Archive | November, 2012

risk of hemorrhage with warfarin-associated coagulopathy

30 Nov

study by Garcia et al:

  • 979 patients seen in community-based cardiology practices with
    • warfarin-treated
    • asymptomatic 
    • INR value ≥5
  • 96% (n = 937) had INR 5-9
  • 13 patients (1.3%) experienced major hemorrhage during the 30-day follow-up period
  • major hemorrhage = bleeding that was
    • fatal,
    • led to hospitalization with transfusion of at least 2 U of packed red blood cells,
    • occurred at a critical site (e.g., intracranial, retroperitoneal)
  • 0.96% experienced major hemorrhage among patients whose INR was >5 and <9.
  • None of the bleeding events was fatal.


  • Intervention with vitamin K was uncommon (8.7%).
  • Most patients were managed by withholding subsequent warfarin doses
  • 50% of patients who were managed conservatively and retested on day 4 or 5 had an INR of 2.0 or less.


asymptomatic INR 5-9 in patients on warfarin: low risk for major bleed (~1%)

treatment options include holding warfarin doses (seems to work ok, for the most part), vitamin K


References: article; picture

random review (i.e. thing i looked up again recently): drop arm test for rotator cuff injury

29 Nov


  • tests for rotator cuff tear; especially supraspinatus


  • have patient abduct arm to 90 degrees
  • ask them to lower arm to side slowly
  • examiner applies gentle pressure to top of arm
  • patient will no longer be able to gradually lower his arm and it will fall (if there’s a decent tear/injury)
  • negative test is a slow, gradual controlled lowering motion of the arm


–its in chinese, but i think that helps you focus on the visual. and the one word most of us will recognize (supraspinatus)




I’m a fan of this test, which patients can usually figure out easily, and sort of tests the same thing (supraspinatus)


References: AAFP Shoulder Exam;; Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition; Rosen’s Emergency Medicine. (2010); picture

spontaneous retroperitoneal hematoma

28 Nov

HIGHLIGHTS from J Emerg Med article:


its RARE: 89 patients over 8 year period at Mayo Clinic with spontaneous retroperitoneal hematoma

Median age was 72 years

Overall, 66.3% were anticoagulated:

  • 41.6% on warfarin,
  • 30.3% heparin,
  • 11.2% low-molecular-weight heparin;
  • 30.3% were on antiplatelet therapy;
  • 16.5% were taking both anticoagulant and antiplatelet medications
  • 15.3% were taking neither anticoagulant and antiplatelet medications

36% presented to ED, 64% developed SRH during inpatient anticoagulation therapy.

most common symptom was pain:

  • abdominal (67.5%),
  • leg (23.8%),
  • hip (22.5%),
  • back (21.3%)

10.1% were misdiagnosed upon their initial encounter.


  • 40.4% were managed in an intensive care unit;
  • 24.7% underwent interventional radiology (IR) procedures
  • 6.7% surgical evacuation
  • 75.3% receivedblood transfusion.


  • 5.6% within 7 days,
  • 10.1% within 30 days,
  • 19.1% within 6 months.



spontaneous retroperitoneal hematoma:

  • rare
  • 2/3rds on anticoagulation, but don’t have to be
  • commonly present with pain (abdominal, leg, hip, back)
  • treatment options include IR, surgical, transfusions
  • good luck


References: article; picture

non-contrast CT for appendicitis

27 Nov

Diagnostic accuracy of noncontrast computed tomography for appendicitis in adults


1258 publications searched, 7 studies met inclusion criteria

1060 patients total included

Pooled data:

  • sensitivity 92.7% (95% CI 89.5-95.0%)
  • specificity 96.1% (95% CI 94.2-97.5%)
  • estimated non-con CT false negative rate: 7.3%
  • range of CT with contrast falst negative rates (from a review): 3-17%



non-con CT not too shabby for appy.


References: article; picture

ISTUMBLED: drugs you can dialyze

26 Nov



memory aids are our friends:

quick hit today.  here’s a little mnemonic to help remember drugs that can be dialyzed:



I – INH/isopropyl alcohol

S – salicyclates

T – theophylline

U – uremia

M – methanol

B – barbiturates

L – lithium

E – ethylene glycol

D – dabigatran, depakote


References: clinics article, fp notebook site, picture

holiday weight gain

20 Nov

Little something for the Thanksgiving layover (gobble gobble):


Weight and body composition change over a six-week holiday period:

Change in weight and body composition was assessed over a six-week holiday period, prior to Thanksgiving Day through after New Year’s Day

Thirteen men and 21 women ranging in age from 23-61 years

majority of participants (24 of 34) perceived that they had gained weight, and four did gain ≥2 kg.

on average there was no difference between pre-holiday weight (74.0±17.8 kg) and post-holiday weight (73.9±18.1 kg), nor between pre-holiday body fat percentage (25.4±9.0%) and post-holiday body fat percentage (25.4±8.9%).


Holiday weight gain: fact or fiction?

convenience sample of 195 adults. 6-week winter period from Thanksgiving through New Years

On average, weight gain averaged only 0.37 kg.

weight gain was greater among individuals who were overweight or obese, and 14% gained >2.3 kg (5 lb).

absolute values for weight gain in this study were less than anticipated.



we gain weight, but maybe less than we think

–happy thanksgiving


References: weight & body composition article; holiday weight gain article; picture

impact of NG lavage on outcomes in GI bleeding

19 Nov

Article by Huang ES et al, reviewed in November’s Emergency Medicine News:

632 VA hospital patients with GI Bleeding

60% got nasogastric lavage (to look for blood in the lavage), 40% did not



  • get endoscopy
  • get endoscopy sooner
  • have high-risk lesions if bloody aspirate on NG lavage



  • transfusion requirement
  • length of hospital stay
  • need for surgery
  • 30-day mortality



  • thought is to help risk stratisfy by looking for bloody aspirates
  • NG lavage rated by patients as one of the most painful ED procedures
  • risk of complications (e.g. epistaxis, aspiration, disrupting clots, etc.)
  • high false negative rates (up to 18%)
  • inaccurate interpretation (up to 50%)



References: huang article, EMN article; picture