Episode 68 Emergency Management of Sickle Cell Disease

A recent needs assessment completed in Toronto found that Emergency providers are undereducated when it comes to the Emergency Management of Sickle Cell Disease. This became brutally apparent to me personally, while I was researching this topic. It turns out that we’re not so great at managing these patients. Why does this matter? These are high risk patients. In fact, Sickle Cell patients are at increased risk for a whole slew of life threatening problems. One of the many reasons they are vulnerable is because people with Sickle Cell disease are functionally asplenic, so they’re more likely to suffer from serious bacterial infections like meningitis, osteomyelitis and septic arthritis. For a variety of reasons they’re also more likely than the general population to suffer from cholycystitis, priapism, leg ulcers, avascular necrosis of the hip, stroke, acute coronary syndromes, pulmonary embolism, acute renal failure, retinopathy, and even sudden exertional death. And often the presentations of some of these conditions are less typical than usual. Those of you who have been practicing long enough, know that patients with Sickle Cell Disease can sometimes present a challenge when it comes to pain management, as it’s often difficult to discern whether they’re malingering or not. It turns out that we’ve probably been under-treating Sickle Cell pain crisis pain and over-diagnosing patients as malingerers. Then there are the sometimes elusive Sickle Cell specific catastrophes that we need to be able to pick up in the ED to prevent morbidity, like Aplastic Crisis for example, where prompt recognition and swift treatment are paramount. A benign looking trivial traumatic eye injury can lead to vision threatening hyphema in Sickle Cell patients and can be easy to miss. In this episode, with the help of Dr. Richard Ward, Toronto hematologist and Sickle Cell expert, and Dr. John Foote, the Residency Program Director for the CCFP(EM) program at the University of Toronto, we’ll deliver the key concepts, pearls and pitfalls in recognizing some important sickle cell emergencies, managing pain crises, the best fluid management, appropriate use of supplemental oxygen therapy, rational use of transfusions and more...

Episode 33: Oncologic Emergencies

In this episode on Oncologic Emergencies Dr. John Foote (University of Toronto's CCFP(EM) residency program director) and Dr. Joel Yaphe (the director of the University of Toronto’s Annual Update in Emergency Medicine conference in Whistler), review 5 important presentations in the patient with cancer: fever, shortness of breath, altered mental status, back pain and acute renal failure; with specific attention to key cancer-related emergencies such as febrile neutropenia, hypercalcemia, superior vena cava syndrome, hyperviscosity syndrome and tumor lysis syndrome.

Best Case Ever 16: Oncologic Emergencies

As bonus to Episode 33 on oncologic emergencies, Dr. John Foote, the CCFP(EM) residency program director at the University of Toronto tells us about his Best Case Ever in which he missed an important cancer-related diagnosis. In the related episode with Dr. Foote and Dr. Joel Yaphe, we will review 5 common presentations in the patient with cancer: fever, shortness of breath, altered mental status, back pain and acute renal failure; with specific attention to key cancer-related emergencies such as febrile neutropenia, hypercalcemia, superior vena cava syndrome, hyperviscosity syndrome and tumor lysis syndrome.

Episode 24: COPD and Pneumonia

In this episode we have the continuation of our discussion on Respiratory Emergencies with Dr. Anil Chopra and Dr. John Foote. We discuss key clinical decisions in COPD assessment and management - how to assess for impending respiratory failure, how best to oxygenate the COPD patient, medication pearls and how best to approach intubating the COPD patient. We then review an approach to hemoptysis as well as tricks of the trade for managing massive hemoptysis. Many pearls of pneumonia work-up and management are detailed as well as how to make important disposition decisions.

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.

Best Case Ever 8: Acute Dyspnea

Acute Dyspnea has a wide differential diagnosis from Metabolic Acidosis to Medically Unexplained Dyspnea. As a bonus to Episode 21 on Pulmonary Embolism and Acute Dyspnea, Dr. John Foote the CCFP(EM) residency program director at the University of Toronto presents his Best Case Ever related to an Acute Dyspnea presentation. In the related episode on Pulmonary Embolism we havet, with Dr. Foote, the triumphant return of Dr. Anil Chopra, the Head of the Divisions of Emergency Medicine at University of Toronto . We kick it off with Dr. Foote’s approach to undifferentiated acute dyspnea and explanation of Medically Unexplained Dyspea (‘MUD’) and go on to discuss how best to develop a clinical pretest 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 pretest 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 closes the podcast. [wpfilebase tag=file id=384 tpl=emc-play /] [wpfilebase tag=file id=385 tpl=emc-mp3 /]