EM Reflections – May 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

 

Top tips from this month’s rounds:

  1. DVT – Anticoagulation Bridging… when is it needed?
  2. Anticoagulated elderly patient with minor trauma. Can we rely on a recent INR?
  3. Abdominal pain in an elderly patient. Does a nonspecific exam and normal vitals exclude serious illness?

 


DVT – Anticoagulation Bridging… when is it needed?

Consider the type of anticoagulation best suited for your patient. Remember warfarin needs bridging until therapeutic INR is achieved.  Ensure that patients discharged after hours have a robust plan for follow up and enough supply until follow up occurs.

Outpatient Management of Anticoagulation Therapy – American Family Physician 2013

 

For Warfarin therapy in DVT, Thrombosis Canada recommends:

Full-dose low molecular weight heparin (LMWH) overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.

 

Bridging is not required when prescribing a Direct Oral Anticoagulant (DOAC) e.g Apixaban or Rivaroxaban.

 

Thrombosis Canada tool to support decision making for Anticoagulation therapy in DVT

Management of DVT:

General measures:
Unless compression ultrasound (CUS) is rapidly available, patients with moderate-to-high suspicion of DVT (except those with a high risk of bleeding) should start anticoagulant therapy before the diagnosis is confirmed.  Imaging confirmation should be obtained as soon as possible.
Outpatient management is preferred over hospital-based treatment unless there is an additional indication for hospitalization.
Initial treatment should have an immediate anticoagulant effect. Therefore, warfarin monotherapy is not appropriate initially.

Treatment Regimens:

Depending on the clinical presentation, one of following regimens should be used for the initial 3 months:

  • Full-dose low molecular weight heparin (LMWH) overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.
  • Full-dose IV heparin overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.
  • Apixaban 10 mg PO BID for 1 week before reducing dose to 5 mg PO BID.
  • Rivaroxaban 15 mg PO BID for 3 weeks before reducing dose to 20 mg PO once daily.
  • Full-dose SC LMWH or IV heparin for at least 5-10 days before switching to dabigatran 150 mg PO BID or to edoxaban 60 mg PO once daily.
  • Full-dose LMWH alone without switching to an oral anticoagulant.
  • Full-dose LMWH for the 1st month or so before switching to a DOAC or warfarin.

 


Anticoagulated elderly patient with minor trauma. Can we rely on a recent INR?

 

Elderly patients on warfarin presenting with minor trauma are commonly seen in the ED.  Many will have been on warfarin for a prolonged period and will have stable INRs. However we can not rely on a previous INR level when assessing the current presentation. Consider the following rational:

  • Why did the patient fall?
  • Do they have a concomitant illness?
  • Are they compliant with their medication?
  • Have they been prescribed or are you considering prescribing new medication that may interact with warfarin?

Clinically Significant Drug Interactions

Anticoagulated patients frequently re-attend the ED with complications of bleeding after discharge following minor injury e.g enlarging hematoma, blood soaked dressings, missed internal bleeding, mobility failure. Consider whether admission for observation may be more appropriate than discharge in this group of patients. For those discharge ensure that they have close support and clear advice on when to return.

Practical tips for warfarin dosing and monitoring – Cleveland Clinic Journal

 

See this recent Medical Student Pearl on Reversal of Anticoagulation in the ED

Medical Student Clinical Pearl – Reversal of Anticoagulation in the Emergency Department

 


 

Abdominal pain in an elderly patient. Does a nonspecific exam and normal vitals exclude serious illness?

Elderly patients presenting to the ED with acute abdominal pain should be considered extremely high risk. Published series have reported mortality rates approaching 10% (https://www.ncbi.nlm.nih.gov/pubmed/7091511)

Presentations can be delayed, physical exam can be innocuous, lab results can be misleading. The risk of serious pathology is much greater and the outcome of delayed diagnosis can be significant.

Abdominal emergencies in the geriatric patient – Int J Emerg Med. 2014; 7: 43.

 

 

An excellent post from ALIEM – 10 Tips for Approaching Abdominal Pain in the Elderly

After seeing your fifth young patient of the day with chronic pelvic pain, constipation, and irritable bowel syndrome, it is easy to be lulled into the mindset that abdominal pain is nothing to worry about. Not so with the elderly. These 10 tips will help focus your approach to atraumatic abdominal pain in older adults and explain why presentations are frequently subtle and diagnoses challenging.

 

Erect CXR – Abdominal Series – Free air under diaphragm in perforated bowel

 

Bottom Line –

Elderly patients with abdominal pain are at a much greater risk of serious pathology and require an extremely thorough assessment before (if ever) discharging with a rule-out diagnosis e.g constipation, gastro, abdo pain NYD etc.

 

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EM Reflections – April 2017

Thanks to Dr. Joanna Middleton for her summary

Edited by Dr David Lewis

 

Top tips from this month’s rounds:


Syncopal/Pre-Syncopal Episode – Usually benign, but sometimes serious…….

Red flag symptoms of potentially life-threatening causes of syncope are syncope with exercise, chest pain, dyspnea, severe headachepalpitations, back pain, hematemesis / melena before the syncopal episode. Palpitations before loss of consciousness are a significant predictor of a cardiac cause of syncope. Focal neurologic deficits, diplopia, ataxia, or dysarthria after the syncopal episode.

 

2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society


Syncope Risk Scores

San Francisco Syncope Rule

Canadian Syncope Risk Score


ECG in Syncope

CanadiEM – Medical Concept – ECGs in Syncope

Download (PDF, 2.02MB)

 


Subarachnoid hemorrhage can present with syncope…

  • 97% – sudden, severe headache – “worst”
  • 53% – syncope
  • 77% – N/V
  • 35% – meningismus

How To Be A Clinical Rock Star Managing Subarachnoid Hemorrhage

 


 

Abdominal Aorta – Aneurysm vs Dissection

Only 2% of all aortic dissections originate from abdominal aorta. Almost all aortic dissections originate in the thoracic aorta.

The majority of abdominal aortic aneurysms are infrarenal

AAA – A comprehensive review

Download (PDF, 516KB)

 


Management of the Unruptured AAA

  • Symptomatic or asymptomatic
  • How can an unruptured AAA be symptomatic???
    • (rapid expansion of the aortic wall, ischemia from blocking off blood vessels, compression of other structures etc)
  • Symptomatic – admit for repair, regardless aneurysm diameter
  • Asymptomatic
    • <5.5cm – likely outpatient
    • “Very large aneurysm” (>6cm) – likely admit for repair

 

Transfers to and from Major Emergency Departments

  • Emergency transfers from referring sites for diagnostic imaging are potentially high risk
  • Adverse events have been reported in the medical literature for this group of patients
  • A detailed handover between referral and receiving site will reduce risk
  • Patient stability must be assessed prior to transfer, on arrival at receiving site and prior to return to referral site.
  • The results of the diagnostic imaging should be taken into context with the patient’s condition prior to release for return to referral site.

Download (PDF, 293KB)

 


 

Hyponatremia – How low is too low?

 

  • All patients with severe (< 120)
  • Any patient that is symptomatic from the hyponatremia

LIFL – Hyponatremia – Diagnosis and Management

 

For the budding critical care physiologist – Deranged Physiology – Hyponatremia

 

 

 

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EM Reflections – March 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:

 


Vertebral Artery Dissection – a tricky diagnosis and potentially catastrophic if missed…

 

Consider dissection in vertigo patients even without history of significant or mild trauma.

Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Dizziness, vertigo, double vision, ataxia, and dysarthria are common clinical features. Lateral medullary (Wallenberg syndrome) and cerebellar infarctions are the most common types of strokes.

Diagnosis – CT Angiography

Treatment – Antiplatelet or Anticoagulation (unless contraindications – see article below)

Cervical Artery Dissection in Stroke Study (CADISS) trial, RCT – antiplatelets versus anticoagulants in the treatment of extracranial carotid and vertebral artery dissections (VADs) = no difference found in outcomes between groups receiving antiplatelets vs anticoagulants. CADISS

Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations – (full text)

Rounds Presentation by Dr Kavish Chandra (R2 iFMEM)

Download (PDF, 755KB)


 

Limping Kids – inability to weight bear is always significant…

Need for thorough investigation of non traumatic hip pain in child unable to weight bear. Don’t get biased with previous diagnosis even if by specialists.

Don’t miss – Septic Arthritis or SCFE


From – Orthobullets.com – Hip Septic Arthritis – Pediatric – Author:

See this SJRHEM ED Rounds on Limping Kids

Take home pearls:

  • A limping/NWB child that can crawl is likely to have pathology below the knee
  • Examine least likely source of symptoms first.
  • Flex, Adduct and Int Rot hip most likely manoeuvre to elicit pain in hip pathology
  • Children >8yrs – X-ray hip first
  • If fever (>38°) or > 24hrs then bloods (incl CRP)
  • CRP < 12 is very reassuring (and a high CRP mandates further Ix to rule out septic arthritis)
  • Positive ultrasound is most likely to be irritable hip
  • Negative ultrasound – X-ray leg

 

 

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EM Reflections – February 2017

Thanks to Dr. Joanna Middleton for her summary

Edited by Dr David Lewis

Top tips from this month’s rounds:


Imaging for Bone Mets

Plain radiographs are not very sensitive for detecting bone metastases. Metastases to bone become apparent on radiographs only after the loss of more than 50% of the bone mineral content at the site of disease. The diagnostic utility of plain films of the skull, spine, and pelvis is limited by superposition effects. In these areas, the sensitivity of plain films for bone metastases is only in the range of 44–50%.

Reproduced from:Imaging of bone metastasis: An update – World Journal of Radiology

Further resources – Diagnostic Imaging of Bone Metasteses

 


Imaging for Thoracolumbar Spine Trauma

Plain radiography is not sensitive for thoracolumbar spine trauma – Trauma of the spine and spinal cord: imaging strategies – European Spine Journal (Full Text)

We have a guideline for imaging Thoracolumbar trauma. Click image below for larger version.

Any of: High energy mechanism, Inability to ambulate, extremity paresthesia, bladder/bowel deficit, saddle anesthesia – mandates CT

 


Cervical Spine Precautions

Not all trauma patients transferred by EMS require cervical spine precautions. New Brunswick EMS have guidelines (click image for full size):

 


 

Rapid Sequence Intubation – Paralysis with Rocuronium

The recommended dose of Rocuronium for RSI is 1.2 – 1.5mg/kg (not 0.6mg/kg as stated in many drug references)

Rocuronium can be rapidly reversed by Suggamadex (and it’s reversal is quicker than waiting for Sux to wear off)

Excellent RSI reference article from LIFL – Rapid Sequence Intubation (RSI)

 

Rocuronium vs. Succinylcholine from reuben strayer on Vimeo.


Graded Assertiveness vs Advocacy

 

A reminder that we all have a responsibility to ‘speak-up’ and challenge when we see an issue. There are a number of described methodologies (see below), however the key factor is acting on your concern, don’t be that person who watches an unfolding series of errors and think ‘I wish I had said something earlier’….

As the person being challenged – be grateful that someone has had the courage to ‘speak-up’ and potentially save your ass!

 

Graded Assertiveness

More from LIFL here – Speaking Up


 

AMI – STEMI – Early Diagnosis and Reperfusion significantly impacts Mortality

We shouldn’t need reminding that early diagnosis of STEMI via history and ECG significantly impacts mortality. Dynamic ECG changes must be recognised and reperfusion strategies initiated as soon as possible.

Delayed reperfusion increases mortality.

 

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EM Reflections – January 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:


1. Presenting Complaint: Abdominal Pain – Might not be due to Abdominal pathology

Keep in mind other life threatening causes of abd pain not in the abd. ( ie Aortic Dissection, PE, ACS, Pneumonia).

ECG on all pts who present with pain between chin and umbilicus.

 

 


 

2. Presenting Complaint: Back Pain – Careful with diagnosis of MSK Back Pain

Careful review of vital signs (current and recorded – including EMS). Persistent hypotension or even an episode of recorded hypotension should warrant further evaluation to rule out other more serious diagnoses (AAA, Pancreatitis, bowel perf, hemorrhage etc). (see article pdf below). PoCUS for AAA is highly sensitive and specific and should be considered in all patients >60 who present with back pain, syncope, transient hypotension etc. Although this study found that Routine Screening for Asymptomatic Abdominal Aortic Aneurysm in High-risk Patients Is Not Recommended in Emergency Departments That Are Frequently Crowded

 

Midline Abdomen, Transverse PoCUS view of the Abdominal Aorta – Spot the abnormality?

 


 

3. Can you reliably differentiate Cardiac Chest pain from Non Cardiac Chest pain by history alone?

Whilst the history is very important in the assessment of a patient with chest pain, it cannot reliably exclude Cardiac Chest Pain. Neither can examination (chest wall tenderness etc). All patients who present to ED with chest pain should have an ECG.

Link to a good article on Non Cardiac Chest Pain here.

 

 


 

Download (PDF, 179KB)

 


 

Download (PDF, 445KB)

 

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EM Reflections – December 2016

Thanks to Dr Joanna Middleton for this summary

Edited by Dr David Lewis

Top tips from this month:


Inotropes in Cardiogenic Shock

1)  Time-to-revascularization is one of the primary determinants of survival in patients with cardiogenic shock secondary to ACS so early consultation with cardiology is needed. Vasopressors and inotropes are a bridge to revascularization.

CAEP 2015 guidelines

Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?

– Recommendation: Cardiogenic shock patients in the ED should receive norepinephrine as the first- line vasopressor. (Strong)

– Recommendation: Cardiogenic shock patients in the ED should receive dobutamine if an inotrope is deemed necessary. (Conditional)


Labs alert

2)  Remember to repeat hemolyzed lab values (especially potassium levels)

what-are-the-causes


Dyspnoea in Pregnancy

3) Asthma in pregnancy – include other pregnancy related causes of SOB (PE, cardiomyopathy, pre-eclampsia etc) in pregnant patients who present with an asthma exacerbation.


SJRH Obstetric Pathway

4)  Pregnant patients – who goes directly to L and D?  Who gets seen in the ED?  See Dr. Sanderson’s suggestions below.

In general, the current triage process for pregnant patients presenting to the ED at > 20 weeks gestation has been working well:

–          Pregnant patients > 20 weeks gestation who have a presenting complaint that may involve a condition relevant to the pregnancy are triaged directly to the Labour and Birth Unit (eg. Abdominal pain, vaginal discharge, vaginal bleeding)

–          Pregnant patients that have a clearly non-pregnancy-related condition, with no apparent risk to the pregnancy, are managed in the ED (eg. Lacerations and minor injuries). Consultation with the Obstetrician on call is available if there are any questions.

–          Pregnant patients with an acute condition with an immediate risk to the maternal health are assessed and managed for that condition in the ED, with urgent consultation to the Obstetrician on call for input regarding any relevant concerns for the pregnancy, including fetal surveillance (eg. Cardiac arrhythmia, acute respiratory compromise, and multiple trauma need to be assessed and managed in the ED as there are not the facilities or the expertise to safely deal with these conditions in the Labour and Birth Unit)

5)  Reminder that Labor and Delivery are able to bring fetal monitor to the ED to assess fetal status.


Posterior Circulation Strokes

arteries_beneath_brain_gray_closer

6)  Review of posterior circulation strokes – I have attached a good review article (BMJ 2014;348:g3175 ).

SUMMARY POINTS

Posterior circulation stroke accounts for 20-25% (range 17-40%) of ischaemic strokes

Posterior circulation transient ischaemic attacks may include brief or minor brainstem symptoms and are more difficult to diagnose than anterior circulation ischaemia

Specialist assessment and administration of intravenous tissue plasminogen activator are delayed in posterior circulation stroke compared with anterior circulation stroke

The risk of recurrent stroke after posterior circulation stroke is at least as high as for anterior circulation stroke, and vertebrobasilar stenosis increases the risk threefold

Acute neurosurgical input may be needed in patients with hydrocephalus or raised intracranial pressure

Basilar occlusion is associated with high mortality or severe disability, especially if blood flow is not restored in the vessel; if symptoms such as acute coma, dysarthria, dysphagia, quadriparesis, pupillary and oculomotor abnormalities are detected, urgently seek the input of a stroke specialist


Ordering CT Angio

vein_of_galen_ax_direct_av_arrow

7)  Reminder to request CTA for patients with persistent neurological deficits suggestive of CVA.


Thanks

Joanna

Download (PDF, 447KB)

Download (PDF, 1.27MB)

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EM Reflections – October 2016

Thanks to Dr Joanna Middleton for this summary

Edited by Dr David Lewis

 


1)  A fracture of the ulna should raise suspicion for a radial head dislocation (i.e. -Monteggia) – these can be subtle.  Proper elbow x-ray films assist in the diagnosis –  look at the radiocapitellar line to r/o radial head dislocation.

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Monteggia_fracturedislocations_Emergency_Department_setting/

figure-1_1372210_monteggia-type-1_ulna-shaft_lat


2)  The posterior interosseous nerve is the most common neuropraxia seen with a Monteggia fracture-dislocation  The PIN is a branch of the radial nerve and is the motor supply to most of the extensor muscles (thumb and wrist extension).

22_thompson_aprch_06_540n


3)  A lactate >4 is a red flag and is associated with higher mortality, particularly if the lactate does not rapidly clear.

http://sinaiem.org/10278-2/

Prognostication: Lactate predicts badness and whether your treatment for badness is working.

capture-1024x346


4)  Crohn’s patients are at risk for intrabdominal abscess, in particular, psoas abscess.  Consider this diagnosis in Crohn’s patients who present with hip pain, particularly if their pain is increased by hip extension

42475ed112f1ca5e40e2cec9e3ffdc7b-1

 

images


5)  EtOH and head injury….low threshold for CT, particularly if there are any focal neurological findings.

iv-fluids-for-alcohol-intoxication


 

6)  EMS records are not always available when we initially see a patient but they often have helpful information.  It is worthwhile to have a look at them, particularly if the history from the patient is vague.

hi-kw-ems

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EM Reflections – May 2016

Presented by Dr Paul Page

Edited by Dr David Lewis

 

Top Tips this month:


Trauma

Reminder to use the NB Trauma – Transfer Protocols

Lower GI Bleed in the Elderly

Because of the broad differential diagnosis for hematochezia, taking a careful medical and surgical history is mandatory to guide the subsequent evaluation. Based on its favorable safety profile, as well as diagnostic and therapeutic capabilities, colonoscopy is the preferred modality for managing patients with severe hematochezia and suspected colonic hemorrhage. Urgent colonoscopy has been reported to increase the diagnostic yield and treatment of bleeding stigmata, as well as reduce the rebleeding rate. While most cases of colonic bleeding can be diagnosed endoscopically and treated appropriately, physicians should be able to recognize the situations when alternatives such as radionuclide imaging, angiographic, or surgical management are indicated.

Colles Fracture

CAST vs Slab
Some debate as to whether a full cast or backslab splint is required after MUA of displaced Colles fracture.
Link to – A practical guide to the application of backslabs, splints, CAM boots and Darco shoes for your paediatric and adult patients.The videos are designed to show you how to do each backslab when required, indications are listed but those that are not are usually discussed with orthopaedics (protocols may vary at different sites). In addition you can follow the links at the bottom for additional tips and videos.
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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.

Download (PDF, 426KB)

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EM Reflections – December 2015

Thanks to Dr Natasha DeSousa for her M&Ms presentation today.

Thanks to those who attended M&Ms. For those of you who missed it, here are the top tips:

1. When burring or curetting a corneal FB from an eye, remember there is always a risk of a scar and too much or too deep anteriorly means a scar in the visual field. Be careful.

Watch this video on corneal FB removal:

2. Transferring unstable patients within a hospital (e.g ED to CT, ED to Cath Lab etc) is associated with risk and requires careful consideration. 

See this article on Medscape (Crit Care. 2015;19(214) ) that discusses the risks involved during intrahospital transfers and proposes a checklist that can be used to ensure preparedness.  See the form proposed below (or here : http://www.ncbi.nlm.nih.gov/pubmed/25947327 )

Checklist_for_Intra-Hospital_Transport_of_Critically_Ill Checklist_for_Intra-Hospital_Transport_of_Critically_Ill 2

3. Personality traits can impact on the clinical interview. When considering a differential diagnosis, ask yourself: “If this were a different patient with the same presenting symptoms and signs, what diagnoses would I be considering?” Some physicians endorse having a list of at least three possibly life-threatening conditions on one’s radar for each presentation. Try it – this is a great way to mitigate the potentially life-threatening impact of fundamental attribution error.

See last month’s report for a full list of clinical decision making biases

4. What is fundamental attribution error?  This is the tendency for people to place an undue emphasis on personality to explain someone else’s behavior in a given situation rather than considering other potential factors.  For instance, “he is wailing out in pain because he has an opiate addiction problem” rather than “he is wailing out in pain because his bowel has just perforated.”

5. Management of Acute pain in the Emergency Department is a priority. See the SJRHEM pain control resource page.

STOP SUFFERING v2015May25

6. The management of spontaneous pneumothorax remains controversial. There are a number of international guidelines e.g British Thoracic SocietyConsider consulting Thoracic surgery when a lung has failed to fully re-inflate after 72 hours of standard treatment.

7. Flexor tendon injuries need to see plastic surgery within 48 hours. Delaying the repair beyond this can result in poorer outcomes. See this article for a further information on flexor tendon injuries in the hand.

TOORTHJ-6-28_F1

Open Orthop J. 2012; 6: 28–35.

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EM Reflections – November 2015

Thanks to Dr Joanna Middleton for her M&Ms presentation today.

Here are the top tips from M and M’s this month.  Thanks to everyone who participated.

1.  Anchoring bias was present in a few of the cases this month.  Try to keep an open mind and look for alternate diagnoses when seeing patients with recurrent visits for similar complaints. Get a list of decision making errors here. Also a nice blog post on this subject from the short coatand finally for the last word on clinical decision making in Emergency Medicine, watch these free lectures by Pat Crosskerry and see his full list of biases below.

Download (PDF, 172KB)

2.  Elderly patients often have multiple complaints and issues when they are admitted to hospital.  When discussing with the admitting physician, please try to communicate the significant/potentially life-threatening abnormal findings that are present during your work-up. See the current guidelines from the CFPC – GUIDE TO ENHANCING REFERRALS AND CONSULTATIONS BETWEEN PHYSICIANS  

3.  Below-knee DVT’s – 10-20% risk of extension/embolization. See UpToDate article. Management options are repeat/serial ultrasounds in low risk patients, vs anti-coagulation in higher risk patients (high clot load, pregnancy, cancer patients etc).  A recent article published in Blood, by Gualtiero Palareti gives an excellent evidence-based insight, with case examples, into this issue. A proposed management algorithm was included.

F2.large

Blood_Journal___How_I_treat_isolated_distal_deep_vein_thrombosis__IDDVT_ 

4.  Undiagnosed diabetics can present with really vague complaints  (see this patient point of view) – have a low threshold for getting an accu-check.

5.  If you have a DKA patient, use the DKA protocol! (Adult DKA, Pediatric DKA) That is why we have a PROTOCOL.  If potassium is low (<3.3) remember to replace prior to starting insulin infusion.  The insulin causes intracellular shift of potassium and resulting arrhythmias/death.

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EM Reflections – October 2015

Thanks to Dr Natasha DeSousa for her M&Ms presentation today.

Top tips from October 2015 M&Ms

1.  Consider a ‘road test’ before sending a patient home, especially if s/he has received multiple doses of narcotics. Ensure that the success or failure of the ‘road test’ is documented in the chart.

2.  If home is the disposition, ensure patients have someone to accompany them if s/he has received multiple doses of narcotics.

3.  Renal stones are painful; remember, we have a Renal Colic protocol that facilitates pain relief before a patient is even seen by a physician.

4.  Beware fundamental attribution bias – intoxicated patients can still have painful fractures that require expedient analgesia.

5.  Documentation facilitates communication between ourselves and other colleagues, and serves as an important medicolegal record of a patient encounter.

6. Newly confused patients or patients with new objective limb weakness should receive an emergent head CT before admission to the hospitalist service. 

7. Avoid administering ASA to newly confused or weak patients before a head CT confirms absence of a SDH/SAH.

8. Consider documenting conversations with Radiology when discussions about CTs occur.

cdr_cthead_poster

Resources

 

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