Keywords: Thrombosis, Cerebral (PubMed Search)
Cerebral Venous Sinus Thrombosis (CVST)
An uncommon but very serious entity that leads to three distinct types of presentations:
Caused by thrombosis of one of the intracerebral venous sinuses (most commonly the transverse sinus) The major risk factor is hypercoagulable disease. May be the underlying cause of a majority of cases of idiopathic intracranial hypertension.
When to suspect:
Keywords: Hypertension, Headache (PubMed Search)
Does Hypertension (elevated BP) Cause Headache?
This is an age old question that many of us have struggled with in the ED for many years...
Other questions include: Does elevated BP cause headaches? Do we need to scan hypertensive patients with headache just because they have a headache? At what level of BP does the BP actually cause headache?
A few quick pearls:
Keywords: Hypertension (PubMed Search)
Avoidable Pitfalls in Managing the Hypertensive Patient
We all see very hypertensive patients on almost every shift. Dr. Winters has an earlier pearl related to pitfalls in treating patients with hypertensive encephalopathy, but I thought it was time to reiterate just a few points.
Keywords: aortic dissection, chest xray (PubMed Search)
So, how good is a screening CXR for aortic dissection?
Keywords: Cardiovascular, CocaineC (PubMed Search)
Key Cardiovascular complications of cocaine:
Restrepo CS, et al. Cardiovascular complications of cocaine: Imaging findings. Emerg Radiol 2008
Keywords: Ischemia (PubMed Search)
Management of acute limb ischemia
Just a few pearls regarding acute limb ischemia
Vasc Surg Reviews 2007
Category: Airway Management
Keywords: laryngoscopy (PubMed Search)
Quick Pearls for Intubating:
1. When intubating, make sure to use two hands!
2. Resist the urge to look for cords
3. Stylet shape is crucial
1. Our very own Ken Butler
2. Rich Levitan-Airway Course
Keywords: subrachnoid hemorrhageRebeleeding (PubMed Search)
Complications of Subarachnoid Hemorrhage
The three dreaded complications of SAH include the following:
Edlow, et al. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. JEM 2008
Keywords: LMWH, PE, Pulmonary Embolism (PubMed Search)
Currently Approved LMWHs for the Treatment of Acute PE:
Make sure to monitor platelet counts regardless of agent chosen.
Konstantinides. Acute pulmonary embolism revisited. Heart. June 2008
Category: Infectious Disease
Keywords: necrotizing fasciitis (PubMed Search)
Necrotizing Fasciitis Pearl
A few things to remember about treating necrotizing soft tissue infections:
So, when shot-gunning the antibiotics in a patient with a really bad soft tissue infection (not the run of the mill cellulitis) consider adding Clindamycin to the regimen.
Infectious Disease Society of America, 2006
Keywords: D-Dimer (PubMed Search)
Causes of an Elevated D-Dimer
Don't forget the multiple causes of an elevated d-dimer:
**See attached PDF-Differential Diagnosis of Elevated D-Dimer
Journal of Thrombosis and Hemostasis, 2008
Keywords: CT, Pulmonary (PubMed Search)
How good was that CT Pulmonary Angiogram You Ordered?
CT is currently the gold standard imaging modality for pulmonary embolism. Since we order these quite a bit in the ED, we should know some of the important nuances regarding interpretation of the scan. All of us at some point have looked at a pulmonary CTA and thought that it looked a bit "fuzzy" or perhaps it didn't "look right" This happens more often in obese patients. There is good literature to show that a suboptimal CTA misses clinically significant PE. So, it is important for emergency physicians to know a little about the CT scan ordered for our patients.
How can you know if the CT scan YOU ordered to rule out PE is really "good enough" to rule out PE?
So, a 34 yo obese patient who gets a CT scan to rule out PE, who has 170 HU in the main pulmonary artery, has not had an optimal CT. Thus, you really haven't ruled out PE even if the read is "negative." Often this is due to poor bolus timing.
American College of Radiology, Appropriateness Criteria, 2006
Keywords: Pulmonary Embolism, Pregnancy (PubMed Search)
Evaluating for Pulmonary Embolism During Pregnancy
Highest risk of PE is within the first week postpartum
Acceptable, safe, and medico-legally sound strategies to rule out PE in pregnancy:
**For explanation of PERC rule, see earlier pearl.
Kline J, Carolinas Medical Center, 2006-2008 published data
Keywords: Pulmonary Embolism, Cancer (PubMed Search)
Ruling Out PE in Cancer Patients: Use D-Dimer??
Most of us are aware of the data that suports using a highly-sensitive d-dimer combined with low-moderate risk score to r/o PE. Sounds simple enough. What about using d-dimer in a cancer patient to rule it out? Well, this is being studied more and more.
Most of us would be a little uneasy about using a d-dimer as a stand-alone test to r/o PE in a cancer patient. After all, they have cancer, aren't they high risk?
The following study showed that the there was a VERY high negative predictive value and a VERY high sensitivity of a negative d-dimer in this group of cancer patients.
|PURPOSE: To prospectively evaluate (a) the diagnostic performance of D-dimer assay for pulmonary embolism (PE) in an oncologic population by using computed tomographic (CT) pulmonary angiography as the reference standard, (b) the association between PE location and assay sensitivity, and (c) the association between assay results and clinical factors that raise suspicion of PE. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval; informed consent was obtained. Five hundred thirty-one consecutive patients were clinically suspected of having PE; 201 were enrolled (72 men, 129 women; median age, 61 years) and underwent CT pulmonary angiography and D-dimer assay. Relevant clinical history, symptoms, and signs were recorded. CT images were interpreted, and the location of emboli was recorded. The negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity, and diagnostic likelihood ratios of the D-dimer assay results were calculated. RESULTS: Forty-three patients (21%) had pulmonary emboli at CT. D-Dimer results were positive in 171 patents (85%). The NPV and sensitivity were 97% and 98%, respectively. The specificity and PPV were 18% and 25%, respectively. No association was shown between clinical history, symptoms, or signs and NPV, PPV, sensitivity, or specificity or between location of PE and sensitivity.
CONCLUSION: D-Dimer results have high NPV and sensitivity for PE in oncologic patients and, if negative, can be used to exclude PE in this population. Combining the assay with clinical symptoms and signs did not substantially change NPV, PPV, sensitivity, or specificity.
King V, Vaze AA, Moskowitz CS, et al. D-dimer assay to exclude pulmonary embolism in high-risk oncologic population: correlation with CT pulmonary angiography in an urgent care setting. Radiology. 2008 Jun;247(3):854-61
Keywords: Aortic Dissection, D-Dimer (PubMed Search)
Does a normal d-dimer rule out aortic dissection?
A lot of research seems to be focused on using d-dimer as a rule-out strategy for acute aortic dissection. The idea is that a d-dimer <500 (which is what we use for ruling out PE in low-mod risk patients) rules out dissection as well.
A few pearls and pitfalls regarding this:
Sodeck, Eur Heart J 2007
Category: Airway Management
Keywords: Pregnancy, Pulmonary Embolism (PubMed Search)
Pregnancy and Acute Pulmonary Embolism
Women who are pregnant or in the postpartum period and women who take hormonal therapy are at an increased risk of pulmonary embolism.
Tapson V. Acute Pulmonary Embolism. N Engl J Med 2008;358:1037-52
Category: Airway Management
Keywords: Thrombolytic, Pulmonary Embolism (PubMed Search)
Thrombolytic Therapy for PE Mike Abraham and I had a very interesting PE case a few nights ago: 30's yo female presented with a two week history of slow onset, progressive DOE. Initially placed in the asthma room because she had a history of asthma. CXR negative. ECG inverted precordial T-waves and S1Q3T3. CT showed massive central, saddle embolus. Troponin 1.2. Normal BP and a pulse of 110. The patient actually laughed when informed of her diagnosis. She was admitted to the PCU. Now, let me share with you how big her clot burden was...it was huge. Biggest I have seen in years. Approximately 70% or so of her total pulmonary circulation was occluded! And, she was laughing. Her BP, though, was never low. The question came up: is this patient a candidate for thrombolytics? After all, she wasn't unstable. Our plan in the ED was to administer tPA based on her clot burden, but she was admitted quickly to the PCU in stable condition and they continued the workup and therapy. Considerations for giving lytics to a PE patient:
Mike Abraham and I had a very interesting PE case a few nights ago:
30's yo female presented with a two week history of slow onset, progressive DOE. Initially placed in the asthma room because she had a history of asthma. CXR negative. ECG inverted precordial T-waves and S1Q3T3. CT showed massive central, saddle embolus. Troponin 1.2. Normal BP and a pulse of 110. The patient actually laughed when informed of her diagnosis. She was admitted to the PCU.
Now, let me share with you how big her clot burden was...it was huge. Biggest I have seen in years. Approximately 70% or so of her total pulmonary circulation was occluded! And, she was laughing. Her BP, though, was never low. The question came up: is this patient a candidate for thrombolytics? After all, she wasn't unstable.
Our plan in the ED was to administer tPA based on her clot burden, but she was admitted quickly to the PCU in stable condition and they continued the workup and therapy.
Considerations for giving lytics to a PE patient:
Tapson V, Up To Date, July 2007
Kline J, Journal of Thrombosis and Hemostasis, 2008
Keywords: AAA (PubMed Search)
Clinical Presentation of AAA
Everyone is familiar with the "classic," textbook, presentation of AAA:
This presentation, however, is not all that common. Many patients simply present with unexplained abdominal and/or flank pain.
Consider the diagnosis in anyone with risk factors (i.e. older folks, family history, etc) who presents with abdominal and/or flank pain. In most cases, CT scanning of this group of patients is the way to go.
And, one last pearl: put the US probe on early. May make a huge difference in time to diagnosis.
Be afraid, be very afraid.
J Vasc Surg, 2007
Keywords: CT Venogram, Ultrasound, DVT, Deep Venous Thrombosis( (PubMed Search)
What study should we be getting to evaluate for DVT in patients with suspected VTE (venous thromboembolic disease)?
Ultrasound of the legs seems to be equivalent to CT Venography (CTV).
Drawbacks of CT Venography (CT scanning into the abdomen/pelvis/legs after pulmonary CTPA):
Despite the fact that leg ultrasound obviously doesn't evaluate for deep pelvis clots and intraabdominal clots (IVC, etc), outcome studies and other studies in recent years show ultrasound is just as good as CTV.
Goodman LR, et al. CT Venography and Compression Sonography are Diagnostically Equivalent: Data from PIOPED II. Am J Roent 2007
Keywords: superior vena cava, svc syndrome (PubMed Search)
Superior Vana Cava Synrome....when to suspect
Two common causes of SVC syndrome include thrombus (secondary to CV catheters) and lung tumors/lymphoma
Consider this diagnosis in patients with a history of cancer and/or who have a central line in place and the complaint of facial swelling. Patients may not look swollen to you.
In addition, make sure to look at their necks and chest wall-presence of asymmetric, prominent veins should prompt consideration for this diagnosis.
A useful clinical tool is to look at the patient's driver's license (assuming they have one) and compare to their appearance on presentation.
Workup in most cases will involve a CT of the chest.
Clinical Oncology, 2007