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|

What do these 3 people have in common?

Lucille Ball (comedienne)
Jonathan Larson (wrote the musical “Rent”)
John Ritter (comedian)

They all died from an aortic dissection. We commonly consider this diagnosis for Emergency Department patients presenting with severe chest pain. There is an International Registry on Aortic Dissection which published a retrospective, descriptive study of 464 patients with dissections.

I find this list helpful, because it illustrates the fact that the classic signs and symptoms aren’t actually very common. Here are some scary examples:

A pulse deficit in the carotid, brachial, and femoral arteries is only present 15% of the time.
A tearing or ripping quality of pain is present in only 50% of patients.
Not all patients have a widened mediastinum or abnormal aortic contour (only 78.7%).

PV Card: Aortic Dissection

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

Reference

Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD). JAMA. 2000;283(7):897. doi: 10.1001/jama.283.7.897

By Michelle Lin, MD|2021-10-13T08:51:53-07:00May 20, 2011|ALiEM Cards, Cardiovascular|

Trick of the trade: Improve your ability to detect a cerebellar lesion

The finger-to-nose exam is typically used to detect a cerebellar lesion. In subtle cases though, this can be be difficult to detect.

How can you improve your sensitivity of this exam?

Trick of the trade: Elbows up!

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By Michelle Lin, MD|2019-01-28T22:48:48-08:00May 18, 2011|Neurology, Tricks of the Trade|

Paucis Verbis: Head CT clinical decision rules in trauma

The ideal clinical decision tool has a sensitivity and specificity of 100%.

You need a high sensitivity to be sure that your negative result indeed predicts a true negative. That means if your clinical decision tool suggests that you don’t need to get a head CT, then your head CT would have been normal.

On the flip side, this realistically means there is a low-moderate specificity. That means a clinical decision tool with at least 1 positive criterion does not always mean that there will be an abnormal finding on head CT.

There are 3 major clinical decision rules that I’ve heard tossed around in the literature:

Canadian CT Head Rules (CCHR)
New Orleans Criteria (NOC)
National Emergency X-Radiography Utilization Study (NEXUS)-II

There is no perfect tool.

Take a look at these decision rules and their inclusion criteria.

The CCHR included patients with GCS 13-15. The NOC initially enrolled only patients with a GCS of 15.
All factor in age (≥65 years for CCHR and NEXUS-II; ≥60 years for NOC).
Interestingly only the CCHR, for better or worse, take into account mechanism of injury. I’m not sure I would obtain a head CT on a pedestrian with a graze wound on the foot from a slow-moving vehicle.

Which do you use? I use a combination of all 3 and my clinical gestalt.

PV Card: Head CT in Trauma – Clinical Decision Tools

Go to ALiEM (PV) Cards for more resources.

By Michelle Lin, MD|2021-10-15T10:59:57-07:00May 13, 2011|ALiEM Cards, Radiology, Trauma|

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