procedural success through opened RA was achieved in all 65 patients. Forearm pain during procedure was present in all cases (VAS score 3 ± 2.1). Access site bleeding EASY score 3 and 4 occurred in 6 patients (8.5%). One patient had discharge of embolic material up the arm without clinical consequences. In one patient, we observed dissection of the interosseous artery. Clinical and duplex long-term follow-up with a median of 4.1 years showed patent RA in only 20 patients. There were no registered cases of hand ischemia. About 61% of patients underwent subsequent PCIs, through other alternative access sites. CONCLUSION: Retrograde recanalization of RAO is successful and safe in patients with need of repeated coronary angiography procedures and inability to use other wrist access sites. Puncturing the collateral and performing retrograde radial angiography through the cannula is a key factor in successful opening of the RAO.

Abstract 301: RescueDoppler: Non-invasive Handsfree Carotid Doppler Ultrasound For Continuous Hemodynamic-guided Resuscitation

Introduction: Intermittent carotid pulse palpation (PP) is used to determine the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR). PP requires interruption of CPR and has low accuracy. Therefore, we investigated if a novel continuous non-invasive hands-free Doppler ultrasound system (RescueDoppler; RD) could detect the presence of pulse/no pulse and ROSC in an experimental setting with ventricular fibrillation (VF) and severe hypotension. Methods: RD was attached to the neck with a self-adhesive bandage onto twelve pigs (mean weight of 30.4 kg). RD used multirange Doppler, with 32 depth ranges over 8 - 45 mm. The transducer dimension was 30 x 6 mm. The RD probe was placed over the carotid artery, while invasive blood pressure was recorded on the contralateral side. Two profound circulatory disturbances were initiated; 1) severe hypotension by vena cava inferior occlusion (VCO) using a 7 Fr Fogarty catheter with gradual balloon inflation and 2) VF by applying a 7.5 V direct current in the myocardium for 2 seconds using an implantable cardioverter-defibrillator placed in the right ventricle apex. The pigs were defibrillated back to ROSC. Mean velocity over one cardiac cycle (time-averaged velocity; TAV) was compared with mean arterial pressure (MAP). Results: RD detected flow in the carotid artery in all 41 VCO sequences (figure), including the lowest induced systolic blood pressure of 19 mmHg. The intraclass correlation coefficient was 0.76 between TAV and MAP. ROSC was equally identified by RD and invasive blood pressure in all 21 VF sequences where the pigs were defibrillated from VF to sinus rhythm (figure). Conclusion: The RD system was simple and required no ultrasound knowledge. RD detected ROSC and blood flow at extremely low invasive carotid blood pressures during VF and VCO. TAV correlated well with MAP. RD could become an essential non-invasive, hands-free tool for continuous hemodynamic-guided CPR.

A Proposed Safe Electromyographic Needle Insertion Technique for the Flexor Pollicis Longus Muscle Using Arterial Pulse Palpation: Preliminary Study with Ultrasonography.

Electromyographic needle access to the flexor pollicis longus (FPL) is challenging because of the risk of injuries to the superficial radial nerve (SRN) or radial artery (RA), which run close to the FPL. This study aimed to investigate the safe electromyographic needle insertion point of the FPL using a newly proposed RA pulse palpation method. Fifty forearms of 25 healthy individuals were studied. At the junction of the middle and distal third of the forearm, an RA pulse was palpated, and 5 mm lateral to the pulse was determined as the preliminary needle insertion point. The distance from the vertical virtual needle pathway to the RA and SRN was measured using ultrasonography. In ultrasonography, the distances from the needle pathway to the RA and the SRN were 3.4 ± 0.8 (range, 2.1-6.0) and 5.9 ± 1.8 (range, 2.4-9.4) mm, respectively. The depth of the FPL muscle was 8.4 ± 1.7 mm. Electromyographic needle insertion into the FPL can be safely performed using the RA palpation method. The needle insertion point is 5 mm lateral to the RA pulse at the level between the middle and distal third of the forearm.

Precise Limb Tourniquet Arterial Occlusion Pressure Determination using Real-Time Ultrasonography and a Capacitive-Based Force Sensor.

Hemorrhage control prior to shock onset is increasingly recognized as a time-critical intervention. Although tourniquets (TQs) have been demonstrated to save lives, less is known about the physiologic parameters underlying successful TQ application beyond palpation of distal pulses. The current study directly visualized distal arterial occlusion via ultrasonography and measured associated pressure and contact force. Fifteen tactical officers participated as live models for the study. Arterial occlusion was performed using a standard adult blood pressure (BP) cuff and a Combat Application Tourniquet Generation 7 (CAT7) TQ, applied sequentially to the left mid-bicep. Arterial flow cessation was determined by radial artery palpation and brachial artery pulsed wave doppler ultrasound (US) evaluation. Steady state maximal generated force was measured using a thin-film force sensor. The mean (95% CI) systolic blood pressure (SBP) required to occlude palpable distal pulse was 112.9mmHg (109-117); contact force was 23.8N [Newton] (22.0-25.6). Arterial flow was visible via US in 100% of subjects despite lack of palpable pulse. The mean (95% CI) SBP and contact force to eliminate US flow were 132mmHg (127-137) and 27.7N (25.1-30.3). The mean (95% CI) number of windlass turns to eliminate a palpable pulse was 1.3 (1.0-1.6) while 1.6 (1.2-1.9) turns were required to eliminate US flow. Loss of distal radial pulse does not indicate lack of arterial flow distal to upper extremity TQ. On average, an additional one-quarter windlass turn was required to eliminate distal flow. Blood pressure and force measurements derived in this study may provide data to guide future TQ designs and inexpensive, physiologically accurate TQ training models.

AAOS Management of Hip Fractures in Older Adults Evidence-based Clinical Practice Guideline.

AAOS Management of Hip Fractures in Older Adults Evidence-based Clinical Practice Guideline.

A DOUBLE HIT: EMERGENT GUILLOTINE AMPUTATIONS DUE TO TOXIC SHOCK SYNDROME ASSOCIATED NECROTIZING FASCIITIS IN THE SETTING OF A VAGINAL CONTRACEPTIVE DEVICE AND PHARYNGITIS

A DOUBLE HIT: EMERGENT GUILLOTINE AMPUTATIONS DUE TO TOXIC SHOCK SYNDROME ASSOCIATED NECROTIZING FASCIITIS IN THE SETTING OF A VAGINAL CONTRACEPTIVE DEVICE AND PHARYNGITIS

CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME: A VICIOUS CIRCLE OF CLOTTING AND BLEEDING

CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME: A VICIOUS CIRCLE OF CLOTTING AND BLEEDING

497. INDOCYANINE GREEN FLUORESCENCE ANGIOGRAPHY VERSUS VISUAL ASSESSMENT FOR GASTRIC CONDUIT PERFUSION ASSESSMENT IN PATIENTS UNDERGOING ESOPHAGECTOMY: A RANDOMIZED CONTROLLED STUDY

Abstract Esophago-gastric anastomosis leakage is one of most feared complication after esophagectomy accountable for major postoperative morbidity and mortality. The high rate of anastomotic complications is due the tenuous perfusion of gastric conduit. This prospective randomized control trial compares the efficacy of intraoperative indocyanine green fluorescence angiography (ICG-FA) against visual assessment (VA) in evaluating the perfusion of gastric conduit and proximal esophageal stump in patients undergoing esophagectomy for cancer. Fifty eight consecutive patients who underwent esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from January 2020 till September 2021 were enrolled. Amongst them 30 patients were randomized to non ICG arm where the perfusion of gastric conduit and esophageal stump was evaluated by visual assessment (VA) based on inspection of the color, the palpation of warmth, pulse, and bleeding from the edges and 28 patients to ICG arm underwent initial appraisal of gastric conduit and esophageal stump perfusion was done by visual assessment followed by ICG-FA. Correlation coefficient was evaluated by Pearson’s R coefficient. Both the groups were similar in demographic parameters. The anastomotic leak was significantly lower in ICG arm [4 % vs 8/28 (27 %) p 0.0261]. Most of the leaks were minor type 1. When visual assessment was compared with ICG assessment, 80% of the vascularized conduits on VA showed good perfusion on ICG-FA. 39% of gastric conduit which seemed to be dusky on VA had good vascularity on ICG-FA. Kappa value was 0.256 p 0.097 i.e., a fair agreement between ICG and visual assessment in evaluating vascularity of gastric conduit was fair. VA of the gastric conduit perfusion can underrate perfusion and hence can jeopardize removal of the devitalized part. ICG fluorescence imaging is an accurate and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. But its utility needs to be validated in larger randomized trials.

Transient return of spontaneous circulation related to favourable outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: A secondary analysis of the SAVE-J II study

AimThis study aimed to investigate the relationship between transient return of spontaneous circulation (ROSC) before extracorporeal membrane oxygenation (ECMO) initiation and outcomes in out-of-hospital cardiac arrest (OHCA) patients, who were resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR). MethodsThis study was a secondary analysis of the SAVE-J II study, which was a retrospective multicentre registry study involving 36 participating institutions in Japan. We classified patients into two groups according to the presence or absence of transient ROSC before ECMO initiation. Transient ROSC was defined as any palpable pulse of ≥1 min before ECMO initiation. The primary outcome was favourable neurological outcomes (cerebral performance categories 1–2). ResultsOf 2,157 patients registered in the SAVE-J II study, 1,501 met the study inclusion criteria; 328 (22%) experienced transient ROSC before ECMO initiation. Patients with transient ROSC had better outcomes than those without ROSC (favourable neurological outcome, 26% vs 12%, P < 0.001; survival to hospital discharge, 46% vs 24%, respectively; P < 0.001). A Kaplan–Meier plot showed better survival in the transient ROSC group (log-rank test, P < 0.001). In multiple logistic analyses, transient ROSC was significantly associated with favourable neurological outcomes and survival (favourable neurological outcomes, adjusted odds ratio, 3.34 [95% confidence interval, 2.35–4.73]; survival, adjusted odds ratio, 3.99 [95% confidence interval, 2.95–5.40]). ConclusionsIn OHCA patients resuscitated with ECPR, transient ROSC before ECMO initiation was associated with favourable outcomes. Hence, transient ROSC is a predictor of improved outcomes after ECPR.

An investigation into the detection of the pulse in conscious and anaesthetized dogs

ObjectivesTo record the success rate of veterinary professionals and students at identifying the pulse in conscious and anaesthetized dogs. To explore the influence of clinical experience, pulse location, anaesthesia and likely confounding variables on the success of pulse palpation. Study designProspective, observational, randomized study. AnimalsA total of 54 client-owned dogs scheduled for general anaesthesia. MethodsFor each dog, three participants (senior anaesthetist, anaesthesia resident/nurse, veterinary student/animal care assistant) attempted pulse palpation at three locations (femoral, radial and dorsal pedal pulse) in conscious and anaesthetized dogs. The time to pulse palpation was measured with a stopwatch for each attempt and data were modelled using a multivariate Cox regression survival analysis (significance p < 0.05). ResultsThe overall success rate of pulse palpation was 77%, with a median time of 10.91 seconds (interquartile range 9.09 seconds). Success rate was lower in conscious dogs (67%) than in anaesthetized dogs (87%). There was a 77% lower likelihood of success at the radial than at the femoral pulse [hazard ratio (HR) 0.23, 95% confidence interval (CI) 0.38–0.69, p < 0.001]. Veterinary students/animal care assistants had a 71% lower likelihood of success than senior anaesthetists (HR 0.29, 95% CI 0.22–0.39, p < 0.001). Age, weight and American Society of Anesthesiologists physical status had no significant influence. Premedication/anaesthetic drugs, heart rate or mean arterial pressure had no significant influence on the time to pulse palpation in anaesthetized dogs. The median time to palpation was less than 10 seconds for all experience groups at the femoral location. ConclusionsPalpation of the femoral location had the greatest likelihood of success with the least amount of time. Monitoring the femoral pulse during induction of anaesthesia is suggested as a method for confirming spontaneous circulation. Pulse palpation improves with clinical experience.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Iliofemoral Artery Endofibrosis Associated with Microembolization

ObjectivesEndoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease.MethodsCase report.ResultsA 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution.ConclusionsFig 2Intraoperative appearance of iliofemoral fibrosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT) ObjectivesEndoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease. Endoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease. MethodsCase report. Case report. ResultsA 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution. A 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution. Conclusions

A Modern Day Timeline for In-Hospital Monitoring in Perfused, Pulseless Pediatric Supracondylar Humerus Fractures.

The perfused, pulseless supracondylar humerus fracture (ppSCHF) remains a consistent topic of discussion in the literature. Inpatient observation of these patients postoperatively for worsening vascular exam or compartment syndrome is frequently recommended but not well studied. The purpose of this study was to evaluate the postoperative complications in a cohort of ppSCHF patients and their timeline to discharge. This study is a retrospective review of a prospectively maintained database of all operatively treated supracondylar humerus fractures from a tertiary pediatric hospital from 2013 to 2019. All patients without a palpable pulse were included. We excluded patients with <4 weeks follow-up. Demographic, operative, and postoperative data were collected, including time from presentation to operating room (OR), time from OR to discharge, and incidence of postoperative complications, including return to OR, compartment syndrome, new neurovascular deficits, and Volkmann contractures. The descriptive statistics were used to summarize the data. Among 1371 operatively treated supracondylar humerus fractures, 39 (2.8%) presented with a ppSCHF. Five (15%) had a signal on doppler ultrasound, whereas 34 (85%) had no signal. Thirty-seven (95%) patients had a Gartland type III fracture and 2 (5%) had type IV fractures. Twenty-two (56%) patients had a neurological deficit, of which 14 had an anterior interosseous nerve deficit. The average time to OR was 6.9 (range 2.2 to 15) hours; 6 (15%) required open reduction. At the time of discharge, 85% of patients had a palpable pulse and 13% had a dopplerable signal. Postoperatively, no patients were returned to the OR for any secondary procedures. The average length of stay after the operation was 25 (range 8.5 to 40) hours, with 92% of patients being discharged by 36 hours postoperatively. No patients developed compartment syndrome, new neurological deficits, or Volkmann contractures at a mean follow-up of 112 (range 34 to 310) days. In our study of 39 patients presenting with ppSCHF, no patient required an unexpected return to the OR, or developed post-treatment compartment syndrome, neurological deficits, or Volkmann contractures. The average time from OR to discharge for ppSCHF was 25 hours. Level II.

590 The Value of Peripheral Pulse Examination in the Diagnosis of Intermittent Claudication

Abstract Aim The primary aim was to objectively evaluate the use of peripheral pulse examination as a screening tool for IC by calculating the sensitivity and specificity. Our secondary aim was to describe the cohort of patients referred to the clinic by their GP and identify areas for improvement and early initiation of best medical therapy. Method This study used a retrospective analysis of a prospectively maintained database. Records of all patients referred to the claudication clinic were collected from October 2018 to October 2019. The most distal palpable pulse of each leg was assigned a value and combined to create a ‘peripheral pulse score’. Risk factors, ABPI results, Peripheral Artery Disease (PAD) status and details of ongoing medical therapy were also recorded. Results 211 patients referred by their GP were included in the study. The absence of bilateral foot pulses was found to have a sensitivity of 86%, specificity 92%, PPV 95% and NPV 79%. There is a strong correlation between peripheral pulse score and ABPI. Only 27% of patients suspected of having IC by their GP were on best medical therapy at their initial clinic visit. Conclusions Peripheral pulse examination is a valuable diagnostic tool for identifying patients with IC and can be used to guide referral to specialist services. We provide evidence for the use of foot pulses as a screening tool to be used by primary care providers. More patients being referred to the IC clinic can be started on best medical therapy for secondary prevention at the time of referral.

Cost-effectiveness of Screening for Atrial Fibrillation Using Wearable Devices

Undiagnosed atrial fibrillation (AF) is an important cause of stroke. Screening for AF using wrist-worn wearable devices may prevent strokes, but their cost-effectiveness is unknown. To evaluate the cost-effectiveness of contemporary AF screening strategies, particularly wrist-worn wearable devices. This economic evaluation used a microsimulation decision-analytic model and was conducted from September 8, 2020, to May 23, 2022, comprising 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older. Eight AF screening strategies, with 6 using wrist-worn wearable devices (watch or band photoplethysmography, with or without watch or band electrocardiography) and 2 using traditional modalities (ie, pulse palpation and 12-lead electrocardiogram) vs no screening. The primary outcome was the incremental cost-effectiveness ratio, defined as US dollars per quality-adjusted life-year (QALY). Secondary measures included rates of stroke and major bleeding. In the base case analysis of this model, the mean (SD) age was 72.5 (7.5) years, and 50% of the individuals were women. All 6 screening strategies using wrist-worn wearable devices were estimated to be more effective than no screening (range of QALYs gained vs no screening, 226-957 per 100 000 individuals) and were associated with greater relative benefit than screening using traditional modalities (range of QALYs gained vs no screening, -116 to 93 per 100 000 individuals). Compared with no screening, screening using wrist-worn wearable devices was associated with a reduction in stroke incidence by 20 to 23 per 100 000 person-years but an increase in major bleeding by 20 to 44 per 100 000 person-years. The overall preferred strategy was wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation, which had an incremental cost-effectiveness ratio of $57 894 per QALY, meeting the acceptability threshold of $100 000 per QALY. The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages (eg, ≥50 years), and with variation in the association of anticoagulation with risk of stroke in the setting of screening-detected AF. This economic evaluation of AF screening using a microsimulation decision-analytic model suggests that screening using wearable devices is cost-effective compared with either no screening or AF screening using traditional methods.

Arterial Cannulation Simulation Training in Novice Ultrasound Users.

Arterial cannulation is an important procedure for hemodynamic monitoring and blood sampling. Traditional radial artery cannulation is performed by using anatomical knowledge and pulse palpation as a guide. Arterial cannulation using ultrasound (US) requires specific training, especially for new US users. We hypothesized that even for new US users, US guidance would facilitate the successful puncture by lower attempts before successful intraluminal cannulation of a simulation model of the radial artery. A prospective randomized controlled crossover study was conducted with new US users on a gelatin phantom wrist. Three sessions of training were proposed: US-guided technique with low blood pressure (BP), palpation-guided technique with high BP, and one secondary comparison with low BP. For the 2 first sessions, all volunteers performed each technique but not in the same order. The main criterion was the number of attempts before successful catheterization of the model artery. A secondary criterion was the number of needle movements (the number of attempts plus the number of needle directional changes). Twenty new US users participated in the study. Numbers of attempts before successful catheterization were significantly lower when using the US technique: 1.1 (± 0.4) for US versus 1.6 (± 0.8) for palpation high BP (P = .02) versus 2.5 (± 1.4) for the secondary comparison, palpation low BP (P < .001). All of the participants achieved success after the 12th needle movement for US technique, after the 19th needle movement for palpation high BP, and after the 25th needle movement for the secondary comparison, palpation low BP. The total time before success was not significantly different between the 2 first sequences (US vs palpation high BP). US technique was more successful than traditional palpation technique for novice US users performing arterial cannulations for the first time. A study in the clinical practice is needed to confirm these results.

Chest Compressions in Pediatric Patients With Continuous-Flow Ventricular Assist Devices: Case Series and Proposed Algorithm.

Patients with continuous flow ventricular assist devices (CF-VAD's) in the systemic ventricle (left ventricle or single ventricle) often have no palpable pulses, unreliable pulse oximetry waveforms and non-pulsatile arterial waveforms despite hemodynamic stability. When circulatory decompensation occurs, standard indicators to begin cardiopulmonary resuscitation (CPR) which are used in other pediatric patients (i.e., significant bradycardia or loss of pulse) cannot be applied in the same fashion. In this population, there may already be pulselessness and development of bradycardia in and of itself would not trigger chest compressions. There are no universal guidelines to dictate when to consider chest compressions in this population. As such, there may be a delay in decision-making or in recognizing the need for chest compressions, even in patients hospitalized in intensive care units (ICU) and cared for by experienced staff who perform CPR regularly. We present four examples of pediatric cardiac ICU patients from a single center who underwent CPR between 2018 and 2019. Based on this case series, we propose a decision-making algorithm for chest compressions in pediatric patients with CF-VADs in the systemic ventricle.