High Sensitivity Troponin Testing

06 Feb
February 6, 2014

High Sensitivity Troponin TestingTroponin testing is an important component of the diagnostic workup and management of acute coronary syndromes (ACS). The increasing sensitivity of troponin assays has lowered the number of potentially missed ACS diagnoses, but this has also created a diagnostic challenge due to a decrease in the specificity of the test. From 1995 to 2007, the limit of troponin detection fell from 0.5 ng/mL to 0.006 ng/mL (see below graph). Robert Jesse summed up this frustration with the following quote:

When troponin was a lousy assay it was a great test, but now that it’s becoming a great assay, it’s getting to be a lousy test. Read more →

Relationship of Radiocontrast, Iodine, and Seafood Allergies

04 Feb
February 4, 2014

Relationship of Radiocontrast, Iodine, and Seafood AllergiesComputed Tomography (CT) scan using radiocontrast is one of the most common imaging modalities used in emergency departments today. Several studies and my own anecdotal experiences indicate that both physicians and patients believe that iodine allergies are linked to seafood allergies and that both are related to a disproportionate increased risk of “allergic” reactions to radiocontrast agents. To add further insult to injury, some hospitals have premedication protocols with steroids and antihistamines requiring up to 12 hours before CT scans with intravenous contrast can be performed. So what is the relationship of radiocontrast, iodine, and seafood allergies? Read more →

Is Pelvic Exam in the Emergency Department Useful?

30 Jan
January 30, 2014

Pelvic Exam SpeculumWomen with undifferentiated abdominal pain and/or vaginal bleeding commonly present to the emergency department. ¬†Many textbooks advocate for the pelvic exam as an essential part of the history and physical exam. Performance of this portion of the exam is time consuming to the physician and uncomfortable for the patient. It is with great regularity that emergency medicine physicians make clinical decisions based on information derived from it, but is this information reliable and does it effect the clinical plan of patients? Read more →

Chest Pain: Can we do 2-hour rule outs?

26 Jan
January 26, 2014

Chest Pain and TimeHospital admissions for chest pain often incur costly and resource-intensive workups for ACS. Is there a way to identify a low risk group who can be discharged home in a timely manner, without further workup, and without short-term adverse events from ACS? Read more →

Chest Pain: Coronary CT Angiography in the ED

26 Jan
January 26, 2014

chest pain and CCTAIt is well known that taking a good history and physical, getting a non-ischemic EKG, and serial cardiac biomarkers, results in a risk of death/AMI of <5% in 30 days. Patients, in whom you still suspect have CAD, should undergo provocative testing within the next 72 hours based on the AHA/ACC guidelines. Their guidelines deem provocative testing as including:

  • Exercise treadmill stress test,
  • Myocardial perfusion scan,
  • Stress echocardiography, and/or
  • Coronary CT angiography (CCTA). ¬† Read more →
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