Welcome back to another edition of Wednesday Wrap-up!
We had some great conference topics today including Geriatric Trauma, Reversal of Anticoagulation, and Toxic Alcohols! The topic I wanted to talk more about was the approach to CAP which was raised during a case discussion today. Unfortunately time was short and the general discussion was brief so I wanted to raise one point for further discussion here. The concept of using the PSI and CURB-65 rules was brought up as an explanation for why a patient should be admitted or discharged. I think Clinical Decision Rules (CDRs) are often great and very useful but it’s important to know their limitations including who is appropriate to apply the rule to and how to apply it. Ultimately, you should never blindly follow any CDR but use it as a tool as you form your own clinical judgement. Personally with regard to PSI and CURB-65 I think these are not strong CDRs for EM. The PSI is cumbersome and requires several lab tests including an ABG and I don’t believe the CURB-65 was ever validated for use in the ED. Here’s a link to a open access review article on mostly PSI but also mentions CURB-65: http://cid.oxfordjournals.org/content/47/Supplement_3/S133.full.pdf+html
I don’t feel like I generally use either of these rules when making dispo decisions but rather may document them in justification for my clinical judgement. Would like to hear other opinions on this subject, please leave your comments below.
JK
Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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2 Comments
Ian deSouza · September 5, 2013 at 12:49 pm
I also use it to justify disposition in my documentation (to appease the admitting medicine nerds, the greedy insurance companies, and the administrator suits).
One issue with the presented case was that the patient was on warfarin. I am curious about who would factor this into their decision-making. Both macrolides and fluoroquinolones are known to potentiate the effects of warfarin. Are there any recommendations about adjusting warfarin dose while these patients are on the recommended antibiotics?
jkhadpe · September 6, 2013 at 11:05 am
I’ve seen some general estimations but I’m not sure you can predict exactly how to adjust the warfarin dose. I would say that if you have to prescribe an antibiotic that would potentially interact then having a discussion with the patient and their PMD would be important so they can have their INR checked and dose adjusted more frequently while taking the antibiotic. Any other thoughts?