In the first of our series on Highlights from North York General's Emergency Medicine Update Conference, Dr. Kylie Bosman discusses Backboard and Collar Nightmares. The idea that backboards and c-spine collars prevent spinal cord injuries came from level 3 evidence in the 1960's and there has never been an RCT to prove this theory. In fact a Cochrane review on the topic in 2007 concluded that "the effect of pre-hospital spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain" and that "the possibility that immobilisation may increase mortality and morbidity cannot be excluded". There have subsequently been several observational studies that describe increased morbidity and mortality associated with backboard and collars in a subset of patients. Dr. Bosman argues that the time has long past that a major paradigm shift needs to occur toward a safer more rational use of backboards and collars in our trauma patients.
There are hundreds of clinical decision rules and risk scales published in the medical literature, some more widely adopted than others. Ian Stiell, the father of clinical decision rules, shares with us his views and experiences gained from co-creating some of the most influential CDRs and risk scales to date. He explains the criteria for developing a CDR, the steps to developing a valid CDR, how best to apply CDRs and risk scales to clinical practice, and the hot-off the-press new Ottawa COPD Risk Score and Ottawa Heart Failure Risk Score for helping you with disposition decisions. It turns out that in Canada, we discharge about two thirds of the acute decompensated heart failure patients that we see in the ED, while the US almost all patients with decompensated heart failure are admitted to hospital. Dr. Stiell's new risk scores may help physicians in Canada make safer disposition decisions while help physicians in the US avoid unnecessary admissions.
In this episode on Whistler's Update in Emergency Medicine Conference 2014 Highlights we have... Chapter 1 with David Carr on his approach to Shock, including the RUSH protocol, followed by a discussion on Thrombolysis for Submassive Pulmonary Embolism.... Then in Chapter 2 Lisa Thurgur presents a series of Toxicology Cases packed with pearls, pitfalls and surprises and reviews the use of Lipid Emulsion Therapy in toxicology....Finally in Chapter 3 Joel Yaphe reviews the most important articles from 2013 including the Targeted Temperature Managment post-arrest paper, the use of Tranexamic Acid for epistaxis, return to play concussion guidelines and clinical decision rules for subarachnoid hemorrhage. Another Whistler's Update in Emergency Medicine Conference to remember.......
In this episode on Appendicitis Controversies, we have the continuation of our discussion on abdominal pain emergencies with Dr. Brian Steinhart & Dr. David Dushenski. We kick off the discussion with key clinical pearls and pitfalls in the history and physical exam with their respective liklihood ratios when assessing patients with abdominal pain for appendicitis - a diagnosis that is still sometimes missed despite its prevalence. Dr. Dushenski hacks apart the Alvarado and Appendicitis Inflammatory Response Scores and we discuss the value of WBC, CRP and urinalysis in the work-up of appendicitis. Next up are the controversies of imaging algorithms using ultrasound and CT abdomen, as well as the factors affecting which imaging algorithm you might pursue. We wrap up the discussion on Appendicitis Controversies with a critical look at the value of antibiotics in the ED for appendicitis and which patients might be appropriate for non-surgical management.
In this episode Dr. Steinhart, (one of my biggest mentors – the doc that everyone turns to when no one can figure out what’s going on with a patient in the ED), & Dr. Dave Dushenski, (a master of quality assurance and data analysis, who would give David Newman a run for his money), discuss the 4 diagnoses that make up the deadly & difficult diagnosis of Mesenteric Ischemia, it’s key historical and physical exam features, the value of serum lactate, D-dimer & blood gas, when CT can be misleading, ED management of Mesenteric Ischemia, the difficult post-ERCP abdominal pain patient, the pitfalls in management of Pancreatitis, the BISAP score for Pancreatitis compared to the APACHE ll & Ranson Score, the comparative value of amylase and lipase, ultrasound vs CT for pancreatitis and much more…
In this episode on Pulmonary Embolsim we have the triumphant return of Dr. Anil Chopra, the Head of the Divisions of Emergency Medicine at University of Toronto, and Dr. John Foote the CCFP(EM) residency program director at the University of Toronto. We kick it off with Dr. Foote's approach to undifferentiated dyspnea and explanation of Medically Unexplained Dyspea ('MUD') and go on to discuss how best to develop a clinical pre-test probability for the diagnosis of pulmonary embolism using risk factors, the value of the PERC rule, Well's criteria and how clinical gestalt plays into pre-test probability. Dr. Chopra tells about the appropriate use of D-dimer to improve our diagnostic accuracy without leading to over-investigation and unwarranted anticoagulation. We then discuss the value of V/Q scan in the workup of PE, and the pitfalls of CT angiography. A discussion of anticoagulation choices follows and the controversies around thrombolysis for submassive PE are reviewed.
As a bonus to Episode 20 on Atrial Fibrillation, we present here, Dr. Clare Atzema, a leading EM researcher in Atrial Fibrillation, telling her Best Case Ever related to Afib. What would you do if you needed to cardiovert a patient who was too obese to fit on an ED stretcher? Dr. Atzema, along with Dr. Nazanin Meshkat and Dr. Bryan Au, discuss the presentation, etiology, precipitants, management and disposition of Atrial Fibrillation in the Emergency Department. The pros and cons of rate vs rhythm control are debated, what you need to know about Afib medications, and the value of the Ottawa Aggressive Protocol discussed. The importance of appropriate anticoagulation is detailed, with a review of the CHADS-VASc score and whether to use anticogulants or ASA for stroke prevention for patients with Afib. We end off with a discussion on how to recognize and treat Wolff-Parkinson-White syndrome in the setting of Atrial Fibrillation. [wpfilebase tag=file id=382 tpl=emc-play /] [wpfilebase tag=file id=383 tpl=emc-mp3 /]
In Part 1 of this Episode on Pediatric Abdominal Pain, Dr. Anna Jarvis, "the mother of pediatric emergency medicine" & Dr. Stephen Freedman, one of the world's pre-eminent pediatric EM researchers, discuss the nuances of the history, physical and work up of Pediatric Abdominal Pain & Appendicitis and key pearls on how to distinguish serious surgical causes from the very common diagnosis of gastroenteritis. An in-depth discussion on the pearls of the history, physical exam, lab tests, imaging including serial ultrasounds vs CT abdomen, clinical decision rules such as the Alvarado Score, best analgesics and antibiotics in pediatric appendicitis follows.
Ep17 P1 StrokeDr. Walter Himmel, "the walking encyclopedia of Emergency Medicine" & Dr. Dan Selchen, the head of the stroke program at St. Micheal's Hospital in Toronto with 30+ years of experience as a stroke neurologist, update us on the literature regarding Emergency Stroke Controversies including the ABCD2 Score to predict Stroke after TIA, as well as the current thinking around the best carotid imaging for patients who have had a TIA. They then review the important findings of the key thrombolysis stroke trials & how we could incorporate these findings into our daily practice. Dr. Selchen reviews the key CT findings we should look for in stroke, & Dr. Himmel takes us through how to manage the dreaded complication of ICH post thrombolysis. This episode is super controversial - so please 'speak your mind' at the bottom of the page.
In Part 1 of this episode on Headache Pearls & Pitfalls - Migraine Headache & Subarachnoid Hemorrhage, Dr. Anil Chopra and Dr. Stella Yiu discuss the best evidenced-based management of migraine headache in the ED including the use of dexamethasone, dopamine antagonists, the problems with narcotics and the efficacy of 'triptans'. An easy way to remember the worrisome symptoms of headache indicating a serious cause is reviewed followed by a detailed discussion of the pearls, pitfalls and controversies around the work-up of Subarachnoid Hemorrhage (SAH) in light of some exciting recent literature, including the basis for a new Canadian decision rule for SAH.