A few weeks ago, I gave a Tricks of the Trade talk for the Stanford-Kaiser Emergency Medicine residents and faculty. I was overwhelmed by the great, creative ideas that came up during our discussion. An always popular topic is the drainage of peritonsillar abscesses. Sometimes it can be difficult to aspirate from a syringe using only one hand, especially with the awkward angle that you might encounter.
Risk stratification of the undifferentiated chest pain patients in the Emergency Department continues to plague emergency physicians. It’s partly the reason why I created a TIMI risk score card for unstable angina and non-ST elevation MI in 2010.
Have you heard of the 9-variable GRACE risk stratification score? Thanks to Jeff Bray (physician assistant in a rural critical access ED), I have now. He graciously shared his personal reference card on this with me, which I only minimally reformatted to fit my Paucis Verbis card dimensions.
GRACE stands for Global Registry for Acute Coronary Events. It supposedly outperforms the TIMI scoring slightly in accurately predicting complications in the short and long term. Instead of calculating this manually, which can be a pain, now there are calculators out there:
Anyone use this scoring system?
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
A 25 year old woman presents to the Emergency Department having syncopized in the waiting room, where she was triaged with the chief complaint of abdominal pain. Ectopic pregnancy immediately bubbles to the top of your differential diagnosis. The patient is too dizzy to walk to the bathroom to give you a urine specimen to check a urine pregnancy test. Plus, she admits that she just urinated in the waiting room bathroom a few minutes ago – so no urine now.
Apply several drops of whole blood (instead of urine) into the pregnancy test cassette. In the photo below, the patient was pregnant with a serum beta-HCG level of 250 mIU/mL whose urine and whole blood qualitative tests were both positive.
Did you know that most urine pregnancy test kits are approved for both urine and serum samples? On a quick Google search, I found that Accutest, Cardinal Health, ICON, OSOM, and Rapid Response all are approved for both. The question is whether this will work for whole blood.
One study 1 in the Journal of Emergency Medicine by Dr. Fromm from Maimonides Medical Center looked at exactly this issue. Whole blood pregnancy test performed extremely well, especially if positive:
In their study, very low beta-HCG values (<159 mIU/mL) occasionally yielded a false negative for whole blood pregnancy tests. The whole blood testing approach missed a total 9 of 425 pregnancies. Interestingly, the urine pregnancy test was also negative in 5 of those 9 and not performed in the other 4.
Believe a positive test. Confirm all tests with a urine qualitative test or quantitative serum beta-HCG.
Another example courtesy of Dr. Joe Habboushe (New York Hospital–Queens of Cornell University) and Dr. Graham Walker (Stanford) 2 :
S = Sample well; T = Test specific (will show bar if +HCG); C = Control (will always have a bar)
A 25 year old woman presents with palpitations, sweating, and shortness of breath since this morning. 6 days ago she had syncopized, was shocked out of V-tach by EMS, and eventually had a defibrillator placed for an unknown arrhythmia. Now, she feels her heart beating in her chest, looks diaphoretic, is tachypnic, but her pulse is 58 and regular.
This is a guest post by Dr. Ian Brown (Stanford):
The Roberts textbook describes the procedure of corneal fluorescein staining as touching a moistened fluorescein strip to the cornea. Maybe it is an irrational fear of a paper cut to the sclera, or a fear of touching an already abraded cornea with the paper, but I try to find an alternative. I have seen physicians hold the eye open with one hand, hold the fluorescein with a second hand and then drip tetracaine on the paper and let it drip into the eye with a third hand. I, unfortunately, only have two hands.
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A sister and brother, aged 7 and 14, respectively present with pharyngitis. The 7F has sore throat, cough, fever, and post-tussive vomiting for 1 day. She has posterior pharyngeal erythema, no lymphadenopathy, no exudate, no petechiae, and looks like a viral URI.
The 14M had culture confirmed GAS pharyngitis 3 weeks ago, was treated with PCN-VK and symptoms resolved. Now, he’s in the ED with signs and symptoms of pharyngitis again, including dysphagia, fever, cough, posterior pharyngeal erythema, swollen tonsils, LAD, and petechiae on his hard palate.
Kawasaki Disease can be easy to diagnose when you have the pediatric patient, who presents with all 5 of the classic clinical findings. What happens when you have the prerequisite fever for ≥5 days, but only 2-3 clinical criteria?
Check out the nice flowchart below which addresses these questions. They summarize the most recent (2004) American Heart Association’s consensus group’s recommendations.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.