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Episode 49 – The AAP BRUE (formerly ALTE) Guidelines

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The Free Open Access Medical Education (FOAM)

We review the American Academy of Pediatrics guideline on Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants.

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Note: Some have voiced concerns that these guidelines potentially downplay the event. The concern is that the yield of these workups and admissions may be low, but possibly worthwhile.  At FOAMcast, we are not qualified to critique these guidelines but there are helpful tables and charts in them to realize that these recommendations really are only for specific events and children AFTER thorough history and physical.

Generously Donated Rosh Review Question

A 6-week-old boy is brought to the emergency room because of cyanosis. He was sleeping comfortably in a supine position right after a feeding when he suddenly choked, became limp and lips turned blue. The mother witnessed the event and blew to the face of the boy. The whole episode lasted for about two minutes. EMS was called and upon arrival at the house, the boy was back to his usual self. At the ER, he boy has normal vital signs with normal physical examination findings.

Answer.

  1.  Admit for cardiorespiratory monitoring. The boy in the vignette had an apparent life-threatening event (ALTE) which is not a specific diagnosis but a description of an acute, unexpected episode that is frightening to the caretaker. ALTE includes one or more of the following features: apnea, color change (may be cyanotic, pallid, erythematous or plethoric), marked change in muscle tone (limpness or rigidity) and choking or gagging. A specific cause for ALTE can be identified in over one-half of patients after a careful history, physical examination, and appropriate laboratory evaluation. The remaining cases are considered idiopathic if no cause can be identified after a thorough assessment. Common etiologies for ALTE include gastroesophageal reflux, neurologic problems (such as seizures), and respiratory infection. The history of an ALTE must be taken seriously, even if the infant appears entirely well by the time he or she is evaluated. In-hospital observation with cardiorespiratory monitoring is indicated for infants whose initial evaluation suggests physiologic compromise. Hospital admission may provide important clinical information where additional episodes may be witnessed by medical personnel during the observation period. In addition, serious underlying medical conditions may become apparent.  Discharging the patient after reassuring the parents (B) and observing the patient for four hours in the ER (C) are not appropriate management strategies for the infant in the vignette who needs admission for cardiorespiratory monitoring. Requesting for complete blood count (D) is not routinely done in the evaluation of an ALTE and would not aid in the management for the infant in the vignette.

References:

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B et al. Subcommittee on Apparent Life Threatening Events. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.  Pediatrics. In Press

Sepsis: Redefined

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The Society of Critical Care Medicine (SCCM)  and the European Society of Intensive Care Medicine (ESICM) redefined sepsis with the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Sepsis is life-threatening organ dysfunction due to dysregulated host responses to infection.  Septic shock is a subset of sepsis where underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality [2]. 

2003 vs 2016 Definitions of Sepsis [1-4]

Sepsis Definitions: Old vs. 3.0

Sepsis Definitions: Old vs. 3.0   —- @FOAMpodcast

Systemic Inflammatory Response Syndrome (SIRS) is out.  

  • Includes normal responses to infection (eg. fever and tachycardia is not dysregulated infection; it’s just infection)
  • SIRS even MISSES up to ⅛ very septic ICU pts (NEJM 2015) [5]. 

qSOFA is in. a qSOFA score of 2 or 3 or a rise in the SOFA score of 2.  The SOFA score requires a ton of lab values so the authors wanted something that could be assessed at triage, hence the quick SOFA score (qSOFA). The authors derived and retrospectively validated this score and compared it to SIRS in a cohort of 148,907 patients [3]

qSOFA scoring

qSOFA scoring   —@FOAMpodcast

Issues:

  • Unclear how to interpret studies (EGDT through ProCESS, PROMISE, ARISE) with new definitions.
  • CMS is not going to adapt.
  • Not endorsed by ACEP or SAEM as emergency providers were not included.
  • qSOFA has not been prospectively validated. It’s unclear how it will perform in this fashion

Notes: Sepsis rates have increased over the past 10 years and it appears that mortality has decreased.  However, less sick patients are included  in this. It appears that the Sepsis 3 authors were hoping for a more specific definition.

References:

  1. Levy MM, Fink MP, Marshall JC. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Critical care medicine. 31(4):1250-6. 2003.
  2.  Singer M, Deutschman CS, Seymour CW, et al: The Sepsis Definitions Task Force The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
    AMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
  3.  Seymour CW, Liu V, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.
  4. Shankar-Hari M, Phillips G, Levy ML, et al.Developing a New Definition and Assessing New Clinical Criteria for Septic ShockFor the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) (JAMA, Feb 22, 2016).
  5. Kaukonen KM, Bailey M, Bellomo R. Systemic Inflammatory Response Syndrome Criteria for Severe Sepsis. The New England journal of medicine. 373(9):881. 2015.

Episode 41 – Vertigo

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The Free Open Access Medical Education (FOAM)

We cover two bits of FOAM, one from Emergency Medicine Literature of note on the use of meclizine for vertigo and an EMcrit episode on the HiNTs exam.

Emergency Medicine Literature of Note – Dr. Ryan Radecki – Treating what you believe is peripheral vertigo?  Using meclizine? So are most people.  But this is not an evidence based practice.  While meclizine is Rosen approved, Tintinalli recommends transdermal scopolamine as the first line treatment [1,2]. Following a recent recall of meclizine (oddly because iron bottles contained meclizine instead of iron), Dr. Radecki probes into why we use meclizine for vertigo.

  • Meclizine is an anti-histamine and has been thought to have anti-emetic properties.
  • A 1968 paper compared 16 anti-emetics/combinations and did NOT conclude that meclizine was the best. In fact, scopolamine and amphetamine performed best. Promethazine (phenergan) is also a good choice based on this paper [3].

EMcrit – Dr. Scott Weingart – The HiNTs exam has taken off, particularly in the FOAM world, as a means of disguising between central and peripheral causes of vertigo. In 2010, an EMcrit episode popularized this in the FOAM world. See this video demonstrating the HiNTs exam.

  • Head Impulse – rapid head rotation by the examiner with the subject’s vision fixed on an object (i.e. examiner’s nose). The examiner rapidly rotates the head towards midline and the patient’s eyes should remain fixed on the target. 
    • Abnormal (loss of fixation on target and movement of eyes away from target followed by correct saccade as patient fixates on target) = peripheral (vestibulo-ocular reflex impaired)
    • Normal = central
  • Nystagmus 
    • Horizontal nystagmus with a unidirectional fast phase (away from affected side) = probably peripheral
      • Patients with horizontal nystagmus may have central pathology but may have direction-changing nystagmus (i.e. fast phase beating in one direction when looking to right and the opposite direction when looking left).
    • Vertical or nystagmus = central pathology
  • Test of Skew Patients should fixate on a target while the provider alternately covers each eye. As the cover is moved from one eye to the other, the uncovered eye must correct for the misalignment and will look up or down to focus back on the target. This slight correction is observed repeatedly as the cover is moved from one eye to the other.
    • Skew deviation/misalignment = probably central, often in posterior fossa abnormalities
    • No skew deviation= peripheral

INFARCT – Impulse Normal, Fast-phase Alternating nystagmus, and Refixation on Cover Test

Issues with HiNTs

  • Can only be performed on patients with continuous vertigo.
  • External validity is a major issue with HiNTs.
    • Providers – Of the 4 studies have examined the operating characteristics of HiNTs, none have used emergency providers and instead have examined how the exam performs in the hands of two neuro-ophthalmologists, neuro-otologists, and neurologists with 4 hours of specialized training in the exam. It’s unclear whether HiNTs would be reliable or valid when performed by emergency providers [4-6].
    • Patients – The patients examined in many of these studies have other indicators of badness on neurologic exam. In one study, patients had to have gait instability and/or truncal ataxia to enroll.  Then, 76/101 (76%) of those patients had a central cause. These patients were sick and not the undifferentiated vertiginous patients we see primarily as emergency providers [4-6].
    • In the words of leading HiNTs expert Dr. Newman-Toker, HiNTs “requires expertise not routinely available in emergency departments.” As such, his team is piloting quantitative video-oculography to aid in diagnosis using HiNTs [7]. An Annals of Emergency Medicine review also warned that HiNTs may not be ready for emergency provider use [9].

More FOAM on HiNTs: EMJclub, EMNerd

Core content 

We delve into core content on vertigo using Rosen’s Medicine (8e) Chapter 19,  and Tintinalli’s Emergency Medicine: A Comprehensive Study Guide  (7e) Chapter 164 “Vertigo and Dizziness.”

Vertigo is often characterized by the sensation of spinning and falls into the broad and frustrating category of “dizziness.”  Often, when a dizzy patient presents we perseverate on characterizes what the patient means by “dizzy.” However, some argue that this is not an appropriate approach as a study found 50% of patients changed the character of their dizziness when questioned again after 10 minutes [9].  Additionally, the clinical characteristics differentiating peripheral from central causes of vertigo are not entirely reliable. Despite these limitations, it is expected that we are familiar with “classic” presentations.

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*”Classic” presentations

Generously Donated Rosh Review Questions 

  1. A 50-year-old man presents with episodic severe vertigo lasting hours, with associated symptoms of unilateral tinnitus, fluctuating low-frequency hearing loss, and aural fullness. 
  2. A 20-year-old woman presents with an acute onset of dizziness. The patient describes the sensation that the room is spinning when she turns her head to the left and it is accompanied by nausea and vomiting. The symptoms resolve with turning her head away from that side. Examination reveals nystagmus elicited by deviating the eyes to the left and no other neurologic findings. 

Answers

1. B. Meniere’s disease is characterized by episodic severe vertigo lasting hours, with associated symptoms of unilateral tinnitus, fluctuating low-frequency hearing loss, and aural fullness. Typical onset is in the fifth decade of life. The cause is uncertain but is speculated to result from allergic, infectious, or autoimmune injury. The histopathologic finding includes endolymphatic hydrops, which is thought to be caused by either overproduction or underresorption of endolymph in the inner ear. Meniere’s disease is a clinical diagnosis mostly based on history. Testing may be obtained to support the diagnosis and rule out other disorders. Audiometry often demonstrates a low-frequency sensorineural hearing loss. An FTA-ABS test may be obtained to rule out syphilis. Electronystagmography (ENG) may demonstrate a unilateral peripheral vestibular weakness on caloric testing. When the diagnosis is uncertain, a brain MRI with contrast is obtained to evaluate for a retrocochlear lesion. The differential diagnosis of Meniere’s disease includes acute labyrinthitis, neurosyphilis, labyrinthine fistula, autoimmune inner ear disease, vestibular neuronitis, and migraine-associated vertigo.The most common cause of peripheral vestibular vertigo in adults is benign paroxysmal positional vertigo (A). BPPV occurs in all age groups but more often between ages 50 and 70 but is not associated with hearing loss and made worse with movement. In a perilymph fistula (C) rapid changes in air pressure (barotrauma), otologic surgery, violent nose blowing or sneezing, head trauma, or chronic ear disease may cause leakage of perilymph fluid from the inner ear into the middle ear and result in episodes of vertigo. Associated signs and symptoms are variable but can include a sudden pop in the ear followed by hearing loss, vertigo, and sometimes tinnitus. Acute vertigo associated with nausea and vomiting (but without neurologic or audiologic symptoms) that originates in the vestibular nerve is known as vestibular neuronitis (D). Vestibular neuronitis can occur spontaneously or can follow viral illness.

2. B. This patient presents with peripheral vertigo most consistent with benign paroxysmal peripheral vertigo (BPPV) and should be treated with an Epley maneuver. Vertigo is defined as the sensation of disorientation in space combined with a sensation of motion. Patients typically describe a “room-spinning” sensation or the feeling of sea sickness. Vertigo can be divided into two types: central and peripheral. Central vertigo are those disorders arising from the central nervous system and include ischemic stroke, vertebrobasilar insufficiency and infectious causes (meningitis, mastoiditis, syphilis). Central vertigo is characterized by longer duration of symptoms, minimal change with position, gradual onset and multidirectional nystagmus. Peripheral vertigo includes BPPV, Meniere’s disease, Labyrinthitis and vestibular neuritis. Peripheral vertigo may have intermittent symptoms (BPPV) or continuous symptoms but should not be associated with other neurologic deficits or changes and should have unidirectional nystagmus. The symptoms in BPPV are elicited by specific movements of the head and relieved by returning the head to a neutral position. The symptoms should be acute in onset and of a short duration. In BPPV, the symptoms are cause by the presence of an otolith in one of the semicircular canals. Although pharmacologic intervention may be necessary in the acute setting with meclizine or benzodiazepines, the best treatment for BPPV is the Epley maneuver. The Epley maneuver is a series of positions that the clinician takes the patient through that leads to expulsion of the otolith from the semicircular canal and relief of symptoms. Imaging with a non-contrast head CT (C) is not indicated in peripheral vertigo of any cause as the patient’s pathology is in the inner ear and not the brain. If a central cause is suspected, MRI of the brain (A) is the best test for diagnosis as the causative lesion will likely be in the posterior fossa, which is not seen well on CT scan. Steroid treatment (D) is the indicated management for vestibular neuritis but does not play a role in the treatment of BPPV.

References:

  1. Chang AK, Olshaker AS. Dizziness and Vertigo. In: Marx JA, Hockberger RS, Walls RM eds.  Rosen’s Emergency Medicine, 8th e.
  2. Goldman B. Chapter 164. Vertigo and Dizziness. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.
  3. Wood CD, Graybiel A. Evaluation of sixteen anti-motion sickness drugs under controlled laboratory conditions. Aerospace medicine. 39(12):1341-4. 1968.
  4. Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. 70(24 Pt 2):2378-85. 2008.
  5. Kattah et al. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging. Stroke. 2009; 40: 3504-3510
  6. Newman-Toker et al. HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness. Academic Emergency Medicine. Volume 20, Issue 10, pages 986–996, October 2013
  7. Newman-Toked DE, Saber Tehran AS, Mantokoudis G et al. Quantitative video-oculography to help diagnose stroke in acute vertigo and dizziness: toward an ECG for the eyes. Stroke. 44(4):1158-61
  8. Cohn B. Can Bedside Oculomotor (HINTS) Testing Differentiate Central From Peripheral Causes of Vertigo? Annals of Emergency Medicine. 64(3):265-268. 2014. 
  9. Edlow JA. Diagnosing Dizziness: We Are Teaching the Wrong Paradigm!. Acad Emerg Med. 20(10):1064-1066. 2013.
  10. Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH, Zee DS. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Mayo Clinic proceedings. 82(11):1329-40. 2007.
  11. Strupp M, Zingler VC, Arbusow V et al. Methylprednisolone, Valacyclovir, or the Combination for Vestibular Neuritis. N Engl J Med. 351(4):354-361. 2004. 
  12. CFishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). The Cochrane database of systematic reviews. 2011. 

Best Pearls and Biggest Trends of 2015

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Sleep through 2015?  We picked the minds of some brilliant Emergency Medicine folk and came up with this short list of important happenings.

TRAUMA

FAST (Focused Assessment using Sonography in Trauma) guided resuscitative –  thoracotomy. (Recommended by Haney Mallemat, Rob Orman).

Bottom Line: If a trauma code comes in and has neither cardiac activity nor pericardial effusion on FAST, the odds of survival are essentially nil.  Inaba and colleagues found the following:

  • Population: 187 patients at LA/USC deemed “appropriate” for thoracotomy (at this institution: penetrating trauma patients with absent vital signs and blunt trauma patients with a loss of vital signs en route or in the resuscitation bay).
  • Intervention: Emergency medicine resident performed FAST before/concurrent with thoracotomy
  • Outcome:  Of the 126 patients without cardiac activity on FAST, none survived.

Many of the patients with cardiac activity did not survive, as well.  This paper gives individuals guidance to make the decision to crack the chest but has stirred up a debate as to whether this would lessen educational opportunities for a potentially heroic procedure.

Say NO to long backboards (Recommended by Lauren Westafer). In January 2015, ACEP recommended against the use of long backboards. Many state and local protocols shifted away from moving this some time ago and even more since.  The FOAM community has been up in arms about the inefficacies and harms of backboards for quite some time, again echoing that FOAM can serve as a forecaster for change to make it less cognitively distressing when time to change our practice.

RESUSCITATION

Peripheral Vasopressors (Recommended by Haney Mallemat, Rob Orman) – We detail the literature underlying the use of peripheral vasopressors in this podcast.

They think that the combination of a systematic review by Loubani et al and The Cardenas-Garcia study, peripheral vasopressors may be safely run through large bore peripheral IVs proximal to the antecubital fossa. Note: These should be closely monitored (protocolized is best) and short durations (<6 h) have been associated with minimal complicaitons.

SEPSIS

Intravenous fluids in sepsis (Recommended by Haney Mallemat). The PROMISE trial was published in early 2015, adding to ProCESS and ARISE. In these studies, patients typically got 2 L of crystalloid upfront and then 2L in the first 6 hours. Over 3 days after enrollment, most got just under 4 L.  Most patients received under 6L IVF.  There has been a movement for more judicious use of fluids in sepsis rather than dumping 4-6 L of IVF upfront.  Marik articulately explained this in this article.

  • Mallemat challenges us: Before giving a fluid bolus use ultrasound and ask these questions, “Does the LV need it, and can the RV take it?”

CMS Core Measure (Recommended by Jeremy Faust).  The National Quality Forum has been pushing for Measure 0500 See this EMcrit podcast on this topic.

ANALGESIA

Pain control in acute low back pain is tricky, and opioids may not help (Recommended by David Newman).

RENAL

Sexual intercourse 3-4 times per week may aid in expulsion of distal kidney stones. This year, two large studies by Pickard et al and Furyk et al demonstrated no benefit in stone passage for ureterolithiasis (particularly in stones <5 mm).  Then, a paper by Dolouglu et al excited many folks, if for entertainment value. Since tamsulosin doesn’t seem to help, what about sexual intercourse, 3-4 times per week, in male patients with partners?

In this study the mean expulsion time did not differ significantly between groups.

MEDICAL EDUCATION

Merging of FOAM resources. (Recommended by Michelle Lin). Blogs and podcasts are growing and often supplement one another. Dr. Lin predicts the future will be in these conglomerates (ex: merging of EMcrit and PulmCrit and massive undertakings such as ALiEM and CandiEM).

Merging of FOAM with traditional journals. (Recommended by Michelle Lin). Projects such as the Skeptic’s Guide to Emergency Medicine have merged with Academic Emergency Medicine and the Canadian Journal of Emergency Medicine (ex: SGEM HOP, journal paper) and massive FOAM resource ALiEM has also collaborated with Annals of Emergency Medicine (Ex:Journal club, paper). The merging of FOAM with paid, traditional resources is the future, per Dr. Lin.

OVERDIAGNOSIS

Overdiagnosis is a problem, and people are starting to rage against it. (Recommended by Lauren Westafer).  An Overdiagnosis conference exists and JAMA Internal Medicine has a series of articles, “Less is More,” frequently detailing evidence of overdiagnosis.

  • One of 2015’s prominent articles for emergency physicians was the Hutchinson et al study.  In this study, CTPA scans read as positive for pulmonary embolism underwent review by 3 chest radiologist who adjudicated that, actually, 25.9% of the “positive” scans (n=45) did not actually have pulmonary embolisms. The harms from this exist beyond the risk of anticoagulation (think about how an ED approach for a myriad of complaints differs for a patient with a history of thromboembolism).

The FOAM community swelled with appreciation and respect for the late Dr. John Hinds.  Please watch his SMACC talk, “Crack the Chest, Get Crucified,” in which his excellence in medical education shines, delivering pearls for nearly anyone.

FOAMcastini – ACEP15 Day 3

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FOAMcast brings you pearls from conferences we attend and presently it’s the American College of Emergency Physicians annual meeting, ACEP15 in Boston.

On this episode we cover the following topics:

Foodborne Illnesses – Dr. David Pigott

Wound Management – Dr. Benjamin Lawner

  • Irrigation – Need 50-100 cc per centimeter of wound. To get adequate PSI, take an 18g angiocath on a 30 cc syringe = 4-15 PSI
  • Some predictors of poor healing and infection
    • Location – head and neck more vascular so less likely to get infected
    • Length – >5 cm more likely to have problems
    • Diabetics – microvascular damange makes healing more problematic

Tips for Presentations – Dr. Haney Mallemat (@CriticalCareNow)

  • Avoid bullet points
  • Be brief
  • Use a sans serif font (and only one font throughout)
  • Limit animations (they can be distracting)

 

FOAMcastini – ACEP15 Day 2

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FOAMcast brings you pearls from conferences we attend and presently it’s the American College of Emergency Physicians annual meeting, ACEP15 in Boston. On this episode we cover the following topics:

Extracorporeal Membrane Oxygenation (ECMO) – Dr. Haney Mallemat (@CriticalCareNow)

ECMO is promising in certain devestating disease processes – essentially heart or lung failure. For example, in the CHEER trial, the investigators had a 54% rate of neuro-intact survival after cardiac arrest with ECMO []. Yet, ECMO can be confusing. Dr. Mallemat simplified this for the emergency physician (see this site for more complete explanations)

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Stop the Madness: Diagnostic Imaging in Nephrolithiasis – Workshop with Drs. Eddy Lang, Rebecca Smith-Bindman, Grant Innes, and Lauren Westafer

Debunking Trauma Myths – Billy Mallon

FOAMcastini – ACEP15 Day 1

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FOAMcast brings you pearls from conferences we attend and presently it’s the American College of Emergency Physicians annual meeting, ACEP15 in Boston.

Jeremy Hoffman and Rick Bukata summarize recent, relevant literature each year (recently known as #hofkata).  This year, our top three favorite

A top 5 list for emergency medicine: a pilot project to improve the value of emergency care.  Schuur et al. JAMA Internal Medicine. 2014.

  • Just say NO to:
    • CTs for trauma patients who are negative using the NEXUS and Canadian tools for cervical spine injuries.
    • CT for ruling out PE without some sort of risk stratification.
    • MRI for Low back pain w/o red flags.
    • Head CT in with mild TBI who do not meet criteria using the New Orleans OR Canadian Head CT tools.
    • Routine coagulation profile (unless they have a known coagulopathy or are hemorrhaging)

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

The effect of malpractice reform on emergency department care.  Moskow et al.   N Engl J Med. 2015 Jan 8;372(2):192.

Dr. Jeff Kline (@klinelab) spoke on pulmonary embolism.

  • High Risk PE? Consider lysis (this is controversial, we are simply reporting Dr. Kline’s talk)
    • Size and location. Massive and proximal= bad
    • SBP <90 for more than 15 min OR 40mmHg drop from baseline
    • Signs of RV strain – echocardiography showing RV dilation OR hypokinesis?
    • Elevated troponin or BNP
    • ECG findings suggestive of cardiac strain: sinus tachycardia, incomplete right bundle branch block, complete right bundle branch block, T-wave inversion in leads V1 – V4.
  • Kline also participated in a knowledge translation workshop where he argued that sub-segmental PEs, without DVT on ultrasound, are NOT a real thing.  This is controversial but he also argued that treating these is associated with harm [Carrier et al]