Keywords: Acute, Aortic Dissection, Neurologic (PubMed Search)
Neurologic Manifestations of Acute Aortic Dissection
A myriad of neurologic presentations of acute aortic dissection have been reported in the literature. Although classic CVA symptoms may occur, nonspecific neurologic symptoms are much more common
Take Home Point:
Keywords: Hypertension, Epistaxis (PubMed Search)
Hypertension and Epistaxis
We commonly encounter patients with epistaxis who are found to be hypertensive. Some have taught over the years that hypertension causes nosebleeds and that some nose bleeds won't stop until the BP is lowered...
Some pearls about HTN/Epistaxis:
Keywords: Warfarin, Skin Necrosis (PubMed Search)
Warfarin-Induced Skin Necrosis (WISN)
Some pearls about a rare, but serious side effect of Warfarin...
55 yo female presented to the ED on the day of hospital discharge for evaluation of this rash.
The rash began 4 days after starting Warfarin. Was being treated for a DVT.
Keywords: Hypertension (PubMed Search)
What Hypertensive Patient Needs a Workup for End-Organ Damage?
Ah, the age old question...which hypertensive patients need an ED workup for end-organ damage? The "workup" for patients includes renal function, urinalysis, CXR, ECG, etc.
Some pearls regarding working patients up:
Keywords: hypertension (PubMed Search)
Keywords: PERC Rules (PubMed Search)
Keywords: Warfarin (PubMed Search)
Reversal of Warfarin
Reversal of Warfarin can be accomplished by administering any of the following:
A few pearls:
Keywords: HeparinPro (PubMed Search)
Anticoagulation with Heparin-How to Reverse?
So you just started Heparin on that ACS patient? Just bolused the patient in room 12 with the large PE with a slug of Heparin? The nurse tells you that one of them just vomited blood and the other just had a large bloody bowel movement. What to do, oh, what to do?
How to reverse Heparin...use Protamine:
Keywords: Thrombosis, Cerebral (PubMed Search)
Cerebral Venous Sinus Thrombosis (CVST)
An uncommon but very serious entity that leads to three distinct types of presentations:
Caused by thrombosis of one of the intracerebral venous sinuses (most commonly the transverse sinus) The major risk factor is hypercoagulable disease. May be the underlying cause of a majority of cases of idiopathic intracranial hypertension.
When to suspect:
Keywords: Hypertension, Headache (PubMed Search)
Does Hypertension (elevated BP) Cause Headache?
This is an age old question that many of us have struggled with in the ED for many years...
Other questions include: Does elevated BP cause headaches? Do we need to scan hypertensive patients with headache just because they have a headache? At what level of BP does the BP actually cause headache?
A few quick pearls:
Keywords: Hypertension (PubMed Search)
Avoidable Pitfalls in Managing the Hypertensive Patient
We all see very hypertensive patients on almost every shift. Dr. Winters has an earlier pearl related to pitfalls in treating patients with hypertensive encephalopathy, but I thought it was time to reiterate just a few points.
Keywords: aortic dissection, chest xray (PubMed Search)
So, how good is a screening CXR for aortic dissection?
Keywords: Cardiovascular, CocaineC (PubMed Search)
Key Cardiovascular complications of cocaine:
Restrepo CS, et al. Cardiovascular complications of cocaine: Imaging findings. Emerg Radiol 2008
Keywords: Ischemia (PubMed Search)
Management of acute limb ischemia
Just a few pearls regarding acute limb ischemia
Vasc Surg Reviews 2007
Keywords: subrachnoid hemorrhageRebeleeding (PubMed Search)
Complications of Subarachnoid Hemorrhage
The three dreaded complications of SAH include the following:
Edlow, et al. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. JEM 2008
Keywords: LMWH, PE, Pulmonary Embolism (PubMed Search)
Currently Approved LMWHs for the Treatment of Acute PE:
Make sure to monitor platelet counts regardless of agent chosen.
Konstantinides. Acute pulmonary embolism revisited. Heart. June 2008
Keywords: D-Dimer (PubMed Search)
Causes of an Elevated D-Dimer
Don't forget the multiple causes of an elevated d-dimer:
**See attached PDF-Differential Diagnosis of Elevated D-Dimer
Journal of Thrombosis and Hemostasis, 2008
Keywords: CT, Pulmonary (PubMed Search)
How good was that CT Pulmonary Angiogram You Ordered?
CT is currently the gold standard imaging modality for pulmonary embolism. Since we order these quite a bit in the ED, we should know some of the important nuances regarding interpretation of the scan. All of us at some point have looked at a pulmonary CTA and thought that it looked a bit "fuzzy" or perhaps it didn't "look right" This happens more often in obese patients. There is good literature to show that a suboptimal CTA misses clinically significant PE. So, it is important for emergency physicians to know a little about the CT scan ordered for our patients.
How can you know if the CT scan YOU ordered to rule out PE is really "good enough" to rule out PE?
So, a 34 yo obese patient who gets a CT scan to rule out PE, who has 170 HU in the main pulmonary artery, has not had an optimal CT. Thus, you really haven't ruled out PE even if the read is "negative." Often this is due to poor bolus timing.
American College of Radiology, Appropriateness Criteria, 2006
Keywords: Pulmonary Embolism, Pregnancy (PubMed Search)
Evaluating for Pulmonary Embolism During Pregnancy
Highest risk of PE is within the first week postpartum
Acceptable, safe, and medico-legally sound strategies to rule out PE in pregnancy:
**For explanation of PERC rule, see earlier pearl.
Kline J, Carolinas Medical Center, 2006-2008 published data
Keywords: Pulmonary Embolism, Cancer (PubMed Search)
Ruling Out PE in Cancer Patients: Use D-Dimer??
Most of us are aware of the data that suports using a highly-sensitive d-dimer combined with low-moderate risk score to r/o PE. Sounds simple enough. What about using d-dimer in a cancer patient to rule it out? Well, this is being studied more and more.
Most of us would be a little uneasy about using a d-dimer as a stand-alone test to r/o PE in a cancer patient. After all, they have cancer, aren't they high risk?
The following study showed that the there was a VERY high negative predictive value and a VERY high sensitivity of a negative d-dimer in this group of cancer patients.
|PURPOSE: To prospectively evaluate (a) the diagnostic performance of D-dimer assay for pulmonary embolism (PE) in an oncologic population by using computed tomographic (CT) pulmonary angiography as the reference standard, (b) the association between PE location and assay sensitivity, and (c) the association between assay results and clinical factors that raise suspicion of PE. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval; informed consent was obtained. Five hundred thirty-one consecutive patients were clinically suspected of having PE; 201 were enrolled (72 men, 129 women; median age, 61 years) and underwent CT pulmonary angiography and D-dimer assay. Relevant clinical history, symptoms, and signs were recorded. CT images were interpreted, and the location of emboli was recorded. The negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity, and diagnostic likelihood ratios of the D-dimer assay results were calculated. RESULTS: Forty-three patients (21%) had pulmonary emboli at CT. D-Dimer results were positive in 171 patents (85%). The NPV and sensitivity were 97% and 98%, respectively. The specificity and PPV were 18% and 25%, respectively. No association was shown between clinical history, symptoms, or signs and NPV, PPV, sensitivity, or specificity or between location of PE and sensitivity. |
CONCLUSION: D-Dimer results have high NPV and sensitivity for PE in oncologic patients and, if negative, can be used to exclude PE in this population. Combining the assay with clinical symptoms and signs did not substantially change NPV, PPV, sensitivity, or specificity.
King V, Vaze AA, Moskowitz CS, et al. D-dimer assay to exclude pulmonary embolism in high-risk oncologic population: correlation with CT pulmonary angiography in an urgent care setting. Radiology. 2008 Jun;247(3):854-61