Is NEXUS dead? Are we admitting too many patients with pneumonia? How useful is the PERC rule? It’s all about decision rules on this episode of ERcast. Ryan Radecki from EM LIterature of Note joins us for a review of four papers:
2. Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.
4. Are Steroids Effective for Treating Bell’s Palsy?
Scott Weingart from emcrit.org gives his 2 cents worth on how we should be using the PERC rule. The question is, “How do we decide if a patient has a low pretest probability so that we can select the proper patients in whom to apply PERC?” Scott recommends using the Well’s score to decide if the patient is low risk. This gives you validated method of establishing a pretest probability rather than guessing. Although guessing/gestalt works pretty well too. Here is a link to Scott’s algorithm.
1. No posterior midline neck tenderness
2. No evidence of intoxication
3. Oriented to person, place, time, and event
4. No focal neurological deficit
5. No painful distracting injury
Age < 50 years
Pulse < 100 bpm
SaO2 > 94%
No unilateral leg swelling
No hemoptysis
No recent trauma or surgery
No prior PE or DVT
No hormone use
Bonus Section: Shoulder Dislocation
The Cunningham Technique for shoulder reduction is all the rage. Check out the ERcast tutorial on how it’s done. Even though this method can get some dislocated shoulders in like a hot knife through butter, remember that all shoulder dislocations are not the same, nor will all patients be relaxed enough to make it work. I think every emergency provider should be proficient with several reduction techniques.
Here are my top 6
6. Traction/counter traction with my elbow hooked inside the patients AC fossa while their arm is bent.
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Hi rob
I did a review and case of Bells palsy a few months back
I agree with you. Steroids. But don’t forget the eye care
Check out the link below
http://wacdocs.csp.uwa.edu.au/2011/08/clinical-case-023-alarm-bells-at-38-weeks/
Your mate. Casey
Any thoughts on what I’ll call the Weingart Approach. If I understood correctly, Scott advocates for c spine injury:
Apply NEXUS. If only c spine tenderness and not a brutal mechanism (severe trauma), then do Canadian Rule and if negative you’re done.
If NEXUS (other than central tenderness) + or any of Canadian rule +, you should image.
X-ray will miss too many injuries (?1/100) and so CT is the initial test of choice if “test *”.
Thoughts!
Pierre, that is exactly what THE MAN espouses.
Hey rob
I have been devouring your podcasts as I figure out my coming need to stay current and your blog is going to be a staple of this graduating residents regimen.
I just did a journal club on perc and came to the same conclusion as Scott Weingart. Perc is meant for those risk stratified as low or very low risk for pe and wells is the standard for such risk stratification. It’s the ddimer for the ddimer. I was even able to convince one of our oldest and most conservative faculty.
Thanks
Eric- “the d-dimer for the d-dimer” is pure brilliance! It’s the simplest way I’ve heard this explained and really brings home the take home message.