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A quick review of FAST

January 24th, 2010 at 6:39 pm by Nick

Thanks to Alan for his look at the utility of FAST exams, incorporating a pioneering study of FAST as well as some more recent work. The three papers he picked are below:

For a review of these papers, and some resources for FAST, see below!

Read More »

Posted in Trauma, Ultrasound, Journal Club, Radiology, Blog | 1 Comment »

Emergency Medicine Conference - Jan 6, 2010

December 24th, 2009 at 7:37 pm by Lisa

Please join us for conference on January 6th in the 8th floor conference room at Elmhurst. The day begins with journal club - please come prepared!!
9a - Journal Club - Huang (see articles below)
10a - Procedure Talk - Trivedi
1030a - US Case of the Month - LaCalle
11a - Trauma Conference - Weingart
12p - M&M - Asaad

Alan has chosen 3 articles to review and requests that everyone comes prepared. Residents as usual the journal articles are behind the normal logon and password.
All: Rozycki et al. Surgeon-Performed Ultrasound for the Assessment of Truncal Injuries: Lessons Learned From 1540 Patients Ann Surg. 1998;228(4):557-67. Paper.
Miller et al. Not so Fast J Trauma. 2003;54:52–60. Paper.
Schnuriger et al. The accuracy of FAST in relation to grade of solid organ injuries: A retrospective analysis of 226 trauma patients with liver or splenic lesion. BMC Medical Imaging 2009, 9:3. Paper.

Posted in Journal Club, Events, News | No Comments »

Managing Agitation in the ED

December 18th, 2009 at 4:54 pm by Nick

Kudos to Dan for his thoughtful analysis of three papers highlighting aspects of agitation management in the emergency department.

Take-home points from Journal Club this week:

* 5mg of midazolam (versed) was significantly faster at causing sedation in violently agitated patients at a large academic ED, compared to 5mg of haldol and 2mg of lorazepam (ativan). Patients getting midazolam also had significantly faster times to recover from sedation, also the least incidence of sedation failure.

* Droperidol has an FDA black box warning for QT prolongation leading to torsades de pointes and death. While the association between droperidol use and QT prolongation is clear, the risk of sudden cardiac death as caused by droperidol is much less clear. Many centers still use droperidol to good effect; an ECG after administration and prior to discharge is strongly recommended (and, if possible, prior to use).

* In treating behavioral emergencies, the accepted and endorsed practice in this country is to confront the violent or uncooperative patient with a ‘show of force’ to obtain consent, and if that fails, forcible medication ensues. Covert administration of meds, while maybe expedient or supported by the patient’s family, threatens the therapeutic alliance and exposes the institution to liability and the practitioner to claims of criminal battery. There exists an opportunity for further study and policymaking, both within our institution and beyond.

An in-depth discuss of the three papers awaits you, below.

Read More »

Posted in Post-Conference Letter, Psychiatry, Arrhythmias, Journal Club, Blog | No Comments »

Emergency Medicine Conference - Dec 16, 2009

December 10th, 2009 at 12:26 am by Lisa

Please join us for conference this Wednesday in the 8th floor conference room at Elmhurst. Please note the early start time for cardiology conference and don’t forget to come prepared for Journal Club.

8a - Joint Cardiology Conference - Dr. Young Yoon
9a - Toxicology Lecture - Dr. Ruben Olmedo
10a - Neck Trauma - Dr. Kaushal Shah
11a - Journal Club - Dr. Daniel Fawaz.

Residents you can find the journal club articles behind the usual logon/password. Dan has chosen 3 different articles to review and requests that each class come prepared. Read the Lewin article and the article assigned for your class.

All: Lewin et al. An Unusual Case of Subterfuge in the Emergency Department: Covert Administration of Antipsychotic and Anxiolytic Medications to Control an Agitated Patient. Ann Emerg Med. 2006;47:75-78. Paper.

PGY1s and 2s: Kao et al. Droperidol, QT Prolongation, and Sudden Death: What Is the Evidence? Ann Emerg Med 2003;41(4):546-58.Paper.

PGY3s ad 4s: Nobay et al. A Prospective, Double-blind, Randomized Trial of Midazolam versus Haloperidol versus Lorazepam in the Chemical Restraint of Violent and Severely Agitated Patients. Acad Emerg Med 2004;(11)7:744-9.Paper.

Posted in Journal Club, Events, News | 1 Comment »

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 »

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 - Oct. 21, 2009

October 18th, 2009 at 8:48 pm by Lisa

Please join us for conference this wednesday in the 8th floor conference room at Elmhurst. Much of the day will have a cardiology spin with a not to be missed ECG conference with Dr Kamenetsky to finish up the day!

8am - Joint Cardiology Conference - Kanika Gupta
9am - Journal Club - Lisa Jacobson (see articles below)
10am - Black Box Tox - Dr. Sharma
11am - Intravenous Pacing Procedures - Anita Vashi
1145am - ECG Conference - Dr. Kamenetsky

Residents: The following journal club articles are accessible by entering the usual login and password. Please read your two assigned articles below.
1st and 2nd Years: Fesmire. Delta CK-MB outperforms delta troonin I at 2 hours during the ED rule out of acute myocardial infarction AJEM 2000 18(1):1-8. Paper.
3rd and 4th Years: Zarich et al. Value of a single troponin T at the time of presentatin as compared to serial CK-MB determinations in patients with suspected myocardial ischemia Clinica Chem 2002; 326:185-192. Paper.
Everyone: Young et al. Serial creatine-kinase-MB results are a sensitive indicator of acute myocardial infarction in chest pain patients with nondiagnostic electrocardiograms: the second emegency medicine cardiac research group study Acad Emerg Med 1997; 4(9)869-877. Paper.

Posted in Journal Club, Events, News | No Comments »

Journal Club Recap

September 14th, 2009 at 1:36 pm by Lisa

Last week’s journal club topic was risk for CVA following a TIA. It has been noted that patients who present with a TIA have a 15-30% risk for stroke within the following 30 days. The ABCD and ABCD2 systems were created to risk stratify patients for either inpatient or outpatient follow up based on the factors of age, blood pressure, neurologic character of the TIA, duration of symptoms, and diabetes. The two articles discussed were:

P M Rothwell, M F Giles, E Flossmann, C E Lovelock, J N E Redgrave, C P Warlow, Z Mehta. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack.
Lancet 2005; 366: 29–36.
Thomas Zambelis, Nikolaos Zakopoulos and Demetrios Vassilopoulos Georgios Tsivgoulis, Konstantinos Spengos, Panagiota Manta, Nikolaos Karandreas. Stroke After a Transient Ischemic Attack: A Hospital-Based Case Series Study. Stroke 2006;37;2892-2897.

The Lancet article was published by the group from England who originally created the ABCD criteria. They used two cohort databases to retrospectively determine 7-day risk of stroke in a group of TIA patients. They determined that an ABCD score of five or greater vastly increased a patient’s risk of stroke within the seven days, and that these patients should be hospitalized.

The group also did a concurrent validation study. We discussed that this is unusual since a validation study is meant to prove generalizability of research, and therefore a subject population should be chosen that is different from, rather than identical to, the original subjects.

The article from Stroke was a retrospective case series. The subjects were consecutive hospital-admitted patients following episodes of TIA. The study found that the ABCD scores correlated to a 30-day risk of CVA and recommended that patients with a score of four or greater be admitted to the hospital.
Our discussion of this article brought up several points. First, the study only included admitted patients, which would have presumably excluded many TIA patients who were discharged. Second, the authors’ statistics include continuous data placed into a binary format, which was statistically significant. Third, there were many patients lost to follow up.
We then discussed how these articles relate to our practice, and how they might change our management. Points that were brought up included:
?In tertiary care centers, the admission decision ultimately rests with the neurology service.
?What level of risk are we willing to accept? Is a 2.5% 7-day risk too high for discharge?
?The work-up for stroke includes an echocardiogram, carotid Doppler ultrasound, and an MRI/MRA of the head and neck. Our patient population at Elmhurst has a low level of education and relatively poor reliability. This work up as an outpatient is complicated and has long waiting times. Often, hospital admission is the only way to guarantee that it will occur.
?An argument in favor of admission of TIA patients was that many patients live alone, or have poor understanding. It is unlikely that they would quickly return to the hospital when they developed acute symptoms of TIA/CVA. Therefore, admission greatly increased the likelihood that these patients would be candidates for thrombolysis.

Posted in Journal Club, Blog | No Comments »

Emergency Medicine Conference - Sept. 2, 2009

August 27th, 2009 at 9:41 am by Lisa

Please join us for conference this Wednesday, September 2nd and 9am in the 8th floor conference room at Elmhurst Hospital. We’ll begin our day with journal club which looks to be an interesting discussion. Please read the articles below before joining us.

9am - Journal Club - Dr. J Chiang
10am - IRB 101 - Dr. I Wilets
11am - Trauma Conference - Dr. S Weingart
12pm - M&M - Dr. S Nadindla
1pm - US Case of the Month - Dr. B Ferguson

Residents: The following journal club articles are accessible by entering the usual login and password.Rothwell et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack The Lancet 2005 July 2; 366:29-36. PMID: 15993230. Paper.
Tsivgoulis et al. Validation of the ABCD Score in Identifying Individuals at High Early Risk of Stroke AFter a Transient Ischemic Attack: A Hospital-Based Case Series Study Stroke 2006; 37:2892-2897. PMID: 17053179. Paper.

Posted in Journal Club, Events, News | No Comments »

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