Cardiac Biomarkers

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Cardiac Biomarkers

Real time, high sensitivity serum biomarkers have played an enormous part in the timely identification and intervention on of cardiac pathology in the Emergency Department. These biomarkers have sufficient sensitivity to identify cardiomyocyte injury even in the absence of physical exam, radiographic, or electrocardiographic findings. Unfortunately, the utility of these studies may be limited or obfuscated in certain clinical contexts. This article will discuss the possible pitfalls and obstacles physicians may encounter in interpreting cardiac biomarkers

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EM Diagnostics: Pleural Fluid and Ascitic Fluid Analysis

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EM Diagnostics: Pleural Fluid and Ascitic Fluid Analysis

Paracentesis and thoracentesis are relatively common procedures in the Emergency Department but the analysis of the fluid can always but a touch confusing.  In this post, PGY-1 Dr. Michael Klaszky walks us through the analysis of pleural fluid and ascitic fluid.

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Hepatitis Panel Interpretation

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Viral hepatitis is a commonly encountered and increasing problem thanks in part to the rise in injection drug use. Here I review the screening recommendations and interpretation of hepatitis B and C serology.  Screening recommendations are based on CDC and US Preventative Task Force guidelines. Prevalence of viral hepatitis is much higher in the ED setting and may warrant expanded screening. This is an active area of research and there are as of yet no formal professional recommendations regarding expanded screening.  In this post we will explore the current screening recommendations for HBV and HCV and detail the interpretation of the test findings.

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ESR, CRP, & Procalcitonin: Acute Inflammatory Markers in the ED

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ESR, CRP, & Procalcitonin: Acute Inflammatory Markers in the ED

Working in the ED one day you seem to hit a run of patients in whom consultants have asked you to order an ESR, CRP.  First, podiatry asked for them for a patient with 1st metatarsal osteomyelitis.  Spine surgery wanted the same for a patient with diskitis. And, ortho wanted them for a possible septic.  You think to yourself, “what am I or my consultant going to do with these test results?” “What are these inflammatory markers anyhow?” And, “what patient’s should I be ordering them in.”

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Clinical Approach to Knee Radiographs

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Early in the morning, you begin your day in your local emergency department. After getting yourself situated, a slow trickle of patients begin to appear on the board. It appears to be a normal morning, all except for the fact that five patients appear, one after the other, who have the same chief complaint: “Knee pain”. It is a good thing you brushed up on reading knee x-rays recently!

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Clinical Concepts in CT Imaging of the Chest

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Clinical Concepts in CT Imaging of the Chest

A 45 yo Female presents to the ED with sudden onset of chest pain, described as worse when taking a deep breath.  She is significantly short of breath and appears distressed.  She recently underwent a total right knee arthroplasty and reports having been bedridden secondary to pain.  Physical exam is remarkable for a right lower extremity with surgical incisions that clean, dry, intact; however, her left lower extremity is swollen with significant tenderness along the popliteal fossa and calf.  

Vitals: Temp 99.2HR 120RR: 28 BP:  130/80 SpO2 90% on RA.

A CTPA is ordered...

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Clinical Concepts in Pelvic Ultrasound

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Clinical Concepts in Pelvic Ultrasound

Your patient is a well appearing, otherwise healthy 22 year old female who presents with lower abdominal pain x3 days.  She is unsure of her LMP, but thinks she had some spotting about a month ago.  Vital signs: Temp 99.3F, HR 92, BP 102/70, RR 20, 98% on RA.  She has a benign, non-gravid abdomen.  Urine pregnancy is positive.  You fire off a quantitative hCG and don’t expect that result to come back for a while.  What do you do next?  

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Interpreting Elbow and Forearm Radiographs

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Interpreting Elbow and Forearm Radiographs

Elbow injuries account for 2-3% of all emergency department visits across the nation (1). Yet, because of the elbow’s complex anatomy and the presence of numerous ossification centers in children, elbow fractures are the third most commonly missed fracture group in the ED (1). Here are some tools to help ED physicians read elbow x-rays more effectively and hopefully identify abnormalities more easily...

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Thoracentesis

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Thoracentesis

General Considerations

Both the diagnostic and therapeutic thoracenteses are performed using a similar technique. The major difference is the amount of fluid removed. The proceduralist may also choose to only use the needle technique as opposed to the needle-catheter unit when obtaining fluid for diagnostic purposes only.

It is generally recommended that needle size be limited to 18-gauge or smaller to minimize risk of pneumothorax and damage to nearby structures.

US-guided thoracentesis is associated with a significantly lower rate of complications and has become the standard of care. (1)  Real-time ultrasound (US) guidance is recommended for small or loculated effusions when there is concern that the diaphragm or lung tissue is <10mm from the pleural surface. It is also recommended in patients with relative contraindications such as coagulopathies and the mechanically ventilated patient.

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Lung Ultrasound: Evaluation for Pleural Fluid and Pneumothorax

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Lung Ultrasound: Evaluation for Pleural Fluid and Pneumothorax

The Basics

Think about gravity: fluid will collect in most dependent region (down); air tends to collect towards the least dependent regions (up)

Air does not reflect sound waves well. Lungs are filled with air. Rather than getting most of our information from visualizing the anatomy (as in a RUQ ultrasound, for example), much of our information comes from “artifact” or ultrasound waves being affected by phase changes.

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