We had yet another fantastic month of conference! Here are some learning points and follow-up resources from Oct EM Conference at Stony Brook.
EBM - RCTs - Dr Singer
Are the results of the study valid:
-Were the patients randomized
-Were all the patients enrolled accounted for - complete follow-up, intention to treat analysis
-Were patients, providers, study personnel blinded
-Were groups similar at the start
-Were groups treated equally
What were the results:
-How large was the treatment effect
-How precise was the estimate of the treatment effect
Will the results help me in caring for my patients:
-Can the results be applied to my patient care
-Were all clinically important outcomes considered
-Are the likely treatment benefits worth the potential harms and costs
From: JAMA 1994: Users' Guide to the Medical Literature: How to use an article about therapy
https://www.med.unc.edu/medselect/files/usersguider-results.pdf
Case and Medical Decision Making - Dr Johnson
-Half of people have at least 10 mmHg difference in SBP or DBP (BP Assessment of Interarm Differences - Arch IM 1996 (PMID 8823153))
-"Normocephalic/atraumatic" in your documentation is useless in adults and doesn't help your billing
-vs "Skull/face/scalp without external signs of trauma, soft tissue swelling, bruising, deformity, bony tenderness to palpation"
-Low risk chest pain patients: use clinical judgment, shared decision making, and decision tools
http://rebelem.com/management-and-disposition-of-low-risk-chest-pain/
-Compare prior EKGs
-Apply clinical decision rule or gestalt to determine pretest probability for all suspected PE patients
M&M: Hyperkalemia arrest
-Order entered in EMR doesn't get done in your timeframe unless you talk to the nurse
-HyperK: peaked T waves, broad, blocks, brady, bizarre
-Steve Smith: any EKG change gets calcium
-LR is fluid of choice in hyperK
https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/
Personality Disorders by Dr Mallon
-Remember: they have the disease and this disease can be devious
-Crush them with kindness
-No black splitting allowed (= d/w the RN to get on same team)
-Set limits on behavior
-Leave no sharps in the room
-Go for their receptors early (if above not working)
-Benzos, haldol, or both
-Ketamine is the last resort
Grand Rounds by Dr Joshua Schiller
https://cordemblog.wordpress.com/2017/01/27/how-was-your-day/
Tox Cases by Dr Schwaner
-Na channel blockade widens QRS
-Never enough atropine - continue until they're dry
-Amlodipine OD can be like diltiazem/verapamil - use high dose insulin
-Don't forget the compartment model; replete K in urinary alkalinization
-For any level, you measure the blood level, which may not be what's doing the damage
EMS - RMAs by Dr Marshall
-You're making a capacity decision to refuse transport - can they make this decision in this given moment
-Competency is determined by a judge
-EMS calls generally because the EMS high risk protocol demands it but EMS thinks they are fine otherwise, the EMS provider on scene is worried, or EMS provider doesn't think there is capacity but wants you to try to persuade them
-Talk to the EMS provider on scene and ask how the patient looks
-Patient has to have a reasonable thought process
-By calling med control, EMS provider loses standing orders - at end of call, state "you have all your standing orders back"
Derm Infections by Dr Mogul
-Most up to date IDSA guidelines for skin and soft tissue infection treatment:
http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_by_Organ_System/Skin_and_Soft_Tissue_Infections/
-Top 10 Myths Regarding the Diagnosis and Treatment of Cellulitis - Jrnl EM 2017 (PMID 28684060)
-If it's red, it's cellulitis
-Bilateral cellulitis
-MRSA coverage for all
-Patients being admitted for cellulitis require MRSA coverage
-Clinda is good for MRSA
-Broad spectrum antibiotics are needed
-If the red area gets larger, it's getting worse
-Skin infection will not occur if on prophylactic abx
-Tick bite + surrounding redness = cellulitis
Mood Disorders by Dr Coleman
-ACEP Clinical Policy 2017 on Acute Psych Patient (PMID 28335913)
https://www.acep.org/Physician-Resources/Policies/Clinical-policies/Clinical-Policy-Adult-Psychiatric-Patient/
-Suicide risk assessment - http://blog.ercast.org/suicide-risk-assessment-in-the-er/
-TRAAPPED SILO SAFE - http://blog.ercast.org/traapped-silo-safe/
Eating/Substance Use disorders by Dr Boyd
From ALiEM AIR and AIR-Pro:
-Eating Disorders
http://pedemmorsels.com/eating-disorders/
-Alcohol Withdrawal
http://www.emdocs.net/alcohol-withdrawal/
Pediatric Seizure by Dr Iyer
-A simple febrile seizure doesn't generally require further eval (EEG, bloodwork, neuroimaging). AAP 2011 Guideline on Simple Febrile Seizure - PMID 21285335
-EMRAP C3 Pediatric Seizure
Headache by Dr Meyers
-Response to analgesia shouldn't be used as the sole indicator of an acute headache's etiology. ACEP 2008 Clin Policy on Acute Headache - PMID 18809105
-EMRAP Feb 2017 - Headache Pathway - utility of 6 hour head CT, Ottawa SAH rule
-Rory Spiegel on CT/LP vs CT/CTA for SAH: https://emcrit.org/emnerd/adventure-second-stain/
-EMRAP C3 Headache
Critical Care by Dr Weingart
-DKA: beta-hydroxybutyrate < 1 is what we want for clearance; anion gap can mislead you
-DKA has big counter-regulatory surge from whatever their underlying cause
-Any endocrine emergency (including DKA) means you need to go hunting:
-6 I's of DKA: infection, infant on board (pregnant), infarct (brain/heart), idiopathic (new onset), ingestion of sympathomimetic, insulin (lack of)
-You should be able to use the vent as NIV; if you feel uncomfortable doing this, use BVM + PEEP valve + 15L NC
Pelvic Trauma:
-Hypotension + trauma = hemorrhage (-> eval the 5 locations)
-Young-Burgess classification of pelvic fractures
-Pelvic binder is at greater trochanters, not iliac crests
https://emcrit.org/emcrit/severe-pelvic-trauma/
For more, Dr Scalea 2010 talk (55 min): http://freeemergencytalks.net/wp-content/uploads/2010/04/Pelvic-Trauma.mp3
Miscellaneous
-Naloxone adverse effects we watch for: resp depression, seizure, cardiac dysrhythmia
-High index of suspicion for aortic dissection
-Review records of recent visits and your imaging