ACEP ’15 Pearls

Here are twelve pearls that the 4th years learned at ACEP!

  1. You can calculate shock index (SI) to help determine mortality
  • SI= heart rate/ systolic bp
  • 0.5-0.7 normal
  • > 0.9 increased mortality
  1. Giving Bactrim to someone on ace inhibitor is a no-no due to risk of hyperkalemia
  1. AMA risk is all about the documentation. The actual disposition label and the patient’s signature do not mean much. Document on how you explained, how well the patient understood, the patient’s decision making capacity, and that you encouraged them to return.
  1.  RVU pearls: In order to get full RVU for reviewing an EKG, you need to chart 4 elements in your EKG interpretation.  Also, charting an abscess as “complex and loculated” gets you way higher RVUs.
  1. You can make a high flow nasal oxygen setup without respiratory therapy.  Attach a nasal trumpet to suction tubing using the adapter you usually use between tubing and an NG tube. Hook that to the wall oxygen and turn all the way up.
  1. You can’t use adenosine to differentiate between VT and SVT — at least 10% of VT will be adenosine responsive. Thank you Amal Mattu.
  1. Evaluating an HIV patient with no recent CD4 count? The absolute lymphocyte count (total WBC x lymphocyte percentage) can act as a surrogate. If <1000, 91% predictive of CD4<200; if >2000, 95% predictive of CD4>200
  1. Thromboelastography (TEG) may be an alternate way to test coagulation in patients, particularly those on anti-platelet agents. It may also help to determine which blood product should be given most emergently: plasma vs. plts vs. factor vs. PRBC. Not sure we have this at RIH, but it may be available at your next shop. I am sure it has limitations and etc., but at least you now know it exists.
  1. Arrhythmogenic Right Ventricular Dysplasia (ARVD) is more common than once thought. Don’t forget to look for that epsilon wave in the EKG of your syncope patients which is a small positive deflection buried at the end of the QRS. You may save that (usually young) person’s life.
  1.  Bismuth subsalicylate (Pepto Bismol) can reduce the incidence of traveler’s diarrhea up to 60%.  And it may have antimicrobial effects against C. difficile.
  1. In blunt pediatric trauma:  Neg FAST + normal lipase, and ALT and AST <100 = no need for CT Abd and Pelvis, just observation. (SE 88%, SP 98%; PPV 94%, NPV 96%, accuracy 96%).   Side note : AST alone has a negative predictive value of 71%, Lipase alone has positive predictive value 75%
  1. Pulmonary embolism is responsible for 50% of deaths after bariatric surgery.

What did you learn at #ACEP15??
Post on the comments below!

Faculty reviewer: Dr. Gita Pensa


1 thought on “ACEP ’15 Pearls

  1. I learned a few things — one pearl is that over half of lateral talus process fractures are missed on Xray. This fracture is common in snowboarders due to being locked in dorsiflexion and torque with falling. US can be helpful for skilled users, or CT to assess if you have a high index of suspicion.

    If you have a Twitter account (and of course you do!) you can check out lots of other pearls under the hashtag #ACEP15.

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