Keywords: Aneurysm (PubMed Search)
Splenic Artery Aneurysm (SAA)
Ever scanned someone and the report says "incidental note of a splenic artery aneurysm"? Well, if it hasn't happened yet, it will sooner or later. This type of aneurysm isn't that rare and with the number of abdominal CTs we order we are bound to see this in clinical practice.
Some important points to remember about SAA:
Keywords: Aortic Dissection (PubMed Search)
Suspect your patient has an aortic dissection? Don't wait to lower the blood pressure.
A few considerations for the patient with suspected aortic dissection:
Bleeding Dialysis Fistula?
Ever see a patient in the ED c/o "my fistula won't stop bleeding"? If you haven't, you probably will in the future.
Here are some helpful tips on getting these bad boys to stop oozing:
Keywords: Altered Mental Status (PubMed Search)
Altered Mental Status-Does Your Patient Have Non-Convulsive Status Epilepticus?
Ever intubated a patient in status epilepticus and wondered if they were still seizing after sedation and paralysis? Ever taken care of an altered patient and wondered if you should consult neurology and attempt to get an EEG?
NCSE is defined as continuous seizure activity without obvious outward manifestations of a seizure. This is important for emergency physicians to consider because it has to be detected early to prevent morbidity and mortality.
When to consider NCSE:
Keywords: Pulmonary Embolism (PubMed Search)
Pulmonary Embolism-Myths and Misconceptions
Just wanted to mention a few myths/misconceptions about acute PE that I have recently heard discussed in the ED.
1. Emergency physicians have to "get help" to give thrombolytic therapy. Sure it makes sense that we consult critical care and perhaps interventional radiology in some cases. But we do not need permission to use this drug by ourselves if indicated. Consider using lytics ESPECIALLY if the patient is unstable or if there is evidence of RV dysfunction (elevated troponin, echo criteria for dysfunction, or CT with large RV and bowing of the septum). What about the patient with RV dysfunction and a normal BP? Evidence is mounting that lytics are indicated to reduce the severity of pulmonary hypertension.
2. "Just get a d-dimer." Be very careful. Lots of false positives. D-dimer often clouds the picture more often than not.
3. "The mortality rate of missed PE is high." Often quoted as a 30%+ mortality rate if missed. Recent data suggests that it is < 5%.
Keywords: D-Dimer, Aortic Dissection (PubMed Search)
Can you use a serum d-dimer to rule out aortic dissection?
The answer to the question, in 2010, is no.
There has been a flurry of recent literature about the use of serum d-dimer to rule out aortic dissection. Some studies have shown a sensitivity of nearly 100%, but other studies have shown sensitivities of only 60-70%....pretty abysmal sensitivities. And despite some of the authorities on the subject touting how good the test is, there is not firm literature to support it. Better yet, there are some active medical malpractice cases I am aware of in which the diagnosis of aortic dissection was missed based on a "negative d-dimer."
My suggestion, and the vascular pearl for the day, is to avoid using d-dimer as a aortic dissection rule out strategy until good evidence (if it ever becomes available) exists. I know that people are using this test to rule out the disease, just realize that EVERY time I have ever given a talk on acute aortic disasters, 2-3 people from the audience always share that they had a case of a "d-dimer negative dissection."
Keywords: ischemia (PubMed Search)
Evaluation of the acutely ischemic limb
Some considerations when evaluating/treating patients with acute limb ischemia:
Category: Airway Management
Keywords: Altered mental status (PubMed Search)
Altered Mental Status-Three Diagnoses That Can "Bite You On The Buttocks"
When evaluating the patient who is altered, consider the following diagnoses:
1. DTs-seems simple enough, right? Remember that some altered patients will not be able to give a history of alcoholism. And this is definitely a diagnosis that can sneak up on you. Bottom line: consider DTs in ALL patients with a delirium.
2. Wernicke's encephalopathy-can also be very difficult to detect. Consider in ALL alcoholic patients with altered mental status and give Thiamine.
3. Herpes encephalitis-speaking from personal experience, this diagnosis can be extremely tough to diagnose. Consider giving emperic Acyclovir in patients with WBCs in their CSF and a negative gram stain. And don't forget to send off a Herpes PCR. As far as clinical presentations, CNS Herpes can present with a wide spectrum of findings, from isolated headache, to new psychobehavioral changes, to severe depression of consciousness and coma. Be aware that this diagnosis isn't common but failure to initiate Acyclovir may be a fatal mistake.
Keywords: bleeding (PubMed Search)
How to stop dialysis fistula/graft bleeding
The number of patients being placed on hemodialysis seems to be increasing. And the ED is where they will go when there is a any complication from their fistula or graft.
Hemodialysis shunts require cannulation with large bore instruments. This combined with heparinization may lead to prolonged bleeding from puncture sites.
What to do when a patient shows up in the ED with persistent bleeding from a fistula puncture site:
Vorwerk D, et al. A simple trick to facilitate bleeding control after percutaneous hemodialysis fistula and graft interventions. Cardiovasc Intervent Radiol 1997.
Keywords: altered mental status (PubMed Search)
Wernicke's encephalopathy, considered a unique complication of alcoholism, is also seen in malnourished patients, bariatric surgery patients, and patients who have undergone bone marrow transplantation.
Some pearls about Wernicke's encephalopathy:
Keywords: Thrombosis (PubMed Search)
Effort thrombosis, also called Paget von Schrotter disease, occurs when either the axillary and or subclavian veins thrombose. The condition is more common in young, healthy (>males) patients and presents with the usual DVT symptoms of arm pain, swelling, and pain.
The disease was originally described in patients performing vigorous activities, like weight lifting or repetitive over-the-head lifting. This type of activity has been reported to kink the subclavian vein and lead to clot formation.
Diagnosis and therapy is the same for any other type of DVT.
Category: Medical Education
Keywords: Pimping (PubMed Search)
The Art of Pimping-And How to Protect Against
This monday's pearl (ok, I know, it's tuesday now) comes from Michelle Lin's blog: academic life in emergency medicine. It is more gem than pearl, and it discusses what medical students and residents do to avoid being pimped. It is a must read!
Here is the link to the discussion on Michelle Lin's blog:
Just a few note worthy "pimping protection procedures":
Category: Medical Education
Keywords: Clinical Reader (PubMed Search)
Well, this monday's pearl is a bit different than prior pearls. I wanted to let you know about a very cool website I came across recently called Clinical Reader. There is a whole lot in the recent medical education literature that discusses "Web 2.0." Web 2.0 involves learning through interactive websites, blogs, podcasts, etc. Medical education is really starting to head out of the classroom, and I wanted to mention a newer website that a lot of folks are talking about.
Clinical Reader is a new medical RSS aggregator. What, you might ask, does this mean?
An RSS aggregator is a site that puts together information for you, that's right, for you. It actually does the work for you. Did I mention that it does the work for you? On this site, for example, if you are interested in "Emergency Medicine," the site finds all (or almost all) EM journals and brings you all of the latest information and updated articles. If you are into "Medical Education," you simply choose that category from a drop down menu and poof, you have all of the latest publications/reviews from the major medical education journals. Just choose your category and/or specialty and you are off and running.
Try it out. It isn't 100% perfect, but it is very cool.
Keywords: Varicocele (PubMed Search)
A varicocele is a collection of venous varicosities in the spermatic veins in the scrotum. This is caused by imcomplete drainage for the pampiniform plexus. This may be seen is up 20% of males and is asymptomatic most of the time. Most are found on the left side.
Why should you care, you might ask? Well, the right spermatic vein drains into the IVC and then into the renal vein, whereas the left spermatic vein drain drains directly into the renal vein.
In the patient with new onset, unilateral varicocele, consider an IVC thrombus/tumor if right sided and a left renal clot if left sided.
A case we had recently was a 30 yo male with nephrotic syndrome (a HUGE risk factor for renal vein thrombosis) who presented with left-sided scrotal swelling. He was found to have a left-sided varicocele. Based on this finding, a renal sono was performed and the diagnosis of left renal vein thrombosis was made.
1. Junnila J, Lassen P. Testicular masses. Am Fam Physician 1998;57:685-92
Got some interesting info today on the costs of some commonly used antihypertensive medications. Keep in mind that in patients with severe hypertension, your options of IV drips are limited.
Here is some info from our hospital:
Fenoldopam - $113.28
Nicardipine - $94.67
Esmolol - $82.15
Nitroprusside - $20.86
Labetalol - $14.40
Nitroglycerin - $2.90
Although Fenoldopam (Corlopam), which has been around for years, is more expensive than Nitroprusside, it is just as effective and without the side effects.
A new drug on the market that we don't have yet, Clevidipine, is just as effective as the big guns Nipride and Fenoldopam. Costs at this point are unknown.
More on antihypertensive medications next week....
Keywords: Thrombocytopenia (PubMed Search)
Management of Heparin-Induced Thrombocytopenia (HIT)
HIT occurs when antibodies form to a Heparin-Platelet Factor 4 (PF4) complex in patients who have been exposed to Heparin.
The main clinical manifestation is thrombosis (arterial/venous). Treatment is unique in that only certain medications can be used.
Medical Management options in HIT:
So, when a patient with a history of HIT shows up in the ED with a DVT/PE or other thrombotic problem, these are your mainstay drugs.
Keywords: Acute MI, papillary muscle rupture (PubMed Search)
Severe mitral regurgitation (MR) after MI, accompanied by cardiogenic shock carries a poor prognosis.
Severe MR in many cases is due to infarction of the posterior papillary muscle, and in these cases the area of infarction tends to be less extensive than in those with MR due to severe left ventricular dysfunction.
Take Home Pearl:
The presence of pulmonary edema and/or cardiogenic shock in a patient with an inferior STEMI should prompt consideration for acute MR due to papilary muscle rupture. Get an echo as fast as you can to confirm or r/o the diagnosis. Treatment is afterload reduction, inotropic support, and urgent surgical repair.
Category: Infectious Disease
Keywords: Encephalitis, Herpes (PubMed Search)
Herpes Encephalitis-When to Consider
Herpes encephalitis is a potential lethal condition with high morbidity. Obviously our job in the ED is to rule-out bacterial meningits. So, when should we consider the diagnosis of herpes encephalitis?
Although no great guidelines exist, consider ordering a herpes PCR when sending studies on the "rule-out meningitis" patient. What about emperically treating a patient with Acyclovir? Again, no great data. Consider treating with 10 mg/kg IV q 8 hours for patients with abnormal CSF (in addition to the Ceftriaxone/Vanc, etc.) if you are worried about them, if they are altered (or encephalopathic), and if the CSF is abnormal (elevated wbc) with a negative gram stain. Acyclovir can always be discontinued when the PCR returns negative.
This week's monday pearl is from our very own Azher Merchant....who recently gave an excellent talk on the risks of radiation.
Be afraid....be very afraid....
Risk is based on acute exposure and is extrapolated largely from atomic bomb survivors.
Effective radiation dose = Sievert (Sv)
Lifetime Attributable Risk of Cancer 1:1000 at 10mSv
Lifetime Attributable Risk of Cancer Mortality 1:2000 at 10mSv
Risk estimates follow a linear rate of change such that:
Lifetime Attributable Risk of Cancer in Adults = Radiation Dose (mSv) x 0.0001
Risk is Cumulative
Lifetime Attributable Risk of Cancer is greater than for adults and is age-dependent
Lifetime Attributable Risk of Cancer Mortality 1:1000 at 10mSv
Common Effective Dose Estimates (mSv)
Background radiation 3.5/year (chronic exposure)
Head, Face 2
Neck, Cervical Spine 2
Chest, Thoracic Spine 8
Abdomen/Pelvis, Lumbar Spine 15
Note that it doesn't take very much radiation to reach the 10 mSv level!
Bottom line: CT if you need to, but carefully consider whether it is worth it or not
One last pearl, carefully consider whether or not you want that d-dimer and don't order one unless you are prepared to order a CT scan.
Keywords: aortic dissection, syncope (PubMed Search)
Painless thoracic aortic dissection (TAD) and syncope
Patients with TAD do not always present with chest pain. In the International Registry of Aortic Dissection (IRAD) study, 2.2% of TAD cases were painless and approximately 13% of TAD cases presented with isolated syncope (i.e. NO PAIN). Other studies have shown that as many as 15% of TAD cases are painless.
Patients with TAD may present after a syncopal episode. The underlying pathophysiology of syncope is related to proximal rupture into the pericardium with resultant tamponade.
Add TAD to your differential diagnosis of unexplained syncope, especially in older folks and especially if a patient "looks bad" and you don't have a reason.