Bio at MichelleLinMD.com
You could have sworn that the patient’s BNP would have been elevated, but it’s normal. What are causes of a falsely low BNP?
*️⃣ Obesity (PMID 16386669)
*️⃣ Flash pulmonary edema (where you are seeing the early presentation and before BNP levels to rise significant)
*️⃣ Constrictive pericarditis or restrictive cardiomyopathy (PMID 16580543)
Remain skeptical of test results and consider confounders.
Read more about BNP results in early peek of upcoming ALiEM series “Lab It Up” with Dr @gabi_alopes and myself. @aliemteam
https://www.aliem.com/lab-it-up-elevated-bnp/ (link in bio)
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #cardiology #laboratory #bnp #heartfailure #chf
Is it time to mourn the death of the insulin drip for DKA? Hot off the press, open access JAMA paper worth reading.
SQ insulin protocol at single institution with almost 8000 patients showed decreased need for ICU admission, fewer hospital readmissions, and no increase in adverse events such as longer stay or hypoglycemia.
Notable: The protocol includes simultaneously starting in the ED-
* SQ long- AND SQ short-acting insulin
* lactated ringers AND d5 1/2NS +/- potassium
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790794 (link in bio)
⭐️ Dr @honburgerz
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #dka #diabetes #insulin #endocrinology
Scleral icterus is generally seen at bilirubin levels >3 mg/dL. Imagine 3 👁️ 👁️ 👁️ s.
Jaundice typically is seen at bilirubin levels >5 mg/dL Imagine a 🤚 with 5 fingers.
👏 Dr @ktagooma
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #liver #cirrhosis #gi #jaundice #icterus
Akathisia is a very uncomfortable side effect of dopaminergic blocking agents such as droperidol, prochlorperazine (compazine), and metaclopramide (reglan) which we often give for migraines, other primary headaches, and nausea. This also occurs with many antipsychotic medications. This occurs in a dose-dependent fashion.
When it happens, some patients get so restless and agitated that they stop ED care and leave against medical advice.
The limited evidence shows that first-line agents might include:
1. Beta blocker such as propranolol 40-80 mg/day
2. Mirtazapine (a tetracycline antidepressant) 15 mg/day
3. Anticholinergic such as benztropine 1.5-8 mg/day, if evidence of Parkinsonism
Second-line agents:
1. Benzodiazepine
2. Amantadine (dopamine agonist) or clonidine (alpha blocker)
3. Mianserin or cyproheptadine (tetracycline antidepressants)
In the Emergency Department, after a single-dose induced akathisia event, do not redose the medication. Then consider giving PROPRANOLOL and a BENZODIAZEPINE to help allay the symptoms.
Read great review: https://pubmed.ncbi.nlm.nih.gov/27928948/ (link in bio)
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #pharmacology #akathisia #droperidol #compazine #reglan #prochlorperazine #metaclopramide #antipsychotic #propranolol
Temporal arteritis (giant cell arteritis):
The updated 2022 classification criteria has been published by the American College of Rheumatology and European Alliance of Associations for Rheumatology. The 1990 ACR guidelines needed 3 of 5 positive criteria. Now it’s an additive point system where a sum of ≥6 has a high validated sensitivity and specificity for TA. See second image for the point system.
Interesting notables:
1. An absolute inclusion criteria is age at least 50 years.
2. An acceptable alternative to a temporal artery biopsy is an ultrasound looking for a halo sign (5 points)
3. Lab cutoffs include an ESR ≥50 mm/hr or CRP ≥10 mg/L (either gets 3 points)
4. You can identify patients at high risk for TA based purely on symptoms (as many as 13 points)
👏 Dr. @ohall10
Read the article: https://www.rheumatology.org/Portals/0/Files/Giant-Cell-Arteritis-Complete-Article.pdf (link in bio)
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #rheumatology #temporalarteritis #giantcellarteritis
Incisional drainage of finger felons is fraught with dangerous nearby structures. Understand the anatomy before the procedure.
⚠️ Avoid the flexor digitorum profundus (FDP) by cutting 0.5 cm distal to the distal interphalangeal joint (DIPJ).
⚠️ Avoid the digital nerve by cutting just below the level of the fingernail but avoiding the distal phalanx bone.
✅ Be sure to incise deeply enough to cut through the various fibrous septae.
💡 Bonus Pearl: if no obvious laterality of abscess, incise on the ulnar aspect of the index, middle, and ring finger. Incise on the radial aspect of the thumb and little finger. In case of chronic pain or numbness complication, these are the non-weight bearing sides of each finger. Imagine needing protective sensation to alert you that you gripped something hot between your thumb and index finger. Or accidentally touched something hot along your radial or ulnar hand.
Review in Orthobullets: https://www.orthobullets.com/hand/6102/felon (link in bio)
H/T to ⭐️ Dr @meghanhewlett
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #felon #incision #drainage #abscess
Fluid resuscitation for burns: We all know about Parkland’s formula at 4 mL/kg/TBSA, but did you know that the American Burn Society recommends the 24-hr fluid volume to be 2-4 mL/kg/TBSA? The lower end, also known as the MODIFIED BROOKE’S FORMULA, has been touted to be a safer target 🎯 goal because of “fluid creep”, or over-administration of fluid.
“Fluid begets more fluid.”
Over-resuscitation can lead to intra-abdominal hypertension, pulmonary edema, compartment syndrome, and burn thickness worsening. Multiple small head-to-head studies showed that cases using Brooke vs Parkland formula goals had similar rates of AKI, acute lung injury, ARDS, ventilation days, and mortality.
So more is NOT better in fluid resuscitation for patients with burns. Be wary of FLUID CREEP.
Great review in open-access 2019 Current Trauma Reports https://link.springer.com/article/10.1007/s40719-019-00166-6 (link in bio)
H/T to ⭐️ Dr @jaydhanoa
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #burn #brookeformula #fluidcreep
Hyperosmolar hyperglycemia state (HHS) is a diabetic emergency. Volume resuscitation is key along with a basal rate of insulin. Despite treatment, have you ever noticed a rising Na level? Don’t worry - this is normal.
Why? The oversimplified schematic shows that glucose is initially an effective solute (remaining in the serum more), which draws water 💧 with it. However, when you give isotonic fluids and insulin, glucose enters cells, causing water to follow. This unmasks the existing hypernatremia. After adequate fluid resuscitation, you may need to convert to hypotonic fluid, SLOWLY correcting the free water deficit. MDCalc has a useful calculator.
Wonderful detailed explanation on EMCrit’s site in the Internet Book on Critical Care. I had to read the explanation several times to get it 👀…
HHS page: https://emcrit.org/ibcc/hhs/#step_%233_%E2%80%93_hypertonicity_management (link in bio)
👏 to Dr @kaitlin_wilde on her resuscitation skills.
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #criticalcare #hhs #hypernatremia #diabetes #endocrine
Scalpel blade numbers matter. A #10 blade is typically found in surgical kits such as thoracotomy trays. The blade has a large, curved cutting edge for making smooth, long, linear incisions.
Hold it overhand like a violin 🎻 bow
- NOT like a 🖊️ pen
Contrast that with #11 and #15 sharp-tipped blades which are more commonly found in the Emergency Department for making more fine, puncture-like incisions.
A tip overheard at recent cadaver procedures lab at thoracotomy station.
More info: https://sites.uw.edu/uwgensurgtechskills/instrument-handling-scalpels/ (link in bio)
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #surgery #scalpel #thoracotomy #trauma #procedure
Post-intubation hypoxia can be frightening, so keep in mind a methodical checklist ✅ such as DOPES.
D isplaced endotracheal tube (reconfirm position)
O bstructed endotracheal tube (suction!)
P atient pathology (eg., pneumothorax, pulmonary edema, pulmonary embolism, bronchospasm)
E quipment malfunction (ventilator - is it connected to oxygen, faulty oxygen probe sensor)
S tacked breaths or other ventilator setting problems
https://litfl.com/post-intubation-hypoxia/ (link in bio)
Great troubleshooting by Dr. Lozano 👏
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #criticalcare #mnemonic #dopes #pulmonary #hypoxia
Limit potassium infusion to 10 mEq/hr for peripheral IVs because of pain, extravasation, and phlebitis. Central lines can infuse faster at rates of 20 mEq/hr, requiring cardiac monitoring. What if a critically ill patient doesn’t have a central line but needs rapid repletion?
Trick of Trade: Place 2 peripheral IVs each infusing as fast as 10 mEq/hr. Place on a cardiac monitor. Pearl from Dr. Munz at #emconf.
Great review of hypokalemia https://emcrit.org/ibcc/hypokalemia/ (link in bio)
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #endocrine #hypokalemia
Ask your patient with eye pain about contralateral photophobia. “Does it hurt your painful eye when I shine a light in your unaffected eye?” If so, it’s highly likely IRITIS. Shining a light on the normal eye causes consensual pupil constriction, which causes ciliary body pain in the other eye with iritis👏 Dr @kgondy
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #ophthalmology #eye #iritis #photophobia
Giving Rhogam to Rh negative pregnant patients is not indicated for fetus <8 gestational weeks because RhD antigen is not present yet. Alloimmunization thus is not an issue. However if in doubt of estimated gestational age, give Rhogam. Note that the Ob and EM guidelines differ in this. ACEP says give it to all first trimester patients. ⭐️ Dr @antnard10
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #obgyn #rhogam
When prescribing phenazopyridine (aka Pyridium) for urinary symptoms such as dysuria or frequency, be sure to warn them that their urine may turn orange or red. Otherwise they may think they’ve developed hematuria! 🩸
Nice 🕵️♂️ work, student Dr. @ijx_vma
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #pyridium #uti
Don’t forget about hypertriglycerides as cause of pancreatitis. Often the blood sample will be a little milk why and be labeled as “lipemic”. Goal triglyceride serum level <500 mg/dL, because of the risk of necrotizing pancreatitis and organ failure. 👏 Dr @ktagooma !
With greater severity, add insulin IV in the setting of hyperglycemia. Can also add plasmapheresis to the treatment regimen. Reference: UpToDate
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #gi #pancreatitis #lipase #hypertriglyceride
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Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
@M_Lin
Latest posts by Michelle Lin, MD (see all)
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