The following articles are potential practice changers that for some reason never got the publicity they may have deserved (they have not enjoyed the limelight). Read my summaries, or better yet read the articles, and make your own decisions.
Vital Signs
Article:
Can I Discharge This Adult Patient with Abnormal Vital Signs from the Emergency Department?
Evidenced based medicine paper reviewing other studies on abnormal vital signs in ED patients and adverse outcomes
Brit Long, et al. JEM 2024 Nov;67(5):e487-e493. Link: click here
Summary of Findings:
Vital sign abnormality with at least twice odds ratio for admission within 7 days after discharge include the following
SBP <=95, HR >100, Temp >99, pulse ox <92% (I slightly modified these to make easier to remember)
Abnormalities associated with death within 7 days of ED visit/discharge
Vitals: tachycardia, vital sign abnormalities that persisted despite treatment
Other red flags: AMS, frequent falls, dispo change by 3rd party, malfunctioning medical device
Vitals AT DISCHARGE associated with 3-fold risk of death within 15 days of ED visit/discharge
SBP <90 or >180, HR >90 or <50, RR >20 or <12, Temp >100.4 or <97, pulse ox <94% (slightly modified)
Lots of overlap so not specific nor sensitive but still important
I use HR >90 and so does SIRS and so does this article.
Returns for admission w/in 72h or worsening condition after admission
HR >100, RR >20 and temp >100.4 were best vital sign predictors of above
Returns/bounce-back to ER
Elevated shock index predictor
Bigger lessons & EM Logic:
Vital signs are not just normal or abnormal, they are a continuum and the closer to abnormal they get the higher should be the level of concern, especially if they do not improve and/or do not have a solid benign explanation. Examples: normalizes, HR always that high (guy last week with flutter), BP improves with orthostatics
Pearl for vital sign trends: triage HR and EKG HR. EKG HR usually about 15 bpm lower
I don’t calculate shock index but closer HR is to SBP the more my level of concern
I teach residents any temp >98.6 should trigger make you question infection if you have not already
Same with a high normal WBC could especially if there is left shift (I use 70% PMN, but the higher the more I worry)
Most of the data we review is on a spectrum and so should be our concern level about each data point.
ACLS / RESUSCITATION:
Refractory V-fib
Beta Blockers
DSD: Dual Sequential Defibrillation: no great studies but in case reports has about twice chance of succeeding
Avoid empiric Bicarb: It has been class III since 2010 and does more harm than good in most patients. It drops the potassium levels which are likely already low in most arrest patients.
Over-testing and the Law of Diminishing Returns: why we shouldn’t do additional tests if the risk is already less than 1-2%. References
Lumbar Puncture: CT before LP indications: IDSA guidelines associated w/ delays in treatment and thereby worse outcomes than Swedish guidelines. Reference
Swedish Guidelines: symptom duration >4 days, pronator drift or signs of herniation (GCS<6 w/ non-reactive pupil, opisthotonus, abnormal breathing, or HTN w/ slow HR).
IDSA Guidelines: decreased immunity, focal CNS history, seizure in the past 1 week, AMS, focal neuro exam or papilledema (wear a mask if checking for this).
Intubation: BUHE for intubation:
Back Up Head Elevated position decreased complications by 13% and offered a better view of the vocal cords
EAR, NOSE & THROAT:
Vertigo: steroids beneficial for vestibular neuronitis:
Antibiotics for Diarrhea: most adults with diarrhea who are ill enough to come to the ED should go home with a script for azithromycin. The shadow literature supports this approach though few doctors do it because they want a stool culture, which typically should only be ordered in patients who have failed first line therapy or who work in the food industry or are sick enough to be hospitalized. The drug of choice used to be Cipro, but with quinolones on the out, the drug the is IN is azithromycIN. Children are much more likely to have a viral cause and so should not receive empiric antibiotics unless cultures are positive. Literature is mixed here however with many guidelines recommending against empiric antibiotics unless the case is “severe”.
Jolt Sign in Meningitis: Is 70-100% sensitive for meningitis so should be done on anyone with fever and headache, especially if vomiting. It is not perfect but it is much better than neck stiffness, Kernig’s or Brudzinski, all of which are less sensitive (see below). Reference 1, Reference 2
Kernig sign: 5% sensitive
Brudzinki sign: 5% sensitive
Nuchal rigidity: 30% sensitive
Photophobia: probably ~30% sensitive
Jolt accentuation: 70-99% sensitive
NEUROLOGY:
Seizure with prolonged post-ictal period: Post-ictal >30min w/o improvement. DDx = SIN (Stroke, ID, NCSE)
Stroke: 1-2% of acute strokes present w/ seizure. Another 1-2% present w/ posturing/myoclonus
Aspirin PLUS Plavix should be considered for secondary prevention for the first 1-3 weeks after a significant TIA (ABCD2 score of 4 or higher) or minor stroke (NIHSS of 3 or less).
With major strokes aspirin alone is recommended due to higher risk of bleeding.
2/3 of massive PE’s are painless:Small PE’s cause peripheral lung infarcts and so are more likely to have pain, which is always pleuritic, and nothing else and therefore can mimic pleurisy, URI, etc. Massive PE’s are central w/o lung infarct and so are painless in 2/3 and may mimic ACS (SOB, ECG changes, troponin leak), pneumonia (WBC high, vitals abnormal), anxiety, CHF, etc. When massive PE’s do cause pain it is typically from RV ischemia and therefore not pleuritic but can also be from smaller PE fragments. Reference
YEARS criteria limits need for CT or VQ in mild D-dimer elevations – VALIDATED
Included: 3616 patients to determine when can use a higher D-dimer cutoff (double the usual one)
Excluded: age <18, blood thinner use
No clinical signs of DVT
A better Alternate diagnosis
No Hemoptysis
Benefit: Using a D-dimer cutoff of twice usual cutoff led to 14% fewer chest CT”s. ~99% sensitive. Better than age-adjusted unless your patient is older than 100, validated in pregnant patient and those under age 50 where radiation may be more of a concern.
Pneumonia: steroids beneficial for admitted pneumonia (not just COVID or COPD/Asthma):
For severe community-acquired pneumonia (CAP) corticosteroids reduce morbidity and mortality with a NNT = 18 to prevent one death. For non-severe CAP admissions, corticosteroids reduce morbidity, but not mortality, with a reduction in time to clinical cure, length of hospital stay, total ICU days, rate of respiratory failure or shock and other complications. Most adult studies used a dose equivalent of ~50 mg prednisone/day for 7 days. References: (1) Seagraves T, et al. Ann Emerg Med. 2019 Jul;74(1):e1-e3. (2) Pliakos EE, et al. Chest. 2019 Apr;155(4):787-794. (3) Stern A, et al. Cochrane Database Syst Rev. 2017 Dec 13;12:CD007720. Reference 1
