Avsnitt
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Dr. Pregerson has all you need to know about strokes, including that posterior strokes are missed twice as often as anterior ones, ruling out mimics like vertigo, headache, and vomiting, and which tests you should be doing in this month’s EM Logic podcast. Read more in the Show Notes.
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Dr. Pregerson dives deep into ACLS, noting that anything that compromises good CPR and early defibrillation can make things worse, and he offers tips for treating ED patients who need CPR, defibrillation, intubation, and medications in this month’s EM Logic podcast. Read more in the Show Notes.
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Saknas det avsnitt?
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Dr. Pregerson parses the literature on steroids for severe infection and why EPs need to know the nuances of how and when to use them in this month’s EM Logic podcast. Read more in the Show Notes.
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Hypokalemia gets a lot of attention in the literature, but Dr. Pregerson said he has never had a patient with hyperkalemic cardiac arrest. Listen in as he discusses the ECG changes seen with hypokalemia and how to treat hypokalemic arrest if you see it. Read more in the Show Notes.
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EPs know blood thinners increase the risk of intracranial bleeding, and there are many classes of blood thinners, each with a different risk profile. Dr. Pregerson delves into antiplatelet agents, warfarin, and DOACs. Read more in the Show Notes.
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Dr. Pregerson digs deep into how missed vital sign red flags account for malpractice cases. He reviews unexplained tachycardia, soft blood pressure, minor temperature elevation, and mild hypoxia. Read more in the Show Notes.
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Dr. Pregerson tells you all you need to know about using CT contrast in the ED. Read more in the Show Notes.
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Dr. Pregerson says EPs have to think like detectives for cases that don’t fit the typical pattern of viral illness and must think more logically about these infections. Read more in the Show Notes.
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Urinalysis can be a ship for fools, Dr. Pregerson says in this month’s podcast where he explains why you need logic not to miss true UTIs. Read more in the Show Notes.
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Pain medications make patients feel better and want to go home, but Dr. Pregerson says don’t send them home with more medication unless a definitive diagnosis was made because they may not come back if the medication masks that their condition has gotten worse. Read more in the Show Notes.
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Dr. Pregerson logically dissects an aortic dissection, answering when to consider a chest CT, where to take the blood pressure, and when to do a pericardiocentesis, this month with bonus video! (https://bit.ly/EMNVideoGallery.) Read more in the Show Notes.
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Dr. Pregerson asks—and answers—the important questions about intubation: Why is it important to synchronize a bag-valve-mask ventilation with the patient’s breathing? Why is upright intubation better? Why you should use the SALAD technique, and what are the benefits of ketamine? Read more in the Show Notes.
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Dr. Pregerson delves into minor and serious cases of hemoptysis, how to treat these patients, and why positioning is so critical. Read more in the Show Notes.
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Dr. Pregerson explains why it’s important to find out why patients want to leave AMA because that might help you change their mind. Either way, chart what patient says and your response and listen to his other tips for handling these discharges. Read more in the Show Notes.
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Dr. Pregerson explains why troponin will sometimes be falsely negative early in an occlusion MI when the benefit of intervention is highest, how a urinalysis can lead you astray, and why some EMRs don’t flag abnormally high bands. Listen in to hear all about these intriguing topics and read more in the Show Notes.
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Lab values aren’t just lab values, and there’s a logic to understanding how to interpret them. Listen in to hear all about this fascinating topic and read more in the Show Notes.
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It’s true that EPs should be looking for horses when they hear hoofbeats, but sometimes they have to go on a zebra hunt, says Dr. Pregerson. Tune in to hear why gastroenteritis, anxiety, and dehydration should set off your Spidey senses. Listen in to hear the answers and read more in the Show Notes.
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Why are most bleeding gastric ulcers painless? Why do people have a vasovagal reflex in the first place? Dr. Pregerson says there are logical answers that he can’t prove are right but most likely are. Listen in to hear the answers and read more in the Show Notes.
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Show Notes:
First ask, “Are you having pain now?” If your patient answers no, consider this unstable angina until proven otherwise even if the pain went away with an antacid. Antacids relieve pain in about 15 percent of ACS. Why? Coincidence. The real lesson here is that the percentage of acute coronary syndrome that presents as unstable angina is probably 15 percent at a minimum. It’s actually probably at least twice that because not everyone tries an antacid. If you are looking for unstable angina, you are less likely to be fooled by false-negative troponins. This is still true of high-sensitivity troponin, although supposedly some literature says it can rule out unstable angina if the level is below the level of detection at least three hours out from peak pain and presentation. It has to be better than normal; it has to be undetectable.
Second Troponin v. Second History: I would like to be spread the following lesson to everyone in EM: “Before you do a second troponin, do a second history!” You need to really nail down the timing and duration of symptoms the best you can or you may be misled. Some patients speak their own language: “Constant” can mean “frequent.” Most of us already know that “no medical problems” can mean “no untreated medical problems” to a lot of people. It is safest to start with the assumption that all chest pain is unstable angina until proven otherwise, that the pain is episodic lasting five to 10 minutes, and that the troponin and ECG may both be useless.
HEART Score Logic: The HEART score is super useful and can help protect you if you send the wrong patient home, but you should still try to avoid doing that. The HEART score’s major blind spot is unstable angina because the troponin and ECG may be normal if pain lasts less than 20 to 30 minutes. Another caveat of the HEART score is grouping together all the patients with scores from 0-3. If the risk of this group is about one to two percent on average, logic dictates that patients with a score of 0-1 are actually at lower risk, but those with a score of 2-3 are likely at higher risk, perhaps three to four percent or even more. What is the actual risk associated with a HEART score of 3? We won’t know until someone does the study, but risk jumps to 10 to 20 percent once you hit the 4-6 score group. If you extrapolate the data, the risk of a MACE at 30 days is probably two to three times the HEART score, so for 3 it would be nine percent, if you use logic.
Back to the question, “Are you having pain now?” If your patient answers yes, your next question should be, “When did the current episode start?” Or better yet, “When was the last time you had no discomfort?” If it was less than two hours earlier, you should be doing serial ECGs every 30 minutes if you can, so you don’t miss a STEMI with an initially nondiagnostic or even near-normal ECG. It can take two hours or even more for ST elevation to manifest in some cases. You want that to be picked up early, not eight hours later when your patient is on the floor and it is too late for cath to help much.
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Show Notes:
Head-Jolt sign: This is about 99% sensitive and 50% specific for meningitis. Have patients rapidly turn their head side to side. If it doesn’t hurt or they have to do it twice, make sure they don’t have meningitis. I will often grab their head and do it for them, but first definitely explain what I am doing to family members.
Eyes-Red eyes: Consensual photophobia or limbal flush suggests iritis or keratitis rather than conjunctivitis.
Pulmonary exam: Demonstrating how you want them to breathe and having them breathe more rapidly in and out is quicker and more sensitive for abnormal lung sounds. If you think you hear consolation when performing lung exam, ask a yes or no question. This can help continue your history, speed up your exam, and identify a pneumonia (a sort of modified egophony). After that and the end of an exhale, tell them to stop breathing and stick out their tongue (if no mask) while you listen to the heart with your stethoscope closer to the heart and without interference from lung sounds or, worse yet, speech. Bonus: Look at their tongue for hydration status.
Vascular-Pulses in the feet: Comparing pedal pulses is critical when there is a possibility of a knee dislocation, an aortic dissection, or acute limb ischemia, all of which can be sneaky and time-sensitive. Popliteal arterial injuries often are diagnosed late due to severe leg pain or spontaneous knee reduction. Aortic dissection rarely extends into an arm but almost always extends into a leg. Acute limb ischemia can mimic DVT, sciatica, or even a stroke.
Ortho-Pain location: Have them touch the exact spot that hurts the most. Without this and a confirmatory exam, you may end up imaging the wrong part of the spine or extremity. If you are lucky, it will only cause a delay; if you are not, it can cause a disaster. I have seen many misses or near misses due to this.
Ortho-Arm/hand neuro exam: Have the patient make an OK sign with the wrist in dorsiflexion and third fourth and fifth fingers spread apart. This allows you to evaluate the median (C5-8), ulnar (C8-T1), and radial nerves (C6-C8) in a five-second motor exam.
- Visa fler