Bio at MichelleLinMD.com
What`s in the near future? 🔮
An epinephrine nasal spray (brand name Neffy) was approved by the Food and Drug Administration in August 2024 for the management of anaphylaxis. This may ultimately replace the traditionally prescribed auto-injector epinephrine, such as EpiPen. The benefits of the spray include:
⏳ Longer shelf life (30 months vs 18 months)
🥵 Can withstand extreme heat for a few days (such as leaving in a hot car)
💉 Reduces needle phobia, potentially improving patient adherence to self-administering epinephrine
Notably, the nasal spray is currently only approved for patients >66 pounds (30 kg). Also if a second spray is needed, be sure that it is administered in the same nostril to “stack” the dose.
💵 What is the cost to the patient per the manufacturing site?
• With commercial insurance: $25 per twin-pack
• Without insurance, using digital pharmacy service (GoodRx): $199 per twin-pack
🔮 Keep a lookout for this new option in your local pharmacies.
Manufacturer site: https://ir.ars-pharma.com/news-releases/news-release-details/ars-pharmaceuticals-receives-fda-approval-neffyr-epinephrine/
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #epi #epinephrine #epinephrineinjection #allergicreaction #anaphylaxis
What`s in the near future? 🔮
An epinephrine nasal spray (brand name Neffy) was approved by the Food and Drug Administration in August 2024 for the management of anaphylaxis. This may ultimately replace the traditionally prescribed auto-injector epinephrine, such as EpiPen. The benefits of the spray include:
⏳ Longer shelf life (30 months vs 18 months)
🥵 Can withstand extreme heat for a few days (such as leaving in a hot car)
💉 Reduces needle phobia, potentially improving patient adherence to self-administering epinephrine
Notably, the nasal spray is currently only approved for patients >66 pounds (30 kg). Also if a second spray is needed, be sure that it is administered in the same nostril to “stack” the dose.
💵 What is the cost to the patient per the manufacturing site?
• With commercial insurance: $25 per twin-pack
• Without insurance, using digital pharmacy service (GoodRx): $199 per twin-pack
🔮 Keep a lookout for this new option in your local pharmacies.
Manufacturer site: https://ir.ars-pharma.com/news-releases/news-release-details/ars-pharmaceuticals-receives-fda-approval-neffyr-epinephrine/
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #epi #epinephrine #epinephrineinjection #allergicreaction #anaphylaxis
Have you heard of the Modified Glasgow-Blatchford Bleeding Score (GBS) for upper gastrointestinal (GI) bleeding risk stratification? How is different from the traditional GBS?
Background: American and European society guidelines in gastroenterology both recommend using a GBS value of ≤1 to identify low-risk patients who may be safe to manage as an outpatient for their upper GI bleed. The GBS calculation incorporates the following objective biometric measurements and historical elements:
Objective measures:
• Blood urea nitrogen (BUN)
• Hemoglobin
• Systolic blood pressure
• Heart rate
History:
• Melena
• Syncope
• Liver disease history
• Cardiac failure history
Often in the ED, determining the presence of non-objective measures can be challenging. The modified GBS calculation incorporates only the 4 objective biometric measures.
How does this modified score compare to the traditional GBS?
Published in Annals of EM this month, a large 2024 multicenter retrospective of 990 hospitalized patients with upper GI bleeds found that a GBS of ≤1 (sensitivity 99%, NPV 89%) and modified GBS=0 (sensitivity 99%, NPV 84%) both had strong discriminatory power in identifying such low-risk patients. The composite outcome measure was the need for a therapeutic intervention within 7 days (blood transfusion, endoscopic, surgical, or interventional radiology hemostasis) and/or death within 30 days. Notably, portal hypertension was NOT an exclusion criteria.
TLDR:
1. With a GBS≤1 or modified GBS=0, the patient may be at low enough risk for outpatient management for upper GI bleed.
2. Use the modified and traditional GBS tools as an adjunct to supplement clinical judgment.
Caution: This study was a retrospective analysis conducted in French hospitals of patients admitted to the hospital. However, the authors noted that the higher acuity nature of these hospitalized patients may result in a spectrum bias, which underestimates the negative predictive power for risk stratification in the ED.
Ref:
Thiebaud PC et al. Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding. Ann Emerg Med. #postitpearls #blatchford
Have you heard of the Modified Glasgow-Blatchford Bleeding Score (GBS) for upper gastrointestinal (GI) bleeding risk stratification? How is different from the traditional GBS?
Background: American and European society guidelines in gastroenterology both recommend using a GBS value of ≤1 to identify low-risk patients who may be safe to manage as an outpatient for their upper GI bleed. The GBS calculation incorporates the following objective biometric measurements and historical elements:
Objective measures:
• Blood urea nitrogen (BUN)
• Hemoglobin
• Systolic blood pressure
• Heart rate
History:
• Melena
• Syncope
• Liver disease history
• Cardiac failure history
Often in the ED, determining the presence of non-objective measures can be challenging. The modified GBS calculation incorporates only the 4 objective biometric measures.
How does this modified score compare to the traditional GBS?
Published in Annals of EM this month, a large 2024 multicenter retrospective of 990 hospitalized patients with upper GI bleeds found that a GBS of ≤1 (sensitivity 99%, NPV 89%) and modified GBS=0 (sensitivity 99%, NPV 84%) both had strong discriminatory power in identifying such low-risk patients. The composite outcome measure was the need for a therapeutic intervention within 7 days (blood transfusion, endoscopic, surgical, or interventional radiology hemostasis) and/or death within 30 days. Notably, portal hypertension was NOT an exclusion criteria.
TLDR:
1. With a GBS≤1 or modified GBS=0, the patient may be at low enough risk for outpatient management for upper GI bleed.
2. Use the modified and traditional GBS tools as an adjunct to supplement clinical judgment.
Caution: This study was a retrospective analysis conducted in French hospitals of patients admitted to the hospital. However, the authors noted that the higher acuity nature of these hospitalized patients may result in a spectrum bias, which underestimates the negative predictive power for risk stratification in the ED.
Ref:
Thiebaud PC et al. Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding. Ann Emerg Med. #postitpearls #blatchford
We know how to treat alcohol withdrawals but do you know about first-line FDA approved options to decrease cravings and increase abstinence for patients with chronic alcohol use disorder? Besides concurrent psychosocial counseling, these have demonstrated benefit per 2023 JAMA meta-analysis and systematic review (PMID 37934220) by McPheeters et al. Amazing NNT stats. Can consider starting medication in the Emergency Department especially if you have an Addiction or Counseling team.
1. Acamprosate (666 mg po TID)
- GABA agonist and glutamate modulator
- NNT 11 to reduce any drinking
- Need to be sober before starting
- Contraindication: Severe renal impairment
- Decreases alcohol withdrawal symptoms of insomnia and cravings
2. Naltrexone (50 mg po daily or 380 mg IM monthly)
- Opioid antagonist
- For oral route: NNT 18 to decrease any drinking and NNT 11 to decrease heavy drinking
- Can start while intoxicated
- Contraindication: Acute hepatitis, liver failure, active opioid use
- Decreases cravings presumably by blocking reward pathway from endogenous opioids and endorphins
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #toxicology #medication #alcohol #alcoholism #aud #naltrexone #acamprosate
We know how to treat alcohol withdrawals but do you know about first-line FDA approved options to decrease cravings and increase abstinence for patients with chronic alcohol use disorder? Besides concurrent psychosocial counseling, these have demonstrated benefit per 2023 JAMA meta-analysis and systematic review (PMID 37934220) by McPheeters et al. Amazing NNT stats. Can consider starting medication in the Emergency Department especially if you have an Addiction or Counseling team.
1. Acamprosate (666 mg po TID)
- GABA agonist and glutamate modulator
- NNT 11 to reduce any drinking
- Need to be sober before starting
- Contraindication: Severe renal impairment
- Decreases alcohol withdrawal symptoms of insomnia and cravings
2. Naltrexone (50 mg po daily or 380 mg IM monthly)
- Opioid antagonist
- For oral route: NNT 18 to decrease any drinking and NNT 11 to decrease heavy drinking
- Can start while intoxicated
- Contraindication: Acute hepatitis, liver failure, active opioid use
- Decreases cravings presumably by blocking reward pathway from endogenous opioids and endorphins
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #toxicology #medication #alcohol #alcoholism #aud #naltrexone #acamprosate
Hot off the press! The PECARN cervical spine injury prediction rule for injured children is published. Much like the head CT rule in blunt trauma, there are HIGH RISK and INTERMEDIATE RISK FACTORS.
High Risk (12.7% cervical injury):
* Abnormal A, B, or C
* Focal neurological deficits
* Severe altered mental status (U=unresponsive on the AVPU scale)
Intermediate Risk (2.8% cervical injury):
* Neck pain or tenderness
* Substantial head injury
* Substantial torso injury
* Disability (Opens eyes only to Verbal or Painful stimuli per AVPU scale)
What is considered a "substantial" head or torso injury? It`s an injury needing inpatient observation or surgery. Examples:
* Skull fracture
* Pneumothorax
* Signs of solid organ injury
* Spinal fracture
* Pelvic fracture
If there is at least 1 high risk factor, consider a CT of the c-spine. If not, and there is at least 1 intermediate risk factor, consider an XR. And if none of the above, you are safe to clinically clear the neck.
See next image for the official PECARN cervical spine injury prediction rule (along with their blunt head CT rules for age <2 and ≥2 years old).
Looking forward to applying this evidence-based approach to pediatric trauma care!
Downloadable PDF of the c-spine graphic: https://pecarn.org/pecarn_news/clinical-decision-rule-cervical-spine/
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #trauma #pediatric #PECARN #radiology #decisionrule #cervicalspine #pecarn
Hot off the press! The PECARN cervical spine injury prediction rule for injured children is published. Much like the head CT rule in blunt trauma, there are HIGH RISK and INTERMEDIATE RISK FACTORS.
High Risk (12.7% cervical injury):
* Abnormal A, B, or C
* Focal neurological deficits
* Severe altered mental status (U=unresponsive on the AVPU scale)
Intermediate Risk (2.8% cervical injury):
* Neck pain or tenderness
* Substantial head injury
* Substantial torso injury
* Disability (Opens eyes only to Verbal or Painful stimuli per AVPU scale)
What is considered a "substantial" head or torso injury? It`s an injury needing inpatient observation or surgery. Examples:
* Skull fracture
* Pneumothorax
* Signs of solid organ injury
* Spinal fracture
* Pelvic fracture
If there is at least 1 high risk factor, consider a CT of the c-spine. If not, and there is at least 1 intermediate risk factor, consider an XR. And if none of the above, you are safe to clinically clear the neck.
See next image for the official PECARN cervical spine injury prediction rule (along with their blunt head CT rules for age <2 and ≥2 years old).
Looking forward to applying this evidence-based approach to pediatric trauma care!
Downloadable PDF of the c-spine graphic: https://pecarn.org/pecarn_news/clinical-decision-rule-cervical-spine/
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #trauma #pediatric #PECARN #radiology #decisionrule #cervicalspine #pecarn
Does your patient have a very elevated anion gap (AG) in the blood test results? It’s almost always associated with metabolic acidosis… even if your pH is elevated. That just means you now have a mixed acid-base status.
The way to think of AG is that it is a formula assessing the difference between measured cations (Na) and measured anions (HCO3- and Cl-). A decrease in unmeasured cations (K, Mg, Ca) can theoretically cause a trace elevation in AG, but it’s almost always an increase in unmeasured anions.
CATMUDPILES 🐈 is a helpful mnemonic to recall the causes of AG metabolic acidosis:
C Carbon monoxide, congenital heart disease, cyanide
A Aminoglycosides
T Theophylline, toluene
M Methanol
U Uremia
D DKA (also alcoholic/starvation ketacidosis)
P Paracetamol, paraldehyde
I Iron, INH, inborn errors of metabolism
L Lactic acidosis
E Ethanol, ethylene glycol
S Salicylates
What are some rare exceptions when an elevated AG is NOT from metabolic acidosis?
* Hyperalbuminemia
* IgA myeloma
These are unmeasured anions.
Helpful read: https://acutecaretesting.org/en/articles/clinical-aspects-of-the-anion-gap
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #endocrinology #acidbase #aniongap #mudpiles #catmudpiles
Does your patient have a very elevated anion gap (AG) in the blood test results? It’s almost always associated with metabolic acidosis… even if your pH is elevated. That just means you now have a mixed acid-base status.
The way to think of AG is that it is a formula assessing the difference between measured cations (Na) and measured anions (HCO3- and Cl-). A decrease in unmeasured cations (K, Mg, Ca) can theoretically cause a trace elevation in AG, but it’s almost always an increase in unmeasured anions.
CATMUDPILES 🐈 is a helpful mnemonic to recall the causes of AG metabolic acidosis:
C Carbon monoxide, congenital heart disease, cyanide
A Aminoglycosides
T Theophylline, toluene
M Methanol
U Uremia
D DKA (also alcoholic/starvation ketacidosis)
P Paracetamol, paraldehyde
I Iron, INH, inborn errors of metabolism
L Lactic acidosis
E Ethanol, ethylene glycol
S Salicylates
What are some rare exceptions when an elevated AG is NOT from metabolic acidosis?
* Hyperalbuminemia
* IgA myeloma
These are unmeasured anions.
Helpful read: https://acutecaretesting.org/en/articles/clinical-aspects-of-the-anion-gap
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #endocrinology #acidbase #aniongap #mudpiles #catmudpiles
Shoulder dislocations post-reduction care isn’t just “wear a sling”. You want to avoid a re-dislocation and a frozen shoulder (adhesive capsulitis).
So for anterior dislocations (which are almost all the shoulder dislocations), provide concrete instructions like:
1. Imagine you are wearing a large billboard sign on your back. Keep your arms in front of it. This avoids hyperextension of the shoulder. A special no-no is combing 🪮 the back of one’s hair (hyperextension AND significant abduction).
2. Every day for a few minutes take your arm out of the sling and bend over to allow your arm to dangle with gravity. You can prop your other arm on a table edge. Rock your body to create pendulous, circular ↔️ 🔄 movements of your shoulder joint. Increase the swinging radius over time. BONUS: While there, range your elbow, wrist, and hand to avoid loss of muscle tone and flexibility.
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedic #shoulderdislocation
Shoulder dislocations post-reduction care isn’t just “wear a sling”. You want to avoid a re-dislocation and a frozen shoulder (adhesive capsulitis).
So for anterior dislocations (which are almost all the shoulder dislocations), provide concrete instructions like:
1. Imagine you are wearing a large billboard sign on your back. Keep your arms in front of it. This avoids hyperextension of the shoulder. A special no-no is combing 🪮 the back of one’s hair (hyperextension AND significant abduction).
2. Every day for a few minutes take your arm out of the sling and bend over to allow your arm to dangle with gravity. You can prop your other arm on a table edge. Rock your body to create pendulous, circular ↔️ 🔄 movements of your shoulder joint. Increase the swinging radius over time. BONUS: While there, range your elbow, wrist, and hand to avoid loss of muscle tone and flexibility.
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedic #shoulderdislocation
Is calcium chloride part of your last resort “kitchen sink” of medications for patients presenting in undifferentiated cardiac arrest?
It used to be. Increasingly retrospective studies, RCTs, and systematic reviews suggest that it isn’t beneficial. In fact, it may cause HARM (less ROSC and higher mortality). One RCT was stopped early for ethical reasons because the intervention arm (calcium) significantly caused more harm.
Why is calcium bad? A theory is that it causes hypercontraction and a “stone heart”.
This does NOT apply to special cases of cardiac arrest such as hyperkalemia, hypocalcemia, or other conditions where calcium is of direct benefit.
Use calcium judiciously in undifferentiated cardiac arrest. This recommendation was supported in the 2023 International Liaison Committee on Resuscitation (ILCOR) consensus statement (open access). PMID 37937881
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #ilcor #cardiacarrest #calcium #resuscitation #ROSC #pharmacist
Is calcium chloride part of your last resort “kitchen sink” of medications for patients presenting in undifferentiated cardiac arrest?
It used to be. Increasingly retrospective studies, RCTs, and systematic reviews suggest that it isn’t beneficial. In fact, it may cause HARM (less ROSC and higher mortality). One RCT was stopped early for ethical reasons because the intervention arm (calcium) significantly caused more harm.
Why is calcium bad? A theory is that it causes hypercontraction and a “stone heart”.
This does NOT apply to special cases of cardiac arrest such as hyperkalemia, hypocalcemia, or other conditions where calcium is of direct benefit.
Use calcium judiciously in undifferentiated cardiac arrest. This recommendation was supported in the 2023 International Liaison Committee on Resuscitation (ILCOR) consensus statement (open access). PMID 37937881
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #ilcor #cardiacarrest #calcium #resuscitation #ROSC #pharmacist
Seems obvious but isolated finger injuries that need Xrays should get FINGER xrays and NOT hand xrays. More is not better.
Why? You can miss some critical details in the hand xrays because:
1️⃣ The xray beam focus is on the capitate rather than the PIP joint for finger films. This results often in more oblique angle (non-orthogonal) views of the fingers.
2️⃣ The other fingers in a hand film may create some overlap in the lateral view, obscuring some finger injuries.
3️⃣ Xrays of the finger can help you identify subtle rotational deformities because the xray beams are much more orthogonal to the areas of interest than hand xrays.
This may seem obvious but even a recent hand surgeon specialist dedicated part of her talk exactly to this point. Thanks 👏 Dr. Lauren Santiesteban for a great talk.
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #radiology #EMconf
Seems obvious but isolated finger injuries that need Xrays should get FINGER xrays and NOT hand xrays. More is not better.
Why? You can miss some critical details in the hand xrays because:
1️⃣ The xray beam focus is on the capitate rather than the PIP joint for finger films. This results often in more oblique angle (non-orthogonal) views of the fingers.
2️⃣ The other fingers in a hand film may create some overlap in the lateral view, obscuring some finger injuries.
3️⃣ Xrays of the finger can help you identify subtle rotational deformities because the xray beams are much more orthogonal to the areas of interest than hand xrays.
This may seem obvious but even a recent hand surgeon specialist dedicated part of her talk exactly to this point. Thanks 👏 Dr. Lauren Santiesteban for a great talk.
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #radiology #EMconf
🚩 Beware of trusting xrays in ruling out a hip fracture, especially in older patients.
Occult hip fractures (xray negative) requiring surgery occurred in 39% of older patients in a 2020 meta-analysis with 2,000+ patients [1].
The American College of Radiology`s Appropriateness Criteria [2] states that despite getting a negative XR, suspected hip fractures need additional cross-sectional imaging with either CT or MR, understanding their sensitivities:
🦴 CT: 69-87%
🦴 MR: 99-100%
If you are still suspicious after a negative CT, obtain a MR, which is the gold standard. Alternatively, if you have a high suspicion already for an occult fracture and can obtain a timely MR, skip the CT and go straight to MR.
Whether that MR happens in the ED or inpatient Medicine service is based on local hospital resource capabilities and protocols.
Refs
1. Haj-Mirzaian A, Eng J, Khorasani R, et al. Use of Advanced Imaging for Radiographically Occult Hip Fracture in Elderly Patients: A Systematic Review and Meta-Analysis. Radiology. 2020;296(3):521-531. PMID 32633673; doi:10.1148/radiol.2020192167 @rsnagram
2. American College of Radiology: https://acsearch.acr.org/docs/3082587/Narrative/ @radiologyacr
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #hipfracture #occultfractures #proximalfemurfracture #radiology
🚩 Beware of trusting xrays in ruling out a hip fracture, especially in older patients.
Occult hip fractures (xray negative) requiring surgery occurred in 39% of older patients in a 2020 meta-analysis with 2,000+ patients [1].
The American College of Radiology`s Appropriateness Criteria [2] states that despite getting a negative XR, suspected hip fractures need additional cross-sectional imaging with either CT or MR, understanding their sensitivities:
🦴 CT: 69-87%
🦴 MR: 99-100%
If you are still suspicious after a negative CT, obtain a MR, which is the gold standard. Alternatively, if you have a high suspicion already for an occult fracture and can obtain a timely MR, skip the CT and go straight to MR.
Whether that MR happens in the ED or inpatient Medicine service is based on local hospital resource capabilities and protocols.
Refs
1. Haj-Mirzaian A, Eng J, Khorasani R, et al. Use of Advanced Imaging for Radiographically Occult Hip Fracture in Elderly Patients: A Systematic Review and Meta-Analysis. Radiology. 2020;296(3):521-531. PMID 32633673; doi:10.1148/radiol.2020192167 @rsnagram
2. American College of Radiology: https://acsearch.acr.org/docs/3082587/Narrative/ @radiologyacr
#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #hipfracture #occultfractures #proximalfemurfracture #radiology
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Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
@M_Lin