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:

• X-ray negative pneumonia
• Early or subacute endocarditis
• Early epidural abscess
• Early osteomyelitis
• Early necrotizing fasciitis
• If the patient clinically has pneumonia but the chest x-ray is negative, consider treating with antibiotics anyway because chest x-ray a 10 percent false negative rate.⁶ You do not need to confirm the diagnosis with CT.

For the remaining infectious diagnoses, the key is to do a thorough physical exam. Look for and document pertinent negatives and follow-up on any positives. You can defend a “miss” when you looked and there was no evidence of an infection in the skin (the more you can examine, the better), axilla, back, or feet, and no murmur or signs of peripheral embolization. You can’t defend it when you just write “WNL” (“Within Normal Limits,” sometimes derided as, “We did Not Look” or “We Never Looked”).

Pulmonary Embolism (PE)

Emergency physicians rarely miss PEs presenting with classic symptoms (chest pain or dyspnea). However, a significant percentage of PEs are present with tachycardia and no chest pain or dyspnea. Look for signs of DVT (present in 40 percent of patients with PE), and tachypnea (RR≥20).⁷ Consider further investigation if either is present. The respiratory rate obtained by the RN is not always reliable.⁸ In the setting of unexplained tachycardia, consider doing it yourself. Doing so will make your care more defendable even in the case a pulmonary embolus is later diagnosed.

Myocardial Infarction (MI)

Missed myocardial infractions are 7-55 percent of unexpected deaths after discharge from the emergency department.⁹ Silent MI is relatively uncommon in young patients and in patients with no risk factors, but more common in patients with diabetes mellitus and up to 15 percent in the elderly.¹⁰ Tachycardia, or alternately, high unexplained variability, can be the only sign of silent MI.¹¹

In elderly patients or patients with multiple cardiac risk factors and tachycardia where you have other explanation, consider an ECG, Troponin, and HEART Score. Be on the lookout for atypical symptoms such as extreme fatigue, acutely decreased exercise tolerance. Document the absence of typical and less typical coronary symptoms, and the absences of and S3 or S4 heart sound and JVD.

Acute Cardiomyopathy/Congestive Heart Failure

• Acute non-ischemic cardiomyopathy/myocarditis and undiagnosed congestive heart failure are underappreciated causes of sudden death after discharge but may be the cause in up to 10 percent.¹² We don’t miss the obvious cases, but subtle cases can escape and die later from lethal arrhythmias.
• Risk factors for acute cardiac pump dysfunction in patients not previously diagnosed include: S3, abdominojugular reflux, JVD, recent MI, crackles, paroxysmal nocturnal dyspnea, any murmur, and lower extremity edema. If any of these are present, a BNP may be warranted. Before you get the BNP result ascertain your clinical Gestalt for CHF—if it’s low and the BNP is also normal, the chances of CHF are very low.¹³

Other Considerations

For most conditions, a thorough physical exam is key:

• Check for cardiac murmurs, and note no S3 or S4
• Full skin exam—selective for GU area/breasts if asymptomatic.
• Palpate the back and percuss costovertebral angle
• Check feet/toes in diabetic patients
• Check for signs of peripheral embolization.

Do I need to admit all patients with persistent tachycardia?

No. Admitting all patients with tachycardia would create more preventable mortality and morbidity through nosocomial and iatrogenic complications, which are not to be ignored. But if you are discharging 20 percent of your patients with persistent tachycardia, that is probably too high. For example, about 16 percent of patients who meet sepsis criteria are discharged, and they have measurable increased risk.¹⁴ In our own experience with infectious diagnoses, we found that a rate of discharge around 10 percent reduces claims by 50 percent. This strikes a good balance between sepsis capture versus over-capture with nosocomial/iatrogenic complications. A significant number of patients can be discharged with no complications but choose them carefully. Most importantly, consider any patient with persistent tachycardia as having double the risk as a matched patient with no tachycardia, and take a pause to consider if the patient might have sepsis, MI, PE, Acute Cardiomyopathy/CHF. Take patient frailty into account. A study using Charlson Comorbidity Index found that an index of 4 or more triples the chances of unexpected death after discharge.¹⁵

What If I Do Discharge a Patient?

The discussion with the patient, documentation, and discharge instructions are the key elements to defending you good care. Explain to the patient what you did to look for dangerous causes of tachycardia, and explain that, in the absence of these findings, the risk is low. Document patient capacity, understanding, and assent. Consider a 24-hour follow-up in the ED for patients you discharge.

Takeaways

The four main killers after discharge with unexplained tachycardia:

1. Sepsis
2. Pulmonary Embolism
3. Myocardial Infarction
4. Acute Cardiomyopathy/Congestive Heart Failure

Depending on the chief complaint and history, there are high risk features you can search for on history and physical exam. If they are present, one or more of the following tests can be a valuable follow-on screening tool: Lactate, Troponin, BNP, D-Dimer, and ECG.

In the setting of persistent tachycardia, a thorough history and physical with attention to finding pertinent negatives and will be appreciated by the patient, enhance you reputation is a physician, and make your care more defendable.

Dr. Bedolla is national director of risk science at US Acute Care Solutions and assistant professor at the University of Texas Dell Medical School.

References

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