Month: July 2017

Gunshot Wounds (Arms and Legs)

July 30, 2017 / Zack

Podcast: Play in new window | Download

Evaluate 5 important structures when evaluating gunshot wounds in an extremity.

Blood Vessel Injuries

3 Categories
- Hard-Signers
  - Mnemonic: HARD Bruit
    - Hypotension
    - Arterial/pulsatile bleeding
    - Rapidly expanding hematoma
    - Deficits (pulse)
    - Audible BRUIT/thrill
  - These patients likely need OR
- Soft-Signers
  - Significant vascular oozing/bleeding
  - Large hematoma
    - These patients need to be screened with ABI (ankle brachial index)
      - ABI <0.9 or asymmetry between extremities is concerning for vascular injury
    - If abnormal, obtain a CTA
- No-Signers
  - No additional management for vascular injury required

Nerve Injuries

Relatively rare
Document neuro exam in the extremity
Consult if abnormal

Bone Injuries

Relatively common
Diagnosed by x-ray
Consult orthopedics for fracture

Soft Tissue Injury

Be sure to count/document number of holes
Typically do not need laceration repair unless cosmetic area
Don’t miss compartment syndrome
- Mnemonic: “P’s”
  - Pain out of Proportion
  - Pain with Passive range of motion
  - Paresthesias
  - Pallor
  - Paralysis
  - Poikilothermia

The Bullet: What To Do With It?

The bullet is almost never removed, unless…
- Very superficial/cosmetic and easy to remove
- In a joint

Additional Reading

NBME Shelf Review Part 2- Trauma (EM Clerkship)

Asthma and COPD

July 23, 2017 / Zack

Podcast: Play in new window | Download

5 core treatments and 5 MORE treatments

5 Core Treatments

Albuterol
- Beta agonist
  - Bronchodilator
- Core treatment for asthma
Ipratropium
- Anti-muscarinic
  - Relax muscles around the airways
- Works synergistically with albuterol
Steroids
- Decrease inflammation in the airways
- Prednisone (PO)
- Methylprednisone (IV)
BiPAP (COPD)
- Decreases work of breathing
- Decreases rates of intubation
- Decreases mortality
Antibiotics (COPD)
- Infection common cause of inflammation

5 More Treatments

Magnesium sulfate
Ketamine
Epinephrine (systemic beta agonist)
Heliox
LAST RESORT – Intubation
- Decrease rate and volume
- Increase expiratory time and inspiratory flow

Additional Reading

Antibiotics in COPD (AAFP)
The Crashing Asthmatic (REBEL EM)

GI Bleed

July 16, 2017 / Zack

Podcast: Play in new window | Download

Basic Categories

Upper GI Bleed
- Symptoms
  - Coffee ground emesis
  - Melena
  - Black tarry stool
    - Digested blood
- Common causes
  - Peptic ulcer disease
  - Varices
Lower GI Bleed
- Symptoms
  - Bright red blood per rectum (BRBPR)
  - Maroon/bloody stools
- Common causes
  - Diverticulosis
  - Colon cancer
  - Angiodysplasia
  - AV Malformations

History

Ask about risk factors for upper GI bleed
- Peptic ulcer risk factors
  - NSAIDS
  - Steroids
  - History of ulcers
- Varices risk factors
  - Heavy alcohol use
  - History of liver disease

Exam

Abdominal exam
- Usually minimal tenderness
- If patient has severe tenderness/peritoneal signs consider alternative diagnosis
  - Perforation
Rectal exam
- Identify stool color
- Guaiac testing
- Hemorrhoids
  - Are they bleeding
- Anal fissures

Testing Plan

CBC
- Looking for anemia
Electrolytes
- Elevated BUN
  - Commonly present in upper GI bleed
Coagulation panel
Type and screen

Treatment Plan

Proton pump inhibitor (upper GI bleeds)
- “-prazoles” such as pantoprazole
Octreotide/Antibiotics if varies suspected

Disposition

Most upper GI bleeds get admitted
Lower GI bleeds depend on risk factors
- Comorbidities
- Clinical findings/stability
  - Vital signs
  - Hemoglobin/Hematocrit

Additional Reading

GI Bleed Emergencies (EM Cases)
GI Bleed (emDOCs)

How to Transfuse Blood

July 9, 2017 / Zack

Podcast: Play in new window | Download

Type and Rh

What information it provides
- Blood type (A, B, AB, O)
- Rh status (Rh positive or negative)
When to order
- Pregnant patients with vaginal bleeding
  - Need if Rh negative (prevents hemolytic disease of newborn)

Type and Screen

What information it provides
- Blood type (A, B, AB, O)
- Rh status (Rh positive or negative)
  - PLUS
- Antibody status
  - Looks for all possible antibodies that may cause transfusion reaction
When to order
- When the patient needs/might need a blood transfusion
  - Test typically takes 30 minutes to run… ORDER EARLY!

Type and Cross

What information it provides
- Blood type (A, B, AB, O)
- Rh status (Rh positive or negative)
- Antibody status
  - PLUS
- Specifically tests against patients blood
This blood is then set aside and officially “matched”
Acts as a final safety step before transfusion

Emergency Release Blood

Universal donor is O negative
Order if you can’t wait 30 minutes because the patient is dying

Additional Reading

Straight Talk with an ER Doc with Scott Weingart (BBGuy Podcast)

Pulmonary Embolism

July 2, 2017 / Zack

Podcast: Play in new window | Download

Introduction

Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries

Can cause pulmonary infarction (which mimics pneumonia on chest x-ray)

Basic Approach to the Diagnosis of PE

Step 1: Consider PE in any patient with signs or symptoms consistent with the disease
- Common signs/symptoms
  - Shortness of breath
  - Chest pain
  - Syncope
  - Tachycardia
  - Hypoxemia
  - Hypotension
Step 2: Do not do additional testing for PE in patients with a CLEAR alternative diagnosis
- Common alternative diagnoses
  - COPD exacerbation
  - Acute coronary syndrome
  - Pneumonia
- Keep in mind that these diagnoses are also the most frequent misdiagnoses in cases of missed PE!!! Be careful.
Step 3: Calculate Wells Score and PERC criteria
- Wells score
  - (I personally use Wells’ Criteria for PE by MDCalc)
  - Define patient as either “Low” “Medium” or “High” risk
- PERC criteria
  - I use the PERC Rule for PE by MDCalc for this as well
- If patient is both low risk wells and meets all PERC criteria…
  - No additional testing needed!!!
Step 4: Get a D-Dimer
- IF…
- Low risk Wells but fails PERC criteria
- Medium risk Wells score
Step 5: Get a CTA
- IF…
- Wells score is high
- Elevated d-dimer
  - (Update: it is now established that you can safely use AGE ADJUSTED D-DIMER)
    - ACEP’s clinical policy supporting this can be found HERE

Final Thoughts

Bilateral lower extremity ultrasounds not sensitive enough to rule out PE
The classic EKG finding is S1Q3T3

Additional Reading

Emergency Evaluation of PE: Diagnosis (Journal of Emergency Medicine)
Wells Criteria (MDCalc)
PERC Criteria (MDCalc)
Age Adjusted D-Dimer Policy (ACEP)

Month: July 2017

Gunshot Wounds (Arms and Legs)

Evaluate 5 important structures when evaluating gunshot wounds in an extremity.

Asthma and COPD

5 core treatments and 5 MORE treatments

GI Bleed

How to Transfuse Blood

Pulmonary Embolism

Links

Recent Posts