June Introduction

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Joseph B. -

Thanks for sharing this great case Anand!

A question was asked in the clip - "How could one have predicted this patient was going to decompensate?" I would suggest that the patient presented in obstructive shock, and their deterioration might have been predicted based on the narrow pulse pressure observed.

The patients stated blood pressure on presentation was 108/75. A narrow pulse pressure is often recognized by gestalt by intensivists, but if it "looks" narrow a rule of thumb calculation can be applied to confirm: if the PP (in this case 33) is less than one half of the DBP (in this case 1/2 of 75 = 37.5), then it is "narrow".

A narrow pulse pressure reflects a very low stroke volume and must be recognized efficiently as the ddx includes tamponade, tension PTX, massive PE, cardiogenic shock, abdo compartment syndrome or severe hypovolemia, and all require immediate specific lifesaving therapies.

We don't look at PP often in the ED, and I always emphasize it in resident eduction as an early clue to recognize badness.

Take care!

Anand S. -

Thanks! Will look into this more for sure

ryan harris -

This comment does not apply to this episodeI just didn't know where to put it.

A couple suggestions for future segments:

1. complications of fracture reductions--- I recently reduced an elderly demented woman's distal radius fracture and created a full thickness skin tear because of the force needed to reduce coupled with thin skin with zero collagen. After I sheepishly irrigated it and quickly stapled it (the quicker you repair it its like it didn't even happen) before applying the splint, I talked to our ortho doc who said--- "good job on the reduction, it happens".
Not sure there is a way to prevent it, but I had never even thought about it happening or trying to prevent it so I though I'd throw it out there.

2. After a brief unevidenced based deliberation in my head I ordered a d-dimer on a young obese female with SOB with a Mirena IUD for her birth control. She would otherwise be PERC neg. Luckily it was negative. I searched EMRAP and came upon the June 2013 board review answer sheet about which hormones count for PERC rule / increased risk of VTE. I also read a few other sources, some seemed trustworthy others questionably trustworthy, They indicated that low dose progestin only hormones don't count, ie don't convey any increased risk of VTE. Seems like there is some dispute about Depo. Could you do a short segment to clarify? Also in the newest medical fad of men being labeled LOW T (as an aside I think this label is awesomely fashioned by a PR firm to sound cool to men so they don't have their feelings hurt), I've read that testosterone Rx for LOW T does increase the risk for VTE, whereas originally it was thought not to convey increased risk. True?

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