St. Luke's Roosevelt

Front 1

Canadian C spine vs Nexus conclusion

Back 1

For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for C spine injury, and its use would result in reduced rates of radiography.

Front 2

specifics of CCR vs NLC

Back 2

CCR more sensitive (99.4% vs 90.7%) and more specific (45.1% vs 36.8%) for injury, and its use would have resulted in lower radiography rates (55% vs 66%)

Front 3

Nexus Low Risk Criteria

Back 3

PAIND

Pain: cervical midline tenderness

Altered mental status

Intoxication

Neuro deficit

Distracting injuries that are painful

Front 4

Canadian C spine rule

Back 4

Any high risk factor that mandates radiography (age at least 65yo or dangerous mechanism or paresthesias in extremities)

no low risk fator that allows safe assessment of ROM (simple rear end MVC, sitting position in ED, ambulatory at any time, delayed onset of neck pain, absence of midline C-spine tenderness)

able to rotate neck actively 45 degrees left and right

Front 5

CCR: dangerous mechanism definition

Back 5

fall from elevation at least 3ft or 5 stairs; axial load to the head (eg diving), a MVC at high speed (> 100 km/hr), or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision.

simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or large truck, a rollover, and being hit by a high-speed vehicle.

Front 6

Early Pregnancy:

Is transvaginal US useful in detecting IUP when serum hCG less than 1,000 mlU/mL?

Back 6

Level C: consider transvaginal US because it may detect IUP when serum hCG level below 1,000 mIU/mL

Front 7

Early Pregnancy:

Is transvaginal US useful in detecting ectopic pregnancy when serum hCG less than 1,000 mIU/mL?

Back 7

Level C: consider transvaginal US because it may detect ectopic pregnancy when serum hCG level below 1,000 mIU/mL

Front 8

Early Pregnancy:

What is the role of serial quantitative hCG determinations in either diagnosing or excluding ectopic pregnancy?

Back 8

Level B: obtain a repeat serum hCG determination at least 2 days after the initial presentation bc it is useful in characterizing the risk of ectopic pregnancy and the probability of a viable intrauterine pregnancy.

Front 9

Early Pregnancy:

Above what serum hCG level is the absence of intrauterine pregnancy by transvaginal ultrasound presumptive e/o ectopic pregnancy?

Back 9

Level B: arrange f/u for patients with a nondiagnostic transvaginal US and a serum hCG level above 2,000 mIU/mL because they have an increased likelihood of ectopic pregnancy.

Front 10

Early Pregnancy:

What is the frequency of tx failure in MTX therapy for ectopic pregnancy and its implication for ED mgmt?

Back 10

Level C: because the sx a/w GI s/e of MTX tx may mimic an acute ectopic rupture, r/o ectopic rupture resulting from tx failure before attributing GI sx to MTX toxicity. Tx failure with single dose MTX ectopic pregnancy can occur in up to 36% of pts.

Front 11

Early Pregnancy:

Is the administration of anti-D Ig indicated among Rh-negative women during the first trimester of pregnancy with threatened abortion, complete abortion, ectopic pregnancy, or minor abdominal trauma?

Back 11

Level B: administer 40ug of anti-D Ig to Rh-negative women in all cases of documented first trimester loss of established pregnancy.

Level C: consider administration of anti-D Ig in cases of minor trauma in Rh-negative patients

Front 12

Evaluation of D-dimer in suspected DVT:

conclusions

Back 12

DVT can be ruled out in a pt who is judged clinically unlikely to have DVT and who has a negative D dimer test. US testing can be safely omitted in such patients.

Front 13

Evaluation of D-dimer in suspected DVT:

clinical model for predicting the pretest probability of DVT

Back 13

1) active CA

2) paralysis, paresis, or recent plaster immobilization of the lower extremities

3) recently bedridden for 3d or more, or major surgery within the previous 12 wk requiring general or regional anesthesia

4) localized tenderness along the distribution of the deep venous system

5) entire leg swollen

6) calf swelling at least 3cm larger than that on the asymptomatic side (measured 10cm below tibial tuberosity)

7) pitting edema confined to the symptomatic leg

8) collateral superficial veins (nonvaricose)

9) previously documented DVT

10) -2 for alternative dx at least as likely as DVT

a score of two or higher indicates that the probability of DVT is likely; a score of less than two indicates that the probability of DVT thrombosis is unlikely.

Front 14

Acute Headache management:

Does a response to therapy predict the etiology of an acute headache

Back 14

Level C: pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache

Front 15

Acute Headache management:

Which patients with HA require neuroimaging in the ED?

Back 15

Level B:

1) new abnormal findings in a neurologic examination (eg, focal deficit, AMS, altered cognitive function) should undergo emergent noncontrast head CT

2) patients p/w new sudden-onset severe HA should undergo an emergent head CT

3) HIV positive patients with a new type of HA should be considered for an emergent neuroimaging study (lymphoma!)

Level C: patients older than 50yrs p/w new type of HA but with a nl neuro exam should be considered for an URGENT neuroimaging study

urgent: prior to d/c

emergent: immediately for r/o of life-threatening or severely disabling entities

Front 16

Acute Headache management:

Does LP need to be routinely performed on ED patients being worked up for nontraumatic SAH whose noncontrast brain CT are interpreted as normal?

Back 16

Level B:

In patients presenting to the ED with sudden-onset, severe HA and a negative noncon CT result, LP should be performed to r/o SAH

Front 17

Acute Headache management:

In which adult patients with a complaint of HA can a LP be safely performed w/o a neuroimaging study?

Back 17

Level C:

1) adult patients with HA and exhibiting signs of increased ICP (papilledema, absent venous pulsations on fundoscopic examination, AMS, focal neuro deficits, signs of meningeal irritation) should undergo a neuroimaging study before having an LP

2) in the absence of clinical findings suggestive of increased ICP, an LP can be performed without obtaining a neuroimaging study