Quick Poll: Procedures on the recently deceased?

The Annals of Emergency Medicine will soon be publishing the following article:

The Ethics of Using the Recently Deceased to Instruct Residents in Cricothyrotomy by Dr. Andrew Makowski

In light of past experiences, and in the context of my “other” occupation as a clinical ethicist, I posted a link on Twitter and got this response from Dr. Casey Parker, of BroomeDocs.com:

 

Followed by this, from Dr. Seth Trueger:

 

This led to a few other responses from some very smart people on Twitter.  See the full conversation, Storified, here

Now, although I was happy to read the piece and felt that Dr. Makowski really did a great job of getting down to the key issues, I’ve begun to wonder.   How common is the practice of performing invasive procedures on recently deceased patients in the Emergency Department?  Have you seen this happen?  Heard of it?  Ever participated?

Please help us out by taking a minute to respond to this short poll (also embedded below).  It’s just my attempt to get a sense of how the EM and Critical Care communities – at least those who are online – feel about the question.  

Thank you! 

 ~David  

~Many thanks to Dr’s Parker and Truger who took the time to give the survey a once-over prior to release. 

 

If you have any trouble with the embedded form, just follow this link: http://goo.gl/forms/5CXxmDMXpC  – please share with your friends!

The poll will be accepting responses until Feb. 6 at 23:59, US ET (GMT-5).

The post Quick Poll: Procedures on the recently deceased? appeared first on EM IM Doc.

Small Bowel Obstruction Likelihood Ratios.

A 78-year old man presents with abdominal pain and decreased oral intake. His vitals are normal but he looks uncomfortable. After you introduce yourself, you palpate his abdomen which is diffusely tender. Your immediate gestalt is “Small Bowel Obstruction” but you’re not sure why. Frankly, you think, “I can do better than gestalt.”

Can you?

1. What are the various positive and negative likelihood ratios for clinical and radiographic features of a small bowel obstruction? (recall +LR>10 is considered useful for genuinely increasing suspicion of disease, -LR <0.1 is considered useful for genuinely decreasing suspicion of disease).

1a. Previous surgery?

1b. Abdominal distension?

 

2. What is the sensitivity and specificity of imaging modalities for small bowel obstruction?

2a. A normal abdominal X-ray?

2b. Air fluid levels seen on abdominal X-ray

2c. CT findings.

 

3. In a trained EM provider, what are the likelihood ratios for small bowel obstruction using bedside ultrasound?

 

Your questions answered!

1. What are the various positive and negative likelihood ratios for clinical and radiographic features of a small bowel obstruction? (recall +LR>10 is considered useful for genuinely increasing suspicion of disease, -LR <0.1 is considered useful for genuinely decreasing suspicion of disease).

1a. Previous surgery? +LR 3.8 (surprisingly unhelpful), -LR 0.19 (pretty good)

1b. Abdominal distension? +LR 5-16 (not helpful or helpful, depending on study cited, and patient). -LR 0.4 (not that helpful).

 

2. What is the sensitivity and specificity of imaging modalities for small bowel obstruction?

2a. A normal abdominal X-ray? sensitivity 66-77% (many false negatives).

2b. Air fluid levels seen on abdominal X-ray? specificity 50-57% (many false positives).

2c. CT findings? 92% sensitive and 93% specific. This is the “gold standard.”

 

3. In an EM provider with “brief training”, what are the likelihood ratios for small bowel obstruction using bedside ultrasound? +LR 9.5 possibly truly useful), -LR 0.04 (impressive). Looking for dilated loops of bowel >2.5cm across and “fluid moving around” instead of a bunch of air.

 

Want to know how to do ultrasound for small bowel obstruction?

http://www.ultrasoundoftheweek.com/uotw-20-answer/

http://5minsono.com/sbo/

http://www.ultrasoundpodcast.com/2012/10/episode-36-small-bowel-obstruction/

 

Other resources:

FOAMcast episode 23 on SBO and Acute Mesenteric Ischemia. 

Rosen’s Chapter 92.  Roline and Reardon. Disorders of the Small Intestine.

Tintinalli Chapter 45. Hess. Intestinal Obstruction and Volvulus.

 

Senior Report 8.11

seniorreport

Case Presentation by Alex Weissman, MD

Chief Complaint: “I feel terrible.”

History of Presenting Illness:
The patient is a 32-year-old female presenting with complaint of feeling “terrible and weak.” She states that this has happened to her twice in the last 24 hours. The first episode occurred upon awakening at 3 AM this morning with a sensation of doom, shortness of breath, chest pain, and in a cold sweat with chills. Subsequently she passed out. She ate some corn, felt better, and went back to sleep. Today, prior to arrival, the patient had another episode where she went into a cold sweat with chills and had a sensation of doom with chest pain and shortness of breath; however, this time she did not pass out. She called EMS, who found her capillary blood sugar was 32 mg/dL. The patient denies being sick recently. She denies insulin or sulfonylurea use. She denies abnormal stress in her life. She states that she has been eating normally. Last menstrual period was 3 years ago, the patient has always had irregular menses. The patient denies associated headache, sudden change in vision, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, pain or numbness in the extremities, recent illness, or recent travel.

Review of System:
Constitutional: Complains of cold sweats and chills
HEENT: Denies headache
CVS: Complains of substernal chest pain
Lungs: Complains of SOB
Abdomen: Denies abdominal pain
Musculoskeletal: Denies pain in the extremities
Genitourinary: Denies dysuria
Skin: Denies rash
Neurologic: Denies numbness
Psychiatric: Denies depression

 

Past Medical History:
Bronchitis, splenomegaly, anemia, thrombocytopenia

Past Surgical History:
Bone marrow biopsy

Social History:
The patient denies use of tobacco, alcohol, or illicit drugs past or present.

Family Medical History:
Addison’s disease in her mother

Physical Exam:
Vitals: Blood pressure: 100/75, Pulse: 60, Respiratory rate: 18, Pulse Oximetry: Not initially recorded, Temperature: 36.2 degrees Celsius
General: Alert and oriented x3, no acute respiratory distress
Head: normocephalic, atraumatic
Eyes: PERRL, EOMI, bilateral conjunctival pallor, no scleral icterus
ENT: No cervical lymphadenopathy, no pharyngeal edema, mucous membranes moist
Cardiovascular: regular rate and rhythm, no appreciable murmurs, capillary refill <2 seconds
Respiratory: no tachypnea, no retractions, clear to ausculation bilaterally, no appreciable wheezes, rhonchi, or rales
Gastrointestinal: normoactive bowel sounds, nondistended, no tympany to percussion, soft and nontender to palpation
Musculoskeletal: Extremities are atraumatic, dorsalis pedis and radial pulses 2+ and regular bilaterally, no peripheral edema
Skin: no rashes or lesions
Neurological:
MENTAL STATUS: awake, alert, oriented
CRANIAL NERVES: face symmetric, pupils 3mm -> 2mm bilaterally, PERRL, EOMI, visual fields full to confrontation
MOTOR: patient moving all four extremities spontaneously, gait normal
SENSORY: intact to light touch

ECG:
Alex

 

Labs:

Initial CBG – 32 mg/dL

Electrolytes:

132 99 13 9.3 51
5.2 22 0.46 2.1

TSH: 3.586 Micro IU/mL

CBC:

4.7 11.1 109
33.3

Serum pregnancy: negative
Insulin: <0.5 mcUnits/mL
Random cortisol: 2.2 mcg/dL

 

Questions:

1) What are the classic physical exam and laboratory findings in primary adrenal insufficiency (Addison’s Disease)?
a) High blood pressure, high serum potassium, high serum sodium, low random cortisol, low serum glucose
b) Low blood pressure, high serum potassium, low serum sodium, low random cortisol, low serum glucose
c) High blood pressure, high serum potassium, low serum sodium, high random cortisol, high serum glucose
d) Low blood pressure, low serum potassium, low serum sodium, low random cortisol, low serum glucose

2) What laboratory test is used to diagnose adrenal insufficiency, what distinguishes primary versus secondary adrenal insufficiency, and what test value would you expect in primary adrenal insufficiency?
a) ACTH stimulating test; ACTH; low or normal ACTH level
b) Random cortisol; cortisol; low cortisol
c) ACTH stimulating test; ACTH; high ACTH level
d) Random cortisol; ACTH; low or normal ACTH level

3) What are some basic differences in symptomatology between primary and secondary adrenal deficiency?
a) Primary: Hypokalemia, hypernatremia, hypoglycemia, dehydration, hypotension, Cushingoid habitus
Secondary: Hyperkalemia, hyponatremia, normotension, hyperpigmentation, hyperglycemia

b) Primary: Hyperkalemia, hyponatremia, hypoglycemia, dehydration, hypotension, hyperpigmentation,
Secondary: Hypokalemia, hyper/hyponatremia, +/- Cushingoid habitus, hypoglycemia

c) Primary: Hypokalemia, hyponatremia, dehydration, hypotension, +/- Cushingoid habitus, hyperglycemia
Secondary: Hypernatremia, hyperkalemia, hyperpigmentation, normotension
d) Primary: Hyperkalemia, hyponatremia, hyperglycemia, normotension
Secondary: Hypokalemia, hypernatremia, hypoglycemia, hypotension, dehydration, hyperpigmentation, +/- Cushingoid     habitus

 

Bonus Question 1. What is the preferred steroid treatment for adrenal crisis and what vital sign abnormality should raise the ED physician’s clinical suspicion for an adrenal crisis?
a) Hydrocortisone – unexplained hypotension
b) Prednisone – unexplained hypertension
c) Dexamethasone – unexplained hypotension
d) Hydrocortisone – unexplained hypertension

 

Bonus question 2: What is the most common infectious cause of primary adrenal insufficiency in the US?
a) Tuberculosis
b) Meningitis
c) Influenza
d) HIV


Filed under: Senior Report, Uncategorized

#EMexams | Crowd-sourcing questions for test-enhanced learning

CALLING ALL STAFF EMERGENCY PHYSICIANS
We need your help! Remember not so long ago when you wrote that little quiz known as the Emergency Medicine Board Exam? No? Have you gone through CBT to forget it? Think back to those days when your life revolved around that little quiz because BoringEM needs your help.

What we’re up to: Introducing #EMexams

We’re compiling a database of practice exam questions to help residents prepare for their tests. Questions will be tweeted from the @BoringEM account using the #EMexam hashtag once a week and followed by a post containing the question and answer on the BoringEM blog. Hopefully we will create an amazing repository of practice questions from staff physicians from across the country and around the world.

There is great education theory that suggests that frequent retrieval practice (e.g. through testing) can enhance memory.  In fact, in medical education it has been suggested that more effortful retrieval (e.g. short-answer questions) may promote better retention than recognition-based testing (e.g. multiple choice questions). [1-3]

We will be focusing on written, short-answer questions because we believe that, in addition to being difficult, they are covered poorly by existing preparation materials and are better for discussion on social media. Remember that these questions do not represent actual exam questions and that any similarity with decades worth of historical board exam questions is purely coincidental. The answers that we publish will be the best that we can determine using this crowd-sourced method and there is no guarantee that it would be considered the most correct answer if you were asked a similar question on an exam. Our goal is simply to assist in exam preparation by providing reasonable potential exam questions and answers.

What we need from you!

We need you to submit your 2nd favorite practice exam question! (Your favorite can be saved to stump your residents.) Submit them, along with your best answer, using the Google form below and we will get them into the realm of social media.

Here’s how it will work:

1. Fill out the form below.
2. Your questions questions/answers will be uploaded onto our database. The BoringEM editorial team will then review the questions and answers in a pre-publication peer review fashion.
3. Once a week a question will be tweeted from @BoringEM using the hashtag #EMexam – please help us create the best answer possible by responding!
4. A few days later a reminder tweet with a link to the answer will be posted on BoringEM.
5. Comments from staff & residents from across the country and around the globe will be welcome as we try to refine the answers to those particularly controversial questions!

Submit your practice question here:

References

1. Larsen, D. P., Butler, A. C., & Roediger III, H. L. (2008). Test‐enhanced learning in medical education. Medical education, 42(10), 959-966.
2. Kromann, C. B., Jensen, M. L., & Ringsted, C. (2009). The effect of testing on skills learning. Medical education, 43(1), 21-27.
3. Larsen, D. P., Butler, A. C., & Roediger III, H. L. (2009). Repeated testing improves long‐term retention relative to repeated study: a randomised controlled trial. Medical education, 43(12), 1174-1181.

Author information

Andrew Petrosoniak
Andrew Petrosoniak
Emergency Physician & Trauma Team Leader. St Michael's Hospital, Toronto, Canada. Interested in both simulation & social media. #FOAMed supporter.

The post #EMexams | Crowd-sourcing questions for test-enhanced learning appeared first on BoringEM and was written by Andrew Petrosoniak.

Ultrasound Leadership Academy: Lower Extremity DVT

By Michael Macias

By Michael Macias

Welcome to the Ultrasound Leadership Academy (ULA) summary blog series. This week, we discuss ultrasound in early pregnancy. The ULA is essentially an online advanced ultrasound education experience put on by the team from Ultrasound Podcast which brings cutting edge learning to emergency medicine personnel through a variety of interactive platforms including video lectures, google hangouts with experts, simulation, live conferences and real time scanning with a pocket-sized ultrasound device known as a Vscan.

Over the next year I will be posting summaries of the key learning points from my experience. If you want to learn more about the program you can visit Ultrasound Leadership Academy or Ultrasound Podcast to see more from the hosts of this awesome program.


Introduction

The annual incidence of deep venous thrombosis (DVT) is in the range of 300,000-600,000 leading to 60,000-100,000 deaths from pulmonary embolism each year. The significant mortality associated with DVT warrants effective diagnosis however given that anticoagulation is not without risk, accuracy is of upmost importance. 

Working in the emergency department, we continue to be a front line for patients presenting with concern for DVT and have specifically appreciated a rise in presentation for a "rule out DVT" as the public has become hypervigilant regarding subtle signs and symptoms. While useful to have general public awareness, this has led to significant increase in testing and potentially over treatment of small isolated calf (distal) DVTs where evidence of both associated morbidity and utility of treatment is not well known. 

  Screen Shot 2015-01-24 at 9.01.24 PM.png  

As we begin to see more patient who need to be ruled out for a DVT, we have to establish a clear method for risk stratification and decide who needs an ultrasound and who does not. Currently, all of these patient's are being whisked off to the vascular lab for duplex studies, however there is growing literature to support beside compression ultrasonography by emergency physicians as the initial study. Multiple studies have demonstrated that this approach is both sensitive and specific for diagnosis of DVT and decreases ED length of stay. 


Anatomy

  Screen Shot 2015-01-23 at 8.55.40 AM.png  

Unlike a formal duplex ultrasound which involves a 45 minute scan of the entire lower leg venous system, bedside compression ultrasonography in the ED is focused on two specific regions, the femoral region and the popliteal region. Now there is a significant amount of evidence to support a "two point" compression test which focuses on the femoral vein at the take off of the saphenous vein, and the popliteal vein just posterior to the knee, as the majority of DVTs occur around these two areas. However, there is growing evidence to suggest that single compression sites at the femoral and popliteal veins may be missing a few proximal isolated DVTs.

   

That being said a regional approach which is a slight modification of the two point compression method seems reasonable. This merely involves a few more minutes of scanning. You will need to examine the femoral region, from the take off of the saphenous vein, down through the proximal superficial femoral and deep femoral veins. You will also examine the popliteal region, from the popliteal vein down through the take off of the anterior tibial vein. 


Technique 

Probe: Linear, high frequency (Though if you patient is very large you can attempt to use a curvilinear probe)

Positioning: Have the patient lie supine with a sheet covering their groin region. Externally rotate and flex the hip slightly to expose the femoral region. When examining the popliteal region, the knee should be flexed at around 45 degrees. 

  

Compression: As we discussed above you will be scanning both the femoral and the popliteal region. In these regions you will be performing direct compression of the vein to ensure there is no clot. In order to confidently rule out clot in the vein you need to be sure that you are obtaining complete compression of the vein and occlusion of the lumen. Essentially your will see the vein winking back at you, letting you know that there is no clot to be found. The questions always comes up about how hard to push and an easy measure to use is arterial compression. If you are pushing hard enough that the artery is starting to compress then you are compressing sufficiently and if your vein lumen is still patent then likely you are seeing a clot. If you are having trouble visualizing the vessels you can use color doppler however for the most part this is not necessary and may cause confusion. 

The only difference between the regional compression versus the single point compression is instead of a single compression, you will compress the vein along the entire region of interest, both in the femoral region and the popliteal region, following along the vein of interest in a transverse plane. Refer to the diagram above a second time to review the anatomy of the regions to compress. 


Clinical Approach 

   

We always have to take into account pre-test probability and consider the likelihood a patient may have a particular disease prior to any testing based on their clinical picture and their risk factors. For DVT we have the Wells score which helps us to predict which patient's are more likely to have a DVT and which probably don't require much testing. 

  From ULA Course DVT Clinical Algorithm

From ULA Course DVT Clinical Algorithm

 

How your algorithm specifically works will highly depend on your clinical setting and the resources you have available but the main point to highlight is that your ultrasound as well as other tests such as the d-dimer need to be placed in context of the patient's risk for having a DVT. Many low risk patients can be ruled out without even having to perform an ultrasound and high risk patients who have a negative ultrasound initially should still have a repeat formal ultrasound performed since their risk is so high that a single exam does not sufficiently rule out a DVT. An alternative algorithm proposed by Dr. Matt Dawson is seen below and focuses on the bedside ultrasound to help rapidly dispo low risk patients without the need for a d-dimer. One algorithm is not particularly better than the other as long as you are incorporating ultrasound into your practice just as you would any other lab test or exam in a bayesian manner. 

  From ULA Course DVT Modified Clinical Algorithm 

From ULA Course DVT Modified Clinical Algorithm 

 

Controversy

I am sure you are wondering, "What about those distal isolated clots that we always find?" Well the evidence for isolated clots in these distal lower leg veins is not great and it seems that even the hematologic community is beginning to advocate for a "don't look, don't tell policy." The risk of PE from these isolated clots is not well known and many surveillance studies appear to overestimate the risk. One study, the CALTHRO study, in which the presence of isolated distal DVT was kept blind to patients, and doctors in charge, found the risk of PE to be 1.6% at 3 months. 

We all know that if we see a clot in the distal lower extremity venous system and tell a patient they have a clot that regardless of the actual risk of morbidity or proximal extension, they are going to want treatment with anticoagulation. Looking at the small amount of literature we do have, patients with distal clots who have proximal extension or PE have risk factors that we associate with DVT anyway. Therefore even looking at this topic from the view of the hematology literature, in the right patients it is reasonable to perform our two region compression exam without examination of the distal vessels. Below is an algorithm proposed by Dr. Gualtiero Palareti, an Italian hematologist, in a recent review on the evidence and clinical management of isolated distal deep vein thrombosis which can be found here.

  Diagnostic/Therapeutic Algorithm for IDDVT From How I treat isolated distal deep vein thrombosis; CUS = Compression Ultrasound; IDDVT = Isolated Distal DVT

Diagnostic/Therapeutic Algorithm for IDDVT From How I treat isolated distal deep vein thrombosis; CUS = Compression Ultrasound; IDDVT = Isolated Distal DVT

 

Continue Learning


THAT'S IT FOR THIS WEEK

If you are interested in learning more about the ULA learning experience, visit their website below:

   

All images are courtesy of the ULA online video course unless otherwise stated. More on DVT ultrasound can be found in "Introduction to Bedside Ultrasound," Volume 1 & 2, from Dr. Mallin and Dr. Dawson. If you are interested in purchasing these ebooks for less than $1, visit Ultrasound Podcast Consumables.



References 

  • Crisp et al. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med. 2010 Dec;56(6):601-10.
  • Kory et al. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011 Mar;139(3):538-42.
  • Blaivas et al. Lower-extremity Doppler for deep venous thrombosis--can emergency physicians be accurate and fast? Acad Emerg Med. 2000 Feb;7(2):120-6.
  • Theodoro et al. Real-time B-mode ultrasound in the ED saves time in the diagnosis of deep vein thrombosis (DVT). Am J Emerg Med. 2004 May;22(3):197-200.
  • Adhikari et al. Isolated Deep Venous Thrombosis: Implications for 2 Point Compression Ultrasonography of the Lower Extremity. Ann Emerg Med. 2014 Nov 20.
  • Palareti et al. Evolution of untreated calf deep-vein thrombosis in high risk symptomatic outpatients: the blind, prospective CALTHRO study. Thromb Haemost. 2010 Nov;104(5):1063-70. 
  • Gualtiero Palareti. How I treat isolated distal deep vein thrombosis (IDDVT). Blood: 2014 Mar; 123 (12).

  • Singh et al. Early follow-up and treatment recommendations for isolated calf deep venous thrombosis. J Vasc Surg. 2012 Jan;55(1):136-40.

  • Schwarz et al. Therapy of isolated calf muscle vein thrombosis: a randomized, controlled study. J Vasc Surg. 2010 Nov;52(5):1246-50. doi: 10.1016/j.jvs.2010.05.094. Epub 2010 Jul 13.

Should Men and Women Use Different Troponin Cut-Offs?

Much ado is made regarding potential differences in symptoms between men and women presenting with acute coronary symptoms.  Little is mentioned, however, about potential differences in laboratory thresholds between the sexes.  Considering women, on average, have decreased myocardial mass than men, any ischemic insult simply damages a smaller absolute quantity of myocardium.  Less damaged tissue, then, ought to lead to lower circulating biomarkers.

Why haven’t we tried this before?  Because the limit of detection of conventional troponin assays are above the clinically important thresholds for delineating such small quantities of circulating molecules.  However, with the advent of highly-sensitive troponins with reasonable precision below  the conventional troponin cut-off of 50 ng/L, it’s now a reasonable concept for investigation.

These authors conducted a yearlong prospective evaluation of all patients with suspected acute coronary syndrome, collecting conventional and highly-sensitive troponins on each.  Treating clinicians and initial adjudication of myocardial infarction were blinded to the results of the hsTnI.  Following conclusion of the study, records and unmasked hsTnI values were provided for independent adjudication and diagnosis changes accordingly.

Initially, 19% of men were diagnosed with Type 1 MI based on conventional troponin testing.  After using a gender-specific cut-off for men of 34 ng/L, only a handful of additional cases were re-classified – rising to 21%.  For women, 11% were initially diagnosed with Type 1 MI.  Using a gender-specific cut-off for hsTnI of 16 ng/L, however, doubled the diagnosis cohort to 22%.

Of course, simply lowering the threshold for any assay increases the rate of diagnosis.  In order to answer the question of whether the re-classified cases were clinically appropriate, all patients were also followed for survival free from death or MI.  While women not diagnosed with MI at initial presentation did well throughout the follow-up period, the women reclassified as MI using the hsTnI threshold suffered the same dismal outcomes as those initially diagnosed with MI.

I like this concept, and this is promising preliminary data.  It remains to be seen whether treatment, including increased treatment intensity for women, based on the gender-specific cut-offs changes clinical outcomes – or whether splitting these little nanograms worth of hairs is just overdiagnosis.  The good news: a clinical trial is ongoing.  I look forward to their results.

“High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study”
http://www.bmj.com/content/350/bmj.g7873 (free fulltext)