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
Keywords: myocarditis, pericarditis, myopericarditis (PubMed Search)
Both acute pericarditis and myopericarditis are intensely inflammatory. As a result, CRP testing is extremely sensitive for these conditions and is excellent for evaluating their presence or absence.
Imazio M, Trinchero R. Myopericarditis: etiology, management, and prognosis. Int J Cardiol 2008;127:17-26.
Keywords: Arthrocentesis, Joint, Fluid, Septic (PubMed Search)
Joint Fluid Analysis:
This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain. For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.
|Diagnosis||Appearance||WBC||PMNs||Glucose % of |
|Normal||Clear||<200||<25||95 - 100||None|
| Degenerative |
|Clear||<4000||<25||95 - 100||None|
| Traumatic |
|Straw colored||<4000||<25||95 - 100||None|
|Acute Gout||Turbid||2000 - 50,000||>75||80 - 100||Negative birefringence|
|PseudoGout||Turbid||2000 - 50,000||>75||80 - 100||Positive birefringence|
|Septic Arthritis||Purulent / turbid||5000 - > 50,000||>75||< 50||None|
| Rheumatoid |
|Turbid||2000 - 50,000||50-75||~75||None|
Benjamin GC. Arthrocentesis. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 3rd ed. Philadelphia: Saunders; 1998:919-932.
Category: Critical Care Literature Update
Keywords: intracerebral hemorrhage, recombinant factor VIIa (PubMed Search)
Recent Articles from the Critical Care Literature
Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage.
Keywords: Kawasaki Disease; Cardiac; Coronary Aneurysm (PubMed Search)
Cardiac Involvement in Kawasaki Disease
So the Pearl is if you have a pediatric patient with a complaint of Chest Pain, ask if there was any history of Kawasaki Disease and get an EKG ASAP if the answer is yes!
Shah B. Lucchesi M. Atlas of Pediatric Emergency Medicine. McGraw-Hill Companies. 2006.
Keywords: drugs of abuse, heroin (PubMed Search)
Keywords: delirium, dementia, CAM, MMSE (PubMed Search)
Category: Infectious Disease
Keywords: diabetes, osteomyelitis, temperature, white blood cell count (PubMed Search)
Does this Patient with Diabetes have Osteomyelitis?
Butalia S, Palda VA, Sargeant RJ, et al. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 2008;299:806-13.
Keywords: Aortic Dissection, D-Dimer (PubMed Search)
Does a normal d-dimer rule out aortic dissection?
A lot of research seems to be focused on using d-dimer as a rule-out strategy for acute aortic dissection. The idea is that a d-dimer <500 (which is what we use for ruling out PE in low-mod risk patients) rules out dissection as well.
A few pearls and pitfalls regarding this:
Sodeck, Eur Heart J 2007
Category: Airway Management
Keywords: Pregnancy, Pulmonary Embolism (PubMed Search)
Pregnancy and Acute Pulmonary Embolism
Women who are pregnant or in the postpartum period and women who take hormonal therapy are at an increased risk of pulmonary embolism.
Tapson V. Acute Pulmonary Embolism. N Engl J Med 2008;358:1037-52
Keywords: low voltage, electrocardiography, effusion (PubMed Search)
Low QRS voltage on the ECG has various definitions; here's my simple definition for low voltage...either one of the following:
If the added QRS amplitudes (whole R wave + S wave) in leads I + II + III total < 15 mm, OR
If the added QRS amplitudes (whole R wave + S wave) in leads V1 + V2 + V3 total < 30 mm.
The potential causes of low QRS voltage includes pericardial effusions, pleural effusions, obesity, COPD, infiltrative cardiac diseases (e.g. sarcoid, amyloid), end-stage cardiomyopathies, severe hypothyroidism.
If the patient has NEW low voltage compared to an old ECG, the only real possibilities are pericardial effusion, pleural effusion, and severe hypothyroidism (e.g. myxedema).
Keywords: calcaneus, fracture, compartment (PubMed Search)
Normally occur due to axial loading mechanism such as:
Keywords: Pertussis (PubMed Search)
Pertussis means "violent cough".
Think of it with prolonged coughing, inspiratory whoop, absolute lymphocytosis, or chronic cough.
Don't Use cough suppressants.
Pertussis can be a life threatening Infection!! Especially in infants and young children.
Pertussis is a reportable infectious disease in the United States.
Keywords: dapsone, methemoglobinemia, methylene blue (PubMed Search)
Keywords: confusion, dementia, delirium, elderly (PubMed Search)
Keywords: pericarditis, cancer, pericardial effusion, metastastic (PubMed Search)
Patients with cancer that present with pleuritic chest pain often have pulmonary emboli, but don't forget about pericarditis. Lung and breast cancer, especially, are known to metastasize to the pericardium and produce pericarditis or pericardial effusions. Anticoagulation for presumed PE in patients with pericardial mets. can produce hemorrhagic tamponade, a disastrous iatrogenic complication, so think twice before starting empiric anticoagulation on patients...make sure your patient doesn't have pericarditis or an pericardial effusion.
The ECG in patients with cancer-related pericarditis or pericardial effusion does not always demonstrate the classic ST elevation wtih PR depression (which is most commonly seen in viral pericarditis). Patients with pericardial effusions often demonstrate low voltage and tachycardia. Electrical alternans, though "classic," only appears in 1/3 of patients with pericardial effusions.
Keywords: hip, fracture, mri, plain films (PubMed Search)
Typically divided into four types:
Perron A.D., Miller M.D., Brady W.J. Orthopedic pitfalls in the ED: Radiographically occult hip fracture. Am J Emerg Med 2002;20:234-237.
Keywords: coumadin, vitamin K, anticoagulation (PubMed Search)
Here is a short list of medications that will actually prevent a patient from being anticoagulated by coumadin. These medications will make it difficult for the patient to reach therapeutic levels and need to be warned about this drug-drug interaction with coumadin:
Reference: Goldfrank's Textbook of Toxicologic Emergencies, 6th Edition
Keywords: Stroke, TIA, ABCD, ABCD2 (PubMed Search)
Category: Critical Care
Keywords: passive leg raising, fluid responsiveness (PubMed Search)
Passive Leg Raising (PLR)
Monnet X, Teboul JL. Passive leg raising. Intensive Care Med 2008;34:659-63.