Keywords: Altered Mental Status (PubMed Search)
Altered Mental Status-Does Your Patient Have Non-Convulsive Status Epilepticus?
Ever intubated a patient in status epilepticus and wondered if they were still seizing after sedation and paralysis? Ever taken care of an altered patient and wondered if you should consult neurology and attempt to get an EEG?
NCSE is defined as continuous seizure activity without obvious outward manifestations of a seizure. This is important for emergency physicians to consider because it has to be detected early to prevent morbidity and mortality.
When to consider NCSE:
Keywords: Temporal Arteritis (PubMed Search)
Temporal Arteritis (TA) is commonly associated with the sudden onset of a unilateral headache centered around the temporal region. The most devastating consequence of TA is blindness though this is only reported in up to 50% of cases though can be bilateral in up to 33% of patients.
According to the American College of Rheumatology criteria for classification of temporal arteritis this diagnosis can be made in the ED without a biopsy. You just need at least 3 of the following 5 items to be present (sensitivity 93.5%, specificity 91.2%) to make the diagnosis :
Hunder GG, Bloch DA, Michel BA, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. Aug 1990;33(8):1122-8
Keywords: altered mental status (PubMed Search)
Wernicke's encephalopathy, considered a unique complication of alcoholism, is also seen in malnourished patients, bariatric surgery patients, and patients who have undergone bone marrow transplantation.
Some pearls about Wernicke's encephalopathy:
Keywords: Hypothermia (PubMed Search)
Finally, remember to monitor the patient closely when you first start rewarming as this can induce cardiac arrest. This is thought to occur as colder peripherial blood returns to the central circulation as peripherial veins and arteries dilated from the warm fluid.
Keywords: Reimburshment, Coding (PubMed Search)
Often charts are down coded as it is not clear from the documentation that your medical decision making was complex.
For instance, if your final diagnosis is GERD, and you do not document that you were also concerned about angina or a pneumothorax your level 5 chart could be coded as a level 3, since the final diganosis does not seem that complex. In order to prevent this document:
I realize that when you are busy this might be the last thing on your mind, but the difference between a level III chart and a level V chart is about $100, and the only additional work is the 3 minutes it would take to document what you did for the patient.
More to come...
Adapted from Michael A. Granovsky's ACEP lecture entitled :"RVU Killers: The Most Common Reimburshment Documentation Errors"
This week's monday pearl is from our very own Azher Merchant....who recently gave an excellent talk on the risks of radiation.
Be afraid....be very afraid....
Risk is based on acute exposure and is extrapolated largely from atomic bomb survivors.
Effective radiation dose = Sievert (Sv)
Lifetime Attributable Risk of Cancer 1:1000 at 10mSv
Lifetime Attributable Risk of Cancer Mortality 1:2000 at 10mSv
Risk estimates follow a linear rate of change such that:
Lifetime Attributable Risk of Cancer in Adults = Radiation Dose (mSv) x 0.0001
Risk is Cumulative
Lifetime Attributable Risk of Cancer is greater than for adults and is age-dependent
Lifetime Attributable Risk of Cancer Mortality 1:1000 at 10mSv
Common Effective Dose Estimates (mSv)
Background radiation 3.5/year (chronic exposure)
Head, Face 2
Neck, Cervical Spine 2
Chest, Thoracic Spine 8
Abdomen/Pelvis, Lumbar Spine 15
Note that it doesn't take very much radiation to reach the 10 mSv level!
Bottom line: CT if you need to, but carefully consider whether it is worth it or not
One last pearl, carefully consider whether or not you want that d-dimer and don't order one unless you are prepared to order a CT scan.
Keywords: Bradycardia (PubMed Search)
Great case of bradycardia today in the ED-requiring transvenous pacemaker....cause?? K 7.6
Some bradycardia pearls:
Keywords: geriatrics, elderly, pharmacology (PubMed Search)
With few exceptions, always assume that elderly patients presenting to the ED with an acute illness are very dehydrated. Here are a few reasons why the elderly patient, even on a normal day, may be mildly dehydrated:
1. The elderly have been shown to have decreased total body water.
2. The elderly have a decreased thirst response.
3. The elderly have a decreased renal vasopressin response.
Given these issues, when an elderly patient develops a systemic illness (especially pulmonary process), they lose even more fluid via insensible losses. By the time they arrive in the ED, unless they are presenting because of overt pulmonary edema, they almost always will benefit from generous IV fluid administration.
Keywords: Errors (PubMed Search)
Diagnostic Errors in the Emergency Department
Believe it or not, there is actually a field of medicine that is devoted to examining how physicians think in clinical practice, i.e. how we make diagnostic decisions. Much of the work on this has been done by Pat Croskerry. This is extremely important for emergency physicians because we frequently have to make split second medical decisions with little to no information.
Why is this so important? If we can understand where errors are made, we can actually improve our own diagnostic skills and reduce our errors rates.
Some key pitfalls that we all fall victim to:
Jerome Groopman, How Doctors Think
Keywords: G6PD, Deficiency (PubMed Search)
Glucose-6-Phosphate Dehydrogenase Deficiency
Also make sure that you are not G6PD deficiency if you are eating with Hannibal Lecter as Fava beans and other legumes can also cause an episode of hemolysis.
A good reference for G6PD deficiency is http://g6pddeficiency.org/index.php
Keywords: Hyphema IOP Ophthalmology (PubMed Search)
Hyphema is an urgent ophthalmologic condition. Due to the high risk of rebleeding and increased intra-ocular pressure, strict follow up with an ophthalmologist is warranted. SELECTED low grade hyphemas in reliable patients may be managed on an outpatient basis. Some pointers that may be helpful for the EM inservice exam:
General indications for "very urgent" ophthalmologic consultation:
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: 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: Frostbite, treatment (PubMed Search)
Now that we are in the cold winter months, we are more likely to see patient with frostbite and hypothermia. Here are some tips for treating frostbite.
Adapted from Frostbite: Treatment and Medication by C. Crawfor Mechem, MD, MS, FACEP as posted on eMedicine.com.
Keywords: EMS, trauma, injury, ISS, triage (PubMed Search)
For the first time since its publication, the centers for disease control has dedicated an entire issue of their Morbidity and Mortality Weekly Report to an emergency medical services topic. Vol 55 RR-1 reviews the, "Guidelines for Field Triage of Injured Patients." The report represents a consensus opinion of national experts in EMS, EM, and trauma care. It outlines which patients may be best served via transport to a trauma center.
CRITERION LINKED TO SEVERE INJURY (Consider transport to nearest TRAUMA CENTER)
From the MMWR: "The National Study on the Costs and Outcomes of Trauma identified a 25% reduction in mortality for severely injured patients who received care at a Level I trauma facility."
The remainder of the report details the triage decision making process, explains trauma center capabilities, and provides an interesting and detailed review of trauma transport criteria. Link to the current issue is attached.
Keywords: Teaching, Emergency Department (PubMed Search)
Teaching in the Emergency Department
Effective ways to teach in the ED:
Bandiera, Thurgur. 2006-2008
Keywords: Glucometer, Accuracy (PubMed Search)
The glucometer is one of the devices that we quickly reach for in the management of our unresponsive patients, diabetics and in the critically ill. Recently, I noticed that our Roche Accu-Check has a big sticker on the case stating that results could be affected by therapies that alter the metabolism of galactose, maltose, and xylose. Since this was a big hole in my fund of knowledge I decided to look up what else affects the accuracy of glucometers.
Now, Dr. Winters already warned used about the inaccuracy of bedside glucometer readings in the critically ill, but what about the patient that is not septic and/or in shock.
Substances/Drugs that have been reported to affect the accuracy of glucometers are:
Anemia also results in higher values, and a capillary blood sample can differ from venous blood by as much as 70mg/dL.
Most errors are more significant when dealing with hypoglycemia.
So the moral of the story is be careful with a bedside glucometer when the reading is low, as the venous blood sample sent to the lab may return even lower. Error on the side of treating the patient with glucose.
Fahy BG, Coursin DB. Critical glucose control: the devil is in the details. Mayo Clin Proc. Apr 2008;83(4):394-397.
Keywords: high altitude illness (PubMed Search)
High altitude illnesses is typically called Acute mountain sickness (AMS) and is associated with two major complications high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).
Symptoms associated with AMS are headache, fatigue, nausea and vomiting, anorexia and insomia. Cough, Cyanosis, hypoxia, and dyspnea are associated with HAPE. HACE is associated with progressive neurologic symptoms and can lead to ataxia and coma.
Factors that increase your risk for altitude illnesses are:
Keywords: Hypothyroidism, Myxedema, Treatment (PubMed Search)
Severe Hypothyroidism or Myxedema Coma
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