>EM Reflections – April 2016

Thanks to Dr Joanna Middleton for this summary

Top tips from this month:

1)  The removal of chest tubes for simple pneumothorax was discussed.  Most physicians send the patient home for 24-48 hours, then reassess with an x-ray.  If the lung is inflated, most physicians clamp the tube for a certain period of time +/- check for air leak (placing end of tube in basin of water) then re-xray and pull the tube if the lung is still expanded.  If it is not expanded, some physicians will send the patient home with a recheck in 24-48hrs, other physicians attach to wall suction and consult surgery.

2)  When checking for lung expansion, consider ordering a single view of the chest.  Often times a patient with a PTX will have numerous X-rays and the lateral is not needed in most cases – this saves on radiation exposure.

3)  Ensure the Heimlich valve is attached correctly by looking for the “flow” arrow that is engraved on the side.  The arrow should be pointed away from the body.

4)  Pericarditis may not always present with the classic EKG findings of diffuse ST elevation.  There should always be a low threshold to exclude a STEMI and consult cardiology if there is any symptoms suggestive of ischemia.

5)  We see lots of people with falls/MSK injuries – be sure to ask WHY the patient fell.  Did they simply trip on the coffee table, or did they trip because they have a visual field deficit from a stroke and couldn’t see the coffee table?

6)  Management of severe asymptomatic hypertension in the ED – most physicians in our department do not treat the asymptomatic patient, although some will start a medication if the patient has no family doctor/uncertain follow-up.  Everyone agreed that the rapid lowering of BP is potentially harmful and should not be done.  This is in keeping with the ACEP guidelines.

EMCRIT link on this:  http://emcrit.org/practicalevidence/2013-acep-management-of-asymptomatic-htn/

I have also attached the 2013 ACEP guideline on this topic.

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