We often do lumbar puncture in the ED. Patients get warned about the potential of a post LP headache.
The literature reports 15% of ED patients have a post LP headache.
Suturing is a common procedure performed in the ED, but we too often forget about the nuances of different suture materials. We get set in our practice patterns. This changed when our ED got the fast-absorbing gut suture for surface wounds, especially for pediatric patients. This makes a return visit for suture removal unnecessary because they quickly become absorbed over time. Increasingly, I have observed plastics surgeons using these for surface wound closure of the face and hands.
Has anyone else used absorbable sutures on the skin for wound closure?
With this new suture material in my armamentarium, I thought it’d be helpful to review suture types and suture removal times for non-absorbable sutures.
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Contact lens wearers are familiar with the phenomenon of the wandering lens. What should you do if you can’t visualize the contact lens of a patient, who presents with a “lost contact lens” in the eye? You have the patient look in all directions and you evert the eyelid, but still no contact lens can be found. The patient swears that it’s there because of the painful foreign-body sensation.
In Wednesday’s post about the Colorado Compendium, Graham mentioned a new 2010 BMJ article on the high-risk signs suggestive of subarachnoid hemorrhage by the gurus in clinical prediction rules in Canada.
We excessively work-up patients for a subarachnoid hemorrhage with a nonspecific headache and no neurologic deficitis. This is because it’s difficult to predict who is high, medium, and low risk for such a bleed. So we throw a wider net so that we don’t miss such a devastating diagnosis. This usually means a CT and LP for many patients with a headache.
In this 5-year multicenter study, the investigators identified clinical decision rules to help identify the higher-risk groups for a subarachnoid hemorrhage. They derived 3 models, based on recursive partitioning. Each has a negative predictive value of 100%.
Before thinking about seeing if your headache patient has any of these high-risk features, pay special attention to see if s/he would have met the inclusion and exclusion criteria of this study.
Inclusion criteria:
Exclusion criteria:
Although none of the models are validated as of yet, the cumulative list of clinical characteristics from these 3 models may be able to help you understand who may be at higher risk:
There is constant debate on whether to image the cervical spine of blunt trauma patients. Fortunately, there are two clinical decision tools available to help you with your evidence-based practice.
The NEXUS and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients.
| Sensitivity (%) | Specificity (%) | |
| NEXUS | 99.6 | 12.6 |
|---|---|---|
| CCR | 99.4 | 45.1 |
National Emergency X-radiography Utilization Study
A patient’s neck can be clinically cleared safely without radiographic imaging if all five low-risk conditions are met:
* Defined as “a condition thought by the clinician to be producing pain sufficient to distract the patients from a second (neck) injury. Examples may include, but are not limited to the following:
Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries.”
The basic approach in this flow-chart is to (1) make sure that the patient meets the same inclusion criteria as in the CCR study. Then (2) determine if there are high-risk findings. If so, go directly to imaging. (3) If there are no high-risk findings, check to see if the patient qualifies as a low-risk candidate where you might be able to clinically clear the c-spine without imaging. (4) If the patient is neither high or low risk, then the patient is moderate risk and requires imaging. Here’s a flow chart that I made to help you remember:
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Note: Many emergency physicians go straight to CT imaging for patients with neck tenderness and moderate/high risk findings. I personally rarely use the CCR algorithm because I can rarely remember all of the criteria. NEXUS is nice because of its simplicity. Where the CCR algorithm IS helpful is in clinical clearance of the low-risk patient with neck pain. I’ve cleared many patients who self-present with a whiplash mechanism (simple rear-end motor vehicle crash) and diffuse neck pain. By NEXUS criteria, you’d have to image them because they have neck tenderness. By CCR criteria, if they can actively rotate their neck 45 degrees left and right, they don’t have a clinically significant c-spine injury. No imaging needed.
After a shift, we often review the day’s case with our learners. We sometimes ask them to self-reflect.
I often used Demian’s ‘Plus/Delta’ approach and ask ‘What did you like /what would you change?’
This approach works well mostly. But, when the answer is ‘I don’t think I would change anything’, it is hard to target teaching and feedback to the learner’s need.
Dyphagia is a disorder of swallowing. It actually occurs in up to 10% of adults older than 50 years old. How can you determine the most likely causes for dysphagia? The secret is to obtain a thorough history and using the algorithm below, which I find really helpful from a review article in American Family Physician.
Adapted from [1]
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