Paucis Verbis: Fibrinolytics for Acute Pulmonary Embolism

When would you give fibrinolytics for a Pulmonary Embolism?

This Paucis Verbis card summarizes recommendations found in Circulation’s recently published Scientific Statement from the American Heart Association. Although it is rare to give fibrinolytics for a pulmonary embolism (PE) in the Emergency Department, it is important to remember when lytics are indicated.

PV Card: Fibrinolysis for Acute Pulmonary Embolism

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

Reference

Jaff M, McMurtry M, Archer S, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16):1788-1830. [PubMed]

By Hans Rosenberg, MD|2021-10-12T16:21:19-07:00Jul 29, 2011|ALiEM Cards, Cardiovascular, Pulmonary|

Paucis Verbis: Diagnostic testing tips for acute abdominal pain

In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic.

My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead — more accurate and less radiation.

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

Reference

Panebianco N, Jahnes K, Mills A. Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin North Am. 2011;29(2):175-93, vii. [PubMed]

By Michelle Lin, MD|2021-10-12T16:23:35-07:00Jul 22, 2011|ALiEM Cards, Gastrointestinal, Radiology|

Tricks of the Trade: Underwater ultrasonography

I’ve heard of underwater basketweaving, but underwater ultrasonography?

Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient’s extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient’s skin and transducer. What’s a quicker and easier way to create some distance yet preserve image quality?

Trick of the Trade

Submerse both the body part and the ultrasound transducer under water.

For this “bath water technique”, start by holding the transducer perpendicular to the wound and about 1 cm away from the skin. You can adjust the distance to optimize the image quality.

Thanks to Andy at Emergency Medicine Ireland blog for these 2 ultrasound images!

This submersion technique has been published in American Journal of EM in 2004 as a painless alternative to gel or a step-off pad, because the transducer does not need to apply any pressure on the patient’s wound.

Reference
Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Amer J Emerg Med. 2004; 22(7), 589-93 PMID: 15666267

By Michelle Lin, MD|2020-04-21T12:30:07-07:00Jul 20, 2011|Tricks of the Trade, Ultrasound|

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

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.

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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.

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

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