Emergency Department Myths (Senior Grand Rounds) – Colin Danko, MD
PCN Allergy and Cephalosporin cross reactivity Penicillin true cross reactivity with cephalosporins is 1-3% Most occur with first gen cephalosporins Third gen cephalosporin or later seems to be ok Contrast induced nephropathy Nephropathy seems to be a lab based issue (? Relevance, not patient centered) The contrast has changed (low osmolar now) 2017 Meta analysis – No AKI with contrast – observational studies No increased rate of CRRT or mortality Lidocaine with epinephrine safety in digital nerve blocks Lido w/ epi in digital nerve block not associated with digital necrosis Safe to use for digital blocks Topical anesthetics in the eye (proparacaine, tetracaine) Safe to use at home for patients with corneal abrasions, provide strict use instructions No change in outcomes (wound healing/complications). Better pain control Kayexalate Not a great improvement in potassium Studies are flawed that reported benefit Side FX: Bowel necrosis - Bad Cricoid Pressure aka Sellick Maneuver Reported to decrease rate of aspiration Study shows doesn’t change rates of aspiration Makes view worse This is different than bimanual intubation (use of your right hand to get cords in view) The Q word (Use of the word quiet in the ED) Not associated with a worse clinical shift or higher volume Vascular Emergencies – Bobby Barnes, MD Arterial Occlusion: Embolic cause >> Thrombotic (80%:20%) ABI important to determine severity: Best Pedal sbp / best brachial sbp Normal > 0.8 Bad < 0.5 Doppler Wave Forms are important: Triphasic -> diphasic -> monophasic -> no wave form Good flow -> less flow -> low flow -> no flow Also listen for venous hum DVT causing ischemia: Phlegmasia cerulea dolens - painful blue limb from DVT Phlegmasia alba dolens - painful white limb from DVT Rutherford Classification: Uses Neurological exam (strength/sensation) and doppler (arterial/venous waveforms) Viable (Class I), Threatened (IIa, IIb), Non-salvageable (III) Management: ASA and Heparin for all unless contraindicated (aortic dissection) Disposition: Rutherford I and IIa Go to IR suite for tPA Have time to tolerate slower treatment with tPA Rutherford IIb and III Go to OR for bypass vs amputation Time is limited Be a Top Earner. Billing and Coding – Walt Green, MD Increase the RVU’s More patient’s per hour – push to “see one more” Document better – 99284 to 99283 is a big change in pay Flow is important Don’t do upstairs workup in the ED, empty the bed Don’t be distracted at work – no Netflix, stock picking, fantasy league 1 RVU = $36 Don’t over-document for low acuity charts (ankle sprain, suture removal, etc) Critical items for Level 5 (99285) chart 4-10-29 4-History 10-ROS 2-social, family, past medical 9-physical exam with 2 bullet points in each section Critical Care Time – 99291 Have a template Starts at 30 minutes and higher Don’t lie about the time spent – High fines Procedural Sedation Have a templated note so that you get the RVU/reimbursement EPIC/EMR charting usually does not allow coders to see and bill this activity --> Lots of money lost
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September 2020
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