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Emergency Medicine Conference - Dec 2, 2009

November 27th, 2009 at 12:47 am by Lisa

Please join us for conference on December 2nd in the 8th floor conference room at Elmhurst. As usual, lunch will be served.

9a - Journal Club - Dr. Constantine, articles below
10a - Guest Lecture - Dr. Marc Grossman
11a - Trauma Conference - Dr. Weingart
12p - US Case of the Week - Dr. Isserman
1230p - Procedure Talk - Dr. Close

Residents the journal articles are behind the usual password.

Demetriades et al. SNOM in solid organs Annals of Surgery 2006;244: 620 – 628. Paper.

Demetriades et al. SNOM in Anterior Abdominal Wall GSWs Annals of Surgery 1997;132:178-183. Paper.

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Key Points - ECGs

November 27th, 2009 at 12:29 am by Lisa

Benign Early Repolarization
Key Points

-precordial
-mostly V2-V4
-never in limb leads alone
-concave up
-J point notching/fishhook
-small STE (<3.5mm)
-tall QRS & TW
-age <45

J point elevation
-an EKG finding, not a diagnosis
-differential includes early repol, hypothermia, Brugada, STEMI
-isolated J point elevation outside the precordial leads is associated
with idiopathic V fib

Measuring the STE
-use PR as baseline
-atria continue to repolarize for 60-80ms after QRS
-also, sometimes you lose the TP if P is shortly after T
OR
-measure 2 boxes after J point

references:
Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in
acute MI: an evidence-based manual of reperfusion therapy
Wang K, Asinger RW, Marriott HJL. ST-segment elevation in conditions
other than acute myocardial infarction. N Engl J Med (2003)

Posted in Arrhythmias, ACS, Blog | No Comments »

Emergency Medicine Conference - Nov 25, 2009

November 18th, 2009 at 6:47 pm by Lisa

Please join us for conference this Wednesday in Hatch Auditorium. We’re pleased to host Dr. Judd Hollander from the University of Pennsylvania for two educational sessions. His visit is sponsored by Sanofi-Aventis, but he assures us he’ll be equally critical or supportive of all interventions discussed.

9a Grand Rounds: Dr. Judd Hollander
10a Journal Club: Drs Hollander, Leung and Vashi (Articles below, please be prepared for this INTERACTIVE session)
11a Pediatric M&M: Dr. Seth Trueger
12p Joint Stroke Conference: Dr. Daniel Singer
1p Pediatric Core Lecture: Dr. Matt Laurich

Lunch will be served.

The following journal club articles are accessible by entering the usual login and password. Please read your two assigned articles below.
Paper.
Stone et al. Bivalirudin for patients with Acute Coronary Syndromes NEJM 2006; 355(21):2203-2216. Paper.
Wiviott et al. Prasugrel vs Clopidogrel in patients with acute coronary syndromes NEJM 2007; 357(20):2002-2015.

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Emergency Medicine Conference - Nov 18, 2009

November 16th, 2009 at 11:12 am by Lisa

This Wednesday’s conference is mock oral boards. It is an opportunity to grow accustomed to the oral board format. Check your emails for a final schedule (you’re only expected to attend the session assigned to you) and for study/preparatory resources.See you Wednesday!

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M&M Pearls - Anticoagulation

November 14th, 2009 at 11:18 am by Lisa

Learning points from the presentation and discussion:

* Decision instruments and an ACEP clinical policy exist to assist in the determination of whether a patient with a minor head injury requires imaging in the ED. These guidelines exclude anticoagulated patients, however, and the threshold to image the brain of head-injured patients who are anticoagulated should be low.

* Head-injured patients who are anticoagulated are at risk for delayed intracranial bleeding after a negative head CT. Options for managing this risk include a period of ED observation, admission to the hospital, and discharge with strict precautions/supervision (with or without a scheduled return visit). These strategies may or may not be combined with a repeat head CT. The duration of increased risk is not known but is thought to be somewhere between 24-72 hours, though delayed bleeds have presented even later than this.

* Intracranial bleeding with coagulopathy is a medical and surgical emergency that is both immediately life-threatening and responsive to ED therapies. These therapies should not wait for consultant collaboration and, where suspicion of ICH is sufficient, initiation of these therapies should not wait until confirmation of ICH.

* For patients with life-threatening bleeding on warfarin: administer vitamin K 10mg IV over 10 minutes and prothrombin complex concentrate. Dosing of PCC is not firmly established and can be based on both weight and INR, but 50 units/kg is a reasonable starting point in an emergency. An alternative is FFP, which should be administered at a dose of 15 ml/kg. At Sinai, a unit of FFP contains anywhere between 150 and 350 cc FFP; assume 200 cc for estimation purposes. FFP is blood type-specific; the blood bank needs to know the patient’s blood type but does not need a blood sample to cross-match.

* PCC reverses INR much more quickly than FFP, is easier to handle, and does not have the volume concerns of FFP. However, it is much more expensive than FFP and is associated with more thrombotic complications than FFP. In patients who are at particular risk of thrombosis, or when bleeding is not life-threatening, consider the benefit:harm between the two options.

* For patients with life-threatening bleeding on unfractionated heparin, stop the heparin infusion. Then administer protamine at a dose of 1 mg/100 u heparin given within the past 30 minutes, .75 mg/100 u heparin given 30-60 minutes ago, .5 mg/100 u heparin given 60-120 minutes ago, and .3 mg/100 u heparin given more than 2 hours ago.

* For patients with life-threatening bleeding on low molecular weight heparin, protamine is only partially effective (consider this before administering LMWH in a patient more likely to bleed - unfractionated heparin may be a better choice). The dose of protamine is 1 mg IV per 1 mg LMWH given in the last 10 hours. If LMWH is causing life-threatening bleeding unresponsive to protamine, consider activated Factor VII.

* For patients with life-threatening bleeding on plavix or aspirin, administer DDAVP at a dose of .3 mcg/kg with 6 units of platelets.

* For patients with life-threatening bleeding and liver failure with INR > 1.2, administer vitamin K 10 mg IV along with either PCC or FFP.

* For patients with life-threatening bleeding and renal disease associated with platelet dysfunction, administer DDAVP at a dose of 20 mcg. FFP or cryoprecipitate may also be used for additional procoagulant effect if necessary.

* For patients with life-threatening bleeding and thrombocytopenia, transfuse platelets to a level of at least 50,000.

Posted in Trauma, Blog | No Comments »

Emergency Medicine Conference - Nov 11, 2009

November 5th, 2009 at 5:04 pm by Lisa

Please join us for conference next Wednesday in Hatch Auditorium. We’re joined by Grand Rounds Speaker, Dr. Suzanne Shepherd, who will address health care issues surrounding immigrants and refugees. We also have an exciting opportunity to finish off the day. Do precipitous breech deliveries scare you? The OB department is sharing their pregnant simulator with us to give us hands on experience with some of the more complicated third trimester OB care that we rarely see.

9a - Grand Rounds: Dr. Suzanne Shepherd - Immigrant and Refugees in the Emergency Department: How Understanding their Journeys Facilitates Your Care
10a - M&M: Dr. Suzanne Bentley
11a - Pediatric Radiology: Dr. Han Bokyung
12p - Third Trimester OB Simulation - Dr. Raymond Sandler

Lunch will be served.

Posted in Events, News | No Comments »

Emergency Medicine Conference - Nov 4, 2009

October 28th, 2009 at 5:35 pm by Lisa

Please join us for conference this Wednesday in the 8th floor conference Room at Elmhurst. We’re joined by Dr. Counselman from ABEM for an interesting lecture and updates on ABEM. We start early - please be on time!

8a - Joint Cardiology Conference - Dr. Leung
9a - Marine Envenomations - Dr. Counselman
10a- ABEM Updates - Dr. Counselman
11a - Trauma Conference - Dr. Weingart (see article below)
12p - M&M - Dr. Friedman

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