This right hand x-ray is from a 40 year old with pain and swelling at the base of his right thumb. What can be observed and what is its significance? Continue reading
Imaging Case of the Week 136
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Imaging Case of the Week 135
These chest x-ray images are from a 39 year old heavy smoker who has presented with right-sided pleuritic chest pain and a fever. What can you glean from these images? Continue reading
Imaging Case of the Week 134
The following chest x-ray is from a 40 year old presenting with a fever and cough. What two abnormalities can be seen? Continue reading
Imaging Case of the Week 133
The following right elbow x-ray is from a 60 year old man with pain and swelling behind the elbow. What can be observed? Continue reading
Imaging Case of the Week 132 – Christmas Quiz
The following OPG x-ray is from a 30 year old. Can you spot the abnormality even if no clinical information is given? Continue reading
Imaging Case of the Week 131
The following erect AP chest x-ray is from a 80 year old with chest pain. There is an incidental finding on the chest-ray. Can you spot it? Continue reading
Lab Case 43 – Interpretation
Young female with SOB and SVT which has resolved after Valsalva. She is currently haemodynamically stable. Continue reading
Fluids in Sepsis: Less is More
I presented this talk at the ACEM Annual Scientific Meeting 2014 – Wednesday 10/12/14
Evidence FOR fluid resus Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. Jama. 1991;266(9):1242-5. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-77. Evidence AGAINST fluid resus Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Negative fluid balance predicts survival in patients with septic shock: a retrospective pilot study. Chest. 2000;117(6):1749-54. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344-53. Rosenberg AL, Dechert RE, Park PK, Bartlett RH. Review of a large clinical series: association of cumulative fluid balance on outcome in acute lung injury: a retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med. 2009;24(1):35-46. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39(2):259-65. Micek ST, McEvoy C, McKenzie M, Hampton N, Doherty JA, Kollef MH. Fluid balance and cardiac function in septic shock as predictors of hospital mortality. Crit Care. 2013;17(5):R246. Brandt S, Regueira T, Bracht H, Porta F, Djafarzadeh S, Takala J, et al. Effect of fluid resuscitation on mortality and organ function in experimental sepsis models. Crit Care. 2009;13(6):R186. including FEAST trial 2011: Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-95. and FEAST re-analysis 2013 and accompanying editorial: Maitland K, George EC, Evans JA, Kiguli S, Olupot-Olupot P, Akech SO, et al. Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial. BMC Med. 2013;11:68. Myburgh J, Finfer S. Causes of death after fluid bolus resuscitation: new insights from FEAST. BMC Med. 2013;11:67. Endothelial Glycocalyx See this great LITFL post which includes an excellent 6 minute video I highly recommend. Also includes great references if you want to know more. Central v Peripheral Lines Ricard JD, Salomon L, Boyer A, Thiery G, Meybeck A, Roy C, et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013;41(9):2108-15. – note the benign outcomes for the 19 cases of extravasation was confirmed in personal correspondence from the author to Dr Scott Weingart. More on this topic on emcrit Noradrenaline’s beneficial effects in septic shock Bellomo R, Giantomasso DD. Noradrenaline and the kidney: friends or foes? Crit Care. 2001;5(6):294-8. Hamzaoui O, Ksouri H, Richard C, Teboul JL. Effect of norepinephrine on cardiac output and preload in septic shock patients. Crit Care. 2007;11(Suppl 2):P37. Hamzaoui O, Georger JF, Monnet X, Ksouri H, Maizel J, Richard C, et al. Early administration of norepinephrine increases cardiac preload and cardiac output in septic patients with life-threatening hypotension. Crit Care. 2010;14(4):R142. Persichini R, Silva S, Teboul JL, Jozwiak M, Chemla D, Richard C, et al. Effects of norepinephrine on mean systemic pressure and venous return in human septic shock. Crit Care Med. 2012;40(12):3146-53. Marik Sepsis Review Article Marik PE. Early management of severe sepsis: concepts and controversies. Chest. 2014;145(6):1407-18. More from Paul Marik at emcrit
Lab case 43
A 28 year old female presents to your Emergency Department with palpitations and shortness of breath. She has no chest pain and no significant past medical history.
On examination she is dyspnoeic with clear lung fields and good air entry bilaterally. She has a normal CXR.
Vitals:
BP 120/60
PR 220/min SVT, which reverts to a sinus rate of 110/min after Valsalva
RR 25
T 36.7 degrees celcius
Sats 84% on 15 litres non rebreather Continue reading
PE: A New Approach to Low Risk Patients
I presented this talk at the ACEM Annual Scientific Meeting 2014 – Monday 8/12/14
Mortality of Untreated PE Calder KK, Herbert M, Henderson SO. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005;45(3):302-10. Stein PD, Hull RD, Raskob GE. Withholding treatment in patients with acute pulmonary embolism who have a high risk of bleeding and negative serial noninvasive leg tests. Am J Med. 2000;109(4):301-6. Benefit of Treatment Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet. 1960;1(7138):1309-12. Nielsen HK, Husted SE, Krusell LR, Fasting H, Charles P, Hansen HH. Silent pulmonary embolism in patients with deep venous thrombosis. Incidence and fate in a randomized, controlled trial of anticoagulation versus no anticoagulation. J Intern Med. 1994;235(5):457-61. Risk of Treatment Carrier M, Le Gal G, Wells PS, Rodger MA. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med. 2010;152(9):578-89. Risk of Contrast Mitchell AM, Jones AE, Tumlin JA, Kline JA. Incidence of contrast-induced nephropathy after contrast-enhanced computed tomography in the outpatient setting. Clin J Am Soc Nephrol. 2010;5(1):4-9. Newhouse JH, RoyChoudhury A. Quantitating contrast medium-induced nephropathy: controlling the controls. Radiology. 2013;267(1):4-8. McDonald JS, McDonald RJ, Comin J, Williamson EE, Katzberg RW, Murad MH, et al. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. Radiology. 2013;267(1):119-28. McDonald RJ, McDonald JS, Bida JP, Carter RE, Fleming CJ, Misra S, et al. Intravenous contrast material-induced nephropathy: causal or coincident phenomenon? Radiology. 2013;267(1):106-18. Davenport MS, Khalatbari S, Dillman JR, Cohan RH, Caoili EM, Ellis JH. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology. 2013;267(1):94-105. Accuracy of CTPA Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med. 2006;119(12):1048-55. Test Threshold Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2(8):1247-55. Lessler AL PJ. In Reply Ann Emerg Med 2010;56(5):587. Summarising Risks v Harms of Testing Newman DH, Schriger DL. Rethinking testing for pulmonary embolism: less is more. Ann Emerg Med. 2011;57(6):622-7 e3. PERC Rule Singh B, Mommer SK, Erwin PJ, Mascarenhas SS, Parsaik AK. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism–revisited: a systematic review and meta-analysis. Emerg Med J. 2013;30(9):701-6. Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):628-52 e75. Clinical Prediction Rule Meta-analayses Ceriani E, Combescure C, Le Gal G, Nendaz M, Perneger T, Bounameaux H, et al. Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2010;8(5):957-70. Lucassen W, Geersing GJ, Erkens PM, Reitsma JB, Moons KG, Buller H, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med. 2011;155(7):448-60. Patient Risk Tolerance Davis MA, Keerbs A, Hoffman JR, Baraff LJ. Admission decisions in emergency department chest pain patients at low risk for myocardial infarction: patient versus physician preferences. Ann Emerg Med. 1996;28(6):606-11. Flynn D, Knoedler MA, Hess EP, Murad MH, Erwin PJ, Montori VM, et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012;19(8):959-67. Geyer BC, Xu M, Kabrhel C. Patient preferences for testing for pulmonary embolism in the ED using a shared decision-making model. Am J Emerg Med. 2013. Hess EP, Knoedler MA, Shah ND, Kline JA, Breslin M, Branda ME, et al. The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5(3):251-9. Kramer MS, Etezadi-Amoli J, Ciampi A, Tange SM, Drummond KN, Mills EL, et al. Parents’ versus physicians’ values for clinical outcomes in young febrile children. Pediatrics. 1994;93(5):697-702.
10. Hess EP, Knoedler MA, Shah ND, Kline JA, Breslin M, Branda ME, et al. The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5(3):251-9.