Walter Himmel takes us through the resuscitation of a sick patient with an UGIB and the management priorities including blood products, antibiotics, TXA, octreotide, pantoprazole and endoscopy in this EMU 365 video...
Much has changed in recent years when it comes to TIA risk stratification, workup and antiplatelet therapy. In this podcast we use the overarching theme of timing to elucidate how to distinguish true TIA from the common TIA mimics, the importance of timing in the workup of TIA, why the duration of therapy with dual antiplatelet therapy and timing of starting anticoagulation in patient with atrial fibrillation, contributes to the difference between preventing catastrophic strokes and causing intracranial hemorrhage...
There exists a kind of self-fulfilling prognostic pessimism when it comes to ICH. And this pessimism sometimes leads to less than optimal care in patients who otherwise might have had a reasonably good outcome if they were managed aggressively. Despite the poor prognosis of these patients overall, there is some evidence to suggest that early aggressive medical management may improve outcomes. As such, the skill with which you manage your patient with ICH in those first few hours could be the most important determinant of their outcome. In this Golden Hour you have a chance to prevent hematoma expansion, stabilize intracerebral perfusion and give your patient the best chance of survival with neurologic recovery.
North York General Hospital's 30th Annual Emergency Medicine Update (EMU) Conference 2017 featured some of the best talks I've ever heard from the likes of Sara Gray, Amal Mattu, David Carr and many more. I had a hard time choosing which talks to feature on this EM Cases podcast. I settled on a potpourri of clinical topics and practice tips: Leeor Sommer on Lyme disease, Chris Hicks on signover, Matt Poyner on patient complaints and Walter Himmel on acute vestibular syndrome...
It's not only run of the mill DKA, starvation and alcoholic ketoacidosis that can cause a metabolic acidosis with elevated ketones. Euglycemic DKA can be caused by the newer diabetes medications sodium-glucose co-transporter 2 inhibitors like Canagliflozin; and it's important to recognize this tricky diagnosis early and initiate treatment for DKA despite a normal serum glucose level...
In this Part 2, DOACs Bleeding and Reversal we discuss the management of bleeding in patients taking DOACs with minor risk bleeds, like epistaxis where local control is easy to access, moderate risk bleeds, like stable GI bleeds and high risk bleeds, like intracranial hemorrhage. We answer questions such as: How do we weigh the risks and benefits of stopping the DOAC? When is reversal of the DOAC is advised? How best do we accomplish the reversal of DOACs? Is there any good evidence for the newest reversal agent? When should we stop DOACs for different procedures, and when should we delay the procedure?
As we get better at picking up thromboembolic disease, and the indications for Direct Oral Anticoagulants (DOACs) widen, we're faced with increasingly complex decisions about when to start these medications, how to start them, when to stop them and how to manage bleeding associated with them. There’s a lot that we need to know about these drugs to minimize the risk of thromboembolism in our patients while at the same time minimizing their risk of bleeding...
In anticipation of Episode 88 and 89: DOACs Use, Misuse and Reversal with the president of Thrombosis Canada and world renowned thrombosis researcher Dr. Jim Douketis, internist and thrombosis expert Dr. Benjamin Bell and 'The Walking Encyclopedia of EM' Dr. Walter Himmel, we have Dr. Himmel telling us the story of his Best Case Ever on anticoagulants and GI bleed. He discusses the most important contraindication to DOACs, the importance of not only attempting to reverse the effects of anticoagulants in a bleeding patient but managing the bleed itself as well as more great pearls. In the upcoming episodes we'll run through 6 cases and cover the clinical use of DOACs, how they work, safety, indications, contraindications, management of minor, moderate and severe bleeding, the new DOAC reversal agents, management of DVT with DOAC anticoagulants, stroke prevention in atrial fibrillation with DOACs and much more...
EM Cases Episode 82 Emergency Radiology Controversies, pearls and pitfalls: Which patients with chest pain suspected of ACS require a CXR? What CXR findings do ED docs tend to miss? How should we workup solitary pulmonary nodules found on CXR or CT? Is the abdominal x-ray dead or are there still indications for it's use? Which x-ray views are preferred for detecting pneumoperitoneum? When should we consider ultrasound as a screening test instead of, or before, CT? What are the indications for contrast in abdominal and head CT? How should we manage the patient who has had a previous CT contrast reaction who really needs a CT with contrast? What is the truth about CT radiation for shared decision making? And much more...
While knowledge acquisition is vital to developing your clinical skills as an EM provider, using that knowledge effectively for decision making in EM requires a whole other set of skills. In this EM Cases episode on Decision Making in EM Part 2 - Cognitive Debiasing, Situational Awareness & Preferred Error, we explore some of the concepts introduced in Episode 11 on Cognitive Decision Making like cognitive debiasing strategies, and some of the concepts introduced in Episode 62 Diagnostic Decision Making Part 1 like risk tolerance, with the goal of helping you gain insight into how we think and when to take action so you can ultimately take better care of your patients. Walter Himmel, Chris Hicks and David Dushenski answer questions such as: How do expert clinicians blend Type 1 and Type 2 thinking to make decisions? How do expert clinicians use their mistakes and reflect on their experience to improve their decision making skills? How can we mitigate the detrimental effects of affective bias, high decision density and decision fatigue that are so abundant in the ED? How can we use mental rehearsal to not only improve our procedural skills but also our team-based resuscitation skills? How can we improve our situational awareness to make our clinical assessments more robust? How can anticipatory guidance improve the care of your non-critical patients as well as the flow of a resuscitation? How can understanding the concept of preferred error help us make critical time-sensitive decisions? and many more important decision making in EM nuggets...