PE in Syncope: An External Validation of the Wells Score

I'm not going to reinvent the wheel -- see some of the fantastic analyses of PESIT (in no particular order) at:

St. Emlyns - Simon Carley
EM Lit of Note - Ryan Radecki
EMNerd at EMCrit - Rory Spiegel

One common thread is that the patients who had PEs seemed to be patients who we would think had PEs, rather than some occult finding we need to hunt for in all of our syncope patients.

Just look at Table 2, emphasis mine, which looks a lot like their Table 1, which is (gasp!) the Wells Score:

Sure, prolonged immobility and recent trauma/surgery don't reach frequentist significance, but they're close, and there just aren't a lot of people in either of those groups.

Literally the only non-Wells factors they find are tachypnea and hypotension.

You cannot make this up:

MOFFITT RENAL REPORT PEARLS 10/21/16: NSAID Renal Syndromes and Amyloid!

Hi Everyone! Thanks to Kenny for presenting the case of a middle-aged man with new onset nephrotic syndrome in the setting of NSAIDs and injection drug use, possibly due to AA amyloid!


Top pearls:

  • NSAIDs can cause nephrotic syndrome via minimal change disease or membranous nephropathy.
  • AA amyloid, which can also cause nephrotic syndrome, is associated with injection drug use.
  • AA amyloid does not cause abnormal SPEP; instead, diagnosis is by fat pad biopsy or biopsy of involved organ.


For those who want more info:

A short list of renal syndromes associated with NSAID use:


  • AKI (ATN, acute papillary necrosis)
  • AIN, chronic tubulointerstitial nephritis/analgesic nephropathy
  • Nephrotic syndrome (minimal change or membranous)
  • Hyponatremia
  • Type 4 RTA (hyperkalemia)
  • Urothelial malignancy!

Amyloidosis overview:

  • AL (primary) amyloid is due to plasma cell dyscrasias (light chain deposition)
  • AA (secondary) amyloid is due to inflammation from chronic infection or rheum disorders
    • AA amyloid is associated with injection drug use (via chronic skin infection)!
  • Other forms of amyloid are associated with dialysis (beta-2-microglobulin fibrils), heritable forms, systemic senile amyloid (transthyretin aka prealbumin), and organ-specific amyloid (e.g. Alzheimer disease, cutaneous amyloid, bladder amyloid)
  • Serum tests (SPEP, free light chains) are only useful for AL amyloid!
  • Fat pad biopsy and congo red staining is positive in all types of amyloid.
  • Further stains distinguish different types of amyloid (e.g. light chains, AA protein)


See these prior blog posts on nephrotic syndrome:



Have a great day everyone!


Filed under: Morning Report, Nephrology

Oxygen for STEMI: Saving lives or Blowing Hot Air

Darth Vader and Yoda balloons

We’ve all seen the patients roll in with EMS nasal cannula snug against their nares. “Why are they on oxygen?” EMS response, “I don’t know he was having chest pain.” EKG shows STEMI! The last thing you’re thinking is whether their nasal cannula should be adjusted but maybe they don’t need the oxygen at all.

According to the AVOID Trial 2015  (an RCT in 441 patients) oxygen may actually make things worse. The authors compared 8L/min of O2 to no O2 in STEMI patients. Their primary endpoint was measuring the myocardial infarct size based on surrogate markers–>cardiac enzymes troponin and CK. They did not find a significant difference in peak troponins but did find those who received oxygen had significantly higher peak CK levels.

Their secondary outcomes found: (1) increase in recurrent MI at hospital discharge in the O2 group [5.5% versus 0.9%; P=0.006], (2) increase in frequency of cardiac arrhythmia in the O2 group (40.4% versus 31.4%; P=0.05), (3) increase in myocardial infarct size found on cardiac magnetic resonance @ 6 months in the O2 group  [20.3 versus 13.1 g; P=0.04)

Their research was based on earlier RCTs that showed a possible deleterious effect of O2 on compromised cardiac tissue most likely 2/2 to: (1) increase coronary vasoconstriction–>decreased coronary blood flow (2) increased production of reactive oxygen species (ROS)–>reperfusion injury and increased vasoconstriction

No significant difference found in adverse events in the 2 groups at 6 mos (although there were more events in the O2 group 21.9% vs no O2 group 15.4%).


In Recap: I probably will opt for no O2 in my STEMI patients but for those other AMI patients stay tuned for the DETO2X-AMI Study!



  • Stub, D., Smith, K., Bernard, S., Nehme, Z., Stephenson, M., Bray, J. E., … & Meredith, I. T. (2015). Air versus oxygen in ST-segment elevation myocardial infarction. Circulation, CIRCULATIONAHA-114.
  • Bradford, C. 2015. AVOID Trial. The Bottom Line.


Pan Scanning for Elderly Falls?

The last abstract for the Clinical Congress of the American College of Surgeons that I will review deals with doing a so-called “pan-scan” for ground level falls. Apparently, patients at this center have been pan-scanned for years, and they wanted to determine if it was appropriate.

This was a retrospective trauma registry review of 9 years worth of ground level falls. Patients were divided into young (18-54 years) and old (55+ years) groups. They were included in the study if they received a pan-scan.

Here are the factoids:

  • Hospital admission rates (95%) and ICU admission rates (48%) were the same for young and old
  • ISS was a little higher in the older group (9 vs 12)
  • Here are the incidence and type of injuries detected:
Young (n=328) Old (n=257)
TBI 35% 40%
C-spine 2% 2%
Blunt Cereb-vasc inj * 20% 31%
Pneumothorax 14% 15%
Abdominal injury 4% 2%
Mortality * 3% 11%

 * = statistically significant

Bottom line: There is an ongoing argument, still, regarding pan-scan vs selective scanning. The pan-scanners argue that the increased risk (much of which is delayed or intangible) is worth the extra information. This study shows that the authors did not find much difference in injury diagnosis in young vs elderly patients, with the exception of blunt cerebrovascular injury.

Most elderly patients who fall sustain injuries to the head, spine (all of it), extremities and hips. The torso is largely spared, with the exception of ribs. In my opinion, chest CT is only for identification of aortic injury, which just can’t happen from falling over. Or even down stairs. And solid organ injury is also rare in this group.

Although the future risk from radiation in an elderly patient is probably low, the risk from the IV contrast needed to see the aorta or solid organs is significant in this group. And keep in mind the dangers of screening for a low probability diagnosis. You may find something that prompts invasive and potentially more dangerous investigations of something that may never have caused a problem!

I recommend selective scanning of the head and cervical spine (if not clinically clearable), and selective conventional imaging of any other suspicious areas. If additional detail of the thoracic and/or lumbar spine are needed, specific spine CT imaging should be used without contrast.

Related posts:

Reference: Pan-scanning for ground level falls in the elderly: really? ACS Surgical Forum, trauma abstracts, 2016.