W. W. Decker

Mayo Clinic - Rochester, Rochester, Minnesota, United States

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Publications (170)674.01 Total impact

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    ABSTRACT: Background Anaphylaxis is a potentially life-threatening allergic reaction that may require emergency medical system (EMS) transport. Fatal anaphylaxis is associated with delayed epinephrine administration. Patient outcome data to assess appropriateness of EMS epinephrine administration is sparse. Objectives 1) Determine the frequency of epinephrine administration in EMS-transported patients with allergic complaints; 2) identify predictors of epinephrine administration, and; 3) determine frequency of ED epinephrine administration after EMS transport. Methods A cohort study was conducted from over 5 years. A total of 59,187 EMS transports of an Advanced Life Support (ALS) ambulance service were studied. Results One-hundred and three patient transports for allergic complaints were analyzed. Fifteen patients received EMS epinephrine and epinephrine was recommended for 2 additional patients who refused, for a total of 17 (17%) patients for whom epinephrine was administered or recommended. EMS epinephrine administration or recommendation was associated with venom as a trigger (29% vs. 8%, OR 4.70, 95% CI 1.28-17.22, p=0.013), respiratory symptoms (88% vs. 52%, OR 6.83, 95% CI 1.47- 31.71, p=0.006), and fulfillment of anaphylaxis diagnostic criteria (82% vs. 49%, OR 3.50, 95% CI 0.94- 13.2, p=0.0498). Four (4%) patients received epinephrine after ED arrival. Conclusion Low rates of epinephrine administration were observed. The association of EMS administration of epinephrine with respiratory symptoms, fulfillment of anaphylaxis diagnostic criteria, and low rate of additional epinephrine administration in the ED, suggest that ALS EMS administered epinephrine based on symptom severity. Additional studies of EMS anaphylaxis management including ED management and outcomes are needed.
    No preview · Article · Sep 2014 · American Journal of Emergency Medicine
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    ABSTRACT: Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines. To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine autoinjectors, and to measure the effect on anaphylaxis guideline adherence. A cohort study was conducted from April 29, 2008, to August 9, 2012. Adult patients in the ED who were diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up, and incidence of biphasic reactions were evaluated. The study included 202 patients. The median age of the patients was 45.3 years (interquartile range, 31.3-56.4 years); 139 (69%) were women. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs 33%; odds ratio [OR] 2.05 [95% CI, 1.04-4.04]) and admitted to the ED observation unit (65% vs 44%; OR 2.38 [95% CI, 1.23-4.60]), and less likely to be dismissed home directly from ED (16% vs 29%, OR 0.47 [95% CI, 0.22-1.00]). Eleven patients (5%) had a biphasic reaction. Of these, 5 (46%) had the biphasic reaction in the ED observation unit; 1 patient was admitted to the intensive care unit. Six patients (55%) had reactions within 6 hours of initial symptom resolution, of whom 2 were admitted to the intensive care unit. Significantly higher proportions of patients with anaphylaxis received epinephrine and were admitted to the ED observation unit after introduction of epinephrine autoinjectors and order set implementation. Slightly more than half of the biphasic reactions occurred within the recommended observation time of 4 to 6 hours. Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.
    No preview · Article · May 2014
  • Win K Shen · Stephen J Traub · Wyatt W Decker
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    ABSTRACT: Syncope, a clinical syndrome, has many potential causes. The prognosis of a patient experiencing syncope varies from benign outcome to increased risk of mortality or sudden death, determined by the etiology of syncope and the presence of underlying disease. Because a definitive diagnosis often cannot be established immediately, hospital admission is frequently recommended as the "default" approach to ensure patient's safety and an expedited evaluation. Hospital care is costly while no studies have shown that clinical outcomes are improved by the in-patient practice approach. The syncope unit is an evolving practice model based on the hypothesis that a multidisciplinary team of physicians and allied staff with expertise in syncope management, working together and equipped with standard clinical tools could improve clinical outcomes. Preliminary data have demonstrated that a specialized syncope unit can improve diagnosis in a timely manner, reduce hospital admission and decrease the use of unnecessary diagnostic tests. In this review, models of syncope units in the emergency department, hospital and outpatient clinics from different practices in different countries are discussed. Similarities and differences of these syncope units are compared. Outcomes and endpoints from these studies are summarized. Developing a syncope unit with a standardized protocol applicable to most practice settings would be an ultimate goal for clinicians and investigators who have interest, expertise, and commitment to improve care for this large patient population.
    No preview · Article · Mar 2013 · Progress in cardiovascular diseases
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    ABSTRACT: BACKGROUND: Risk factors for increased anaphylaxis severity are poorly understood. Angiotensin-converting enzyme (ACE) inhibitors have been associated with severe anaphylactic reactions in patients with hymenoptera venom allergy. Studies evaluating the association between beta-blockers and severe anaphylaxis have been conflicting. OBJECTIVE: To evaluate the association between antihypertensive medication use and increased anaphylaxis severity. METHODS: We included emergency department anaphylaxis patients aged 18 years and older. Markers of severe anaphylaxis were defined as (1) syncope, hypotension, or hypoxia; (2) signs and symptoms involving 3 or more organ systems; and (3) hospitalization. Antihypertensive medications evaluated included beta-blockers, ACE inhibitors, calcium channel blockers, angiotensin receptor blockers, and diuretics. Simple and multiple logistic regression analyses were conducted to estimate the association between antihypertensive medication use and markers of increased anaphylaxis severity. RESULTS: Among 302 patients with anaphylaxis, 55 (18%) had syncope, hypoxia, or hypotension, 57 (19%) required hospitalization, and 139 (46%) had 3 or more organ system involvement. After adjusting for age, gender, suspected trigger, and preexisting lung disease, beta-blocker, ACE-inhibitor, diuretic, or antihypertensive medication use in aggregate remained associated with both 3 or more organ system involvement and need for hospital admission. The adjusted associations between antihypertensive medication use in aggregate and 3 or more organ system involvement yielded an odds ratio of 2.8 (95% CI, 1.5-5.2; P = .0008) and with hospitalization an odds ratio of 4.0 (95% CI, 1.9-8.4; P = .0001). CONCLUSIONS: In emergency department anaphylaxis patients, antihypertensive medication use is associated with increased organ system involvement and increased odds of hospital admission, independent of age, gender, suspected trigger, or preexisting lung disease.
    Full-text · Article · Feb 2013 · The Journal of allergy and clinical immunology
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    Full-text · Article · Feb 2013 · Annals of Emergency Medicine

  • No preview · Article · Oct 2012 · Annals of Emergency Medicine
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    ABSTRACT: Diagnostic criteria were proposed at the Second Symposium on the Definition and Management of Anaphylaxis convened by the National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN). Validation is needed before these criteria can be widely adapted into clinical practice. Our aim was to retrospectively assess the diagnostic accuracy of the NIAID/FAAN criteria for the diagnosis of anaphylaxis in emergency department (ED) patients. A retrospective cohort study of ED patients presenting from April to October 2008 was conducted. Patients given a diagnosis of an allergic reaction or anaphylaxis and a subset of patients with related diagnoses were included. Electronic medical records were reviewed and data were abstracted to determine whether the NIAID/FAAN criteria were met. Records were also independently reviewed in a blinded fashion by 2 experienced attending allergists. Final diagnosis by allergists was considered the reference standard. Of 214 patients, 86 (40.2%) met the NIAID/FAAN criteria for anaphylaxis. Allergists gave 61 (28.5%) patients diagnoses of anaphylaxis, 59 (96.7%) of whom satisfied the NIAID/FAAN criteria. The interrater agreement between allergists was substantial (κ = 0.77). The test characteristics of the NIAID/FAAN criteria were as follows: sensitivity, 96.7% (95% CI, 88.8% to 99.1%); specificity, 82.4% (95% CI, 75.5% to 87.6%); positive predictive value, 68.6% (95% CI, 58.2% to 77.4%); negative predictive value, 98.4% (95% CI, 94.5% to 99.6%); positive likelihood ratio, 5.48; and negative likelihood ratio, 0.04. These results suggest that the NIAID/FAAN criteria are highly sensitive but less specific and are likely to be useful in the ED for the diagnosis of anaphylaxis.
    No preview · Article · Nov 2011 · The Journal of allergy and clinical immunology
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    ABSTRACT: Introduction. Etiology of acute ischemic stroke (AIS) is known to significantly influence management, prognosis, and risk of recurrence. Objective. To determine if ischemic stroke subtype based on TOAST criteria influences mortality. Methods. We conducted an observational study of a consecutive cohort of patients presenting with AIS to a single tertiary academic center. Results. The study population consisted of 500 patients who resided in the local county or the surrounding nine-county area. No patients were lost to followup. Two hundred and sixty one (52.2%) were male, and the mean age at presentation was 73.7 years (standard deviation, SD = 14.3). Subtypes were as follows: large artery atherosclerosis 97 (19.4%), cardioembolic 144 (28.8%), small vessel disease 75 (15%), other causes 19 (3.8%), and unknown 165 (33%). One hundred and sixty patients died: 69 within the first 30 days, 27 within 31–90 days, 29 within 91–365 days, and 35 after 1 year. Low 90-, 180-, and 360-day survival was seen in cardioembolic strokes (67.1%, 65.5%, and 58.2%, resp.), followed for cryptogenic strokes (78.0%, 75.3%, and 71.1%). Interestingly, when looking into the cryptogenic category, those with insufficient information to assign a stroke subtype had the lowest survival estimate (57.7% at 90 days, 56.1% at 180 days, and 51.2% at 1 year). Conclusion. Cardioembolic ischemic stroke subtype determined by TOAST criteria predicts long-term mortality, even after adjusting for age and stroke severity.
    Full-text · Article · Oct 2011 · Stroke Research and Treatment

  • No preview · Article · Oct 2011 · Annals of Emergency Medicine
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    Ronna Campbell · Wyatt Decker

    Preview · Article · Aug 2011
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    ABSTRACT: This clinical policy from the American College of Emergency Physicians is the revision of a 2003 clinical policy on the evaluation and management of adult patients presenting with suspected pulmonary embolism (PE).(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.
    Full-text · Article · Jun 2011 · Annals of emergency medicine
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    ABSTRACT: Angioedema is often treated in the emergency department (ED). Few studies have evaluated self-injectable epinephrine (SIE) prescribing patterns for angioedema. To describe presentation and management of ED patients with angioedema and determine factors associated with epinephrine administration, hospital admission and SIE prescription. We conducted a retrospective cohort study of all ED patients with angioedema between January 2005 and December 2006. Of 63 patients, 39 (61.9%) were female. Median age was 49 years. Precipitating factors were identified in 36 (57.1%) patients. History of other allergic conditions was seen in 37 (58.7%) patients. Seventeen (27.0%) patients received epinephrine, 55 (87.3%) received antihistamines, and 51 (81.0%) received steroids. Epinephrine was administered more commonly in patients with edema of the tongue (risk ratio [RR], 5.28, 95% confidence interval [CI] 1.95-14.33, P = .0003), tightness/fullness of throat (RR, 3.31, 95% CI 1.62-6.76, P = .006), and dyspnea/wheeze (RR, 3.04, 95% CI 1.41-6.59, P = .005). Hospitalization was more common in patients with dyspnea/wheeze (P = .028) and allergic history (P = .006). Thirteen patients (22.0%) were discharged with SIE. An SIE prescription was associated with younger patients (median age, 26 years [interquartile range (IQR) 15-50] vs a median age 57.5 years [IQR 43-68], P = .004) and patients with throat tightness/fullness (RR, 4.2, 95% CI 1.8-9.8, P = .005). Patients with respiratory symptoms and allergic history were likely to be admitted. Epinephrine use was more frequent in patients with signs and symptoms of oropharyngeal edema. Younger patients and those with tightness/fullness of throat were likely to be prescribed SIE. Further studies are needed to determine who would benefit from epinephrine use and SIE prescription.
    No preview · Article · Jun 2011 · Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology
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    ABSTRACT: Anaphylaxis is a potentially life-threatening allergic reaction commonly managed in the emergency department (ED). Data describing patients 50 or 65 years or older with anaphylaxis are limited. To describe the presentation and management of patients with anaphylaxis who were 50 or 65 years or older and to compare these findings with those of younger patients. A consecutive cohort study of patients presenting to an ED with approximately 80,000 visits per year was conducted. Patients who met diagnostic criteria for anaphylaxis from April 2008 to June 2010 were included. Data were collected on suspected causes, signs and symptoms, management, ED disposition, and follow-up. The study included 220 patients. Food was the most common suspected cause of anaphylaxis for patients younger than 50 (42.2%) or 65 years (38.5%) but was much less common in patients 50 (14.8%, P < .001) or 65 years or older (14.3%, P = .01). Cardiovascular symptoms were more likely to occur in older patients (≥50 years old, 55.6% vs 30.1%, P < .001; ≥65 years old, 64.3% vs 32.3%, P = .002). Patients 50 or 65 years or older were less likely to be dismissed home directly from the ED (≥50 years old, 35.2% vs 56.6%, P = .006; ≥65 years old, 32.1% vs 54.2%, P = .03) and were less likely to be prescribed self-injectable epinephrine (≥50 years old, 40.7% vs 63.3%, P = .004; ≥65 years old, 32.1% vs 61.5%, P = .003). In ED patients presenting with anaphylaxis, age of 50 or 65 years or older is associated with a decreased likelihood of food-induced anaphylaxis, increased likelihood of experiencing cardiovascular symptoms, decreased dismissal to home directly from the ED, and decreased prescriptions for self-injectable epinephrine.
    Full-text · Article · May 2011 · Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology
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    ABSTRACT: This clinical policy from the American College of Emergency Physicians is an update of the 2004 clinical policy on the critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. A writing subcommittee reviewed the literature as part of the process to develop evidence-based recommendations to address 4 key critical questions: (1) In a hemodynamically unstable patient with blunt abdominal trauma, is ultrasound the diagnostic modality of choice? (2) Does oral contrast improve the diagnostic performance of computed tomography (CT) in blunt abdominal trauma? (3) In a clinically stable patient with isolated blunt abdominal trauma, is it safe to discharge the patient after a negative abdominal CT scan result? (4) In patients with isolated blunt abdominal trauma, are there clinical predictors that allow the clinician to identify patients at low risk for adverse events who do not need an abdominal CT? Evidence was graded and recommendations were based on the available data in the medical literature related to the specific clinical question.
    No preview · Article · Apr 2011 · Annals of emergency medicine
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    ABSTRACT: We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack. This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days. The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days. The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.
    Full-text · Article · Jan 2011 · Annals of emergency medicine
  • Wyatt W Decker · Latha Ganti Stead

    No preview · Article · Jan 2011 · Annals of emergency medicine

  • No preview · Article · Jan 2011
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    ABSTRACT: We assess the methodological quality and prognostic accuracy of clinical decision rules in emergency department (ED) syncope patients. We searched 6 electronic databases, reviewed reference lists of included studies, and contacted content experts to identify articles for review. Studies that derived or validated clinical decision rules in ED syncope patients were included. Two reviewers independently screened records for relevance, selected studies for inclusion, assessed study quality, and abstracted data. Random-effects meta-analysis was used to pool diagnostic performance estimates across studies that derived or validated the same clinical decision rule. Between-study heterogeneity was assessed with the I(2) statistic, and subgroup hypotheses were tested with a test of interaction. We identified 18 eligible studies. Deficiencies in outcome (blinding) and interrater reliability assessment were the most common methodological weaknesses. Meta-analysis of the San Francisco Syncope Rule (sensitivity 86% [95% confidence interval {CI} 83% to 89%]; specificity 49% [95% CI 48% to 51%]) and the Osservatorio Epidemiologico sulla Sincope nel Lazio risk score (sensitivity 95% [95% CI 88% to 98%]; specificity 31% [95% CI 29% to 34%]). Subgroup analysis identified study design (prospective, diagnostic odds ratio 8.82 [95% CI 3.5 to 22] versus retrospective, diagnostic odds ratio 2.45 [95% CI 0.96 to 6.21]) and ECG determination (by evaluating physician, diagnostic odds ratio 25.5 [95% CI 4.41 to 148] versus researcher or cardiologist, diagnostic odds ratio 4 [95% CI 2.15 to 7.55]) as potential explanations for the variability in San Francisco Syncope Rule performance. The methodological quality and prognostic accuracy of clinical decision rules for syncope are limited. Differences in study design and ECG interpretation may account for the variable prognostic performance of the San Francisco Syncope Rule when validated in different practice settings.
    Full-text · Article · Oct 2010 · Annals of emergency medicine
  • M. K. Meyer · A. R. Kanthala · W. W. Decker · R. L. Campbell

    No preview · Article · Sep 2010 · Annals of Emergency Medicine

  • No preview · Article · Sep 2010 · Annals of Emergency Medicine

Publication Stats

3k Citations
674.01 Total Impact Points


  • 2003-2014
    • Mayo Clinic - Rochester
      • • Department of Emergency Medicine
      • • Department of Cardiovascular Diseases
      Rochester, Minnesota, United States
  • 2010
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2009
    • University of Rochester
      • School of Medicine and Dentistry
      Rochester, New York, United States
    • General Hospital, Celje
      Tsel'e, Celje, Slovenia
  • 2008
    • Polytechnic University of Puerto Rico
      San Juan, San Juan, Puerto Rico
  • 2006
    • Mayo Foundation for Medical Education and Research
      • Department of Emergency Medicine
      Scottsdale, AZ, United States
    • The American College
      Bryn Mawr, Pennsylvania, United States
  • 2005
    • American college of Physicians
      Philadelphia, Pennsylvania, United States
  • 2004
    • University of Washington Seattle
      Seattle, Washington, United States
    • University of California, Davis
      Davis, California, United States
    • University of Minnesota Duluth
      Duluth, Minnesota, United States