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 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.

June 24, 2019

Shock is one of the most important problems with which physicians will contend with.  The magnitude of the problem is illustrated by the high mortality associated with shock.  Assessment of perfusion is independent of arterial pressure, in that hypotension does not always need to be present to define shock.  Emphasis in defining shock is based on tissue perfusion in relation to cellular function. In this post, the basics of shock, we will define shock, discuss the causes of lactate elevation, and review the main categories of shock.

June 13, 2019

Background Information: Syncope is defined as a sudden transient loss of consciousness (LOC) followed by complete resolution. It represents 1-3% of all emergency department (ED) visits. 1 1% of all hospitalizations are due to syncope as it may have resulted from a serious underlying condition, such as arrhythmia, acute cardiac ischemia, pulmonary embolism or internal hemorrhage. 2,3 Prior studies have demonstrated that up to a half of these serious conditions, particularly arrhythmias, are missed during ED evaluation and become evident after disposition. 1 Several risk stratification tools, such as the Canadian Syncope Risk Score (CSRS; Figure 1) and the San Francisco Syncope Rule (SFSR; Figure 2) have been developed to help identify serious outcomes. 4,5 The authors of this study sought to describe the time to occurrence of serious arrhythmias relative to when the patient arrived in the ED and based on their CSRS risk category. Furthermore, their goal was to use the results of this study to provide guidance for decision making regarding duration and location of cardiac monitoring.

May 30, 2019

Background: Syncope, defined as a transient loss of consciousness with spontaneous and complete recovery to pre-event status, is a common emergency department (ED) presentation. Recently, we have discussed the lack of clinical utility in distinguishing syncope from near-syncope in terms of outcomes. In that discussion, we concluded: “In older adults (> 60 years of age), near-syncope appears to portend an equal risk of death or serious clinical event at 30 days when compared to syncope. These two entities should be considered as one when decisions are made in terms of evaluation in the ED.” While we argue for evaluation and disposition to be the same, we don’t address what the best disposition or plan is. While it is common to admit older patients with syncope/near-syncope from the ED, admission doesn’t inherently yield better outcomes.

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