Case: A 18-year-old male with no medical history presents to the emergency department (ED) complaining of “feeling like I am having a heart attack” which started suddenly 1 hour ago. The patient ate from a food truck the night before and developed several episodes of forceful vomiting prior to arrival in the ED. What finding in this supine chest radiograph aids in the diagnosis? Click on image for a larger view.
Welcome to the inaugural post for an exciting new ultrasound-based case series called “Ultrasound For The Win!” (#US4TW). In this peer-reviewed case series, we will focus on real clinical cases where bedside ultrasound changed the management or aided in the diagnosis. In our first case, we present a 28-year-old female with shortness of breath.
We are very excited this month to bring you our fourth ALiEM-Annals of EM Global Journal Club on the use of age-adjusted D-dimer levels to help exclude the diagnosis of pulmonary embolism (PE). We hope you will participate in an online discussion of the four posted questions below from now until August 29th. Respond by commenting below or tweeting (#ALiEMJC). Mark your calendars: On Thursday, August 28th at 16:30 CST (17:30 EST), we will be hosting a 30-minute live Google Hangout with Drs. Jeff Kline and Jonathan Kirschner, the authors of the Annals of Emergency Medicine Journal Club for the ADJUST-PE Trial, that is informed by the discussion. Later this year, a summary of this journal club will hopefully be published in Annals of EM.
Most of us would agree that massive PE is treated with fibrinolysis and non-massive PE is treated with anticoagulation. The area of great debate has been the optimal treatment for sub-massive PE. The MOPETT Trial was published in January 2013 and although the patient population was small, it did show a huge benefit in pulmonary pressures at 28 months with fibrinolysis. The next study we have all been waiting for is the Pulmonary Embolism Thrombolysis (PEITHO) trial, which was just published yesterday in the NEJM, evaluating fibrinolysis for patients with intermediate-risk PE.
A 75 year old woman is found to have pneumonia. With a CURB-65 of 3 and a PORT score of 95, she is correctly treated her for community acquired pneumonia with Ceftriaxone and Azithromycin, and admitted. Unfortunately, the admitting service points out that no blood cultures were drawn! What is the evidence for this?
Originally from Clinical Monster blog
Kline 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?
A 45 y/o male with moderate persistent asthma presents with wheezing and cough following a viral URI. He is tachypneic and has diffuse wheezing. PEFR is 250 (>50% below his normal). Initial ABG is 7.46/33/70 on room air with a lactate of 2.0 mmol/L. He receives IV steroids and 4 rounds of albuterol nebulizers. On repeat evaluation, his work of breathing and wheezing have improved and his PEFR is now >300. He is completed alert and oriented with a BP of 118/70 and a HR of 110. Repeat ABG shows 7.35/35/100 on room air; however, his lactate is now 7 mmol/L.
Is the rise in his lactate expected following beta-agonist therapy?