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

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

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|

Trick of the Trade: Epistaxis control with tongue blades

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

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.

(more…)

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.

(more…)

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