Pneumonia

Lights criteria (High protein and LDH = exudate), determines presence of exudate with protein and LDH levels

  • Pleural fluid protein to serum protein ratio >0.5
  • Pleural fluid LDH to serum LDH ratio >0.6
  • Pleural fluid level >2/3 of upper value for serum LDH
  • Additional criteria – Confirm exudate if results equivocal
    • Serum albumin – pleural fluid albumin <1.2g/dL

 

Guillain Barré Syndrome (GBS)

  • Guillain-Barre Syndrome is a difficult diagnosis to make and an accurate history and physical examination including reflexes and ambulation of the patient can help to identify this life-threatening diagnosis
  • LP results will reveal a normal opening pressure, elevated protein level with no cells
  • Intubation consideration: remember the 20-30-40 rule and avoid succinylcholine for RSI
  • Management options: IVIG or plasmapheresis should be considered in patients with GBS. They should be monitored closely in the hospital for progression.
  • Steroids have no role in the treatment of GBS.

 

Ticking Time Bombs

Several of the conditions discussed here can easily be overlooked because they may present, at least initially, with non-concerning symptoms. However, they have the ability to cause serious harm. Remember,

  • Address abnormal vital signs or have a cohesive explanation as to why you are not addressing them.
  • Abnormal vital signs without a clear explanation, as well as vital signs that do not resolve with treatment, should prompt expanded consideration of the patient’s complaint, further investigation, and likely both.
  • Bad things happen and even healthy people get sick.

 

The Heart Score

  • The risk of ACS in patients with negative biomarkers and normal ECGs approaches 0.2%.
  • Prior risk scores, such as TIMI and GRACE, provide little, if any benefit, in risk stratification for ED chest pain patients.
  • The HEART score and pathway can risk stratify patients into three separate categories: low (0-3), moderate (4-6), and high score (> 7).
  • Low-risk patients on the HEART pathway demonstrate likelihood of ACS that approaches < 1%, and it is easy to use in the ED.
  • Risk factors, history, ECG, troponin, follow up, gestalt, patients with points 3 or 4, and research design are areas of potential weakness.
  • Further improvement of the HEART pathway at this time is difficult, but in patients at moderate risk, CCTA may hold promise for evaluation of risk. This requires further study.

 

Hip Dislocation

  • Early identification and reduction is key to prevent complications
  • Always perform a full trauma and neuro exam, particularly of ipsilateral joints as concomitant injuries are common with traumatic dislocations
  • Don’t be reassured by negative post-reduction XRs as small fractures can occur. You should always consider CT

 

How To Use Continuous Wall Suction for Paracentesis

 

Recommended limits for total fluid removal vary depending on the source, but the consensus among guidelines is 5–6 liters without the need for volume expanders to lessen chances of major complications.