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Likelihood Ratio (LR) in Emergency Medicine

1/19/2015

Run to the operation room!

Clinical Scenario

A 70 yo woman is brought to the ED by ambulance.
She’s suffering from vomit, lach of flatus and abdominal pain since 24 hours says the nurse. 
She’s pale, the abdomen shows a midline scar. There is diffused tenderness with rebound.
Abdomen US and X rays show abnormal distended loop of small bowel.

Ok, Ok I saw the images, there’s an occlusion says the surgeon at phone but, you know, I need a CT!

Are there CT findings that identify patients requiring a run to the operation room? 






Conclusion 

Fortunately more than half of patients who present with SBO, resolves with non operative therapy. But on the other hand, more than 50% of bowel obstructions with ischemia are misdiagnosed. 
When all 3 Zielinski's signs are present strong consideration of early operative exploration should be take into account. 



Bibliography 

MD Zielinski
J Am Coll Surg 2011 212 1068-1076 

CS Santillan
Radiol Clin N Am 2013 51 17-27


Ciro Paolillo

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12/25/2014

My heart hates Christmas


Clinical Scenario

It’s 7 pm on Christmas day, a 32 yo woman refers palpitations since the morning. I was with my frends yesterday nigth, I think I had drank a bit too much. I Hate Christmas, it brings me down.
She’s awake, alert and oriented, her mood is low. Vital signs are normal,  EKG shows a sinus rhythm. 




 I’m sure it’s nothing but this damn holidays…


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10/24/2014

NO fever, NO bacteriaemia?

Clinical Scenario

A 80 yo nursing home resident woman  is brought to the ED by ambulance. 
“Hypothension, cough and a hystory of heart failure ”, refers the nurse. 
She looks pale and confused, her respiratory rate is 22, oxygen saturation on room air is 90%. Ear temperature is 36,5°C, BP  is 90/60 mmHg, HR is 95.
There’re pulmonary rales. Lactate are 4 mmol/dl.

Is it a low flow heart failure or is there and underline pneumonia? Does the absence of fever rule out bacteriaemia? 







Conclusion 

Although fever has been incorporated into prediction rules for blood infections, proven infection may be present in the absence of fever. 
Temperature as a single parameter is a poor indicator of bacteremia. 


Bibliography 

TA Seigel 
J Emerg Med 2012 vol 42 n3 pp 254-259. 


Ciro Paolillo


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8/06/2014

Diagnosis of scaphoid fractures.
 Are plain radiographs reliable?


Clinical Scenario

It’s a busy wednesday morning in ED. 
A 18 yo guy presents with the right hand upraised and dressed. 
In the other hand he has a bundle of X ray.   
“About ten days ago, it was a Saturday night, I was with my new girl-friend. Hitting a punch bag as hard as possible I felt pain to my right wrist. My doctor ordered wrist X ray. It’s not broken, he says, but I’m very afraid, when I move the wrist  it pains me so much”.
On clinical examination there is snuff box tenderness, the axial loading maneuvre on the thumb is positive (see previous post). 
The emergency phisician takes an accurately look at the X rays. They are of high quality, the study had 4 views of the scaphoid, there’s no evidence of irregularity of cortex, the scaphoid fat pad seems normal.
“Repeat X-ray” orders the doctor….


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6/28/2014

Is a cold steak enough in black eye?

Clinical Scenario

A young guy comes to the ED after a car crash. While he was driving, the car in front of him stopped abruptly so they crashed. Fortunately speed was low and he does not report major trauma, but a black eye due to an impact towards the airbag. You promptly evaluate his sight and find no deficit, no diplopia, palpation does not show fracture steps or enphysema, skin sensation is preserved.



It’s nothing, just put a cold steak on it!

Would you really say this?


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6/16/2014

Is my hand broken?

Clinical Scenario

A 24 y/o guy presents in ED with the left hand upraised. 
“I fell off my bike yesterday – he says – I remember a serious impact with an outstreched palm.”
There aren’t wounds, he feels pain on the radial side of  left wrist, there is an anatomical snuffbox tenderness. The clamp sign is positive, but the resisted pronation maneuvre and the longitudinal compression test are negative.  

Is it broken? Asks worried the guy.


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4/11/2014

Ottawa ankle rules. 
Does it really work?

Clinical Scenario

A 16 yo guy is brought in ED by his mother after a scholar accident.
While he was running, he crashed. 
My son has a sore ankle!  Is it broken? Asks the mother seriously worried.  
The ankle his slightly tumefied, there isn’t bone tenderness at the posterior edge or tips of either malleolus, neither there is pain during the pressure of the navicular bone or the base of the fifth metatarsal. 
Are you able to take 4 steps? - asks the doctor.


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