Paucis Verbis: NSAIDS and upper GI bleeds

Do no harm.

We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?

Ketorolac has the highest upper GI complication RR (14.54) for all of the studied NSAIDs. Compare this with the overall risk of traditional COX-1 NSAIDS (RR=4.5) and COX-2 inhibitors (RR=1.88). So before giving ketorolac, first check that patients don’t have a history of a GI bleed or peptic ulcer.

PV Card: NSAIDs and Upper GI Bleed

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Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Massó G, Patrignani P, Tacconelli S, García R. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum. 2010;62(6):1592-1601. [PubMed]

By Michelle Lin, MD|2021-10-12T16:27:37-07:00Jul 15, 2011|ALiEM Cards, Gastrointestinal, Tox & Medications|

Doing well as a new EM attending physician

You are super-excited to get your first real job as an emergency physician after residency. Then this immediately turns into a nauseating, super-terrified feeling, right?

After posting two entries to help medical students do well on their EM clerkship rotation, a commenter suggested that I provide a list of tips for doing well as a new EM attending physician. Although there is slightly variation for community versus academic faculty, many of the basic tenets hold true:

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By Michelle Lin, MD|2019-01-28T22:39:21-08:00Jul 14, 2011|Medical Education|

Trick of the Trade: Anesthetizing the nasal tract

One of the most uncomfortable procedures that we do on patients is a nasogastric (NG) tube. The maximal pain comes when the NG tube has to make a right angle turn in the posterior nasopharynx. The same goes for the nasopharyngeal (NP) fiberoptic scope. There are many approaches to topical anesthesia, including using benzocaine sprays, gargling with viscous lidocaine, squirting viscous lidocaine in the nares +/- afrin spray, and nebulizing lidocaine. None, however, really apply an anesthetic directly over the most sensitive area AND test for its effectiveness.

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By Michelle Lin, MD|2016-11-11T18:52:40-08:00Jul 13, 2011|ENT, Tricks of the Trade|

Emergency Medicine factoids on Twitter

The medical profession is slowly incorporating Twitter. If you have a Twitter account, here are some great Twitter accounts to follow:

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By Michelle Lin, MD|2019-01-28T22:41:34-08:00Jul 12, 2011|Medical Education, Social Media & Tech|

Paucis Verbis: Cardiac tamponade or just an effusion?

What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it’s relatively easy to detect a pericardial effusion.

But what we more want to know in the immediate setting is: Is this cardiac tamponade?

You can look for RA systolic or RV diastolic collapse. What if it’s equivocal? How good is the clinical exam and EKG in ruling out a tamponade?

Answer

Poor to average, at best. The Beck’s triad of hypotension, distended neck veins, and muffled heart sounds are important to remember … only on tests.

Think about performing a pulsus paradoxus test to see if it’s >12 mmHg. This is a sign of physiologic compromise. Note that the typical cutoff has been 10 mmHg but 12 mmHg is a more specific test.

PV Card: Cardiac Tamponade

<span data-mce-type="bookmark" style="display: inline-block; width: 0px; overflow: hidden; line-height: 0;" class="mce_SELRES_start"></span>
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Hemal Kanzaria for suggesting this JAMA article!

Refrence

Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007;297(16):1810. doi: 10.1001/jama.297.16.1810

By Michelle Lin, MD|2021-10-13T08:35:56-07:00Jul 8, 2011|ALiEM Cards, Cardiovascular, Ultrasound|

Trick of the Trade: Epistaxis control with tongue blades

For epistaxis, the classic teaching is to pinch the nose to control the bleeding. A persistent nosebleed often is the result of one’s natural inclination to constantly check if there is still bleeding every few seconds. Applying pressure on-and-off makes it difficult for the bleeding to stop.

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By Michelle Lin, MD|2016-11-11T18:52:47-08:00Jul 6, 2011|ENT, Tricks of the Trade|

A faculty’s perspective: Doing well on your EM clerkship

To follow-up with Dr. Connolly’s perspective about the Top 10 tips for medical students to rock the EM clerkship rotation, I thought I would post some additional tips. Here are some more pearls:

11. Take ownership of your patients.

This means that you should take it upon yourself to make sure that your patient’s care is stellar, addresses key clinical and social issues, and is timely. Constantly check for your patient’s results. Don’t be the last to hear of your patient’s lab or imaging results. Figure out why there are unexpected delays. Address any psychosocial issues which may hamper your patient’s clinical improvement in the ED. (more…)

By Michelle Lin, MD|2016-11-11T18:52:47-08:00Jul 5, 2011|Medical Education|

About Michelle Lin, MD

PV Card: NSAIDs and Upper GI Bleed

Reference

Answer

PV Card: Cardiac Tamponade

Refrence

11. Take ownership of your patients.