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EM-Critical Care Evidence-Based Medicine Neurology Trauma

Hypertonic Saline vs Mannitol for TBI with Increased ICP

By wendyrollerblades, 9 yearsAugust 24, 2015 ago

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Welcome to the official blog of the Kings County/SUNY Downstate Emergency Medicine Residency!

We are the residents (and some attendings) of the Kings County Hospital Emergency Department who have put together a unique mostly resident-authored blog for medical professionals.

If you have ideas for a post or are just looking for a fun way to do some individualized learning, e-mail us at CountyEMBlog@gmail.com and come be a part of our team!

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Before you Walk in the Room: Abnormal Uterine Blee

Before you Walk in the Room: Abnormal Uterine Bleeding
Is your patient presenting with abnormal uterine bleeding? Use the mnemonic PALM-COEIN to quickly formulate a differential before you walk in the room.
#emergency #emergencymedicine #medicalstudent #emresident #resident #intern #ms4 #ms3 #foamed #awayrotation #subi #differential #mnemonic #step1 #step #step3

County EM presents a case of an 18 year old male B

County EM presents a case of an 18 year old male BIBEMS after being found collapsed during a half marathon. He is obtunded, diaphoretic, tachycardic, tachypneic, and has a rectal temp of 107F.
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Exertional Heat Stroke

Take Home Points:

1. Though there are no head-to-head comparisons, cold water immersion appears to be the most effective method of rapid cooling

2. Consider placing defibrillator pads before water immersion

3. Consider the use of a body bag for rapid initiation of cold water immersion

4. Employ an ‘all hands on deck’ strategy to obtain ice from the nearest source

Check out our story and highlight reel for direct links to the article! Also check out our website for more juicy content!

Morning Report Recap- Dr. Natassia Buckridge on Ke

Morning Report Recap- Dr. Natassia Buckridge on Ketamine vs PNB for analgesia

Before you Walk in the Room: Headaches
The key to

Before you Walk in the Room: Headaches
The key to tackling headaches? Knowing primary from secondary.
#emergency #headache #migraine #emergencymedicine #em #emresident #medicalstudent #ms4 #ms3 #awayrotation #rotations #subi #diagnosis #foamed #step1 #step2 #step3

BYWITR: Joint Pain
Is your patient presenting with

BYWITR: Joint Pain
Is your patient presenting with joint pain? Think arthritis. Here's a way you can formulate a differential diagnosis before you walk into the room.
#emergency #emergencymedicine #medicalstudent #emresident #resident #intern #ms4 #ms3 #foamed #awayrotation #subi #differential

Slit lamp mechanics with our very own Dr. Silverbe

Slit lamp mechanics with our very own Dr. Silverberg!

Before You Walk In The Room: Eye Pain
Going to see

Before You Walk In The Room: Eye Pain
Going to see a patient with a painful eye? remember to take an anatomical approach!
#emergency #emergencymedicine #medicalstudent #emresident #resident #intern #ms4 #ms3 #foamed #awayrotation #subi #differential

County EM presents a case of an 18 year old male B

County EM presents a case of an 18 year old male BIBEMS after being found collapsed during a half marathon. He is obtunded, diaphoretic, tachycardic, tachypneic, and has a rectal temp of 107F.
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Exertional Heat Stroke

Take Home Points:

1. Exertional heat stroke is a time-sensitive diagnosis.

2. The core body temperature threshold of > 40 degrees Celsius may be inaccurate. More attention should be focused on pathological symptoms in the right clinical context.

3. Anticipate common complications including thrombocytopenia, coagulopathy, liver damage, acute kidney injury, lactic acidosis, cardiovascular dysfunction, and rhabdomyolysis.

Check out our story and highlight reel for direct links to the article! Also check out our website for more juicy content!

Before you Walk in the Room: Sinus Tachycardia
He

Before you Walk in the Room: Sinus Tachycardia
Heart rate not going down? Looking for the cause?
Use the mnemonic "FHAST PACED" to quickly identify potential causes of tachycardia in your patient.
#emergency #emergencymedicine #medicalstudent #emresident #resident #intern #ms4 #ms3 #foamed #awayrotation #subi #differential

H2H: De Winters Pattern: An OMI Equivalent for Pro

H2H: De Winters Pattern: An OMI Equivalent for Proximal LAD Occlusion
#emergency #emergencymedicine #medicalstudent #emresident #resident #intern #ms4 #ms3 #foamed #awayrotation #subi #differential #mnemonic

BYWITR: Syncope
Picked up a patient with syncope?

BYWITR: Syncope
Picked up a patient with syncope? Use this framework to formulate a differential before you walk in the room
#emergency #emergencymedicine #medicalstudent #emresident #resident #intern #ms4 #ms3 #foamed #awayrotation #subi #differential

County EM presents a case of a 40-year-old woman w

County EM presents a case of a 40-year-old woman with a history of CAD and prior RCA stent who arrives to the ED with chest pain for one day. Her triage vitals are within normal limits but you notice the patient holding her chest in pain with diaphoresis. Besides ECG and blood work, what else can be used to risk stratify the patient for ACS?
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TTE for Regional Wall Motion Abnormalities

Take Home Points:

1. Regional wall motion abnormalities occur early, before ECG changes or pain

2. Consider TTE if ECG is non-diagnostic for OMI, especially in patients with moderate to high likelihood of OMI

3. Look at a prior TTE, if available

4. Know the “false-positive” causes of regional wall motion abnormalities

5. Learn the coronary anatomy to correlate with regional wall motion abnormalities

Check out our story and highlight reel for direct links to the article! Also check out our website for more juicy content!

Welcome to our Before you Walk in the Room series-

Welcome to our Before you Walk in the Room series-
Altered mental status
Is your patient confused or acting out of character? Identify the cause with AEIOU-TIPS, a mnemonic for altered mental states
#emergencymedicine #residency #medicalstudent #meded #foamed #intern #ms4 #ms3 #mnemonics

Welcome back to part 3 of Hypertrophic Cardiomyopa

Welcome back to part 3 of Hypertrophic Cardiomyopathy!
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Take Home Points:

1. When patients with known or suspected HCM present hypotensive, maximize preload and afterload and avoid inotropes and chronotropes as they may worsen LVOTO.

2. Patients with HCM can have poor tolerance to atrial fibrillation and rhythm control strategy with cardioversion or antidysrhythmics drugs should be considered.

3. First-line treatment to prevent recurrent of ventricular dysrhythmias in HCM patients are beta-blockers.

4. ICD placement in patients with HCM has been shown to reduce mortality and is a class 1 recommendation in those with an episode of SCD in the past, ventricular fibrillation, or sustained ventricular tachycardia. Remember to ask about SCD risk factors such as family history of SCD or unexplained syncope.

5. Patients with symptoms should be admitted while those that are asymptomatic with known or suspected HCM can follow up with cardiology on an out-patient basis.

Check out our story and highlight reel for direct links to the article! Also check out our website for more juicy content!

Welcome to "Did You Ask?" a segment where we talk

Welcome to "Did You Ask?" a segment where we talk about important pieces of information that you need to get on history when examining patients.
Today we're gonna be talking about back pain one of the most common chief complaints in the ED.
#emergency #emergencymedicine #medicalstudent #emresident #resident #intern #ms4 #ms3 #foamed #awayrotation #subi #differential #mnemonic #backpain #step1 #step2 #step3 #ms1 #ms2

Welcome back to part 2 of Hypertrophic Cardiomyopa
$Welcome back to part 2 of Hypertrophic Cardiomyopathy! . . . . Take Home Points: 1. Ask about chest pain, shortness of breath, palpitations, and/or syncope on exertion during your interview 2. ECG findings are not diagnostic but classic findings include LVH, pathologic ‘dagger’ Q waves, deep S waves in V1-V3, and high R wave in V4-V6 with abnormal T waves 3. A bedside parasternal short axis view with an end-diastole wall thickness ≥ 15 mm is highly suspicious for HCM and warrants further investigation 4. Beta blockers are first line pharmacological intervention and in those with refractory symptoms consider disopyramide or surgical intervention via myomectomy or alcohol septal reduction Stay tuned for part 3 as we discuss treatment of emergent conditions and prevention of SCD! Check out our story and highlight reel for direct links to the article! Also check out our website for more juicy content!$

Heart 2 Heart
Identifying Wellen's Syndrome- Keep

Heart 2 Heart
Identifying Wellen's Syndrome- Keep an eye out for reperfusion T waves in the inferior or lateral leads if you have transient reperfusion of the RCA or LCx- the same pattern can happen in any of the coronary distributions!

County EM presents a case of a 59-year-old male wi

County EM presents a case of a 59-year-old male with a past medical history of hypertension, hyperlipidemia, and gastroesophageal reflux disease was brought in by EMS to the ED with severe chest pain
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Hypertrophic Cardiomyopathy (HCM)

Take Home Points:

1. HCM includes a complex interplay of left ventricular outflow tract obstruction (LVOTO), mitral regurgitation, diastolic dysfunction, myocardial ischemia, arrhythmias, and autonomic dysfunction

2. Although classically thought of as septal hypertrophy leading to LVOTO, multiple variants have been identified. Variants including concentric, reverse septal, neutral, and apical HCM have been identified, and nearly any pattern of LV wall thickening can occur with HCM.

3. Common adverse events include sudden cardiac death, symptoms of left ventricular outflow tract obstruction, heart failure, and arrhythmias

4. Patients with HCM are at higher risk for myocardial ischemia even in the absence of CAD.

5. The pathophysiology of anginal chest pain and rising troponin in HCM is related to increased oxygen demand secondary to hypertrophy, microvascular dysfunction, and small coronary vessel medial hypertrophy, which causes decreased coronary flow reserve and regional myocardial ischemia.

Stay tuned for part 2 as we discuss early identification of HCM!!

Check out our story and highlight reel for direct links to the article! Also check out our website for more juicy content!

Today we share a post on the pathophysiology and m

Today we share a post on the pathophysiology and management of priapism. The big takeways are as follows:

1) Priapism is either ischemic or non-ischemic and this is one of the most important distinctions to make as untreated ischemic priapism leads to fibrosis and permant sexual dysfunction.

2. Cavernosal blood gas in ischemic priapism will show elevated PaCO2 > 60 mmHg, decreased PaO2 < 30 mmHg, and pH < 7.25.

3. The most important treatment for priapism is drainage. This is achieved by injecting a 20-gauge needle into the 3 o'clock or 9 o'clock (sometimes both) position to aspirate blood from the corpus cavernosum. It is important to only aspirate from these positions to avoid injury to dorsal vessels or the urethra.

4. Once drainage is complete, inject phenylephrine into the corpus cavernosum to help prevent re-accumulation.

5. Most pharmacies will give you a phenylephrine bottle with 10 mg/mL concentration. You should dilute this ten-fold: take 1 mL of phenylephrine and mix into a 9 mL saline flush, creating a new concentration of 1mg/mL, or 1000 mcg/mL. You can inject 0.5cc of your phenylephrine mixture into the corpus cavernosa using the same needle you used for drainage (limit to 3 injections).

6. Lastly, all patients with priapism should be scheduled for urgent urology follow-up. For patients with recurrent episodes, or where multiple attempts at drainage have proven unsuccessful, you can consider an emergent urology consult.

Check out our story and highlight reel for direct links to the article! Also check out our website for more juicy content!

Today we share a post on the management of intracr

Today we share a post on the management of intracranial hemorrhage. The goal in the ED is to prevent hematoma expansion, edema, and herniation. The big takeaways are as follows:

1. For patients presenting with systolic blood pressure (SBP) between 150 and 220 mmHg, acute lowering of SBP to a target of 130 to 150 mmHg is safe and reasonable

2. Seizure prophylaxis is not routinely recommended except in lobar involvement.

3. Studies show that hypertonic saline leads to a greater reduction in ICP when compared to mannitol.

Check out our story and highlight reel for direct links to the article! Also, check out our website for more juicy content!

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