Paucis Verbis: Spinal epidural abscess

One of the most challenging diagnoses to make is that of a spinal epidural abscess (SEA), especially if you work in an Emergency Department which cares for many IV drug users and HIV patients. There’s never before been a published diagnostic guideline or algorithm which helps you with risk-stratification.

In the Journal of Neurosurgical Spine, a diagnostic guideline was prospectively evaluated on a small population (n=31) as compared to historical controls (n=55). They found that an ESR test had a sensitivity of 100% if a patient had at least 1 risk factor for SEA. A CRP test was much less helpful.

Not a practical algorithm

Unfortunately, they didn’t study the utilization rate of the MRI scanner with this guideline. Are they getting better results (fewer diagnostic delays and fewer cases of patients later in their clinical course) because they are just MRI-scanning more people? Almost everyone in my ED with back pain would fall into the Urgent/Emergent MRI box… I’m not a fan of this algorithm.

Regardless, this algorithm may help you in shaping your diagnostic decision and medical decision making documentation.

PV Card: Spinal Epidural Abscess

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

Reference

Davis D, Salazar A, Chan T, Vilke G. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine. 2011;14(6):765-770. [PubMed]

By Michelle Lin, MD|2021-10-12T16:17:13-07:00Aug 5, 2011|ALiEM Cards, Infectious Disease, Neurology|

Paucis Verbis: Clostridium Difficile

I just finished taking the 2011 LLSA exam to remain eligible for recertification. The only good thing about this test is that it gives me interesting topics for my Paucis Verbis cards.

Here’s a card on a disease process that is becoming increasingly prevalent — Clostridium difficile. This is a summary based on the 2010 guidelines by Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).

Because healthcare workers are often the culprit for transmitting C. difficile to other patients, be sure you wash your hands with soap and water really well. Wear gloves. Be aware that alcohol-based hand rubs (eg. hand sanitizers) are ineffective in killing C. difficile spores.

PV Card: Clostridium Difficile Infection

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

Reference

Cohen S, Gerding D, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455. [PubMed]

By Michelle Lin, MD|2021-10-13T08:41:07-07:00Jun 24, 2011|ALiEM Cards, Gastrointestinal, Infectious Disease|

Paucis Verbis: Post-exposure prophylaxis (non-occupational)

You know how chief complaints present to the ED in multiples? In one week, I had several cases where patients were asking for post-exposure prophylaxis treatment NOT in the content of a sexual assault. I haven’t had to manage such cases in a long time and so needed to look up the recent guidelines from the CDC.¹

The trick is not to forget about all the co-existing problems and infections beyond just HIV. Specifically, don’t forget about gonorrhea, chlamydia, and trichomonas.

PV Card: Post-Exposure Prophylaxis for Non-Occupational Contact

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

References

STD Treatment. Centers for Disease Control. http://www.cdc.gov/std/treatment/default.htm.
Landovitz RJ, Currier JS. Postexposure Prophylaxis for HIV Infection. New England Journal of Medicine. 2009;361(18):1768-1775. doi: 10.1056/nejmcp0904189

By Michelle Lin, MD|2026-06-16T16:03:12-07:00Apr 1, 2011|ALiEM Cards, Infectious Disease|

Trick of the Trade: Topical anesthetic cream for cutaneous abscess drainage in children

Abscess drainage can be painful and time consuming in the ED. Can this article help? ¹

Trick of the Trade

Apply a topical anesthetic cream on skin abscesses prior to incision and drainage (I and D).

In this press-released article in American Journal of Emergency Medicine, the authors found that application of a topical 4% lidocaine cream (LMX 4) was associated with spontaneous cutaneous abscess drainage in children.

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By Stella Yiu, MD|2019-07-10T21:29:20-07:00Mar 16, 2011|Infectious Disease, Pediatrics, Tricks of the Trade|

Trick of the Trade: Website resource on HIV medications

At our department’s first annual UCSF High Risk Hawaii Conference 2 weeks ago, Dr. Rachel Chin taught about complications from all of the HIV drugs on the market now. It’s a virtual alphabet soup: EFV, TDF, FTC, oh my. How do you keep track of them all?

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By Michelle Lin, MD|2019-01-28T23:04:30-08:00Mar 2, 2011|Infectious Disease, Social Media & Tech, Tricks of the Trade|

Trick of the Trade: Serial lactate measurements in sepsis?

Does your Emergency Department have computerized spectrophotometric catheters to measure continuous central venous oxygen saturation (ScvO2) in early goal directed therapy (EGDT) for severe sepsis? That’s what was used in the original Rivers’ EGDT study.

I’ve never even seen one before.

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By Michelle Lin, MD|2019-01-28T23:05:12-08:00Feb 16, 2011|Infectious Disease, Tricks of the Trade|

Trick of the Trade: Conveying risk for postexposure prophylaxis

A health care worker hurried in to the ED after being poked with a needle.

‘It was an old 18G needle with dried blood’, she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, ‘What does very low risk mean?’

Is there another way to covery risk for patients?

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By Stella Yiu, MD|2019-02-19T18:21:27-08:00Feb 9, 2011|Infectious Disease, Tricks of the Trade|