Month: August 2016

Abdominal Pain Basics

Elderly people die from abdominal pain

Step 1: Risk Stratify

  • Certain patient groups have VERY high mortality when having abdominal pain
    • Geriatrics
    • Immunocompromised
    • Diabetics

Step 2: Consider Genitourinary Causes

  • Be especially cautious with lower abdominal/flank pain
    • Mention that you performed or considered performing GU exam during presentation!
  • Common GU causes of abdominal pain
    • Testicular/ovarian torsion
    • Prostatitis/pelvic inflammatory disease
    • Ectopic pregnancy

Step 3: High-Yield Tests to Consider

  • CBC and Electrolytes
  • EKG and Troponin
  • Liver Panel and Lipase
  • Urinalysis and Urine pregnancy

Step 4: Order Appropriate Imaging

  • CT scan is most useful test with abdominal pain in adults
    • Need to give IV contrast if concerned for vascular pathology
    • Usually performs just as well as ultrasound (even in cases where ultrasound is the classic, initial test)
  • 3 “exceptions” to the CT first rule
    • If concerned for biliary pathology
      • RUQ ultrasound
    • If concerned for genitourinary pathology
      • Testicular/Pelvic ultrasound
      • Renal ultrasound (kidney stone)
    • If concerned for Abdominal Aortic Aneurysm
      • Bedside Aorta ultrasound

Step 5: Disposition

  • Classic teaching is that patients discharged with undifferentiated abdominal pain need follow up in 12-24 hours
  • It’s ok to have them come back to the ED if necessary

Additional Reading

Stroke

Get your attending!

Step 1: Obtain Last Known Well

  • Stroke treatments including tPA and thrombectomy both require last known well
    • <3-4.5 hours for tPA
    • <24 hours mechanical thrombectomy

Step 2: Finger Stick Blood Glucose

  • Hypoglycemia is classic mimic of CVA
  • Results can be obtained immediately

Step 3: STAT Head CT Without Contrast

  • Poor sensitivity for ischemic stroke
    • Primary use is identification of hemorrhagic stroke
    • Required prior to administration of tPA!

Step 4: Perform NIHSS

Step 5: Give tPA (If No Contraindications)

  • Follow department protocol and contraindications
    • Frequently being updated

Additional Reading

Shortness of Breath

You need an organized, anatomical approach.

Step 1: Consider Differential Diagnosis

  • Upper airway
    • Angioedema
    • Foreign body
    • Abscess
  • Lower airway
    • COPD
    • Asthma
  • Alveoli
    • Pneumonia
    • Pulmonary edema
  • Blood
    • Anemia
    • Acidosis
      • DKA
      • Sepsis (lactic acid)
      • Toxins (salicylic acid)
  • Blood vessels
    • Pulmonary embolism
    • Aortic dissection
  • Heart
    • Myocardial infarction
    • Acute heart failure
    • Cardiac tamponade

Step 2: Examine Anatomically

  • Upper airway
    • Stridor
    • Voice changes
  • Lower airway
    • Wheezing
  • Alveoli
    • Crackles
  • Blood
    • Pallor
  • Heart
    • Dysrhythmia
    • Jugular vein distension (JVD)
    • Edema

Step 3: Testing Plan

  • Common tests
    • Chest x-ray
    • EKG
    • CBC
    • Electrolytes
  • Less common tests
    • Blood gas
    • Troponin
    • BNP
    • D-Dimer

Step 4: Calculate Wells Score and PERC

Additional Reading

Syncope

6 EKG Findings. 6 Risk Factors. 6 Mimics.

Step 1: Get an EKG

  • This is the only “required” test for a patient with syncope
  • Other common tests
    • CBC
      • Evaluate for anemia
    • hCG
      • If patient might be pregnant

Step 2: Look For 6 High Risk EKG Patterns

  • Mnemonic: QT-BRIDE
    • QT prolongation
      • Especially QTc >500
    • Brugada pattern
    • Right heart strain
      • Tachycardia
      • S1Q3T3
      • Inverted T waves precordial leads
    • Ischemic changes
      • ST segment elevation/depression
      • T wave inversion
    • Delta waves
      • Seen in Wolf-Parkinson White (WPW)
    • Epsilon waves
      • Seen in arrhythmogenic right ventricular dysplasia (ARVD)

Step 3: Ask the 6 High Risk Historical Questions

  • Mnemonic: CHESS +1
    • Cardiac history
      • CHF
      • Structural heart disease
    • Hematocrit <30%
    • “Elderly”
    • Shortness of Breath
    • Systolic BP <90
    • (+1) Family history of sudden cardiac death

Step 4: Consider 6 Deadly Syncope Mimics

  • 15% of the following diseases reportedly present as “syncope”
    • AKA “Rule of 15s”
  • Subarachnoid hemorrhage
  • Myocardial infarction
  • Pulmonary embolism
  • Aortic dissection
  • Abdominal aortic aneurysm
  • Perforated GI
    • Ulcers
    • Ectopics

Additional Reading

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