- Hypotension: sustained or transient (<15minutes) with or without shock is considered high risk
- Largest and most challenging group of PE patients are normotensive
- Risk stratification options include evaluating co-morbidities and susceptibility to PE including cancer (metastatic or localized), cardiopulmonary disease and cardiac disease
- Clinical Scoring options include PESI and HESTIA which evaluated for comorbidities, AC bleeding risk and presence or absence of severe vital sign abnormalities.
- They notably do not incorporate any assessment of RVD.
- American Heart Association and European Society of Echocardiography guidelines prominently include RVD assessment with echo, cardiac biomarkers or CT RV LV ratio
- Right ventricle dysfunction is the common pathway to clinical deterioration and PE related death or cardiopulmonary disability.
- Methods of evaluating for RVD include:
- Pulse oximetry: <90% more severe, 90-94% moderate, >94% low risk
- moderate(tachycardia, S1Q3T3, or incomplete RBBB)
- more severe" inverted T waves V1-V3
- severe: bradycardia <40 bpm, RBBB, ST elevations, V1-V3 or aVR, T wave inversions II, III AVF
- Troponin I or T elevations as high as 7 fold increase in adverse events
- BNP/proNBNP >90, >900 limited specificity 5-7 fold increase in adverse events
- Both biomarkers elevated Odds ratio of 8.4
- Both biomarkers low death and short term serious adverse event
- PE provoked RVD is defined by RV dilatation (a requirement) with or without septal deviation or RV
- RV hypokinesis (with RV dilatation indicates more advanced RV dysfunction.
- Tricuspid regurg velocity limited use as worsened RV contractility can weaken the tricuspid
regurgitation to undetectable levels
- CT useful for diagnosis but also risk stratification looking for 1) clot burden but more important is
2) RV strain RV:LV ratio>1.0
- Low risk PE patients may be considered for brief observation and initial treatment or considered for outpatient anticoagulation
- Clinical scoring systems like PESI and HESTIA do not include any RVD assessments
- Low risk categorization by PESI scores may have RVD (as high as 35 % in one study) which gives a different risk categorization if AHA or ESC guidelines were used.
- Current version of ESC guidelines include RVD assessments mainly in non low risk PESI scoring however presence of RVD is not uncommon amongst those with low risk by PESI
- Some studies with low risk category by PESI and +RVD show no adverse outcomes, others show patient experience adverse outcomes.
See RVD assessment with Goal Directed Echocardiography tutorial on Compendium:
— Relatively common cause of fatigue and weight gain
— Symptoms: everthing slowed down or decreased
— Primary vs secondary based on TSH: primary high, secondary (and tertiary) low
— Important to increase T4 dose during pregnancy
— Myxedema coma is deadly and requires urgent treatment
— IV T4 and T3 with supportive care
- Secure the airway early
- Administer blood products early
- Do not forget to administer all components of blood including FFP and platelets; know your institution's massive transfusion protocol if you have one
- Chronic conditions such as liver failure and renal failure can cause coagulopathy; consider reversal with vitamin K and/or vasopressin
- PPI's help reduce risk of rebleeding and reduce need for transfusion
- Most common causes of exsanguination from GI bleed are:
4. Diverticular disease
- Upper GI bleeds are much more likely to cause exsanguination than Lower causes
Special considerations for the ED care of IV drug users:
1) Increased risk for immunocompromising illnesses such as HIV, hepatitis
2) IVDU can also lead to primary immune system dysfunction
3) Specific conditions that are of greater concern in IV drug users: cellulitis, epidural abscess, renal abscess, osteomyelitis, endocarditis
4) Update tetanus
5) Investigate social determinants of health and address as able
A thoracolumbar fracture is considered unstable if:
a) more than one column is involved
b) a vertebrae has acutely lost >50% height
- Ultrasound has utility in almost all ED patients and should be a cornerstone of both diagnosis and aiding in resuscitation for a critically ill patient (don't forget to document your images!)
- Utilize peak flow to trend patient's burden of illness in asthma exacerbations.
- Consider single/two dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone.
- Think about myiasis in a non-healing papule/plaque/ulcer in a patient coming from a tropical area. Treatment is skin biopsy with removal of larvae.
1. Short-term goals should be attainable (you can do it), actionable (there are things that would be required of you in the NEAR future to do it) and with fixed time constraints.
2. Long term goals have few limitations although it is best to break them up into time intervals such as five-year, 10 year, twenty-year and lifetime.
3. When addressing long-term goals think through what you want to have accomplished, where your time will be spent, etc,
4. Remember that ultimately you are trying to write down how you want to develop yourself long term. This should encompass both personal and vocational growth.
• ST elevation is an uncommon but recognized EKG finding in PE
• Clinical history is often times the most significant factor in determining STEMI vs. PE
• Bedside ultrasound, scrutinizing of EKG are keys to diagnoses
• Back pain the elderly is a red flag and almost always requires evaluation
• Infectious etiologies of back pain are a challenging ED diagnosis
• Infectious back pain can rarely be caused by anaerobic and gas-forming organisms, can lead to sepsis