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Likelihood Ratio (LR) in Emergency Medicine

10/31/2011

Acute dyspnoea and Lung Ultrasound


It’s a dark night when a red code arrive at the ED by ambulance. 
Paramedics tell you: “called for acute dyspnoea, I think it’s a COPD exacerbation, he is wheezing, I gave him bronchodilators and steroids, but he is worsening”.
He has a history of  COPD and hypertension. 
He presents sweaty, dyspneic, arterial pressure is high (220/110).
Physical examination is normal except for wheezing.
AP Chest X ray shows no signs of congestion.

Can you exclude an acute pulmonary oedema? 
Or something else than your stethoscope and x ray is needing? 







Conclusion 

Lung ultrasond has been shown to have greater diagnostic accuracy in differentiating the causes of acute dyspnoea in emergency settings compared with the traditional methods commonly employed in emergency departments (ED).
Its major advantages, particularly over radiographic tech- niques, are the absence of ionising radiation, speed and the fact that it is unaffected by the patient’s breath-hold limita- tions or agitation. 
The reliability of ULCs makes this method appealing for use in the emergency care setting. ULCs provide a direct, morphological, readily apparent imaging of abnormal increases in lung water. Recognition of diffuse interstitial involvement through B-line detection allows some pulmonary diseases to be rapidly ruled out, in particular, COPD exacerbation, which is one of the most common causes of acute dyspnoea. 


Bibliography 

Lichtenstein D, Mezière G (1998) 
A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet tail artifact. 
Intensive Care Med 24:1331–1334

L. Cardinale G. Volpicelli F. Binello G. Garofalo S.M. Priola A. Veltri C. Fava
Clinical application of lung ultrasound in patients with acute dyspnoea: differential diagnosis between cardiogenic and pulmonary causes
Radiol med (2009) 114:1053–1064

Lichtenstein DA (2007) 
Ultrasound in the management of thoracic disease. 
Crit Care Med 35:S250–S261




Ilenia Spallino


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10/21/2011

Acute appendicitis and Symptoms


A 21 y/o man presents to the ED with pain in right low quadrant (RLQ) , anorexia, nausea and vomiting. His abdomen is soft, with a mild tenderness in RLQ, the psoas sign is positive. The pain is aggravate by cough. You perform kindly a rectal examination with pain.  



Are this signs useful for the diagnosis of acute appendicitis?










Conclusion 

No clinical signs alone is able to rule in or out an acute appendicitis. Rectal examination, still diffused, is not of any utility. 

May we need somwthing else?



Bibliography 


Meta-analysis of the clinical and laboratory diagnosis of appendicitis
British Journal of Surgery 2004; 91: 28-37
R.E.B. Anderson


Ciro Paolillo













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10/18/2011

Acute dyspnoea and X-Ray

It’s a dark night when a red code arrive at the ED by ambulance. 
Paramedics tell you: “called for acute dyspnoea, I think it’s a COPD exacerbation, he is wheezing, I gave him bronchodilators and steroids, but he is worsening”.
He has a history of  COPD and hypertension. 
He presents sweaty, dyspneic, arterial pressure is high (220/110).
Physical examination is normal except for wheezing.
AP Chest x ray shows no signs of congestion.

What about the LR of various chest x ray signs of congestion?













Conclusion 

Approximately 1 of every 5 patients with decompensated heart failure had no signs of congestion on ED chest radiography. Twenty percent of cardiomegaly observed on echocardiography is missed on chest radiography, and pulmonary congestion can be minimal or absent in patients with significantly elevated pulmonary artery wedge pressures. Although cephalization, interstitial edema, and alveolar edema were highly specific (96%, 98%, and 99%,respectively) for decompensated heart failure, their low sensitivity (41%, 27%, and 6%, respectively) makes them poor screening tools. The presence of congestion on chest radiography in ED patients with acute decompensated heart failure found a sensitivity of 81%. The presence of cardiomegaly has been shown to have moderate sensitivity (79%) and specificity (80%). Pleural effusion, when present, has been shown to be highly suggestive of acute decompensated heart failure in ED patients (sensitivity 25%; specificity 92%).

Clinicians should not rule out heart failure in patients with no radiographic signs of congestion

…and so what?



Bibliography 

Sean P. Collins, MD* Christopher J. Lindsell, PhD Alan B. Storrow, MD William T. Abraham, MD On behalf of the
Prevalence of Negative Chest Radiography Results in the Emergency Department Patient With Decompensated Heart Failure
ADHEREScientific Advisory Committee, Investigators and Study Group*
Annals of Emergency Medicine

Knudsen CW, Omland T, Clopton P, et al. 
Diagnostic value of B-type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. 
Am J Med. 2004;116:363-368.



Ilenia Spallino

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10/05/2011

Acute dyspnoea and clinical findings

It’s a dark night when a red code arrive at the ED by ambulance. Paramedics tell you: “called for acute dyspnoea, I think it’s a COPD exacerbation, he is wheezing, I gave him bronchodilators and steroids, but he is worsening”. He has a history of  COPD and hypertension. He presents sweaty, dyspneic, arterial pressure is high (220/110). Physical examination is normal except for wheezing.

What is the LR of clinical signs in the diagnosis of pulmonary oedema?













Conclusion 

The absence of pulmonary rales (sensitivity 0.60; specificity 0,78; LR + 2,73 LR – 0,51) and the presence of wheezing (sensitivity 0.22; specificity 0,58; LR+ 0,52 LR – 1,34) decreased the likelihood of heart failure insufficently to rule out a pulmonary oedema in a patient presenting with acute dyspnoea.
In acute setting you might  need something more than your stetoscope 

….but is it x ray?



Bibliography 

Does this dyspneic patient in the emergency department have congestive heart failure?
Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Department of Medicine, University of British Columbia, Canada.JAMA. 2005 Oct 19;294(15):1944-56.


Ilenia Spallino


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