BCE 77 Pulmonary Embolism Workup in Pregnancy

This Best Case Ever elucidates the practical challenges of working up pregnant patients in the ED with a suspicion of pulmonary embolism. Since this recording, the first ever multi-center prospective outcome study looking at the pulmonary embolism workup in pregnancy was published in the Annals of Internal Medicine. A suggested algorithm and analysis of the study by Lauren Westafer are provided in these show notes....

Ep 113 Pulmonary Embolism Challenges in Diagnosis Part 1

Dr. Kerstin DeWit and Dr. Eddy Lang answer the questions that plague us on almost every shift: Which patients require any work-up at all for PE? What’s the utility of PERC and Well’s scores? Should the newer YEARS decision tool supplant Well’s? When should we order a D-dimer? What’s the diagnostic role of CXR, ECG, POCUS, CTA and VQ? How should we work up pregnant patients for PE? How can we use shared decision making strategies for PE to help us do what’s best for our patients, and many more...

Journal Jam 9 – D-dimer to Rule Out Aortic Dissection

The EM Cases Team is very excited to bring you not only a new format for the Journal Jam podcast but a new member of the team, Dr. Rory Spiegel, aka @EM_Nerd an Emergency Medicine physician from The University Maryland Medical Center in Baltimore, the founder of the EM Nerd blog and the co-host of the Annals of EM podcast. The new format sees Justin Morgenstern, Teresa Chan, Rory Spiegel and Anton Helman doing deep dives into the world's literature on specific practical questions while highlighting some important evidence-based medicine concepts. The question we ask in this Journal Jam podcast: Is there a role for D-dimer testing in the workup of aortic dissection in the ED?

Journal Jam 1: Age Adjusted D-dimer with Jeff Kline and Jonathan Kirschner

In this first ever episode of the Journal Jam podcast, a collaboration between EM Cases, Academic Life in EM and The Annals of Emergency Medicine's Global Emergency Medicine Journal Club, Teresa Chan and I, along with Jeff Kline, Jonathan Kirschner, Anand Swaminathan, Salim Rezaie and Sam Shaikh from ALiEM, discuss the potential for Age Adjusted D-dimer to rule out pulmonary embolism in low risk patients over the age of 50. We discuss 4 key questions about the ADJUST-PE Study from JAMA in March 2014 including: Would you order a CTPA on a 60 year old woman with an age adjusted D-dimer of 590 ng/L? The problem until now has been that the older the patient, the more likely the D-dimer is to be positive whether they have a PE or not, so many of us have thrown the D-dimer out the window in older patients and go straight to CTPA, even in low risk patients. If you are a risk averse doc, this strategy will lead to over-utilization of resources, huge costs, length of stay, radiation effects etc; and if you’re not so risk averse, then you might decide not to work up the low risk older patient at all and miss clinically important PEs. expert peer reviewFor all the questions discussed on this podcast, the original Google Hangout interview from which this podcast was based, and the crowd sourced opinions from around world, visit the ALiEM website. Many thanks to all the talented people who made this podcast possible. Together, we're smarter!

Episode 42: Mesenteric Ischemia and Pancreatitis

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…

Best Case Ever 21 Abdominal Pain – Thinking Outside the Box

As a bonus to Episode 42 on Mesenteric Ischemia & Pancreatitis, Dr. Brian Steinhart presents his Best Case Ever of Abodominal Pain – Thinking Outside the Box. While about 10% of abdominal pain presentations to the ED are surgical, there are a variety of abdominal pain presentations that have diagnoses outside the abdomen – so one needs to be thinking outside the box. In the related 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…

Episode 28: Aortic Dissection, Acute Limb Ischemia and Compartment Syndrome

Dr. Anil Chopra & Dr. David Carr discuss the breadth of presentations and key diagnostic clues of Aortic Dissection. They review the value of ECG, CXR and biomarkers as well as compare and contrast the use of Transesophageal Echo and CTA in this sometime elusive diagnosis. Being the authors of the Tintanalli chapter on Occlusive Arterial Disease, they give as lots of clinical pearls and pitfalls when it comes to Acute Limb Ischemia. We end with a discussion on the trials and tribulations of Compartment Syndrome.

Best Case Ever 13: Aortic Dissection

Dr. David Carr, the past author of Tintinalli's chapter on occlusive arterial disease, tells us his Best Case Ever related to Aortic Dissection. In the related Episode 28: Aortic Dissection, Acute Limb Ischemia & Compartment Syndrome, we discuss the breadth of presentations and key diagnostic clues of Aortic Dissection. We review the value of ECG, CXR, biomarkers and the use of Transesophageal Echo and CTA in this sometime elusive diagnosis. We debate lots of clinical pearls and pitfalls when it comes to acute limb ischemia, and end with a discussion on the trials and tribulations of Compartment Syndrome.
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Episode 21: Pulmonary Embolism

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.

Episode 14 Part 2: Thunderclap Headache – Cerebral Venous Thrombosis and Cervical Artery Dissection

emergency headacheIn Part 2 of this episode on Thunderclap Headache - Cerebral Venous Thrombosis & Cervical Artery Dissction, Dr. Stella Yiu and Dr. Anil Chopra review the presentation, work-up and management of some of the less common but very serious causes of headache including Cervical Artery Dissection (CAD), Cerebral Venous Thrombosis (CVT) and Idopathic Intracranial Hypertension (IIH). They tell us the most effective ways in which we can minimize the chance of the common Post-LP Headache. They answer questions such as: How does a carotid artery dissection present compared to a vertebral artery dissection? What is the evidence for chiropractic neck manipulation as a cause for Cervical Artery Dissection? How do antiplatelets compare to heparin for the treatment of Cervical Artery Dissection? What is Spontaneous Intracranial Hypotension? What is the differential diagnosis for headache in the peri-partum patient? Does D-dimer have a role in ruling out Cerebral Venous Thrombosis in the low risk patient? What is the imaging modality of choice for suspected Cerebral Venous Thrombosis? What is the value of opening pressure when performing an LP? What are the key headache diagnoses that can be missed on plain CT of the head and would warrant further investigation? and many more.....