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

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

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|

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.

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

Paucis Verbis: Lifetime attributable risk of cancer from CT

How great would it be if you could give patients concrete numbers when you are talking about cancer risk and CT? Well, Dr. Hans Rosenberg (Univ of Ottawa) has come up with just such a table.

Using this table you can say that the risk is about “one in …”

PV Card: Cancer Risk from CT

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

Reference

Smith-Bindman R. Radiation Dose Associated With Common Computed Tomography Examinations and the Associated Lifetime Attributable Risk of Cancer. Archives of Internal Medicine. 2009;169(22):2078. doi: 10.1001/archinternmed.2009.427

By Michelle Lin, MD|2021-10-13T08:43:55-07:00Jun 10, 2011|ALiEM Cards, Radiology|

Trick of the Trade: Fingertip injuries

Fingertips can get injured in a variety of ways such as machetes, meat grinders, and broken glass. You name it, and we’ve probably seen it. Some don’t actually need anything invasive done because the skin is basically just torn off. The wound just needs to be irrigated, explored, and then bandaged to allow for secondary wound closure.

What do you do if the finger injury keeps oozing and the finger tip is too painful for the patient to apply firm pressure? Poking the finger with 2 needles to perform a digital block seems a bit overkill.

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By Michelle Lin, MD|2020-02-12T20:41:43-08:00Jun 8, 2011|Orthopedic, Trauma, Tricks of the Trade|

Paucis Verbis: Pulmonary Embolism Clinical Prediction Rules

“Should I get a D-Dimer test or CT chest angiogram on my patient with atypical chest pain to rule-out a pulmonary embolism?” This is a common question asked by emergency physicians on a routine basis.

Here are 3 clinical prediction rules: PERC, Wells, and Simplified Geneva Score. Personally, I’ve never used the Geneva Score, but it’s worth looking at.

A WORD of CAUTION

These rules should be used with caution, because none of these scoring protocols are perfect. For instance, in a recent publication in the Journal of Thrombosis and Haemostasis, the authors found that the PERC rule does not actually safely exclude PEs.¹ Big bummer for us clinicians.

PV Card: Pulmonary Embolism Clinical Prediction Rules

Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Kit Tainter (Mount Sinai PGY-4 EM resident) for coming up with the idea for this card!

Reference

Hugli O, Righini M, Le G, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9(2):300-304. [PubMed]

By Michelle Lin, MD|2021-10-13T08:47:00-07:00Jun 3, 2011|ALiEM Cards, Pulmonary|

Paucis Verbis: Outpatient treatment for diverticulitis

The classic prior teaching for the treatment of diverticulitis includes:

Hospital admission
Bowel rest (NPO)
IV fluids
Broad spectrum IV antibiotics

Do ALL patients need to be admitted? There is some early literature suggesting that there is a small sub-population who fare well with outpatient treatment.

This article from Annals of EM in the “Best Available Evidence” series summarizes the existing literature well.

PV Card: Diverticulitis

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

Word of caution

This paper only provides guidelines, based on the limited evidence out there. Still use your common sense. For instance, I’d still admit patients who are elderly (>80 years old) or have evidence of any perforation on CT. If on the fence, admit the patient.

Still it’s nice to see that the treatment of uncomplicated diverticulitis on an outpatient basis has some supporting literature.

Reference

Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of Emergency Medicine. 2011;57(6):600-602. doi: 10.1016/j.annemergmed.2010.11.008

By Michelle Lin, MD|2021-10-13T08:49:38-07:00May 27, 2011|ALiEM Cards, Gastrointestinal|

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