Top Headlines in Clinical Emergency Medicine 
 Abstracted from EM:RAP by Chris Feier, MD
1.Use of the PERC (Pulmonary Embolism Rule-out Criteria) rule can significantly decrease work-up for pulmonary embolism.
To apply this rule, the clinician must first use clinical gestalt to classify the patient as low risk. The PERC rule, which consists of eight clinical criteria including history, physical and vital signs, can then be used. If both of these criteria are met, then there is less than a 2 percent risk that this patient has a PE and no further work-up is needed.
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

2.Norepinephrine is the vasopressor of choice for septic shock.
Studies have shown significant benefits over dopamine including improved splanchnic blood flow, better achievement of hemodynamic goals, and increased likelihood to survive hospital stay if given norepinephrine. Vasopressin as a low dose background agent has also been shown to have beneficial effects when used with a primary vasopressor such as norepinephrine.

3.Bedside Echo can alter management in patients with shock secondary to TCA overdose.
Tricyclic antidepressants block reuptake of norepinephrine thereby causing depressed myocardial contractility and decreased systemic vascular resistance. A quick bedside echo to determine left ventricular function can determine if the patient is in shock from the depressed myocardium or from peripheral vasodilation. In the case of cardiogenic shock, the vasopressor of choice would be dobutamine to increase cardiac contractility and perfusion. On the other hand, if the echo showed grossly normal cardiac function but an empty heart chamber, fluid resuscitation and norepinephrine would be the treatment of choice.

4.The Primary treatment for anaphylaxis is IM Epinephrine.
The therapeutic algorithm for anaphylaxis should begin with epinephrine 0.3-0.5 mg IM, which can be repeated every 5-15 minutes. The intramuscular route has been shown to have better absorption and more rapid peak plasma concentrations than the subcutaneous route and is therefore the route of choice. If the patient is still in extremis, then a diluted solution of epinephrine 0.1mg should be given intravenously. Extreme caution should be used when giving epinephrine intravenously as most adverse effects are from this route.

5.Anaphylactic symptoms may recur up to 72 hours after the initial event.
The disposition of the patient with anaphylaxis that improves after treatment poses a difficult problem to the emergency physician. Anaphylaxis shows a biphasic form in as high as 20% of patients in some series, and has recurred in patients that initially presented to the Emergency Department with stable vital signs. Admission or an Observation Unit would not be an unreasonable disposition for these patients, especially those that exhibited high risk features.



# Top Articles -- Subjectively or Objectively?Chris Carpenter 2008-01-16 15:39
Interesting selections. Are these Mel's subjective selections or has some survey of practicing EM physicians' rated them the top articles of 2007? If this is simply one physician's opinion, I'd suggest there is a better way to rate the top articles. Using the McMaster Health Information Research Institute, Best Evidence Emergency Medicine screens over 400 journals monthly filtering EM relevant articles through validated methodological filters. The highest quality evidence is then submitted to ~30 practicing (community and academic, rural and urban) physicians who then rate the articles for clinical relevance and newsworthiness. This is the model of the ACP Journal Club and vastly enhances the external validity (generalizabili ty) of the label "Best Articles of 2007".
# Publication of the PERC ValidationR. S. Sahsi 2008-01-18 02:20
As far as I've been able to determine, the necessary "external validation" of the PERC rule appears in the literature only as an abstract from its oral presentation at the 2007 SAEM conference. I would be interested in seeing said study data once formally published in a peer-reviewed journal prior to advocating its use on a broader scale.

If it has been published (other than its mentioned appearance in Acad EM), I would appreciate the reference and will stand corrected.
# PERC ValidationChris Feier 2008-01-20 16:16
The Best of EM:RAP is a compilation of the top learning pearls of the monthly audio CME series-EM:RAP by Mel Herbert. Dr Jeff Kline, who is the lead author on the PERC rule article, gave a lecture on the PERC rules for the december issue of EM:RAP. The original article can actually be found in the Journal of Thrombosis and Haemostasis (J Thromb Haemost 2004; 2: 1247–55). They prospectively validated the rules in a low risk group(n=1427) and a very low risk group(n=382) and found sensitivities of 96% and 100% respectively. Basically, the idea is to use this rule as a d-dimer in your low risk patients to avoid further testing.

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