Kline et al developed a clinical decision tool based on parameters that could be obtained from a brief initial assessment to reasonably exclude the diagnosis of pulmonary embolism (PE) without the use of D-dimer in order to prevent unnecessary cost and the use of medical resources. 1 Many of us have used the Pulmonary Embolism Rule-out Criteria (PERC) rule by now, but we should be clear on what it includes. Are we using it appropriately?
A 45 y/o male with moderate persistent asthma presents with wheezing and cough following a viral URI. He is tachypneic and has diffuse wheezing. PEFR is 250 (>50% below his normal). Initial ABG is 7.46/33/70 on room air with a lactate of 2.0 mmol/L. He receives IV steroids and 4 rounds of albuterol nebulizers. On repeat evaluation, his work of breathing and wheezing have improved and his PEFR is now >300. He is completed alert and oriented with a BP of 118/70 and a HR of 110. Repeat ABG shows 7.35/35/100 on room air; however, his lactate is now 7 mmol/L.
Is the rise in his lactate expected following beta-agonist therapy?
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Intravenous sodium bicarbonate seems like a wonderful drug. It fixes acidosis, pushes potassium into cells, alkalinizes urine, and even helps with smelly feet. However, this literature review of four conditions casts some doubt into the seemingly cure-all that is bicarbonate.
Multi-detector computed tomographic pulmonary angiography (CTPA) allows for better visualization of peripheral pulmonary arteries allowing for diagnosis of small peripheral emboli limited to the subsegmental pulmonary arteries. Interestingly as these SSPE’s get diagnosed more and more, two questions come to mind:
A recent study in 2013 Blood looked at these questions. 1
Health-care associated pneumonia (HCAP) is the term used to describe patients presenting with pneumonia who may be at higher risk of multi-drug resistant (MDR) pathogens than other patients presenting from the community due to recent contact with the health care system. What are the criteria for HCAP?
To provide a resource for evidence-based Emergency Medical education, this list of must-read landmark articles was created to supplement the Emergency Medicine (EM) internship year of training. There are 52 articles so that one article can be read at leisure each week of the year. I searched national databases and polled faculty at the University of Washington to identify articles that faculty would expect any EM resident to be familiar with or that they felt were practice-changing in EM. Articles were selected for the final list based on the quality of study design, sample size, and relevance for EM residents.
Acute pulmonary embolism (PE) is a common condition that can be both severe and difficult to diagnose. Half of all acute PE cases are diagnosed in the emergency department, and acute PE follows acute coronary syndrome as the second most common cause of sudden unexpected death in outpatients. Also, right ventricular dysfunction is a consequence of massive/submassive acute pulmonary embolism and correlates with a poor prognosis and high mortality rate. Although an ECG lacks both sensitivity and specificity for acute PE, there are some clues that can help in determining the size of an acute PE.