Paucis Verbis: NSAIDS and upper GI bleeds

Do no harm.

We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?

Ketorolac has the highest upper GI complication RR (14.54) for all of the studied NSAIDs. Compare this with the overall risk of traditional COX-1 NSAIDS (RR=4.5) and COX-2 inhibitors (RR=1.88). So before giving ketorolac, first check that patients don’t have a history of a GI bleed or peptic ulcer.

PV Card: NSAIDs and Upper GI Bleed

<span data-mce-type="bookmark" style="display: inline-block; width: 0px; overflow: hidden; line-height: 0;" class="mce_SELRES_start"></span>
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Massó G, Patrignani P, Tacconelli S, García R. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum. 2010;62(6):1592-1601. [PubMed]

By Michelle Lin, MD|2021-10-12T16:27:37-07:00Jul 15, 2011|ALiEM Cards, Gastrointestinal, Tox & Medications|

One of the most uncomfortable procedures that we do on patients is a nasogastric (NG) tube. The maximal pain comes when the NG tube has to make a right angle turn in the posterior nasopharynx. The same goes for the nasopharyngeal (NP) fiberoptic scope. There are many approaches to topical anesthesia, including using benzocaine sprays, gargling with viscous lidocaine, squirting viscous lidocaine in the nares +/- afrin spray, and nebulizing lidocaine. None, however, really apply an anesthetic directly over the most sensitive area AND test for its effectiveness.

(more…)

By Michelle Lin, MD|2016-11-11T18:52:40-08:00Jul 13, 2011|ENT, Tricks of the Trade|

Paucis Verbis: Cardiac tamponade or just an effusion?

What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it’s relatively easy to detect a pericardial effusion.

But what we more want to know in the immediate setting is: Is this cardiac tamponade?

You can look for RA systolic or RV diastolic collapse. What if it’s equivocal? How good is the clinical exam and EKG in ruling out a tamponade?

Answer

Poor to average, at best. The Beck’s triad of hypotension, distended neck veins, and muffled heart sounds are important to remember … only on tests.

Think about performing a pulsus paradoxus test to see if it’s >12 mmHg. This is a sign of physiologic compromise. Note that the typical cutoff has been 10 mmHg but 12 mmHg is a more specific test.

PV Card: Cardiac Tamponade

Thanks to Dr. Hemal Kanzaria for suggesting this JAMA article!

Refrence

Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007;297(16):1810. doi: 10.1001/jama.297.16.1810

By Michelle Lin, MD|2021-10-13T08:35:56-07:00Jul 8, 2011|ALiEM Cards, Cardiovascular, Ultrasound|

For epistaxis, the classic teaching is to pinch the nose to control the bleeding. A persistent nosebleed often is the result of one’s natural inclination to constantly check if there is still bleeding every few seconds. Applying pressure on-and-off makes it difficult for the bleeding to stop.

(more…)

By Michelle Lin, MD|2016-11-11T18:52:47-08:00Jul 6, 2011|ENT, Tricks of the Trade|

Paucis Verbis: Blunt cerebrovascular injuries

In the setting of blunt trauma, it is easily to overlook a patient’s risk for blunt cerebrovascular injuries (BCVI). These are injuries to the carotid and vertebral arteries. Often they are asymptomatic with the initial injury, but the goal is to detect them before they develop a delayed stroke.

Who are at risk for these injuries?
What kind of imaging should I order to rule these injuries out?
Do I really treat these patients with antithrombotic agents even in the setting of trauma to reduce the incidence of CVA?

FYI: A simple seat-belt sign along the neck does not warrant a CT angiogram. Patients with higher risk findings such as significant pain, tenderness, swelling, and/or a bruit probably need imaging.

PV Card: Imaging for Blunt Cerebrovascular Injuries

<span data-mce-type="bookmark" style="display: inline-block; width: 0px; overflow: hidden; line-height: 0;" class="mce_SELRES_start"></span>
Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.

References

Burlew C, Biffl W. Imaging for blunt carotid and vertebral artery injuries. Surg Clin North Am. 2011;91(1):217-231. [PubMed]
Paulus E, Fabian T, Savage S, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. J Trauma Acute Care Surg. 2014;76(2):279-83; discussion 284-5. [PubMed]
Bruns B, Tesoriero R, Kufera J, et al. Blunt cerebrovascular injury screening guidelines: what are we willing to miss? J Trauma Acute Care Surg. 2014;76(3):691-695. [PubMed]

By Michelle Lin, MD|2021-10-13T08:38:34-07:00Jul 1, 2011|ALiEM Cards, Cardiovascular, Radiology, Trauma|

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

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|

Trick of the Trade: Cunningham maneuver for shoulder dislocation

We commonly see patients with shoulder dislocations in the Emergency Department. There are a myriad of approaches in relocating the joint, which includes scapular rotation, Snowbird, and Kocher maneuvers.

I recently stumbled upon the Cunningham technique after hearing about it from Dr. Graham Walker (of MDCalc fame) on TheCentralLine.org.

(more…)

By Michelle Lin, MD|2019-01-28T22:43:28-08:00Jun 22, 2011|Orthopedic, Tricks of the Trade|

Previous 1···160 161 162 163 164 165166167 168 169 170 171 172···183 Next