Stony Brook
EMergency Medicine
Residency

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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Copyright 2019 Designed by Michael Beck MD

The Best in FOAM Education

May Conference Pearls

June 1, 2018

The weather has warmed up nicely, and we had a great month of conference! Here are some learning points and follow-up resources from May 2018 EM Conference at Stony Brook.

 

EKGs: Hyperacute T Waves by Dr Meyers

Summary:

     -We are alone in reading EKGs: no radiologist, no cardiologist, no guidelines, no formal education

     -Mattu and many others say: >90% of chest pain lawsuits in EM are due to a missed EKG finding

     -Hyperacute T waves indicate ACO, and may or may not be followed by STE prior to adverse patient outcome

     -Lytics/PCI theoretically should have even greater mortality benefit for a patient with hyperacute T waves than the same patient later showing a STEMI

     -STEMI criteria misses ~25-30% of ACO

     -“NSTEMI” occlusions do worse than NSTEMI non-occlusions, and there is no RCT disproving the obvious logic that acute occlusions need immediate PCI just like STEMI

     -You really really need to be able to find these hyperacute T-waves

     -Hyperacute T-waves is just one of the many topics you must know above and beyond the STEMI criteria

-http://hqmeded-ecg.blogspot.com/2017/04/ten-cases-of-hyperacute-t-waves-in-v4-v6.html

 

Grand Rounds: Massive GI Bleed by Dr Swadron

Summary:

     -Assume upper

     -Assume variceal

     -Think IR and surgery right away

     -Intubate early

     -Institute massive transfusion

     -Use octreotide and PPI empirically

     -Add antibiotics if suspected varices

     -Use balloon tamponade if still bleeding

-EMRAP C3 April 2016: Massive GI Bleed

-EMRAP HD Videos:

     -Linton, Blakemore, & Minnesota Tubes Overview: https://www.youtube.com/watch?v=Yv4muh0hX7Y

     -Placement of a Linton Tube for Bleeding Varices: https://www.youtube.com/watch?v=VgfQqxP0mTc

     -Placement of a Blakemore Tube for Bleeding Varices: https://www.youtube.com/watch?v=NHelCd5Jtp4

     -Placement of a Minnesota Tube for Bleeding Varices: https://www.youtube.com/watch?v=4FHIiA_doWU

     -Real Footage of Minnesota Tube Placement: https://www.youtube.com/watch?v=SVbn6Ozpvms

-EMCrit Blakemore Tube Placement for Massive Upper GI Hemorrhage:

     -https://emcrit.org/emcrit/blakemore-tube-placement/

     -https://www.youtube.com/watch?v=EGcEiUIY9vY

 

Critical Care by Dr Weingart

Communication during stressful resuscitation

-Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care. 2011;26(2):155-9. PMID 21482347

-Fly (resuscitate) by voice: share your mental model

-Avoid mitigating language: firm and direct

-Graded assertiveness: team member can speak up

-Sterile cockpit: eliminate distractions/extraneous thought in critical moments

-Closed loop communication: give directive and it's repeated back to you

-Tactical pause: regrouping; "what am I missing"

-Hot debrief: after any critic resusc, in 1-3 min, go over what took place, objections, lingering emotions, improvements

 

Running a cardiac arrest

-EMCrit Podcast 191: Cardiac Arrest Update

     -https://emcrit.org/emcrit/cardiac-arrest-update/

 

Cadaver Lab:

One sim will not be enough for you to be able to do something like a lateral canthotomy 6 months later; however, you will have a better chance if you have primed your mind, gone through the sim, reviewed it afterwards with a physical experience to peg your knowledge to, and then continue to visualize mental reps in the future.

Don’t practice until you succeed. Practice until you cannot fail.

 

Cricothyrotomy by Dr Braude:

-https://youtu.be/wVQFJR7qmrQ

-https://emcrit.org/emcrit/surgical-airway/

 

Chest Tube - NEJM:

-https://youtu.be/L-XSJYQWmeQ?list=PL5v3YzNPkiRNbTuPrlAPrA3cvWRgTMKzB

 

Pigtail - EM Ottawa:

-https://youtu.be/nrxuZwFpigI

 

Thoracotomy - UMEM:

-https://youtu.be/A57ZB_J4FuY?list=PLUHz8ejVtn9AlkH0SWP6FuQMCORrHf2na

-https://emcrit.org/emcrit/procedure-of-thoracotomy/

 

Lateral Canthotomy - EMRAP:

-https://youtu.be/tgQaKVGynFA

 

EZ IO - EMRAP:

-https://youtu.be/KHXSfh2ZRDM

 

Pericardiocentesis - NEJM:

-https://youtu.be/sy6pKUJzPOk?list=PL5JaZVPnPe4a8dW3J_rortbLOnzJeb4MG

 

Compartment Measurement - EMRAP:

-https://www.youtube.com/watch?v=XXp0EtKtlF8

 

Sim: Newborn Resuscitation

-AHA/AAP Neonatal Resusc Guidelines Figure 1:

     -Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Reprint). Pediatrics. 2015;136 Suppl 2:S196-218. PMID 26471383

     -http://pediatrics.aappublications.org/content/136/Supplement_2/S196

-EMRAP Sept 2016: Pediatric Pearls – AHA Neonatal Resuscitation Guidelines

-Umbilical Vein Catheterization - NEJM:

     -https://www.youtube.com/watch?v=Cm4h4Qynbj4

 

Principles of Opioid Therapy for Cancer Pain by Dr LaTorre

-Take care with rapid redosing of morphine:

     -Lötsch J, Dudziak R, Freynhagen R, Marschner J, Geisslinger G. Fatal respiratory depression after multiple intravenous morphine injections. Clin Pharmacokinet. 2006;45(11):1051-60. PMID 17048971

     -In short, 26F is post-op and had pain. Got 5mg IV morphine, wait 45 min, 10mg more, wait 45 min, 10mg more, wait 15 min, 10 mg more IV morphine. This led to analgesia. 40 min later, she coded.

     -Note that plasma levels do NOT correspond to brain levels.

     -Furthermore, note Table 1, which shows the longer transfer half life of morphine vs hydromorphone and fentanyl.

-Another issue with morphine is the clearance of it and its metabolites during renal and/or hepatic impairment, which is not uncommon in the ED.

     -https://www.uspharmacist.com/article/opioid-dosing-in-renal-and-hepatic-impairment

-ACEP Policy on sub-dissociative ketamine:

     -http://www.acepnow.com/article/acep-policy-low-dose-ketamine/

     -Subdissociative-Dose Ketamine for Analgesia. Ann Emerg Med. 2018;71(3):e35. PMID 29458820

     -https://www.annemergmed.com/article/S0196-0644(18)30039-8/pdf?code=ymem-site

     -"Because of SDK’s excellent safety profile and activity as an analgesic, not an anesthetic, special administration procedures and monitoring are not required."

 

Critical Case Discussion: Central line confirmation

-Arrest lines are difficult to accurately place; lines must be confirmed post-ROSC for prolonged use

-Central line kit tubing for confirmation: https://vimeo.com/16556049

-Rapid atrial swirl sign for confirmation: https://vimeo.com/54210738

 

Senior Grand Rounds: Gender and Sexual Minorities by Dr Weiss

-Haider AH, Schneider EB, Kodadek LM, et al. Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity : The EQUALITY Study. JAMA Intern Med. 2017;177(6):819-828. PMID 28437523

     -https://www.ncbi.nlm.nih.gov/pubmed/28437523

-AAMC Diversity and Inclusion Videos and Resources

     -https://www.aamc.org/initiatives/diversity/431388/videos.html

-AAMC Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Nonconforming, or Born with DSD - A Resource for Medical Educators

     -https://members.aamc.org/eweb/upload/LGBTDSD%20Publication.pdf

 

Clinical Pearl: Lyme by Dr Kotelnik

-Doxycycline safe in rickettsial diseases in children:

     -https://www.cdc.gov/rmsf/doxycycline/index.html

     -Todd SR, Dahlgren FS, Traeger MS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr. 2015;166(5):1246-51. PMID 25794784

          -https://www.jpeds.com/article/S0022-3476(15)00135-3/pdf?ext=.pdf

-IDSA - 10 facts about Lyme:

http://www.idsociety.org/Ten_Facts_About_Lyme_Disease/

-CDC on Lyme disease testing:

https://www.cdc.gov/lyme/healthcare/clinician_twotier.html

-IDSA Lyme 2006 guidelines (update coming this summer):

     -Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43(9):1089-134. PMID 17029130

          -https://academic.oup.com/cid/article/43/9/1089/422463

 

Clinical Pearl: Peritonsillar abscess drainage by Dr Florescu

-Ultrasound guidance with intracavitary probe:

     -http://www.ultrasoundpodcast.com/2012/01/episode-21-full-peritonsillar-abscess-podcast/

     -Secko M, Sivitz A. Think ultrasound first for peritonsillar swelling. Am J Emerg Med. 2015;33(4):569-72. PMID 25737413

          -http://edus.ucsf.edu/sites/edus.ucsf.edu/files/wysiwyg/PTA%20Ultrasound%202015%20Am%20J%20EM.pdf

-Ultrasound guidance with linear probe:

     -Bandarkar AN, Adeyiga AO, Fordham MT, Preciado D, Reilly BK. Tonsil ultrasound: technical approach and spectrum of pediatric peritonsillar infections. Pediatr Radiol. 2016;46(7):1059-67. PMID 26637999

 

Pediatric DKA by Dr Panesar

-DKA developed slowly, so treat slowly

     -IVF bolus only if hemodynamic instability (which can include tachycardia)

     -No insulin bolus

-From ALiEM AIR Series:

     -http://pedemmorsels.com/cerebral-edema-diabetic-ketoacidosis/

-PECARN DKA FLUID study is an RCT attempting to address fluids in pediatric DKA. It's going to published soon.

     -https://www.pecarn.org/publications/documents/pediatricdiabeticketoacidosis.pdf

 

PGY2 EBM: Cervical Spine Clearance in Blunt Trauma by Dr Mogul

-EAST guidelines: Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma. 2009;67(3):651-9. PMID 19741415

     -https://journals.lww.com/jtrauma/Fulltext/2009/09000/Practice_Management_Guidelines_for_Identification.37.aspx

-EMRAP January 2016: C-Spine Clearance in the Obtunded

-EMRAP February 2016: Do We Still Need The C-Collar

-EMCrit Podcast 63 and Wees:

     -https://emcrit.org/emcrit/cervical-spine-injuries-i/

     -https://emcrit.org/emcrit/why-should-we-kill-off-plain-films-c-spine/

     -https://emcrit.org/emcrit/more-on-c-spine-imaging/

-https://emcrit.org/emnerd/the-adventure-of-the-crooked-man/

 

PGY2 EBM: Lung ultrasound for pneumonia by Dr Bracey

-http://www.ultrasoundpodcast.com/2016/06/ultrasound-pneumonia-thoracentesis-ultrasoundmd-asked-now-got-foamed/

-http://www.ultrasoundpodcast.com/2016/07/ultrasound-pneumonia-thoracentesis-part-2-actually-ultrasoundmd-foamed/

-https://lifeinthefastlane.com/ultrasound/lung/pneumonia/

-https://emcrit.org/emnerd/case-shadows/

-https://emcrit.org/emnerd/case-shadows-part-ii/

 

Interesting Case: Bradycardic and Hypotensive -> CCB OD by Dr Sherman

-https://thecasualtyconsultant.org/2017/03/05/embullet-too-much-of-a-good-thing/

From ALiEM AIR Tox 2017 and AIR-Pro Tox: https://www.aliem.com/2017/06/air-series-toxicology-module-2017/ , https://www.aliem.com/2016/12/air-pro-toxicology-part-2/

-https://emergencymedicinecases.com/low-slow-poisoning/

-https://coreem.net/core/hiet/

 

Tox: Iron and Lead by Dr Schwaner

From ALiEM AIR Tox 2015: https://www.aliem.com/2015/01/air-series-toxicology-module-2015/

-https://www.aliem.com/2014/08/management-iron-toxicity/

 

Tox: Hypoglycemics by Dr Schwaner

-http://www.thepoisonreview.com/2014/02/13/6-pearls-about-metformin-and-lactic-acidosis/

-https://emcrit.org/toxhound/poursomeoctreotide/

 

Intro to Healthcare Finance by Dr Morley

-https://www.acep.org/administration/reimbursement/observation---physician-coding-faq/

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