At my institution, trauma patients frequently receive the “Pan Scan,” to rule out acute injury. Recently, Payrastre et al published the SCRAP Rule article in CJEM 2012 1 looking to derive and internally validate a clinical decision rule that would identify blunt trauma patients at very low risk for major thoracic injury with 100% sensitivity, thereby eliminating need for a chest CT. Currently, the decision on whether to perform a chest CT is made mostly by clinical judgment.
“Done Fell Out”, or DFO, is a common saying in the South to describe syncope. Although the saying is funny the diagnosis is not. Syncope accounts for about 3–5% of ED visits and 1–6% of hospital admissions. In patients >65, syncope is the 6th most common cause of hospitalization.
How do you approach the management of patients with syncope?
Case Writer: Clare Desmond, MD
Peer Reviewer and Editor: Nikita Joshi, MD
A 57-year-old male (75 kg) presents to the ED after a witnessed seizure. He describes a history of seizure disorder and is prescribed phenytoin, but recently ran out. A level is sent and, not surprisingly, results as < 3 mcg/mL (negative). After a complete workup, the decision is made to ‘load’ him with phenytoin 1 gm and discharge him with a prescription to resume phenytoin. An IV was not placed.
Can you rapidly load him orally?
It is well known that taking a good history and physical, getting a non-ischemic EKG, and serial cardiac biomarkers, results in a risk of death/AMI of <5% in 30 days. Patients, in whom you still suspect have CAD, should undergo provocative testing within the next 72 hours based on the AHA/ACC guidelines. Their guidelines deem provocative testing as including:
A patient’s contact lens broke when she was trying to take it off. She feels the pieces are still inside her eye, but she was unable to fish them out. When you look through the slit lamp, you are unable to to see whether there are contact lens pieces inside since they are clear.