A 61-year-old male with diabetes mellitus presented with generalized malaise, low grade subjective fevers. Review of systems was negative for chest pain, respiratory symptoms, abdominal pain, or localizing infectious symptoms. Temperature was 99.1, respiratory rate 18, blood pressure 146/80, pulse 110, and oxygen saturation was 98 percent. The documented physical exam included a brief HEENT exam, normal heart sounds without murmurs, abdomen soft and non-tender. There was no back exam, skin was noted as “no rashes” and the neurological exam was described as “alert and oriented.” Influenza, COVID, and chest radiograph were negative for infection. CBC was normal and UA negative. Glucose was slightly elevated, but the anion gap was normal. The patient remained tachycardic and was discharged with a diagnosis of “viral syndrome.” The patient presented approximately 18 hours later with hypotension and multiple sepsis markers. Back exam showed a rapidly expanding area of cellulitis with blebs. Despite rapid surgical intervention for necrotizing fasciitis, he died of fulminant sepsis.

In deposition, it was clear the clinician did not perform a thorough examination, in particular an exam of the skin and back. Furthermore, the plaintiff expert described the persistent tachycardia as a “smoking gun.” Rather than risk a trial and exemplary damages, the defense team, with the clinician’s consent, settled the case for an undisclosed amount.

Introduction

Studies show 20-25 percent of patients presenting to the Emergency Department (ED) have tachycardia.¹ Of these, 80 percent are admitted, while 20 percent are discharged. However, the 20 percent who are discharged with tachycardia (4 percent of all ED patients) account for up to 71 percent of unexpected deaths with potential diagnostic error.²

The good news is that by carefully screening this small subset of discharged patients, you can significantly reduce adverse outcomes in discharged patients.

Background

The causes of death after discharge are highly heterogeneous. Among these, there are four conditions which, when missed, are most likely to present with generalized, minimal, or no symptoms and tachycardia. They constitute up to 40 percent of unanticipated deaths after discharge from the emergency department.

1. Sepsis, especially occult sepsis and early pneumonia³
2. Pulmonary Embolism^4,5
3. Silent Myocardial Ischemia
4. Acute Cardiomyopathy/Congestive Heart Failure

Before discharging any patient with unexplained tachycardia, consider these four conditions.

Sepsis

Approximately 20 percent of ED patients present with an infection, and 40 percent of those have sepsis. The source of infection is evident 95 percent of the time, but in 5 percent of cases, it is not immediately apparent. High-risk cryptic infections include: