Keywords: Hypertensive (PubMed Search)
Follow-up for the Hypertensive Patient
We see hypertensive patients every day, every shift. And, we discharge many of them. So, when do you get them follow-up?
The JNC-7 recommends that patients with BPs > 180/110 mm Hg have follow-up within 7 days. Like most of the HTN recommendations in the primary care setting, this recommendation is based on a "smart person" concensus....and no data.
This is a tremendous issue for us in the ED, because we don't want to see a bad outcome in our discharged hypertensive patients.
Some pearls regarding discharging the very hypertensive (but asymtomatic) patient:
Keywords: Hypertension, End-Organ Damage (PubMed Search)
Evaluation of End Organ Damage in Hypertensive Patients
No evidence to date supports the ED workup for end-organ damage in asymptomatic hypertensive patients.
End-Organ Damage Pearls:
Keywords: aortic dissection (PubMed Search)
BEWARE sudden onset thoracic back pain
Just reviewed a case last week of a person who presented with back pain (thoracic) as the sole manifestation of an aortic dissection. No chest pain, belly pain, etc. JUST severe, acute, thoracic back pain.
Keys to staying out of trouble:
Keywords: ED Teaching (PubMed Search)
Pitfalls in ED Teaching
One of the best ways to improve as a teacher is to understand what mistakes expert educators have made in the past.
The following is a short list of pitfalls offered from some of the great teachers in our specialty:
Keywords: Pulmonary Embolism (PubMed Search)
Pulmonary Embolism-Beware Two Important Atypical Presentations
Seems like we have had several atypical PE presentations recently so I thought it timely to quickly highlight some of the well-reported presentations of pulmonary embolism. Remember, although we won't and can't diagnose every case, these types of presentations should at the very least prompt us to consider the diagnosis.
Atypical PE Presentations:
Keywords: Feedback, Teaching (PubMed Search)
Feedback as a Teaching Tool
Why do we, in general, stink at giving feedback?
Consider a few quick pearls that will increase your success at giving valuable feedback:
Keywords: Teaching, Emergency Department (PubMed Search)
Teaching in the Emergency Department
Effective ways to teach in the ED:
Bandiera, Thurgur. 2006-2008
Thrombolytic Therapy for Pulmonary Embolism
Indications for administration of fibrinolytic therapy for acute PE:
Kline. Carolinas Medical Center.
Stein. Pulmonary Embolism. 2008
Keywords: Acute, Aortic Dissection, Neurologic (PubMed Search)
Neurologic Manifestations of Acute Aortic Dissection
A myriad of neurologic presentations of acute aortic dissection have been reported in the literature. Although classic CVA symptoms may occur, nonspecific neurologic symptoms are much more common
Take Home Point:
Category: Infectious Disease
Keywords: Infections, Temperature (PubMed Search)
This pearl is dedicated to Dr. Michael Rolnick....
Infections That Cause Temperature-PulseDissociation
Certain infections may cause temperature-pulse dissociation (relative bradycardia in association with fever).
Remember that normally there will be an increase in pulse rate by 10 bpm for every 1 degree increase in temperature. So, if a patient has a temperature of 103 F, expect them to be tachycardic.
Any intracellular organism has the potential to cause a relative bradycardia (Faget's sign)
Infections that cause dissociation:
Keywords: Neutropenic Entercolitis (PubMed Search)
A neutropenic cancer patient that presents with right lower quadrant abdominal pain, fever, and bloody diarrhea should raise suspicion for typhlitis (necrotizing colitis, cecal inflammation). This most commonly occurs in patients with hematologic malignancies who have been treated with cytotoxic agents. This condition is high risk and is associated with high morbidity and mortaiity.
1. D'Souza S, et al. Typhlitis as a presenting manifestation of acute myelogenous leukemia. South Med J 2000;93:218-220
2. Ellerin TB, Diaz LA. Evidence-Based Medicine-500 Clues To Diagnosis and Treatment. 2001
Keywords: Chest Pain (PubMed Search)
There is clearly no way you can document everything on a chest pain chart. However, there are some pretty important things that should be on the chart.
Some key things to consider documenting:
1. Daniel Sullivan, M.D.
2. The great Amal Mattu, M.D.
3. Larry Weiss, M.D.
Keywords: Hypertension, Epistaxis (PubMed Search)
Hypertension and Epistaxis
We commonly encounter patients with epistaxis who are found to be hypertensive. Some have taught over the years that hypertension causes nosebleeds and that some nose bleeds won't stop until the BP is lowered...
Some pearls about HTN/Epistaxis:
Keywords: Warfarin, Skin Necrosis (PubMed Search)
Warfarin-Induced Skin Necrosis (WISN)
Some pearls about a rare, but serious side effect of Warfarin...
55 yo female presented to the ED on the day of hospital discharge for evaluation of this rash.
The rash began 4 days after starting Warfarin. Was being treated for a DVT.
Keywords: Hypertension (PubMed Search)
What Hypertensive Patient Needs a Workup for End-Organ Damage?
Ah, the age old question...which hypertensive patients need an ED workup for end-organ damage? The "workup" for patients includes renal function, urinalysis, CXR, ECG, etc.
Some pearls regarding working patients up:
Category: Infectious Disease
Keywords: Pneumonia (PubMed Search)
Healthcare Associated Pneumonia (HCAP)....why is this important for the emergency physician?
Most of us are very familiar with the types of pneumonias commonly seen in clinical practice: community-acquired pneumonia (CAP), hospital-acquired pneumonia(HAP), and ventilator-associated pneumonia (VAP). But, some may not be that aware of a relatively newer type of pneumonia that has been well-defined, healthcare-associated pnemonia (HCAP). Experts in infectious disease and critical care now say that we (the ED) should be assessing ALL pneumonia patients for HCAP risk factors.
Why care, you ask?
Risk factors: (most are common sense)
Keywords: hypertension (PubMed Search)
Keywords: PERC Rules (PubMed Search)
Keywords: Warfarin (PubMed Search)
Reversal of Warfarin
Reversal of Warfarin can be accomplished by administering any of the following:
A few pearls:
Keywords: HeparinPro (PubMed Search)
Anticoagulation with Heparin-How to Reverse?
So you just started Heparin on that ACS patient? Just bolused the patient in room 12 with the large PE with a slug of Heparin? The nurse tells you that one of them just vomited blood and the other just had a large bloody bowel movement. What to do, oh, what to do?
How to reverse Heparin...use Protamine: