Opioids are amazingly effective for pain control. Patients on chronic opioids, however, often struggle with constipation. These patients may fail supportive treatment with enemas and laxatives.
A 50 y/o man with a history of CHF and COPD is brought in by ambulance in severe respiratory distress. He is sitting upright with a RR 30 and O2 saturation of 79% on room air. Is this a CHF or COPD exacerbation? This is a common dilemma faced in the ED. Fortunately there are likelihood ratios to help you risk stratify using a Fagan nomogram.
Note that there are 3 tables:
See the blue font for the likelihood ratios ≥ 3.0.
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
Bartholin abscesses are challenging to manage, partly because of Word catheter insertion. Sometimes, the space is not large enough (unable to fit the catheter) or too large (catheter falls out). How else can you “pack” the abscess space?
Let’s be honest. When was the last time results from urine drug screens (UDS) changed your management plan? Many times it takes hours for the patient to give the urine sample anyway. And, with all of the false positives out there, how do we know what the heck the result is actually telling us?
Do you order blood cultures for all your ED patients with a fever? Obviously no. What’s your decision making process on ordering this test? There are really no findings or tests with high specificity (rules-IN bacteremia), except interestingly “shaking chills”. Notice almost all the criteria listed below approach a likelihood ratio (LR) of 1.0. Two prediction rules do exist, however, to help you virtually rule-OUT bacteremia:
The list of LRs also will be helpful to show learners in the ED that an isolated serum WBC number is useless risk-stratifier.
A 55 y/o man with a PMH of hypertension presents with a community-acquired pneumonia on CXR, no fevers, no chills, no vomiting.
What is the patient’s pre-test and post-test probability for having bacteremia? Use these helpful stats from the Rational Clinical Examination series from JAMA.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
This discussion doesn’t address WHETHER we should get blood cultures despite a risk for bacteremia in the setting of uncomplicated pneumonia receiving IV antibiotics or pyelonephritis with a pending urine culture.
Why are we still teaching the traditional incision and drainage approach to simple abscess drainage? They require frequent, painful packing changes to ensure persistent drainage of retained pus.
Incision and loop drainage (I&LD) technique
As per usual, Dr. Rob Orman (ercast) beat me to this. He already reviewed the technique on his blog in 2010. This stems from a landmark article in the Journal of Pediatric Surgery, which involves creating a persistently draining fistula at two points by using a small vascular loop, tied into a non-tensile loop.
It makes sense to extrapolate and use this technique for both pediatric and adult patients with uncomplicated abscess, especially if the patients may not follow-up for packing changes as scheduled. The added benefit is that showering is encouraged to help encourage drainage without the risk of dislodging the secured loop.
Does anyone have experience with this that they would like to share? Particularly, what if you don’t have the skinny vascular loops in your Emergency Department?
Per the Tsoraides article1: