Hippo ERcast March 2022

Jeff Kline Answers Your Clotting Questions

Pulmonary embolism testing hinges on pretest probability, and D-dimer becomes far less specific in COVID. Pregnancy, PERC nuance, and newer D-dimer strategies all change how clinicians can safely avoid over-imaging while still respecting missed-clot risk. COVID, PE, and D-dimer Poor specificity in COVID: A normal D-dimer still helps exclude PE, but in COVID the standard threshold has only about 15% specificity, making positive results common and often unhelpful. CT over reflex dimer: In sick COVID patients with real concern for pulmonary embolism, CT pulmonary angiography is the more useful test because D-dimer can stay markedly elevated for weeks without a visible macro clot. Ambulatory versus admitted risk: Discharged ambulatory COVID patients do not appear to need extra PE testing or routine anticoagulation simply because of COVID, while admitted patients carry substantially higher thromboembolic risk. Early clotting signal: Thrombotic risk seems to rise early, around the onset of myalgias, but how long that risk persists after acute illness is less certain. We get into the practical timing uncertainty in the episode. PERC in COVID: Available reports suggest PERC still performs if every criterion is met, with the oxygen saturation cutoff doing important work in COVID patients. PERC nuance and new cutoffs Highest heart rate counts: For PERC, the official answer is to use the highest recorded heart rate, so a transient tachycardia at triage still makes the patient PERC positive. YEARS-guided dimer strategy: Low-risk patients who are PERC positive can sometimes use a higher D-dimer threshold when the YEARS score is zero, a shift that reduces imaging without losing safety. We walk through that pairing in the chapter. Which clots get missed: The main PEs below the higher D-dimer threshold are typically subsegmental or chronic clots, not the larger obstructive events most clinicians are trying to catch. Why 500 is low: The classic 500 ng/mL cutoff is framed as overly conservative, reflecting a push for near-perfect sensitivity rather than the clinically meaningful clots that drive outcomes. Gestalt decision domains: Kline breaks PE suspicion into five elements: knowledge, present data, visual impression, pattern recognition, and normative behavior, giving gestalt a more explicit structure. Pregnancy PE evaluation and practice Normal dimer still helps: A normal D-dimer can support stopping the PE workup in pregnancy across any trimester, rather than treating pregnancy itself as a reason to ignore the test. Pregnancy-adapted thresholds: Pregnancy-adjusted D-dimer strategies can safely raise the cutoff in selected low-pretest-probability patients, while keeping a lower threshold when YEARS features are present. Bedside leg ultrasound role: For pregnant patients with an intermediate D-dimer result, bedside venous ultrasound for DVT can clarify the workup before moving straight to chest imaging. Austere setting bridge therapy: When transfer delays make PE workup impractical, a single dose of low molecular weight heparin or rivaroxaban may be reasonable if there are no contraindications. Documenting considered PE: If PE crossed your mind but you chose not to test, document that you considered it and why it was unlikely; that charting distinction is worth hearing in the podcast.

OB Nightmares: Peri-Mortem C-Section

Maternal cardiac arrest demands immediate pregnancy-specific ACLS: relieve aortocaval compression, secure oxygenation early, and prepare resuscitative hysterotomy without delay. In a gravid patient with a uterus at or above the umbilicus, the key decision is when to move from standard CPR to peri-mortem cesarean while coordinating OB, anesthesia, and neonatal teams. Maternal Cardiac Arrest Basics Aortocaval compression relief: Pregnant arrest is mechanically different: left uterine displacement while the patient stays supine reduces vena caval compression and preserves CPR quality, with one person assigned to that task. Pregnancy airway pitfalls: Hypoxemia develops faster in pregnancy because functional residual capacity is lower and oxygen consumption is higher, so the most experienced airway operator should handle intubation or bag-mask rescue. Access above the diaphragm: IV or IO access should be obtained above the diaphragm because the gravid uterus can impede venous return from below, a practical detail that matters early in the code. Arrest cause framework: Use an A-H plus trauma differential for maternal arrest: anesthesia, bleeding, cardiac disease, drugs, embolic causes, fever, general metabolic problems, hypertension, and trauma. We lay out the high-yield pregnancy causes in the episode. Early team mobilization: Maternal code management is a parallel-process event requiring adult resuscitation, OB, anesthesia, and neonatal or pediatric support at the bedside as quickly as possible. Peri-Mortem Cesarean Decision and Technique Gestational age trigger: If the uterus is at or above the umbilicus, think viable uterine decompression and prepare for resuscitative hysterotomy rather than waiting for prolonged standard ACLS. Four-minute decision point: Start peri-mortem cesarean after 4 minutes of maternal resuscitation, aiming for delivery by 5 minutes to improve maternal hemodynamics and neonatal survival. Vertical incision preference: A vertical abdominal incision is the fastest ED approach and usually causes less blood loss, a useful procedural default when seconds matter. Four-layer abdominal entry: The abdominal wall is opened through fat, fascia, rectus, and peritoneum before entering the uterus, and that anatomy-first framing makes the procedure more manageable under stress. We walk through the tactile landmarks in the chapter. Immediate post-delivery priorities: After cord clamping and handoff to pediatrics, remove the placenta, rapidly close the uterus, pack the abdomen, and return focus to maternal resuscitation; post-delivery uterotonics and antibiotics follow. Bedside kit readiness: A dedicated cesarean kit with scalpel, clamps, towels, suture, needle driver, and scissors should be preassembled so the procedure can start without a scavenger hunt.

Lit Matters #1: Treating Bacteremia: Lead with a β-lactam

Early antibiotic sequence appears to matter in bloodstream infection. In hospitalized patients with bacteremia receiving both vancomycin and a broad-spectrum beta-lactam, giving the beta-lactam first was associated with lower early mortality, reinforcing the practical rule to cover gram-negative pathogens up front. Antibiotic Order in Bacteremia Sequence-of-therapy signal: In suspected bloodstream infection, the first antibiotic may influence survival; starting with a broad-spectrum beta-lactam was associated with lower 48-hour and 7-day mortality. Gram-negative first principle: Beta-lactams cover the organisms most likely to kill patients early in bacteremia, including many gram-negatives, while still covering most non-MRSA gram-positive pathogens. Common frontline beta-lactams: Piperacillin-tazobactam and cefepime accounted for most first-dose beta-lactam use, with meropenem used less often; we get into the practical implications in the episode. MRSA exception signal: When the bloodstream infection was MRSA, giving the beta-lactam before vancomycin did not show the same mortality benefit, a useful boundary on the main takeaway. Why the effect fits: The finding is biologically plausible: early beta-lactam therapy may better blunt gram-negative burden and could reduce endotoxin-related harm in pathogens such as E. coli. High-risk host relevance: This matters most in vulnerable patients like those with neutropenia, where gram-negative bacteremia is more common and early appropriate coverage is especially time-sensitive.

EEM Rewind The 3 Types of V Tach

Ventricular tachycardia is not one rhythm problem but three clinically distinct entities: monomorphic VT, polymorphic VT with a normal QTc, and torsades de pointes with a prolonged QTc. Correct classification changes the drug choice, the role of cardioversion, and which common antiarrhythmics can make the rhythm worse. Three Types of Ventricular Tachycardia Monomorphic VT pattern: Sustained monomorphic VT usually reflects scar-mediated reentry from prior MI or other structural heart disease, making electricity plus procainamide the core treatment approach. Polymorphic VT with normal QT: Generic polymorphic VT is usually an ischemia or Brugada problem rather than a torsades problem, so management pivots toward shock, ACS treatment, and cause-specific follow-up. Torsades definition: Torsades de pointes requires polymorphic VT plus a prolonged QTc on a baseline or peri-event ECG; a rhythm strip alone cannot make the diagnosis. That distinction is worth hearing in the episode. Baseline ECG importance: The key diagnostic move is to find the QTc before or just after the run, because the bedside appearance of twisting complexes does not reliably separate torsades from other polymorphic VT. Wrong drug hazard: Amiodarone and procainamide are useful in other VT syndromes but can worsen torsades by lengthening repolarization further, a high-stakes treatment error in the unstable patient. Cause-Specific Treatment Pearls Monomorphic VT therapy: For persistent monomorphic VT, shock remains first-line and procainamide is the most successful antiarrhythmic, while amiodarone can be especially useful in electrical storm because of beta-blocking effects. Ischemic polymorphic VT approach: Polymorphic VT with a normal QTc should trigger a search for acute coronary syndrome and consideration of the cath lab, not reflex treatment as torsades. Brugada syndrome clue: A normal-QTc polymorphic VT pattern can point to Brugada syndrome, where electrophysiology referral and defibrillator evaluation matter more than routine antiarrhythmic thinking. Magnesium for torsades: Magnesium is first-line therapy for torsades when shock alone is not enough, followed by strategies that shorten repolarization and prevent recurrence. We walk through the pacing logic in the chapter. Electrolyte correction goals: Torsades often rides on hypokalemia, hypomagnesemia, or hypocalcemia, so treatment includes aggressive correction after conversion with potassium and magnesium targets kept deliberately high.

Lit Matters #2: Don’t Chase PE in All COPD Exacerbations

Pulmonary embolism can mimic a COPD exacerbation, but routine PE screening for every admitted COPD flare did not improve 90-day patient-oriented outcomes in the SLICE randomized trial. The practical takeaway is selective PE workup based on clinical suspicion, not reflex D-dimer testing for all. PE Testing in COPD Exacerbation SLICE trial takeaway: Hospitalized COPD exacerbation patients did not have better 90-day outcomes with a formal PE search strategy than with usual care, despite more testing and more emboli found upfront. Selective suspicion matters: Patients in whom PE was already clinically suspected were excluded, reinforcing the real message: investigate PE when the story points there, not just because COPD and PE can overlap. D-dimer first strategy: The intervention used D-dimer followed by CT pulmonary angiography if positive; about half had a negative D-dimer, and we get into why that still did not translate into better outcomes in the episode. Detected PE burden: Among patients with a positive D-dimer who underwent CTPA, PE was found in 8.8%, mostly without any need for fibrinolysis, thrombectomy, or IVC filter-level escalation. Patient oriented outcomes: The primary composite outcome was essentially identical at 90 days, about 30% in both groups, which undercuts routine PE risk stratification as a default admission pathway. Bedside practice shift: If it looks like COPD and acts like COPD, routine PE workup is not mandatory; reserve imaging and anticoagulation decisions for cases with genuine PE signals or atypical deterioration.

How (and Why) to Use an Interpreter

Professional medical interpretation is a quality, safety, and civil-rights issue in emergency care. Patients with limited English proficiency receive worse diagnostics, less analgesia, and poorer discharge understanding without language access, while trained interpreters improve accuracy, satisfaction, and downstream utilization. Interpreter Use in Emergency Care Legal access requirement: Title VI requires meaningful language access for patients with limited English proficiency in federally funded care, making family or ad hoc interpretation more than a workflow shortcut gone wrong. Diagnostic accuracy gap: Professional interpreters improve the history you actually get; one striking example is CT pulmonary angiography yield rising from 3.23% without an interpreter to 7.37% with one. Ad hoc error risk: Family and other ad hoc interpreters are about twice as likely to make clinically significant mistakes, with false-fluency errors being a common and dangerous pattern. Patient-centered outcome gains: Language barriers are linked to 66% less analgesia and roughly 50% worse understanding of diagnosis and plan, while formal interpretation markedly closes that gap. Technology that actually helps: Video and in-person interpretation perform best for discharge comprehension, while Google Translate misrenders about half of discharge instructions. We get into the practical tech options in the episode. Time and cost reality: Using an interpreter adds about 16 minutes to an ED visit on average, but professional language access reduces unnecessary testing, lowers readmissions, and can save substantial system costs.

Lit Matters #3: EVT Alone vs Lytics + EVT for Stroke

Direct-to-thrombectomy-center anterior-circulation stroke is not yet a settled case for skipping IV alteplase before endovascular therapy. MR CLEAN–NO IV found EVT alone was neither superior to bridging thrombolysis plus EVT nor proven noninferior, keeping alteplase in the conversation for eligible patients. EVT Alone vs Bridging Thrombolysis Direct-center stroke population: The trial enrolled patients presenting straight to EVT-capable stroke centers with proximal anterior-circulation occlusion within 4.5 hours, so the findings apply best to thrombectomy-ready systems rather than transfer-in settings. Primary disability outcome: Functional recovery favored neither shortcut nor clear equivalence: median 90-day modified Rankin score was 3 with EVT alone versus 2 with alteplase plus EVT, and EVT alone did not show superiority. Noninferiority not established: The key practice point is not that EVT alone failed, but that it was not proven close enough to alteplase plus EVT to be considered an acceptable substitute. We get into why superiority and noninferiority answer different bedside questions in the episode. Reperfusion signal: Successful reperfusion numerically trended higher with alteplase plus EVT, reinforcing the biologic case that bridging thrombolysis may still help before clot retrieval even when thrombectomy is available. Safety and mortality signal: Symptomatic intracranial hemorrhage was similar at about 5% in both groups, while 90-day mortality was numerically higher with EVT alone, a cautionary pattern even without a definitive difference. What this changes now: For alteplase-eligible patients already at a comprehensive stroke center, this study does not support routinely skipping lytics before thrombectomy, though the unresolved exceptions are where the nuance lives in the chapter.

Must Be Human

Clinical work can erode empathy through repetition, time pressure, and burnout. Preserving humanity at the bedside is not sentimental; it improves trust, communication, and the patient experience in emergency medicine. Humanity in Clinical Practice Daily Practice Erosion: High-volume emergency care can blunt empathy through cognitive overload and routine exposure to suffering, making detachment feel efficient even when it harms connection. Bedside Human Connection: Small interpersonal moves can restore presence at the bedside, especially when a patient is frightened, vulnerable, or reduced to a chief complaint on a board. Humanity as Clinical Skill: Compassion is a practical clinical skill, not an extra, because trust and clear communication often shape adherence, disclosure, and the tone of the encounter. Simple Reminder Effect: A brief reminder can reset how a clinician shows up in the room and change the interaction in ways that are easy to forget during a packed shift. That reset lands well in the episode.