Paucis Verbis card: When murmurs need echo evaluation

Have you been in a situation where you are the first to detect a cardiac murmur in a patient? If you are hearing it in a busy, loud Emergency Department, I find that it’s at least a grade III.

Should you order an echocardiogram for further outpatient evaluation? It depends on the grade and characteristic of the murmur, in addition to the patient’s symptoms. For instance, all diastolic murmurs require an echo. There is a useful ACC/AHA algorithm which helps you decide.

PV Card: When Murmurs Need Echocardiography Evaluation

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Amy Kinard, an Emergency RN and aspiring Family Nurse Practitioner, for drafting this useful Paucis Verbis card for me during her studies. Keep the great ideas coming, everyone!

Reference

Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(15):e523-e661. doi: 10.1161/circulationaha.108.190748

By Michelle Lin, MD|2021-10-18T10:05:29-07:00Sep 17, 2010|ALiEM Cards, Cardiovascular|

Trick of the trade: I got ultrasound gel in my eye!

Bedside ultrasonography is increasingly being used in the ED to examine the eye. For instance, it can be used to detect a retinal detachment, vitreous hemorrhage, and high intracranial pressure. The technique involves applying ultrasound gel on the patient’s closed eyelid. A generous amount of gel should be used to minimize the amount of direct pressure applied on the patient’s eye by the ultrasound probe.

Sometimes, however, no matter how careful you and the patient are, some gel accidentally contacts the eye itself.

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By Michelle Lin, MD|2019-01-28T23:23:16-08:00Sep 15, 2010|Tricks of the Trade, Ultrasound|

Trick of the Trade: Burned fingertips as a clinical clue

A patient presents to your Emergency Department with altered mental status and somnolence. You don’t smell alcohol on breath and you don’t see needle track marks. What clinical clue points you towards cocaine or methamphetamine ingestion?

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By Michelle Lin, MD|2016-11-11T19:00:30-08:00Sep 8, 2010|Tox & Medications, Tricks of the Trade|

Paucis Verbis card: Pertussis

Is your Emergency Department administering Tdap immunization boosters instead of dT boosters? Patients with wounds are getting updated not only for tetanus and diphtheria, but also now for pertussis.

Apparently there has been sharp rise in the national incidence of pertussis (Bordetella pertussis shown in image) in 2010. The infection has been documented in both infants (underimmunized less than 3 months old) and adolescents/adults (loss of immunity after 10 years). In fact, the CDC has issued an epidemic warning in California.

How do you diagnose pertussis ? What are the classic symptoms? Better yet, how do you rule-it out clinically?

You won’t like the answer. It often presents like the common cold and clinical symptoms are minimally helpful in making the diagnosis. So, according to the American Academy of Pediatrics, you should treat anyone under the age of 3 months in whom you suspect pertussis. Complications from pertussis in infants include apnea, seizures, secondary pneumonia, and death. That means any with an innocent cough should be treated with azithromycin!

The following is a meta-analysis article from JAMA on diagnosing pertussis in adolescents and adults.

PV Card: Pertussis

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Cornia P, Hersh A, Lipsky B, Newman T, Gonzales R. Does this coughing adolescent or adult patient have pertussis? JAMA. 2010;304(8):890-896. [PubMed]

By Michelle Lin, MD|2021-10-18T10:07:39-07:00Sep 3, 2010|ALiEM Cards, Infectious Disease, Pulmonary|

Trick of the Trade: "Pour some sugar on me" | Reducing a rectal prolapse

Rectal prolapses are typically caused by weakened rectal muscles, continued straining, stresses during childbirth, weakened ligaments, or neurological deficits.

How do you fix them? You can attempt manual reduction of the prolapse by using direct pressure. On the other extreme, corrective surgery can be performed from either an abdominal or perineal approach.

Trick of the Trade: Pour some sugar on it.

Def Leppard may have been right. Rectal prolapses often are associated with quite a bit of rectal mucosal edema. Sprinkle granulated sugar onto the area. Wait 15 minutes. The sugar reduces the edema by osmotically drawing out the fluid. The prolapse often reduces spontaneously or with gentle manual pressure.

References

Ramanujam PS, Venkatesh KS. Management of acute incarcerated rectal prolapse. Dis Colon Rectum. Dec 1992;35(12):1154-6.
Coburn WM III, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. Sep 1997;30(3):347-9.

By Michelle Lin, MD|2021-03-01T09:25:47-08:00Sep 1, 2010|Gastrointestinal, Tricks of the Trade|

Paucis Verbis card: TIMI risk score

How do you risk-stratify undifferentiated chest pain patients in the Emergency Department? There are a multitude of causes for chest pain. We are always taught to think of the 5 big life-threats: ACS, PE, aortic dissection, tension pneumothorax, and pericardial tamponade.

So how do YOU risk-stratify your patients for unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI)? STEMI’s are usually obvious. UA and NSTEMIs — not so much.

Fortunately a 2000 JAMA article and a followup Academic Emergency Medicine 2006 study have solidified the TIMI risk scoring system as a reasonable risk-stratification tool for all-comer ED patients with chest pain requiring an ECG.

Generally there is an upslope in risk at a TIMI score of 3 and greater.

PV Card: TIMI Risk Score

Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.

References

Pollack C, Sites F, Shofer F, Sease K, Hollander J. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med. 2006;13(1):13-18. [PubMed]
Antman E, Cohen M, Bernink P, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000;284(7):835-842. [PubMed]

By Michelle Lin, MD|2021-10-18T10:09:44-07:00Aug 27, 2010|ALiEM Cards, Cardiovascular|

Trick of the Trade: Increasing students responses to the differential diagnosis

Anyone who teaches medicine asks students to list their differential diagnosis when discussing a new clinical case. It’s also part of several models for education including the One-Minute Preceptor and SNAPPS.

For the most part, students are good at coming up with answers to the differential, but what do you do when they strike out? Or what if the answer is always the same, i.e. chest pain = myocardial infarction?

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By Robert Cooney, MD MSMedEd|2016-11-20T11:17:15-08:00Aug 25, 2010|Medical Education, Tricks of the Trade|