Keywords: AV Fistula (PubMed Search)
Management of Ruptured AV Fistula
This pearl pertains to a case I had 2 weeks ago. A 65 yo male presented with a massively swollen left forearm in the region of his AV fistula. On ultrasound he had a 6 X 6 cm aneurysm. He was seen by vascular and transplant surgery and taken to the OR for repair.
So, the question came up, what would an emergency physician do if this bad boy actually ruptured? Well, obviously we would hold pressure. But what if that didn't work? Well, shouldn't the patient go to the OR? The answer is a resounding yes, but what if there is no surgeon around. There is not much literature on how to handle this devastating vascular catastrophe.
As a rule of thumb, if an AV Fistula ruptures (not leaks) and the patient is exsanguinating in front of you:
J Vasc Surg 2005
Keywords: Hypertension (PubMed Search)
Side Effects of Hydrochlorothiazide
Consider the following when prescribing HCTZ from the emergency department:
The side effects of hydrochlorothiazide include hypokalemia,hypercalcemia, hypomagnesemia, metabolic alkalosis, hyponatremia, hyperuricemia (may worsen gout), hyperglycemia, hypercholesterolemia, hypertriglyceridemia.
Journal of Hypertension, 2006
Keywords: Leukemia (PubMed Search)
Suspected Acute Leukemia in the ED
Key ED Interventions for patients with astronomically high WBC counts:
Keywords: hemorrhage (PubMed Search)
Hemorrhage Volume on Head CT
Ever wanted to speak the same language as our neurosurgical colleagues? Ever wonder what they are doing, calculating, or thinking about as they look at the head CT of the large intracranial hemorrhage?
Most of the neurosurgeons want to know basic information about patients with head bleeds. One thing they always calculate is the hemorrhage volume...i.e. how many mLs of blood are in the bleed? This can be easily done in the ED by using the following formula: called the ABC formula.
A X B X C/2 X 0.6= mL of blood
A= largest width of the bleed (in cm)
B=largest width perpindicular to A
C=number of cuts you see blood on
So, if A=2cm, B=2cm and the bleed is seen on 3 cuts.....
2 X 2 X 3/2 X 0.6=3.6 mL of blood (not very much in the opinion of a neurosurgeon)
Most of the big bleeds that neurosurgeons drain or take to the OR are 50 cc or so. So, when you call a neurosurgeon and tell them that the patient has 60 mLs of blood, you will definitely get their attention.
PEA Arrest...Look for AAA rupture and Cardiac Tamponade
If a patient presents in cardiac arrest (particularly PEA), consider the following diagnoses in addition to the causes commonly taught in ACLS:
A 2004 study in Resuscitation by Meron et al. showed the following:
Take home point for the emergency physician:
Meron, et al. Resuscitation 2004
Keywords: DVT, Pulmonary Embolism (PubMed Search)
DVT and Asymptomatic Pulmonary Embolism
A few important pearls about PE:
Journal of Thrombosis and Hemostasis and Chest-2006, 2007
Keywords: Fever (PubMed Search)
A few pearls about neutropenic fever:
IDSA Guidelines on Neutropenic Fever, 2002. New Guidelines coming Summer 2008!
Keywords: Pulmonary Embolism (PubMed Search)
Treatment of Pulmonary Embolism
Treatment of acute PE:
If administering thrombolytic therapy (currently tPA is the only FDA approved drug) for massive PE, most authorities recommend UFH (Unfractionated Heparin) because the infusion needs to be turned off while the tPA hangs for 2 hours.
Although other agents are being promoted for the treatment of acute PE, like direct thrombin inhibitors, many institutions do not have these drugs available yet. Plus, they are expensive and have not been shown to be superior to standard therapy (at least yet)
References: Kline, Journal of Thrombosis and Hemostasis, 2005, 2006, 2007
Keywords: Variceal Bleed (PubMed Search)
Medical Regimen for Suspected Variceal Bleed
To review what Dr. Bond and Dr. Winters have already posted:
Three medical therapies have been shown to be effective in patients with severe upper GI bleed thought to be due to esophageal varices:
Most of our gastroenterologists recommend this regimen (all three therapies)
Other things to consider:
Keywords: Oncologic, Emergency, SVC Syndrome (PubMed Search)
Clinical Presentation of SVC Syndrome
SVC syndrome (caused either by tumor or thrombosis of the SVC) classically presents with facial swelling, arm swelling, and dilated chest wall veins. The problem in the real world is that often times the manifestaions are a bit more subtle.
Some SVC syndrome pearls:
Keywords: BP, Hypertension, Angioedema (PubMed Search)
Direct Renin Inhibitor-Aliskiren (Tekturna)
This drug is the 1st in a new class of antihypertensives called direct renin inhibitors-1st approved in 2007. This drug, along with three others being developed, inhibits the entire Renin-Angiotensin-Aldosterone System (RAAS) which has been shown to lead to definitive 24 hour blood pressure control.
Why should emergency physicians care, you ask?
J Hypertension March 2007
Category: Airway Management
Keywords: Asthma (PubMed Search)
Care of the Crashing Asthma Patient
Several things should be considered in the crashing asthmatic:
Keywords: AAA, aneurysm (PubMed Search)
AAA...be afraid, be very afraid
Abdominal Aortic Aneurysm (AAA) is known as the great masquerader in the elderly for good reason....
Keywords: Inferior Vena Cava, Physical Examination, Thrombosis (PubMed Search)
Physical Examination finding in inferior vena cava thrombosis
Consider IVC thrombosis if you ever see vertically oriented, dilated abdominal wall veins, or dilated veins on the back. As opposed to abdominal wall veins that radiate out from the umbilicus in patients with cirrhosis-known as caput medusae.
Etiologies include hepatic tumors abutting the IVC, renal cell tumors, open abdominal surgery, catheter related, IVC filter-related.
Keywords: Fenoldopam, Hypertension (PubMed Search)
Intravenous Fenoldopam has been shown in recent years to be a very effective antihypertensive medication. Studies have compared it to Nitroprusside (Nipride), the older generation "gold standard" antihypertensive, and have found to be just as effective.
Journal of Hypertension 2007
Keywords: Pulmonary, Pulmonary Embolism (PubMed Search)
Pulmonary CTA Sensitivity and PIOPED II
The publication of PIOPED II has led some to doubt the sensitivity of pulmonary CTA for pulmonary embolism. This study reported an overall sensitivity of 83% which could be increased to nearly 90% with the addition of CTV (CT Venography). 83% is a horrible sensitivity. So, why should you care?
Keywords: PE, Pulmonary Embolism (PubMed Search)
Optimal pulmonary artery opacification for detecting pulmonary embolism-how good was the CT you ordered?
The PE literature is pretty clear about one thing: a CT with well-timed opacification of the pulmonary arteries is very sensitive for detecting pulmonary embolism. This means that there needs to be enough contrast in the central pulmonary arteries to be able to detect clot. So how can you be really sure the PE Protocol CT you ordered is adequate? Have you really ruled out PE?
What does this mean for the emergency physician?
Some predict that in the future WE (the emergency physician) may in fact be held accountable for knowing whether or not a CTPA (CT Pulmonary Angiography) is optimal or not.
(1) Kline-Carolinas Medical Center (2) Journal of Thrombosis and Hemostasis 2007 (3) AJR 2006,2007
Keywords: Pulmonary Embolism (PubMed Search)
Risk Factors for Pulmonary Embolism
Can you imagine one of our patients saying"Dr. Abaraham, I have what is known in the hematology community as a Factor 5 Leiden mutation"?
Keywords: catheter, lytics (PubMed Search)
Thrombolytic infusion for occluded central venous catheters
For patients with long-term indwelling central venous catheters (dialysis catheters, Hickmans, etc) who develop catheter occlusion, consider infusion of thrombolytic therapy for catheter salvage.
How do you do it, you ask?
This treatment is very safe and is well tolerated.
Journal of Vascular Access, 2006
Keywords: Pulmonary Embolism (PubMed Search)
The PERC Rules revisted
How can I rule out PE without ANY testing, you ask? Do I have to get a d-dimer on that low risk patient?
Do these things keep you up at night like they do me?
Consider using the PERC rule (Pulmonary Embolism Rule Out Criteria)
This set of rules was mentioned in an earlier pearl, but there are now 3 large studies (and one on the way) that validate the use of these rules.
So, if you have a patient who is LOW risk for PE but you would like to document something in the chart that proves you thought about the diagnosis and clinically ruled it out:
If the patient is LOW risk for PE by your clinical gestalt and if the answer to ALL of the following questions is YES, then the patient is considered PERC negative:
PERC negative + Low Risk clinical gestalt = PE ruled out
Jeff Kline, PERC rule. Journal of Thrombosis and Hemostasis. 2007/2008