August 15, 2019

Background: The clinical diagnosis of pulmonary embolism (PE) can be challenging given its variable presentation, thus requiring dependence on objective testing. Decision instruments such as PERC and the Wells’ score help stratify patients to low or high probability, enabling focused use of CT pulmonary angiography (CTPA) for diagnosis. However, despite these algorithms, there is evidence of increasing use of CTPA along with diminishing diagnostic rate (less than 10%). This combination results in the overdiagnosis of subsegmental PEs, unnecessary exposure to radiation and false positive results. These issues are compounded in patients with pregnancy. While we know that pregnancy increases risk of venous thromboembolism (VTE) our testing rates far exceed the added risk exposing thousands of women to the afore mentioned potential harms.

In 2017, the YEARS algorithm established a simplified algorithm for evaluation with a two-tiered D-dimer threshold in an effort to reduce the number of patients getting CTPA  (van der Hulle 2017). The YEARS algorithm asks three questions: 1) Are there clinical signs of DVT? 2) Does the patient have hemoptysis? and 3) is PE the most likely diagnosis. If the answer to all 3 questions is no, the D-dimer threshold is set at 1000 ng/mL FEU (500 ng/mL DDU) and if the answer is “yes” to any of the 3 questions, the D-dimer threshold is set at 500 ng/mL (250 ng/mL DDU). However, this study had very few pregnant women enrolled.

August 12, 2019

Background:  In patients with ICH, antiplatelet therapy is withheld due to the perceived risk of hematoma expansion.  Often, these medications are either not restarted or there is prolonged delays until they are restarted, but the risk of occlusive vascular events might be higher without resumption of antithrombotic therapy. A meta-analysis of observational studies found no difference in the risk of hemorrhagic events and a lower risk of occlusive vascular events associated with antiplatelet therapy resumption after any type of intracranial hemorrhage (ICH); however, randomized trials for antiplatelet efficacy in occlusive vascular disease have excluded patients with a history of intracerebral hemorrhage. Due to the paucity of evidence, no guidelines have strong recommendations about long-term anti-platelet therapy after ICH. The RESTART Trial [1] aimed to address the question of whether or not to start antiplatelet therapy following an intracerebral hemorrhagic stroke.

August 8, 2019

Background: Trauma patients can be a rather difficult patient population to treat with multiple ongoing issues.  There is always a balance of hemorrhage control vs prophylaxis for venous thromboembolism (VTE), as both can cause increased morbidity and mortality.  One method to balance this challenging issue is retrievable inferior vena cava (IVC) filters, which at face value sound like a nice solution (Prevent VTE while avoiding worsening hemorrhage).  The main issue with IVC filters is there is limited high quality data to support the use of these devices and IVC filters are not without their own long-term complications as well. Finally, there are also conflicting recommendations depending on which guidelines you choose to read [3][4][5].

August 7, 2019

Take Home Points

  • There is no real distinction between syncope and near syncope.

  • Older folk with near syncope or syncope should be treated the same.

  • Patient with high risk features its reasonable to admit but if they’re low risk, well-appearing and have reasonable follow up discharge home is fine.

August 5, 2019

Background Information: Non-steroidal Inflammatory drugs (NSAIDs) such as Ibuprofen are of the one of the most commonly used oral analgesics in the emergency department. 1 These medications work by inhibiting the enzymes cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). These are two enzymes which lead to prostaglandin production and ultimately promote pain, fever and inflammation. Prostaglandins also serve to line the stomach epithelium and protect it from the digestive acids. The COX-1 enzyme also plays a role in platelet activation through the production of Thrombaxane-2. Understanding the physiology behind these important enzymes helps us better anticipate the expected adverse effects that may occur when prescribing NSAIDs, especially at higher doses or over an extended period of time. Due to its linear kinetic effects, higher doses of ibuprofen results in longer duration of analgesia and not necessarily more effective pain control. 3, 4 The authors of this study sought to identify the analgesic effects of three different doses of ibuprofen. Furthermore, they hypothesized that a lower dose had comparable analgesic effects when compared to higher doses.