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ED Rules (conts that started by EMEDPA)

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Great idea: consortium of practical of "gotcha" rules:


1. Best ED rule: Vital signs are VITAL. explain every abnormality by exam and dx.


2. A pt with abdominal pain and a negative w/u including triple contract CT still needs explaination, and either overnight admit for the appy to "show up", or the mesenteric ischemia to "declare itself", or repeat exam by you or a partner in 8 hours.


3. Ditto kids under 12mos with fevers that are "viral"


4. ANY pt over 50 with "vertigo" probably does NOT have labrynthitis. remember cerebellar ischemia occurs just as frquently in this group as angina. MRI/MRA has put a lot of egg on "inner ear" diagnosticians. Labrinthistis in this age group does occur, but not as frequently as we thought.


5. NGT all GIB. That which is red from below in fact may well be coming from above, and briskly.


6. 90% Febrile seizures in kids are infact roseolar/ecchoviral in etiology. Bet the mom a rash will occur.


7. Afebrile infant seizures, on the other hand, are bothersome. Sz w/u Plus Urine Drug Screens. Had two cases where kids seized after ingesting powder from a plastic packet that was laying on the floor. UDS Pos cocaine.


8. Don't wait for the CT: Treat the meningitis then CT if you must(adult pt) prior to LP (you have 4-6 hrs before cultures are affected)


9.. Ditto presumed gm neg septic shock. If you cannot get the cultures drawn in 10 minutes, start the abx anyhow.


10. Trauma = a tube in every hole, finger in the rear, primary and secondary surveys quick. If shipping, base dx clinically and don't waste time CT'ing.


11. In COPDers: intubate sooner rather than later.


12. Versus: In flash pulmonary edema/CHF, try natricor and BPap first


13. Pneumothorax, pneumomediatseinum, pneumoperitoneum, and pneumopericardium are really the only 4 things you absolutely never ever should miss on a CXR.


14. Notice I did not say pneumonia. Re-read #13.


15. 9 out of 10 times it is true that the pt will tell you what is wrong with them. And if what they said is not true, it tells you what fear they need to have satisfied for them to feel that they were well taken care of.


16. UPT on ALL women with a uterus which still can menstruate.


17. Lyme disease is the only cause of a patient demonstrating all forms (1st, Mobitz 1+2, and 3rd degree) Heart Block I know of. In this patient, draw Lyme titers, start appropr. abx while setting up Trannsvenous pacer.


18. Since most GC tx's are not spirochetocidal, draw the RPR when you send the GC and Chlaymdia...if is on the uprise, you know. And then give a 14 day supply of doxy afer the ED Roceph or Cip, and Zith. The doxy IS spirochetocidal.


19. SpO2 and FSBSs ARE vital signs


20. You ain't dead until you are warm and dead (in the case of young drowning, hypothermic patients...see case below)


That's all for tonight.

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Hey i just saw what may seem like #4 in clinic two days ago. 60 yo WM c/o 2 day hx of vertigo. +n/ . no sob, no dyspnea, no diaphoresis, no syncope. My precptor sent him over to the ED to get w/up(no changes in EKG) per INS would not allow stat CT. I haven;t heard anything about him yet.


Thanks for the great tips. It will come handy during my ED rotation. :)

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...and immunocompromised pts who can not mount a white count in reaction to infection...and folks recently on abx because this can hide the otherwise obvious surgical condition...for example lady misdiagnosed at another er as uti, given levaquin for 7 days still having lower abd pain with nl temp and nl white count...guess what ...missed perfed appy.....

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  • 5 years later...
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sent to me by a colleague at an em conference:



-Thrombolytics in a hospital code may result in a rare save, but probably don't work. There is a better chance of making a save if the arrest is do to PE rather than MI.

-Prehospital thrombolytics for asystole have been studied and do not work.

-Thrombolytics, if given pre-arrest to patients in critical condition from PE, probably does work.

-Therapeutic hypothermia is all the rage right now. However, much of the research is low quality or manufacturer support, and many of the results look too good to be true. Fortunately passive (and cheap) cooling techniques such as cooled IV fluids are as good as expensive cooling techniques.

-Protocols recommend that cardiac arrest patients (with return of circulation) should get 30cc/kg of cold fluids



Therapeutic Controversies

-For new atrial fibrillation, it's ok to cardiovert and send home to followup as an outpatient. Admission usually doesn't add much to the patient's care.

-Some states have statewide registries for narcotic prescriptions, which cuts down on drug seeking behavior.

-Beware the "drug seeking" back pain patient, this time they could have an epidural abscess or cauda equina.

-We often underdose dental blocks. When doing dental blocks use lots and lots of marcaine with epi. 5-6cc, yes 5 to 6cc, is well tolerated and will last a long long time.

-There still are not enough EM doctors in the country, and the use of PAs and NPs is steadily rising.

-PAs and NPs are both equally good at patient care.

-EZ-IO is being used a lot more in adults. For kids, an IO is quicker and potentially less painful than multiple IV tries. Just be sure to warn the parent about what's happening and why you're doing it!

-Therapeutic hypothermia after cardiac arrest may or may not work, but it's cheap and easy so until we have better research, we might as well try.

-Head bleeds: Even with a high resolution 64 slice head CT and CTA of the head, if there is concern about SAH, then the standard of care still includes LP. Bummer.

-The literature on PEs is evolving: small PEs may not need treatment any treatment. Patients with stable vital signs may be safe for outpatient anticoagulation. Sick looking patients need admission and possibly thrombytics.

-Always send two sets of troponin at least a few hours apart. Newer, high-sensitivity troponin tests that are positive sooner are on the horizon.

-Cardiologists are now saying that a "normal" angiogram gives you a clean bill of health for only about 6 months.

-Nurse initiated ordersets cause some unnecessary testing, but result in better ED workflow and shorter stays.

-For recurrent kidney stones symptoms, if you really want an imaging study, save cost and radiation by ordering a renal ultrasound instead of CT.

-Do CTs really cause cancer? Probably, and the lifetime risk of fatal cancer when you scan a kid may be even higher than the 1 in 2000 rate previously quoted.



-Ultrasound may be helpful in equivocal cases, but is not consistently accurate unless tubal abscess is present.

-ESR is sometimes elevated in PID, but why bother sending this test?

-PID vs appendicitis is a diagnostic quagmire: labs are not helpful, so do a thorough exam and liberally consult GYN.

-Most recent CDC treatment guidlelines are from 4/07:

Outpatient: ceftriaxone IM plus PO doxycycline, +/- flagyl

Inpatient: cefotetan plus doxy, +/- flagyl


Pediatric Urine

-Thanks to good vaccines against pneumonia and meningitis, UTI is now the most common bacterial infection in febrile infants.

-Bagged urine samples are notoriously contaminated, and should NOT be sent for culture.

-If a bagged UA is negative, great, it's negative and there is no UTI. If it's positive, you need a catheter sample to be sure because the bag sample is contaminated 40+% of the time.

-Ultrasound by the nurse to confirm a full bladder leads to better success rate getting cathed samples.

-Consider topical lidocaine before doing the catheter.

-Most families want to stay in the room for IV starts and catheters on their kids.

-On the pediatric UA, leukocyte esterase alone does not mean there is a UTI and does not mandate antibiotics. LE plus nitrites is much more accurate.

-WBCs are present on UA of many febrile kids and is NOT diagnostic of UTI, but is simply caused by there febrile/inflammatory state.



(a selection of relevant and new research)

-We often forget to give sedation after RSI. Etomidate wears off quickly, but Sux lasts a long time=paralyzed but awake patients, oh no!

-Nationwide UTIs are 20%+ resistant to Bactrim, resistance to Cipro is climbing dramatically. Macrodantin is a great alternative: well tolerated, cheap, effective.

-Tylenol is better than motrin for pediatric fever control; alternating doses of Tylenol/ibuprofen are marginally better than therapy with tylenol only.

-Giving an unnecessary antibiotic for an URI does NOT reduce the number of patients that bounceback to the ED! Education and good DC instructions work better.

-Procalcitonin levels are inaccurate in pediatrics.

-ALTE in a preterm infant needs a full sepsis workup.

-Most of febrile but immunized kids 3-36 months don't need any testing except possibly a catheter UA.

-A first febrile seizure does not need an LP. (I think we all knew this, but now there is finally research to back us up)

-Abscesses heal just fine without packing.

-Oxycodone should be used cautiously by the elderly because older folks metabolize it slowly and therefore accidentally overdose easily.

-Banana bags are expensive and are not routinely needed for intoxicated patients.

-For asthma exacerbations, 3 days of prednisone are as good as 5 days. (single dose decadron might also be just as good also)

-For bronchiolitis, nebulized epi doesn't work, steroids don't work, and there is only a small chance that albuterol works. Nasal CPAP works

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Pediatric Rehydration/Feeding

If a kid is dehydrated enough to need IVF, there is also a good chance that they are experiencing some starvation ketoacidosis, and they need both IVF and glucose.

For this reason, a good fluid choice for pediatric IVF is D5NS.

For mild-moderate dehydration, oral hydration (with Zofran and small sips of fluid) is as good as IV hydration.

Interestingly, parent satisfaction scores are better with IV hydration than PO.

When starting an IV, try to routinely use something to ease pain: EMLA, subQ lidocaine, Painease spray, etc. It may help the kid, and it definitely helps the parents to feel better.

Do kids need bowel rest after gastroenteritis? No. Do kids need a BRAT diet? No. Kids recover more quickly when they go right back to their regular diet.

Consider switching bottle fed infants to a soy-based formula after GI illness, as this is easier on their recovering intestines.

Apple juice is a bad choice for kids with GI symptoms because it causes diarrhea. (It's almost effective as prune juice)


Imaging of the C-spine, 2010

If NEXUS criteria are negative, don't do any imaging.

If you think the patient doesn't have a broken neck, don't waste money and time and radiation doing an unnecessary film.

If you DO think there may be a C-spine fracture, CT is much more sensitive than XR and should be your first choice test.

At some trauma centers they've found that CT is quicker and cheaper (for the hospital, not the patient) than 5-views via XR.

In kids, CT is much more accurate than plain films of the C-spine, so if the patient needs imaging, do a CT. But, CT is more radiation to the kid so only do imaging if the kid really needs it!

Flexion and extension views should never be done again, as the same info can be gotten more easily and accurately from CT or MRI

Doctors don't get sued in cases where no C-spine images were ordered because pts that don't have symptoms don't need images. Doctors do get sued when they miss fractures on XR that CT could have found.



Any study that has ever shown benefit from TPA for CVA has been manufacturer supported and controversial.

There are plenty of studies that show more harm than benefit with TPA, particularly when given in community hospital settings.

Conspiracy and Drug Company Influence? You decide: Recent publication of ECASS 3 research suggests extending the TPA window from 3 hours to 4.5 hours, and this has been endorsed by American Heart (AHA). Genetech, the makers of TPA, have given the AHA $10million over the last few years that studies have been going on. However, ECASS 1 and ECASS 2 and ATLANTIS trials all showed bad outcomes with TPA, but are not discussed by the AHA.…..

Invasive approaches such as stents and directed intravascular TPA are being studied at university centers, but so far the research shows worse outcomes. Bummer.

ED doctors are more likely to get sued for not giving TPA than for giving it. Bummer.

However, ACEP has a policy stating that TPA can be considered for stroke care but TPA is not "standard of care"


Diabetic Problems

In the hypoglycemic patient, 1 amp of D50 is rarely enough; 1 amp has less calories than half a Snickers Bar. Consider giving 2 amps to all hypoglycemia patients.

For hypoglycemia secondary to sulfonylurea medications, octreotide should be given as it blocks release of insulin and can shorten course and severity of symptoms.

Still doing ABGs for patients with DKA? There is a huge body of literature that shows that VBG is just as good. But why check a VBG at all, when a BMP and UA can tell if if the patient has acidosis and ketosis.

Another nail in the coffin of blood gases: you don't really need to know the pH. Even if pH is <6.9, bicarb should not be given as it worsens outcomes. Current recommendations from ADA and others: don't give an IV bolus of Insulin for DKA patients. Instead, give 1-2 liters of fluid and recheck a BMP. Consider adding potassium to your IVF, then start insulin drip at 5-10units/hr.

Using an approved "DKA order set" leads to better patient care, shorter ICU stays, fewer complications, and streamlined nursing care.



Should flu vaccine be mandatory for medical staff? Studies so that there is less flu related morbidity and mortality in facilities with mandatory staff immunization.

Rapid flu swaps are only about 50% accurate for H1N1. Little did I know that they're only about 70-80% sensitive for regular Flu A and B. The only thing less accurate than a flu swab is a physician trying to diagnosis flu by clinical criteria!

There is an advantage to doing a flu swab, at least in kids: If it is positive you know what you're dealing with and it seems to spare kids from unnecessary testing and medications.

Antivirals including Tamiflu are not very effective, but there is a small benefit when they're given very early in the illness (<36 hours). Unfortunately 12% of people given Tamiflu develop resistant strains of the flu, which can then get passed to others. Therefore, we probably shouldn't be giving this medicine to people unless they're really sick, as resistance is developing too quickly.

There is no indication for giving Tamiflu to otherwise health ED employees who develop symptoms, but these sick staff members should avoid patient contact.

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  • 4 months later...

1. A Physician Assistant is not a Semi-Pro, you are held to the same standard as a Physician.

2. Since death is very still, move quickly. Especially as it pertains to your ABC’s.

3. If it hurts, palpate it. If it hurts, X-ray it.

4. Do not practice castration through procrastination. Any patient that you suspect testicular torsion needs an immediate surgical consult.

5. Pain within 14 feet of the heart is an MI or Aortic disaster until proven otherwise.

6. The frequent flyer might be giving you another opportunity to get it right.

7. All children and elderly patients should be observed walking.

8. Very often when a man seeks medical care, there is a woman urging him to do it. Talk to her.

9. A fingerstick glucose is always indicated in altered mental status.

10. If they are ages 6 – 60 and have a uterus, get a pregnancy test. Immaculate conception is very, very common.

11. Remember that more than one bad thing can happen at once.

12. Elderly, Diabetics and Immunodeficient present their illnesses differently and rarely present with “classic” symptoms.

13. Belly Pain + Lot’s of Birthdays = Admit

14. Back or flank pain is a leaking AAA until proved otherwise.

15. When you need to buy some time to think, ask the elderly to describe their bowel habits.

16. With every med order or prescription you write, review in your mind how to manage anaphylaxis.

17. Patients who say they feel like they’re going to die, typically do. Listen to them.

18. Before you speak to a patient, in your mind tell them that you love them.


Dr. Leingang created these rules, an amazing doctor.

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