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Likelihood Ratio (LR) in Emergency Medicine

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?















Conclusion

As you can easily see in the pictures above, all this clinical signs are very specific but poorly sensible, a recent study by Büttner M, et al. shows that the prevalence of fracture, in patient with a minor head injury (GCS>13) with a black eye, is more than 66%, this sign alone shoul lead to a CT investigation.


Bibliography 

Büttner M, et al.
 Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retro-spective analysis in a level I trauma centre over 10 years. 
Br J Oral Maxillofac Surg (2014)

Ilenia Spallino
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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.








Conclusion

If there’s a suspicion of a scaphoid fratture, clinical maneuvers have a little role in the diagnosis. Only the pain evocated by the resisted pronation or pinching the scaphoid, can increase the overall suspicion. Absence of the snuffbox tenderness cannot be used alone to rule out.
Of course, other tests are necessary. What about conventional X ray?



   to be continued...


Bibliography 

CR Carpenter
Adult scaphoid fracture
Acad Emerg med 2014 21:102-121 

CA Germann
Risk management and avoiding legal pitfalls in the emergency treatment of high-risk orthopedic Injuries
Emerg Med Clin N Am 2010 28: 969-996 

Ciro Paolillo


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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.






Conclusion 

If correctly performed (see the video) the Ottawa ankle rules have been shown to have high sensitivity, so if there is not an high pretest probability it rules out a fracture without any further test.
Their use leads to reduction of radiography, costs, and waiting time. 


Bibliography 

LM Bachmann
Systematic review.
BMJ vol 326 22 feb 2003

IG Stiell 
JAMA 1993 3 March vol 269 n9


Ciro Paolillo e Ilenia Spallino
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2/09/2014

Does every shoulder pain means magnetic risonance?


Clinical Scenario

A 35 y/o male come to the ED because of pain in his right shoulder, he refers the pain started some month ago during a tennis match, the pain continued but it wasn't so high so he kept playing in the last months, now it is worse. "My tennis mate told me I should perform a magnetic resonance, because it might be a rotator cuff disease" (RCD).
You listen to the patient but decide first to act as a physician and make the old and fascinating physical examination...
What you find is a normal movement of the shoulder, no pain in abducting the arm (arch test), no weakness or pain in internal and external rotation. (see video)


And so what?

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1/24/2014

Alarm symptoms and gastric cancer. Are they alarms or they are alarming?


Clinical Scenario

It’s a busy Monday morning in ED. 
A doctor at the phone – calls the nurse – there’s a primary care physician. 
Hi – says a voice on the other side –  I’m in a patient’s home. 
He’s a 40 yo man with dyspepsia, his wife refers weight loss of about 10 Kg in the last three months. He is pale, but not tachicardic, abdomen is treatable, on rectal examination I find normal stool. 

I’m warried he probably has a gastric cancer, Is it possible to schedule an urgent gastroscopy for this morning?


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1/15/2014

Age of 45 and dyspepsia.



Clinical Scenario

It’s the begining of another night shift in ED. Rik, an agreable young colleague approximates: Hi- he says – I have just seen a 60 y/o man who refers epigastric pain since 2 days. He denies bleeding and weight loss, he isn’t anemic. The bedside US shows a normal gallbladder and a normal abdominal aorta, ECG is OK. It seems an uncomplicated dyspepsia, but he is a 60y/o, I’m worried about a grastric cancer. 


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1/07/2014

Clinical diagnosis of gastric ulcer. 
Does your gastroenerologist perform better?


Clinical Scenario

A 35 yo smokerman presents at morning to the ED. He refers epigastric pain since seven days. The pain worses after eating, he refers nausea without vomit and he denies melena and weight loss.
Palpation causes pain in epigastric region, there’s not fever, nor tachicardia, hemoglobin is 13 g/dL.  
Bedside US evidences a normal gallblader.  

Take antiacid said my doctor and don’t smoke – he says – I’m worried, Is it an ulcer? I wish to consult a gastroenterologist.


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