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:
I find it amazing that I know more non-emergency physicians virtually in the social media world rather than in person. Primarily through Twitter, I follow and am followed by medical educators from various specialties. If you haven’t joined Twitter yet, I think it might be time. There is a whole world of collaboration and conversation going on in this virtual community, which crosses specialties and geography.
Last week, Dr. Javier Benítez (@jvrbntz) was tweeting a Question of the Day, referencing a 2010 Paucis Verbis card on overanticoagulation, which was based on the 2008 American College of Chest Physicians (ACCP) guidelines. About 8 minutes after I retweeted his question, Dr. Roy Arnold (@cholerajoe), a pulmonary/critical care physician kindly informed me that the 2012 ACCP guidelines have been out since February.
So this PV card is replacing the 2010 card with revised recommendations. For more in-depth discussion, definitely take a look at Dr. Scott Weingart’s great podcast over at EMCrit. He helps to clarify holes which the 2012 ACCP guidelines don’t really address such as:
What if the patient is minorly bleeding with a high INR?
What if you only have the 3-factor PCC (factors II, IX, X) and not the recommended 4-factor PCC (factors II, IX, X plus factor VII)?
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
To give or not to give a cephalosporin in penicillin-allergic patients?
I remember back to my days in pharmacy school when I learned that there was approximately a 10% risk of cross-reactivity, if a cephalosporin was given to a penicillin-allergic patient. They probably said something about the risk being less with 3rd and 4th generations cephalosporins, but lets be honest… who remembers anything but that magic 10%? When I started working more with physicians, I found that they also learned the same 10% rule in medical school. Well, I guess that means it’s fact, right? Not so fast!