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Paucis Verbis: D-Dimer test

LabD-Dimer: To order or not to order?

That’s the question when it comes to risk stratifying a patient for a pulmonary embolism with a low pretest probability. One should consider confounding conditions which may cause an elevated D-Dimer level. There’s always confusion about what may cause an elevated D-Dimer besides venous thromboemboli. So I thought I would make a pocket card as a reminder.

PV Card: D-Dimer Test


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

Reference

  1. Wakai A, Gleeson A, Winter D. Role of fibrin D-dimer testing in emergency medicine. Emerg Med J. 2003;20(4):319-325. [PubMed]
By |2021-10-10T08:49:42-07:00Jul 27, 2012|ALiEM Cards, Cardiovascular, Pulmonary|
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Paucis Verbis: Blunt cardiac injury

blunt cardiac injury

Do you always get a troponin for patients who sustain blunt chest trauma?

Hopefully your answer is no. Of note, it is also NOT indicated as a screening test for those in whom you suspect a blunt cardiac injury (BCI). It can be normal in the setting of arrhythmias and it can be falsely elevated in the setting of catecholamine release or reperfusion injury from hypovolemic shock.

The initial screening test should include an ECG and a FAST ultrasound exam. If you have abnormal ECG findings, then a troponin is warranted (in addition to hospital admission).

Below summarizes a suggested algorithm from the recent EM Clinics of North America publication series. Definitive statements are challenging because there is no gold standard to diagnose BCI.

PV Card: Blunt Cardiac Injury


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

Reference

  1. Bernardin B, Troquet J. Initial management and resuscitation of severe chest trauma. Emerg Med Clin North Am. 2012;30(2):377-400, viii-ix. [PubMed]
By |2021-10-10T08:52:32-07:00Jun 29, 2012|ALiEM Cards, Cardiovascular, Trauma|
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Paucis Verbis: GRACE score for ACS risk stratification

ChestPain grace risk score for ACS

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?

PV Card: GRACE Risk Score for ACS


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

References

  1. Eagle K, Lim M, Dabbous O, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA. 2004;291(22):2727-2733. [PubMed]
  2. D’Ascenzo F, Biondi-Zoccai G, Moretti C, et al. TIMI, GRACE and alternative risk scores in Acute Coronary Syndromes: a meta-analysis of 40 derivation studies on 216,552 patients and of 42 validation studies on 31,625 patients. Contemp Clin Trials. 2012;33(3):507-514. [PubMed]
By |2021-10-10T19:05:05-07:00Apr 13, 2012|ALiEM Cards, Cardiovascular|
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Modern EM: Case #4 – Palpitations

Case # 4: Palpitations

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.

(more…)

By |2016-11-18T10:03:19-08:00Apr 9, 2012|Cardiovascular, Social Media & Tech|
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Paucis Verbis: Kawasaki Disease

Kawasaki diseaseKawasaki 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?

  • What ARE the 5 classic findings?
  • When do you do waitful watching?
  • When do you perform an echo?
  • When do you treat empirically?

Check out the nice flowchart below which addresses these questions. They summarize the most recent (2004) American Heart Association’s consensus group’s recommendations.

PV Card: Kawasaki Disease (AHA 2004)


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

Reference

  1. Newburger J, Takahashi M, Gerber M, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004;110(17):2747-2771. [PubMed]
By |2021-10-10T19:08:53-07:00Mar 23, 2012|ALiEM Cards, Cardiovascular, Pediatrics|
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Paucis Verbis: aVR Lead on ECG

ECG leads aVR lead

What lead is the most overlooked on the ECG?

 Answer: aVR Lead

This lead can provide some unique insight into 5 different conditions:

  1. Acute MI
  2. Pericarditis
  3. Tricyclic antidepressant (TCA) and TCA-like overdose
  4. AVRT in narrow complex tachycardias
  5. Differentiating VT from SVT with aberrancy in wide complex tachycardias by using the Vereckei criteria (possibly better than Brugada criteria)

PV Card: The aVR Lead on ECG


Adapted from [1-4]
Go to ALiEM (PV) Cards for more resources.

See also:

References

  1. Williamson K, Mattu A, Plautz C, Binder A, Brady W. Electrocardiographic applications of lead aVR. Am J Emerg Med. 2006;24(7):864-874. [PubMed]
  2. Vereckei A, Duray G, Szénási G, Altemose G, Miller J. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89-98. [PubMed]
  3. Kireyev D, Arkhipov M, Zador S, Paris J, Boden W. Clinical utility of aVR-The neglected electrocardiographic lead. Ann Noninvasive Electrocardiol. 2010;15(2):175-180. [PubMed]
  4. Riera A, Ferreira C, Ferreira F, et al. Clinical value of lead aVR. Ann Noninvasive Electrocardiol. 2011;16(3):295-302. [PubMed]
By |2021-10-11T15:47:33-07:00Nov 18, 2011|ALiEM Cards, Cardiovascular, ECG|
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