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3 04, 2014

High Sensitivity Troponin T and Acute Myocardial Infarction: One and Done?

2016-12-20T12:26:50+00:00

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There has been a lot of publicity about evaluation of chest pain patients in the emergency department (ED) with high sensitivity troponin testing. In the past with older troponin assays, clinicians would evaluate patients, get an ECG, and an initial set of cardiac biomarkers. The subsequent set of biomarkers would be performed at 6-8 hours later before determination of disposition. In the past few years, several studies have been published evaluating point of care troponins,  sensitive troponins, and high sensitivity troponins which have changed our practice and evaluation of these patients.  An early version of a study was recently released in the Journal of the American College of Cardiology (JACC) stating that for ED chest pain patients, we may be able to discharge patients from the ED with an initial normal ECG and single high sensitivity troponin T (hs-cTnT). So is it true… one and done?

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11 02, 2014

When the PERC Rule Fails

2016-11-11T19:19:14+00:00

PEKline et al developed a clinical decision tool based on parameters that could be obtained from a brief initial assessment to reasonably exclude the diagnosis of pulmonary embolism (PE) without the use of D-dimer in order to prevent unnecessary cost and the use of medical resources. 1 Many of us have used the Pulmonary Embolism Rule-out Criteria (PERC) rule by now, but we should be clear on what it includes. Are we using it appropriately?

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6 02, 2014

BISAP, EHMRG, ORT: 3 New Medical Scores You’ve Never Heard Of

2017-03-05T14:18:46+00:00

MDCalcLet’s face it. You’ve heard about the A-a gradient. And free water deficit. And even the APACHE-II score. But how useful are these in your daily practice? You don’t care that much if a patient has shunt physiology in the first case, nor exactly how much free water they’re lacking in the second. And in the third case, your clinical acumen is probably pretty good at predicting a sick patient’s mortality already. But what about the new medical scores of BISAP, EHMRG, and ORT?

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5 02, 2014

Blood Pressure Management in Adults (JNC 8 and ACEP Policy)

2016-11-11T19:18:24+00:00

Black tonometer and heart isolated on whiteHypertension is one of the most common conditions seen in primary care clinics and emergency departments (EDs).  Frequently, patients are found to have asymptomatic hypertension and referred to EDs for management, despite the fact that rapidly lowering blood pressure is not necessary and may be harmful.  Yet many clinics still refer these patients for emergent management. In December 2013, the Eighth Joint National Committee (JNC 8) published a new, open-access, evidence-based hypertension guideline in JAMA.  They only cited randomized clinical control trials to answer three questions:

  1. Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
  2. Does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
  3. Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? (more…)
17 01, 2014

Should We Admit All Patients with Sternal Fractures?

2016-11-11T19:18:08+00:00

Sternum-FractureThe detection rate of sternal fractures following motor vehicle collisions and blunt trauma to the chest and abdomen has increased over the past decade.  The reason for this increase is most likely from the use of seat belts and better imaging modalities such as computed tomography (CT) in trauma patients. I can recall as a resident being told that any patient with a sternal fracture should be admitted to trauma because of the high likelihood of blunt cardiac injury and high mortality rate associated with this injury, but is this always true?

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15 01, 2014

Approach to Difficult Vascular Access

IVExpertPeerReviewStamp2x200Intravenous (IV) access is a basic and invaluable skill for emergency physicians. For patients requiring rapid fluid resuscitation, airway management, or medication administration, the placement of one or more IV lines is absolutely essential. Most patients do well with a simple, landmark-based, blind placement of a superficial peripheral IV. However, we often encounter situations where this may be difficult or impossible to achieve, and so we all should have a repertoire of other sites and techniques to employ.

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