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  PERC Rule for PE
Posted by: dbrosnahan - 05-29-2016, 07:42 AM - Forum: General Discussion - No Replies

PERC Rule for Pulmonary Embolism rules out PE if all criteria are present and pre-test probability is <15%.

1. Age < 50
2. HR < 100
3. O2 Sat on Room Air > 95%
4. No Prior History of Venous Thromboembolism
5. No Trauma or Surgery within 4 weeks
6. No Hemoptysis
7. No Exogenous Estrogen
8. No Unilateral Leg Swelling

This clinical test can be used in place of a d-dimer in many cases.

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  HINTS Exam for Vertigo
Posted by: dbrosnahan - 05-29-2016, 07:19 AM - Forum: General Discussion - No Replies

HINTS examination is 100% sensitive and can rule out central lesion with 96% specificity.

HINTS exam:
1. Head impulse test
2.  Nystagmus
3. Skew deviation.

Head Impulse Test:
1. Have patient fix their eyes on your nose or point on the wall.
2. Move their head in the horizontal plane to the left and right.
3. When the head is turned towards the affected side look for a  corrective saccade

Nystagmus:
1. Have patient look to extreme gaze positions.
2. biphasic ocular oscillation in different gaze positions alternating a slow eye movement, or smooth pursuit, in one direction and a fast eye movement, or saccadic movement, in the other direction

Test of Skew:
1. Have pt look at your nose with their eyes and then cover one eye.
2. Then rapidly uncover the eye and quickly look to see if the eye moves to re-align. (dis-conjugate vertical gaze, e.g. strabismus)
3. Repeat with on each eye

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  Unique Names in the ED
Posted by: dbrosnahan - 05-29-2016, 03:05 AM - Forum: General Discussion - No Replies

I am not going to make a list of names here because in many instances there may be only 1 person on the planet with this unique name and they will know for sure, I am talking about them, even if in a positive manner.

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  Medtronic ED Interrogation
Posted by: dbrosnahan - 05-28-2016, 05:05 AM - Forum: General Discussion - No Replies

http://www.medtronic.com/us-en/healthcar...ients.html

Medtronic is selling a box and service that can download information from an ED patient's pacemaker or AICD and upload that information over the internet to be reviewed without the Medtronic tech being present.  This process is simple enough to be performed by a nurse or tech.  If a change needs to be made to the AICD/pacemaker, then a tech can be sent at that point.  This sounds like it could save some time. 

Medtronic CareLink Network
Medtronic CareLink Express Service

http://www.carelinkexpress.com

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  Antibiotics for Uncomplicated Diverticulitis
Posted by: dbrosnahan - 05-18-2016, 11:22 PM - Forum: General Discussion - No Replies

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0049728/

The Cochrane Review looks at 3 studies to make conclusions and recommendations about antibiotic use for uncomplicated diverticulitis.   Because of this review, recommendations have recently emerged against antibiotic treatment for uncomplicated diverticulitis.  I am still looking into this, but if these recommendations are primarily based on this Cochrane Review and these studies, I have an issue with them. First, this  Cochrane Review is flawed in my mind.  Why? Because the 3 studies that they use to make their conclusions were not designed to answer the question they are raising.  The 3rd and so-called "best" study was designed to answer the duration of IV antibiotics.  So, using these 3 studies to make the conclusion they do is worse than "ad hoc" and not good scientific evidence. 

On the flip side, I suppose up until now, it would be ethically difficult to design a study to measure the effectiveness of non-treatment.  Now, I hope we can expect someone to diagnose people with uncomplicated diverticulitis, not treat them, and then measure the short-term and long-term consequences.  But, don't sign me or anyone I know up for that study.

http://jama.jamanetwork.com/article.aspx...id=1814217

This JAMA review concludes that "Randomized trials and cohort studies have shown that antibiotics and fiber were not as beneficial as previously thought" but again, the studies in the review were not designed to study the benefit of non-treatment..

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  Spermicide for Poison Ivy
Posted by: dbrosnahan - 05-17-2016, 02:08 AM - Forum: General Discussion - No Replies

Zanfel is an excellent treatment for contact dermatitis for poison ivy.   Zanfel removes the urushiol from the skin causing the skin reaction. However Zanfel is expensive about $30 for a small tube.  The active ingedient in Zanfel is nonoxynol-9 which is a common spermicide.  Can spermicide gel with nonoxynol-9 be used in place of Zanfel?  Several internet forum posts say yes

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  Open Fracture Classification
Posted by: dbrosnahan - 05-16-2016, 03:06 AM - Forum: General Discussion - Replies (1)

ICD-10 asks for a classification of open fractures from 1-3.  Gustilo open fracture classification focuses on the extent of soft tissue injury and degree of contamination.

I -- Open fracture, clean wound, wound <1 cm in length
II -- Open fracture, wound > 1 cm but < 10 cm in length without extensive soft-tissue damage, flaps, avulsions
III -- Open fracture with extensive soft-tissue laceration (>10 cm), damage, or loss or an open segmental fracture. This type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for 8 hr prior to treatment

IIIA --Type III fracture with adequate periosteal coverage of the fracture bone despite the extensive soft-tissue laceration or damage
IIIB -- Type III fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. Will often need further soft-tissue coverage procedure (i.e. free or rotational flap)
IIIC -- Type III fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury.

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  Dremel Rotary Tool in the ED
Posted by: dbrosnahan - 05-09-2016, 01:52 PM - Forum: General Discussion - No Replies

    On several occasions we have had to employ the use of a Dremel Rotary Tool in the ED to cut off various thick steel ring or nut-like objects stuck on fingers and around genitalia. For some objects the typical ring cutters (manual or battery) will not work. Tips for proper use include: 1. eye protection for MD, nurse and patient as sparks will be generated. 2. Removal of any flammable materials. 3.  continuous stream of water to cool the cutting disk and metal object as it is being cut.  A large bladder/foley catheter irrigation bag with regular IV tubing can be hung to provide a good supply. 4. Shielding the patient skin from the cutting blade using aluminum finger splinting material with the foam removed (You will have to bend the aluminum along the long axis to fit between metal object and patient skin).

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  Intubating Stylet for G-Tube Insertion
Posted by: dbrosnahan - 05-09-2016, 01:27 PM - Forum: General Discussion - No Replies

    EM Physicians are called upon to replace gastric tubes on a regular basis.  Too often nursing home patients come to the ED after having had their G-tube out for some time and their gastrostomy is already contracted up. A Mallinckrodt adult intubating stylet can be used to gently dilate a mature gastrostomy track.  If dilation is successful, a small 14 gauge g-tube can be placed. The intubating stylet has a rather rounded tip that prevents any significant trauma on insertion. Additionally, a pediatric mallinckrodt intubating stylet can be placed in the g-tube to provide added rigidity to assist in placing the g-tube.

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  BRUE is the new ALTE
Posted by: dbrosnahan - 05-09-2016, 12:31 PM - Forum: General Discussion - No Replies

http://www.jwatch.org/na41150/2016/04/25/brue-new-alte
http://pediatrics.aappublications.org/co.../e20160590

Definition of BRUE:
--Event lasting <1 minute in an infant <1 year of age that is associated with at least one of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in muscle tone (hypertonia or hypotonia); altered level of responsiveness.

--Patient must otherwise be well-appearing and back to baseline health at the time of presentation, and, on evaluation, have no condition that could explain the event.

Low Risk Criteria:
--Age >60 days
--Gestational age ≥32 weeks and post-conceptional age ≥45 weeks
--First BRUE
--No CPR by trained provider
--No features in the history of concern (e.g., possible child abuse, family history of sudden unexplained death, toxic exposures)
--No worrisome physical exam findings (e.g., bruising, cardiac murmurs, organomegaly).

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