Decision Tools: PERC, NEXUS and CURB-65

Is NEXUS dead? Are we admitting too many patients with pneumonia? How useful is the PERC rule? It's all about decision rules on this episode of ERcast. Ryan Radecki from EM LIterature of Note joins us for a review of four papers:

1. Hospital admission decision for patients with community-acquired pneumonia: variability among physicians in an emergency department

2. Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.

3. National Emergency X-Radiography Utilization Study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography.

4. Are Steroids Effective for Treating Bell's Palsy?

 

Scott Weingart from emcrit.org gives his 2 cents worth on how we should be using the PERC rule. The question is, "How do we decide if a patient has a low pretest probability so that we can select the proper patients in whom to apply PERC?" Scott recommends using the Well's score to decide if the patient is low risk. This gives you validated method of establishing a pretest probability rather than guessing. Although guessing/gestalt works pretty well too. Here is a link to Scott's algorithm.

 NEXUS Criteria

1. No posterior midline neck tenderness

2. No evidence of intoxication

3. Oriented to person, place, time, and event

4. No focal neurological deficit

5. No painful distracting injury

Canadian C-Spine Rules

PERC Rule

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

MD Calc Wells Score Calculation Engine

 Bonus Section: Shoulder Dislocation

The Cunningham Technique for shoulder reduction is all the rage. Check out the ERcast tutorial on how it's done. Even though this method can get some dislocated shoulders in like a hot knife through butter, remember that all shoulder dislocations are not the same, nor will all patients be relaxed enough to make it work. I think every emergency provider should be proficient with several reduction techniques.

Here are my top 6

1. Cunningham technique

2. Scapular manipulation

3. Milch/Modified Milch

4. Kocher method

5. Spaso Technique

6. Traction/counter traction with my elbow hooked inside the patients AC fossa while their arm is bent.

 

The best way to keep up on hot topics in emergency medicine: R and R in the Fastlane