Dr. Mitesh Patel is Co-founder and CEO of Docphin. These guys have made a really cool "Personalized Health Information Network". This is a slick website and iPhone app, and we give you the scoop on it in this podcast.
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World Sepsis Day is on Thursday the 13th of September.
Here is a link to a game to help you learn about sepsis
On World sepsis day follow the conversation on twitter
Twitterchat – an international conversation via Twitter in relation to sepsis.
We will host an international Twitterchat and ask the audience 3 questions
related to sepsis, this will generate a conversation across Twitter. This is a
fantastic opportunity to discuss topics related to sepsis treatment and
management, connect with people interested in similar topics and discuss
strategies to overcome challenges. We will be using the #WSD12, please join in.
1.5 out of 5 stars
Empiric Management of Cyanide Toxicity Associated with Smoke Inhalation. O’Brien DJ et al. Prehosp Disaster Med 2011;26:374-382.
Whether or not to use empiric hydroxocobalamin to treat victims of smoke inhalation is a hotly debated topic for which all sides agree there is no (and will probably never be any) definitive evidence. A recent editorial in Annals of Emergency Medicine summed up the situation:
The lack of controlled efficacy data for smoke inhalation, combined with uncertainties about safety in patients, make an adequate risk:benefit calculus difficult. A call for routine empiric administration of hydroxocobalamin to smoke inhalation victims seems unwarranted until we have more data. For now, clinicians should assess patients individually and use cautious judgement. It appears reasonable to consider empiric hydroxocobalamin for victims who are comatose, in cardiac arrest, or have clear signs of cardiovascular extremis.
The stated goal of this current study was to “review published and recently presented studies on the empiric prehospital and emergency department treatment of suspected cyanide poisoning in smoke inhalation victims and to develop treatment protocols for clinical use in the US.” Unfortunately, there are absolutely no methods described indicating how relevant literature was identified, evaluated, or reviewed. Nor is there any hint about how the suggested treatment protocols were put together. Suffice it to say that all four authors disclosed that they are or have been affiliated with manufacturers and/or distributors of the Cyanokit.
Thus, I did not find it surprising that the guidelines they came up with call for fairly liberal empiric use of hydroxocobalamin. One aspect they do not discuss is the cost either of supplying ambulances with hydroxocobalamin, or of increased empiric use of the antidote in the emergency department. With the cost of a single treatment running approximately $1000-$2000, and unused antidote having to be replaced at regular intervals, that cost would not be insignificant.
Related posts:
Is the initial lactate level helpful in managing patients with carbon monoxide poisoning?
Potassium cyanide ingestion and hydroxocobalamin
More on Cyanide Antidote Smackdown: Hydroxocobalamin vs. Sodium Nitrite
Hydroxocobalamin vs. Sodium Nitrite: Cyanide Antidote Smackdown
Just gave a talk on FOAM (or FOAMe as I spelled it) FREE OPEN ACCESS MEDICAL EDUCATION – an acronym coined by Mike Cadogan at the Dublin ICEM 2012 conference.
The legend will state that the idea of FOAM was borne over a pint of Guinness and, like Guinness, – FOAM is good for you! [To view my Prezi click here].
The concept of FOAMe came about because Mike felt that the term “social media” when used in an Emergency Medicine context tends to turn people off. This is particularly evident with older generation docs who are picturing some kid with skinny-ass-hanging-out-jeans Tweeting about Kim Kardashian. This is unfortunate, because, in so doing, these docs aren’t benefiting from engaging in this incredible online conversation.
So, like others, I am trying to be an apostle for FOAM … [and I can understand why Mike has found it challenging to speak about].
Why should we engage in FOAM?
I have found Twitter CLINICALLY useful. Additionally there is a constant conversation going on about emergency medicine that you really need to be a part of because guess what? YOU have something to share!
Why NOT to immerse yourself in FOAM?
Here’s my thoughts about your concerns.
My name is Nadim and I am a luddite. I learned how to have an online presence by being challenged by my peers – you can too.
There IS a lot of great stuff out there. If you just want to follow ONE thing -follow LifeInTheFastLane
Your concerns regarding peer review are valid. Most of the avaunt guard that are out there should have a profile that explains who they are and what they are about. The LifeintheFastLane folks have tried to catalogue some of the great-tasting FOAM out there [click here] … BUT Just like any Journal Article – you need to critically assess what you’re reading. In a short while you will sift through the stuff that you find useful.
I would go one step further and sign up for a Twitter account. Follow some of the folks on the LifeInTheFastLane link above.
Don’t just take my word for it!
Here’s Anne Marie Cunningham’s take on why you should be a Twittering doc
Read Ronan Kavanagh’s blog [click here] - proof that engaging on the Twitterverse leads to meaningful collegiality and collaboration across international borders.
Here’s Mike’s ICEM2012 Talk on FOAM hosted on the blog of one of my brilliant collegues Andy Neil [click here].
So get out there and sample some FOAM! It has the potential to transform the way you practice – at the very least you will have pushed your envelope a little bit.
If you head over to the ICEM 2012 website they’ve added pdf files of the slide shows of most of the talks from the conference. There are also some videos of the plenary sessions from the mornings.
The videos don’t seem to be embeddable but I’ve arranged them below for direct access if you want them.
Wednesday, 27th June: Welcome Address from President Michael D. Higgins and Plenary: Emergency Medicine Public Health and Policy Making
Click to View
Thursday, 28th June: Clinical Decision Making in Emergency Medicine – Prof. Patrick Croskerry.
Click to View
Friday August 29th: Articles You Should Read – Prof. Richard Cantor and Plenary 2: George Podgorny Lecture – Prof. Peter Cameron
Click to View
Saturday August 30th: Post Cardiac Arrest Syndrome – Prof. Clifton Callaway – Prof. Laurie Morrison / ICEM 2014 Hong Kong Invitation
Click to View
Don’t forget the audio from the entire conference is available on freeemergencytalks.net (cheers Joe!) and LITFL has a nice little post with all the audio of the talks arranged by track and day.
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If you struggle to remember the vast pharmacopeia that sloshes about your ICU and the ring-structure reconstructing part of your brain is less well developed than the average anaesthetic trainee - fear not! In 2010 Kiwi intensivist, Dr Paul Young, put together a Frank Shan-esque book of spells that targeted commonly encountered potions for his unit and then released it as a literary gem. And instead of waiting for the royalty dollars to come rolling in (Anyone who has published a medical book knows this is a markedly unsuccessful retirement strategy), he let the guys on Life In The Fast Lane publish the entire thing for free.
So the next time you want to refresh a detail on a particular ICU medication, follow this link for almost everything you need to know and nothing that you don't. |
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Real patient encounter …
A 22 year old guy comes to the registration grabbing his chest. He’s having palpitations and chest pain.
He’s a pack a day smoker, has no family history of heart disease, and was out late the prior evening partying. So when he woke up, he was dragging a little. He had to be at his construction job in an hour, so he drank a “Monster” energy drink. When he got to work, he still felt tired, so he drank another “Monster” energy drink. That’s when the palpitations and chest pain started. He was anxious and felt a little short of breath, too.
The EKG from triage showed a mild sinus tachycardia of 106. No arrhythmia. No ischemia. His physical exam was completely normal except for his anxiety and his elevated pulse. He got an aspirin and some Ativan.
A half hour later, he wasn’t feeling any better even though his pulse was in the 80s.
Now everything points at this guy being acute “Monster” caffeine overdose. It was suggested that he be discharged with a prescription for Ativan and an order to lay off the caffeine. But because he was still symptomatic, he got an entirely unnecessary cardiac workup. His second EKG was normal sinus rhythm and still showed no ischemia. His CBC, chemistries, cardiac enzymes, and urine drug test were all normal.
Oh, and his chest x-ray showed a complete collapse of his left lung.
The problem with labeling testing “unnecessary” – even though the tests may be normal most of the time, they aren’t normal all of the time.
Where do we draw the line between what is and is not “unnecessary”?
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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat's Call Room, please e-mail me.
This is the discussion for 77 year old female: Unresponsive, if you have not read the case report we recommend you start there!
First, a hat tip to our readers who were unafraid to tackle this challenging scenario. Second, we were very impressed to see a number of readers correctly identify this challenging rhythm!
When we left off our crew was attending to an altered 77 year old female they picked up at a local skilled nursing facility. The patient's presentation seemed fairly routine for an Altered Mental Status rule-out.
However, once she was placed on the monitor her status became less clear:
Given the fast rate and possibility for SVT, atrial fibrillation, or even ventricular tachycardia the crew needed more information.
When faced with an uncertain rhythm strip it is best to acquire more leads, and a 12-Lead is a wonderful way to do so:
So what are we looking at?
Ok, I can read the comments; tell me what it is!
The answer is easiest to see in the initial rhythm strip. A closer inspection reveals that when you try to line up Leads II and III, they do not even march out!
If we were to display a tracing of the pulse oximetry waveform, it would likely be more evident that only Lead III is providing a useful display.
So why did our patient's pulses not match with her cardiac rhythm?
And why did our patient have an irregular tachycardic rhythm in every lead but Lead III?
Both prehospital and hospital providers who routinely acquire electrocardiograms are familiar with artifact obscuring rhythm and 12-Lead interpretation. Common causes of artifact on the ECG include power line intereference, patient movement, and baseline wander. Lesser known causes of artifact on the ECG include cable failure, neurostimulators, lead placement over arterial pulse points, and electrode manipulation.
Cardiac monitors are designed with electrical filters which screen out intereference which is of a frequency that exists outside the range of physiologic parameters. Unfortunately, if the frequency of an artifact occurs at a near-physiologic rate it will be up to the provider interpreting the ECG to mentally "screen out" the interference.
In this case our patient has advanced Parkinson's disease, which is a degenerative neurological disorder affecting the central nervous system. The most visible symptom of this disease is the motor dysfunction and the characteristic tremors it produces in the periphery. As with any patient motion, it can cause artifact on the surface ECG.
If we take a closer look at Leads II and III we can see that the Parkinsonian Tremors present produced artifact at a rate of 250-300 and looked surprisingly like Atrial Fibrillation with WPW!
There have been multiple case reports of Parkinsonian Tremors mimicing ventricular tachycardia, ventricular fibrillation, atrial flutter, and supraventricular tachycardia. In one case, a comatose ventilated patient inappropriately received defibrillation for what appeared to be ventricular tachycardia!
When evaluating a patient with tremors it is best to place the leads in the Mason-Likar configuration, i.e. the limb leads are placed on the chest and abdomen. However, sometimes even that will not help and a switch to an anterior-posterior configuration (roughly approximating the pads position, or V4-RA and V8-LL) may be your only option to record a semi-clean tracing.
Remember, as prehospital providers it is important that we be able to explain our findings on the ECG because it may have a large impact on the patient's inhospital care.
Epilogue
Our crew was perplexed as to the discrepancy between the patient's pulse rate and that the rhythms in Leads II and III seemed, "out of sync". They contacted medical control for guidance and were advised to transport to the closest facility and to withold rate control while the patient's blood pressure was adequate.
Narcan was administered due to a persistently low SpO2 and pinpoint pupils. The remainder of the transport was unremarkable and the patient's vital signs remained relatively unchanged. A palpable pulse of 70 was weakly present at the radials while a monitored heart rate of 250-280 was given.
Upon arrival at the receiving facility the patient was noted to have converted to a normal sinus rhythm, with an RBBB and ocasional PVC's. However, during the course of her ED stay she had another "bout of tachycardia" on the monitor and was sent to the floor for observation. It is the opinion of this author that the patient's recurrent tachycardia was merely artifact, likely similar to that seen in her prehospital ECG's.
We hope you enjoyed this case as much as we did!
So this ECG has generated a fair bit of interest and quite a few comments both here and on Twitter. I trickled out a bit more information in the second post, but here is the final act:
I figured there were essentially three options for this patient (with a few minor variations possible) given that it was midnight and the “cardiology” registrar was a covering respiratory registrar:
1) Activate cath lab
2) Treat like a non-STEMI and consider a cath in the morning
3) Get an Echo looking for regional wall motion abnormalities and use that to guide decision re. primary cath urgently or not
Frankly, I think these are all reasonable options, with only logistical differences. He is a young man, and with his story is going to score a cath at some point anyway – only the timing of it remains to be decided. I thought he had myopericarditis, but that his more severe pain from two days prior sounded suspicious for ischaemic pain, so I wasn’t prepared to ignore that. I toyed with the idea of a late night Echo-tech call-in, but elected to treat him as a non-STEMI-plus, in that he got aspirin, clopidogrel, heparin and in consultation with the very sleepy on-call interventional cardiologist (who I think liked my plan because he got to stay in bed, rather than beacuse of innate superiority to other approaches), a tirofiban infusion. An Echo was organised for the morning and he went to CCU.
Echo report (paraphrased summary):
- Mildly impaired LV function with two regional wall motion defects (inferoposterior basal and mid segment hypokinesis) with an EF of 50%.
- There was a tiny posterior effusion.
- Valves and other chambers NAD other than mild TR.
He not suprisingly went for a cath that morning too:
- LAD: 70% stenosis, diffuse disease
- LCx: 100% stenosis
- Proximal 1st obtuse marginal: 70% stenosis
- RCA: 60-70% stenosis
- Conclusion – triple vessel disease, culprit lesion in LCx, akinetic inferior wall
The serial troponins went from 16 to 9 to 6 over the next 24 hours. The patient was discharged and referred for a CABG. The discharge summary prepared by the cardiology resident didn’t mention myopericarditis, but in discussion with the cardiologist himself, it was clear that his opinion was that the patient indeed had myopericarditis secondary to his infarct, which almost certainly occured 2 days prior and correlated with his more severe and typical sounding episode of pain.
This ECG from just before his cath and Echo is much more consistent with myopericarditis, with widespread saddle-morphology ST elevation, PR depression, and PR elevation in aVR:
So there you have it – a late-presenting MI (perhaps STEMI?) AND myopericarditis. This syndrome of early post-MI pericarditis may be rarer in the post-thrombolysis/PCI era, and is also known as PIP or PAMISP. It’s a bit too early for the autoimmune mediated Dressler’s syndrome (which is definitely rare in the post-interventional era), as suggested by some commenters, which tends to kick in from around 2 weeks post-MI. From emedicine on the topic:
“The incidence of early pericarditis after MI is approximately 10%, and this complication usually develops within 24-96. Pericarditis is caused by inflammation of pericardial tissue overlying infarcted myocardium. The clinical presentation may include severe chest pain, usually pleuritic, and pericardial friction rub.
The key ECG change is diffuse ST-segment elevation in all or nearly all of leads. Echocardiography may reveal a small pericardial effusion. The mainstay of therapy usually includes aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Colchicine may be beneficial in patients with recurrent pericarditis.”
Founded by ACEM luminary Sally McCarthy, the New South Wales Emergency Care Institute (ECI) is a great resource for those of you preparing for the exam.
Click on the "Doctors" tab in the slider-menu, and have a look at their Clinical Tools. There you'll find a wealth of clinical guidelines (mostly from NSW Health) and even links to some useful apps.
There's a "Top 20 Sites" page (which EDExam features on!), showcasing the top Emergency Medicine online education resources, as well as a section on Clinical Education and Training with links to various courses. There's some quick reference guides to various bits of ED equipment as well.
There is still no "one stop shop" when it comes to Emergency Medicine webucation, but the ECI site has a lot of great, local information for those of you preparing for the ACEM Fellowship exam, and I recommend you check it out.
An article in the China Daily highlights the acute shortage of nurses being experienced in in Hong Kong.
A recent survey of 2,180 public sector nurses reported a ratio of one nurse to every 10 or 11 patients.
In their emergency departments the ratio was as low as one nurse to every 14 patients. Yipes.
Pretty concerning. Especially when you consider the manager to nurse ratio suggested by the accompanying photo.
Five clipboard wielding managers assessing the exactitudes of the hospital corners being performed by one nurse.
And I thought we were under pressure!
You can read the whole article here.
Deakin University is offering a new masters course in clinical leadership that on first blush looks a bit useful for anyone aspiring to a senior clinical position in their workplace.
This Master's program is designed to provide senior clinicians with the skills and breadth of understanding that they need in order to undertake leadership roles within the Australian Healthcare system. The program is being offered widely but Deakin is committed to ensuring that the program is relevant to Australia's clinical leaders. The program will be offered largely on line, with the Clinical Leadership components being taught and experienced in a series of intensive residential programs conducted over the course of a year. These programs will bring together industry leaders and students in a high quality learning environment with a focus on leadership for system, organisational and care delivery improvement.
Units:
Core selective units – students must enrol in one of the following list:
Applicants must be clinicians who hold Bachelor level qualifications from an Australian university or Higher Education Institution recognised by the Australian Qualifications Framework.
The next intake is in November, and the course runs 12months full time or part time equivalent.
Interested? You can find out more here.
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A few months ago I posted on the use of US for diagnosing pneumonia. Check out that post here. I have been trying it out since, but haven’t seen a good going fresh pneumonia for a while…..
Since then the guys at Ultrasound podcast have released an awesome lecture by Vicki Noble on the same – it is 30 minutes well spent for anyone who wants to use US and change the way they approach dyspnoea in the ED.
Today we saw a sick kid with “a bit of a cough” who had good going consolidation on US of the chest and on CXR. So I am putting up the images for you all to see. It is a simple technique – just put the probe where you would usually put your bell and look for detail of lung, fluid collections, air bronchograms and “hepatisation” behind the white pleura.
It is quick, no radiation, painless, and easy to do at any hour of the day or night.
Sure, there is a learning curve. Takes time to train the eyes and be confident, however the result is a pretty clear diagnosis to guide therapy and disposition decisions. I think that in time, one can get good enough to pick pneumonia early and avoid some X-rays. US compares well with plain films in terms of accuracy – but it leaves the stethoscope for dead – so I think I will use it when I am looking for a source in a sick patient, or when my exam is equivocal in a well looking patient. Any thoughts on this?
If you are not familiar with chest US – this is a wildly abnormal image – usually no detail of the lung architecture can be seen below the pleura.
For a great demonstration of this check out the above mentioned US Podcast talk. Matt and Mike pay me $20 everytime one of you click on their site – hurry and check it out – I think they are offering a prize for their 100th visitor. Enjoy
Casey
One of the things you will be seeing in the upcoming weeks and months is the addition of board/inservice exam review content. I will be making some board review podcasts, and will also be posting some questions here on the blog. My hope is for interaction, so feel free to answer questions, post questions, and interact.
One disclaimer: all questions that I post on the blog are ones that I made up. I will not be posting questions from any books, nor do these questions come directly from the Emergency Medicine Boards. My goal is to emphasize what I found to be important points in my studying and review, as well as conceptual approaches to studying for the exam. I will not be posting anything that is not free public knowledge about the exams already. Do not expect insider information. Since I am making these up, do not expect them to necessarily be board level quality. Basically, I’m not doing anything against the rules!
First question:
A 65 year old make with a history of hypertension and a 50 pack year history of smoking presents s/p syncope and abdominal pain. On exam, his HR is 110/min, BP 82/40, RR 16, and Pox 98% on RA. You note abdominal tenderness in the midline, and a palpable pulsitile abdominal mass on exam. What is your next step in the management of this patient?
A. Arteriogram
B. CT scan of the abdomen and pelvis with IV contrast
C. MRI of the abdomen
D. Point of care ultrasound of the abdomen
3 out of 5 stars
Fatal gastrointestinal hemorrhage after a single dose of dabigatran. Kernan L et al. Clin Toxicol 2012;50:571-573.
The RE-LY trial, the major study evaluating use of dabigatran etexilate (Pradaxa) as an anticoagulant to prevent stroke in patients with atrial fibrillation, excluded subjects with creatinine clearance less than 30 ml per minute. Since elderly patients frequently have undetected renal insufficiency, sometimes with normal creatinine levels, this population is at increased risk for major bleeding when taking this drug. In fact, in the European Union, the manufacturer recommends that patients older than 75 years of age have renal function tested before being put on dabigatran and regularly thereafter.
This somewhat puzzling case report reinforces this point. A 92-year-old man took an initial 150-mg dose of dabigatran at 10 pm. He awoke the next day with significant bleeding per rectum. On presentation to hospital 11 hours after ingestion, he was hypotensive (62/30 mmHg) and anemic (hemoglobin = 9.9 g/dL). His creatinine clearance at that time was 24.2 ml per minute; apparently, previously it was 33.9.
The patient was resuscitated and an actively bleeding gastric ulcer seen on endoscopy was treated with local epinephrine injections. On hospital day 3 he appeared stable. However, on day 6, gastrointestinal hemorrhage recurred, and despite treatment the patient died the following day.
I’m not sure I’m convinced that -- even given the patient’s renal insufficiency -- the single dose of dabigatran was responsible for the fatal GI bleed 6 days later. Even with the reduced creatinine clearance, I would expect most of the drug to be gone by that time. Although dabigatran is cleared predominantly by the kidneys, the major problem in renal failure would be increased levels as drug accumulates with repeated dosing. Unfortunately, no drug level was measured in this case. Nevertheless, the authors make some points worth considering:
The authors recommend that “baseline renal function and occult stool studies should be performed prior to ignition of [dabigatran].”
Related posts:
Dabigatran: is laboratory monitoring really unnecessary?
Dabiagtran and the trauma patient
Dabigatran Toxicity: The Top 10 Questions
Review: the bleeding patient on dabigatran
Dabigatran etexilate: a new challenge for emergency physicians and toxicologists
The next crop of climbers taking on Mt FACEM are no doubt starting to experience the impending doom of the clinical exams as they creep closer and closer.
Hopefully the latest LITFL database will help alleviate some of this understandable angst.
We’ve created a collection of free online videos featuring demonstrations of systematic approaches to physical examination as well as short videos showing individual physical signs. They are helpful for novice practitioners as well as those brushing up their skills in readiness for a Fellowship grilling.
So click here to go to the LITFL ‘Clinical Examination’ page and search over 150 useful videos!
If you know of other great free online videos that should be in this database for anyone and everyone to use, leave a comment with your suggestion.
(Remember to check the database to see if it’s there first…)
Vive la FOAM!
The post Clinical Examination Video Database appeared first on Life in the Fast Lane medical education blog.
Coronary computed tomographic angiography: seeing the arteries is, apparently, believing. Here it is, an update on the two hottest trials in EM—and the editorial that could change everything.
