Podcasts about mdcalc

Play Episode Listen Later May 15, 2024 70:36

Welcome to Episode 35 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 35 of “The 2 View” – the spring editorial edition! POCUS in the ED for Cholecystitis March 2024: Annals of Emergency Medicine. SoundCloud. Published January 2022. Accessed May 2, 2024. https://soundcloud.com/annalsofem/march-2024 The Center for Medical Education. Upper Abdominal Disorders | The EM Boot Camp Course. YouTube. Published July 12, 2022. Accessed May 2, 2024. https://www.youtube.com/watch?v=ESxRdeEYeHk Wilson SJ, Thavanathan R, Cheng W, et al. Test Characteristics of Emergency Medicine-Performed Point-of-Care Ultrasound for the Diagnosis of Acute Cholecystitis: A Systematic Review and Meta-analysis. Ann Emerg Med. Published October 18, 2023. Accessed May 2, 2024. https://www.annemergmed.com/article/S0196-0644(23)01214-3/abstract PECARN Validation Holmes JF, Yen K, Ugalde IT, et al. PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. Lancet Child Adolesc Health. PubMed. NIH: National Library of Medicine: National Center for Biotechnology Information. Published May 2024. Accessed May 2, 2024. https://pubmed.ncbi.nlm.nih.gov/38609287/ PECARN Pediatric Head Injury/Trauma Algorithm. MDCalc. Accessed May 2, 2024. https://www.mdcalc.com/calc/589/pecarn-pediatric-head-injury-trauma-algorithm PECARN Pediatric Intra-abdominal injury (IAI) algorithm. MDCalc. Accessed May 2, 2024. https://www.mdcalc.com/calc/3971/pecarn-pediatric-intra-abdominal-injury-iai-algorithm PECARN Spotlight: Tools Validated. EM Pulse PodcastTM. EM Pulse PodcastTM - Bringing research and expert opinion to the bedside. Published April 18, 2024. Accessed May 2, 2024. https://ucdavisem.com/2024/04/18/pecarn-spotlight-tools-validated/ Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

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32 - EMTALA, Head Injuries, Provider In Triage, Appendicitis

Play Episode Listen Later Jan 22, 2024 66:02

Welcome to Episode 32 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 32 of “The 2 View” – EMTALA, provider-in-triage positions, head injuries, appendicitis EMTALA / Head Injuries / Provider In Triage Latner A. Man Escorted Out of Hospital Without Being Seen: Is This an EMTALA Violation? Clinicaladvisor.com. Published April 11, 2023. Accessed January 21, 2024. https://www.clinicaladvisor.com/home/my-practice/legal-advisor/man-escorted-out-of-hospital-emtala-violation/ Centers for Medicare and Medicaid Services. Emergency Medical Treatment & Labor Act (EMTALA). Cms.gov. Accessed January 21, 2024. https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act MDCalc. Canadian CT Head Injury/Trauma Rule. Mdcalc.com. Accessed January 21, 2024. https://www.mdcalc.com/calc/608/canadian-ct-head-injury-trauma-rule Appendicitis Latner A. PA and NP Fail to Diagnose Appendicitis. Clinicaladvisor.com. Published December 6, 2023. Accessed January 21, 2024. https://www.clinicaladvisor.com/home/my-practice/legal-advisor/pa-np-fail-appendicitis/ Roberts M, Sharma M. 29 - Toxoplasmosis, the OPAL trial, medical marijuana, appendicitis, and colchicine. The 2 View: EM PA & NP Podcast. Published November 20, 2023. Published October 13, 2023. Accessed January 21, 2024. https://2view.fireside.fm/29 Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Questions: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

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30 - Phenylephrine Fail, Neurosyphilis Review, A Non-STD Genital Ulcer, Non-Sustained V-Tach

Deep Roots with NaijaBabeinTexas

Play Episode Listen Later Nov 3, 2023 77:40

Welcome to Episode 30 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 30 of “The 2 View” – oral phenylephrine, visual diagnosis plans, and NSVT. Oral Phenylephrine Myers Z. FDA panel: Many oral allergy meds don't work. WTTV CBS4Indy. Published October 15, 2023. Accessed October 17, 2023. https://cbs4indy.com/news/fda-panel-many-oral-allergy-meds-dont-work/ Neurosyphilis Review Hamill MM, Ghanem KG, Tuddenham S. State of the art review: neurosyphilis. Clin Infect Dis. Published August 18, 2023. Accessed November 1, 2023. doi: 10.1093/cid/ciad437 Visual Diagnosis - Behcet's Disease Behcet's Disease. Vasculitis Foundation. Published July 18, 2012. Accessed October 17, 2023. https://www.vasculitisfoundation.org/education/behcets-disease/ ACEP Clinical Policy on Ischemic Stroke Clinical Policies – Acute Ischemic Stroke. ACEP. Published May 2023. Accessed November 2, 2023. https://www.acep.org/patient-care/clinical-policies/acute-ischemic-stroke The VAN Assessment to Identify Large Vessel Occlusion Strokes. Core EM. Published May 17, 2018. Accessed November 2, 2023. https://coreem.net/journal-reviews/the-van-assessment/ Los Angeles Motor Scale (LAMS). MDCalc. Accessed November 2, 2023. https://www.mdcalc.com/calc/3959/los-angeles-motor-scale-lams Rapid Arterial oCclusion Evaluation (RACE) Scale for Stroke. MDCalc. Accessed November 2, 2023. https://www.mdcalc.com/calc/3941/rapid-arterial-occlusion-evaluation-race-scale-stroke NSVT: Non-Sustained Ventricular Tachycardia Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. Published August 1, 2018. Accessed October 17, 2023. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000549 Farzam K, Tivakaran VS. QT Prolonging Drugs. StatPearls Publishing; 2023. Accessed October 17, 2023. https://www.ncbi.nlm.nih.gov/books/NBK534864/ Foth C, Gangwani MK, Ahmed I, Alvey H. Ventricular Tachycardia. StatPearls Publishing; 2023. Accessed October 17, 2023. https://www.ncbi.nlm.nih.gov/books/NBK532954/ Ep 1 Lady G and Courage Under Fire. Burnt. Published January 27, 2021. Accessed November 2, 2023. https://podcasts.apple.com/us/podcast/ep-1-lady-g-and-courage-under-fire/id1551194920?i=1000506903956 Glaucomflecken. Will and Kristin's Cardiac Arrest Story with Paramedic Lieutenant Aaron Gregg. Published August 22, 2023. Accessed October 17, 2023. https://www.youtube.com/watch?v=CQtYoKPNsrM Laslett DB, Cooper JM, Greenberg RM, et al. Electrolyte Abnormalities in Patients Presenting With Ventricular Arrhythmia (from the LYTE-VT Study). Am J Cardiol. PubMed. NIH: National Library of Medicine: National Center for Biotechnology Information. Published August 15, 2020. Accessed October 17, 2023. https://pubmed.ncbi.nlm.nih.gov/32565090/ Nonsustained ventricular tachycardias. Bmj.com. BMJ Best Practice. Accessed October 25, 2023. https://bestpractice.bmj.com/topics/en-us/831 PVCs and Nonsustained VT: When to Worry? How to Treat? - Penn Physician VideoLink.; 2015. Published January 7, 2015. Accessed October 17, 2023. https://videolink.pennmedicine.org/videos/pvcs-and-nonsustained-vt-when-to-worry-how-to-treat TualatinValleyFire. Dr. Will Flanary - Cardiac Arrest Survivor. Published February 16, 2021. Accessed October 17, 2023. https://www.youtube.com/watch?v=wu9uAwnSrJU Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

state management fail worry disease treat prevention fda pac stroke american colleges burnt msn emergency medicine sustained genitals circulation medical education pubmed bmj ulcers cir tach courage under fire clinical practice guidelines acep lady g published may published october published july published august accessed october accessed november ventricular tachycardia clin infect dis heart rhythm society mdcalc statpearls publishing core em

Mood Disorder's with Dr Ajufo

Play Episode Listen Later Jun 19, 2023 46:40

Hello & welcome the audience to episode 1, season 3 of deep roots with NaijaBabeinTexas. I have a fabulous guest, “Dr. Ijeoma Ajufo,” on the show today; she is a licensed physician specializing in Psychiatry. We will discuss mood disorders, especially depression and bipolar, in our communities. In my experience, Africans, African Americans, Nigerian Americans, etc., don't understand mental health illnesses. We allow the sigma and our religion to impact our ability to ensure our family gets the care they need. People forget that mental illness is as severe as any other health disease, i.e., cancer, diabetes, etc. Our goal is to educate our audience on this topic. Dr. Ajufo and I discuss the causes, risk factors, types, and stigmas of mood disorders. How to recognize the patterns. As well as how to get management and treatment. There are several ways to get care. If you have suicidal thoughts: Please get care immediately by calling 911, going to an Emergency Room, or texting 988 is a Suicide and Crisis Lifeline. For care in Texas: Don't hesitate to contact Dr. Ajufo at her practice. Northridge Behavioral Health Website: northridgebehavioral.com Address: 2829 Babcock Rd, Suite 126 San Antonio, Texas 78229 Tel #: 210-475-3048 Resources: -https://www.who.int/news-room/fact-sheets/detail/depression -https://www.gradschools.com/get-informed/careers/types-of-mental-illnesses PHQ-9 (Patient Health Questionnaire-9) - MDCalc. -https://www.who.int/news-room/fact-sheets/detail/mental-disorders -https://www.mayoclinic.org/diseases-conditions/mood-disorders/symptoms-causes/syc-20365057 --- Send in a voice message: https://podcasters.spotify.com/pod/show/naijababeintexas/message

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26 - Solve 2023 EM Coding Headaches, Diagnosing Dementia, PE in Pregnancy, and More

Play Episode Listen Later May 31, 2023 75:14

Welcome to Episode 26 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 26 of “The 2 View” – Save time charting & code accurately, dementia, PE in pregnancy, and the PCN shortage. PCN Shortage Ault, A. FDA Drug Shortages. Current and Resolved Drug Shortages and Discontinuations Reported to FDA. FDA issues new rule on drug shortages. Community Oncology, 9(1), 34. U.S. Food & Drug. Published April 26, 2023. Accessed May 9, 2023. https://doi.org/10.1016/j.cmonc.2011.12.003 Bendix, A. Shortage of penicillin limits access to the go-to drug for syphilis. NBC News. Published April 27, 2023. Accessed May 9, 2023. https://www.nbcnews.com/health/health-news/shortage-penicillin-limits-access-go-drug-syphilis-rcna81777 Global shortages of penicillin. Shortages of benzathine penicillin. Global Sexually Transmitted Infections Programme. World Health Organization. Who.int. Accessed May 9, 2023. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/stis/treatment/shortages-of-penicillin Dementia Alzheimer's Disease Fact Sheet. Alzheimer's Disease and Related Dementias: Basics of Alzheimer's Disease and Dementia. National Institute on Aging. Accessed May 9, 2023. https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet Home. Alzheimer's Disease and Dementia. Alzheimer's Association. Accessed May 9, 2023. https://www.alz.org/ Silbert, L, Erten-Lyons, D. Memory Loss, Confusion in a 51-Year-Old Fired From Her Job. Medscape. Published March 2, 2023. Accessed May 9, 2023. https://reference.medscape.com/viewarticle/850363 PE in Pregnancy Negaard M. YEARS Algorithm for pulmonary embolism (PE). MDCalc. Accessed May 9, 2023. https://www.mdcalc.com/calc/4067/years-algorithm-for-pulmonary-embolism-pe Stals MAM, Moumneh T, Ainle FN, et al. Noninvasive diagnostic work-up for suspected acute pulmonary embolism during pregnancy: a systematic review and meta-analysis of individual patient data. J Thromb Haemost. 2023;21(3):606-615. NIH: National Library of Medicine: National Center for Biotechnology Information. PubMed. Published December 22, 2022. Accessed May 9, 2023. https://pubmed.ncbi.nlm.nih.gov/36696189/ Thromboembolism in Pregnancy. ACOG: The American College of Obstetricians and Gynecologists. Acog.org. Practice Bulletin, Number 196. Published July 2018. Accessed May 9, 2023. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/07/thromboembolism-in-pregnancy Charting & Coding 2023 Emergency Department Evaluation and Management Guidelines. ACEP: American College of Emergency Physicians. Acep.org. Last Updated: October 2022. Accessed May 9, 2023. https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs American Medical Association. 2023 Emergency Medicine Coding Guide. MDCalc. Accessed May 9, 2023. https://www.mdcalc.com/calc/10454/2023-emergency-medicine-coding-guide CPT Evaluation and Management (E/M) Code and Guideline Changes. AMA: American Medical Association. Ama-assn.org. Accessed May 9, 2023. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf ICD-10-CM Coding for Social Determinants of Health. AHA: American Hospital Association – Advancing Health in America. Aha.org. Published January 2022. Accessed May 9, 2023. https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf Level of MDM (based on 2 of 3 elements of MDM) number and complexity of problems addressed. ACEP: American College of Emergency Physicians – Advancing Emergency Care. ERCODER. Acep.org. Accessed May 9, 2023. https://www.acep.org/siteassets/sites/acep/media/reimbursement/acep---2023-ed-mdm-grid.pdf Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

24 - Molnupiravir, Easy EM Coding Calculator, and Thumb Injuries

Play Episode Listen Later Feb 24, 2023 44:26

Welcome to the 2 View - Episode 24 Welcome to Episode 24 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 24 of “The 2 View” – New street drug xylazine/"tranq," app for EM coding changes, FPL injuries, hemorrhoids. Molnupiravir Butler CC, Hobbs FDR, Gbinigie OA, et al. Molnupiravir plus usual care versus usual care alone as early treatment for adults with COVID-19 at increased risk of adverse outcomes (PANORAMIC): an open-label, platform-adaptive randomised controlled trial. Lancet. PubMed. NIH: National Library of Medicine, National Center for Biotechnology Information. Published January 28, 2023. Accessed February 21, 2023. https://pubmed.ncbi.nlm.nih.gov/36566761/ Molnupiravir. COVID-19 Treatment Guidelines. NIH. Last Updated: September 26, 2022. Accessed February 21, 2023. https://www.covid19treatmentguidelines.nih.gov/therapies/antivirals-including-antibody-products/molnupiravir/ Easy Emergency Medicine Coding Calculator American Medical Association. 2023 Emergency Medicine Coding Guide. MDCalc. Accessed February 21, 2023. https://www.mdcalc.com/calc/10454/2023-emergency-medicine-coding-guide CPT Evaluation and Management (E/M) Code and Guideline Changes. Ama-assn.org. AMA: American Medical Association. Accessed February 21, 2023. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf Graham. 2023 Emergency Medicine Level of Service/Billing Guidelines Overview. Published December 31, 2022. Accessed February 21, 2023. https://www.youtube.com/watch?v=WuV8O3SuXJI The Center for Medical Education. Documentation Changes that Can Help Your Practice. Published August 16, 2022. Accessed February 21, 2023. https://www.youtube.com/watch?v=gHLBjzQt4vo Xylazine DEA Joint Intelligence Report. The Growing Threat of Xylazine and its Mixture with Illicit Drugs. U.S. Department of Justice Drug Enforcement Administration. Dea.gov. Published October 2022. Accessed February 21, 2023. https://www.dea.gov/sites/default/files/2022-12/The%20Growing%20Threat%20of%20Xylazine%20and%20its%20Mixture%20with%20Illic it%20Drugs.pdf FDA warns about the risk of xylazine exposure in humans. Fda.gov. FDA. Published November 8, 2022. Accessed February 21, 2023. https://www.fda.gov/media/162981/download Hoffman J. Tranq dope: Animal Sedative Mixed with Fentanyl Brings Fresh Horror to U.S. Drug Zones. The New York Times. Published January 7, 2023. Accessed February 21, 2023. https://www.nytimes.com/2023/01/07/health/fentanyl-xylazine-drug.html. National Institute on Drug Abuse. Xylazine. National Institute on Drug Abuse: Advancing Addiction Science. Published April 21, 2022. Accessed February 21, 2023. https://nida.nih.gov/research-topics/xylazine Overdose C on O. Toxicity of Xylazine and How It Impacts People Who Use Drugs by Dr. Joseph D'Orazio. Published June 15, 2022. Accessed February 21, 2023. https://www.youtube.com/watch?v=Rqpf0jIuyCo Flexor Pollicis Longus and Other Thumb Injuries Gault D. A review of repaired flexor tendons. J Hand Surg Br. ScienceDirect. Published October 1987. Accessed February 21, 2023. https://www.sciencedirect.com/science/article/abs/pii/0266768187901811 Urbaniak JR. Repair of the flexor pollicis longus. Hand Clin. Europe PMC. Published February 1, 1985. Accessed February 21, 2023. https://europepmc.org/article/med/3912396 Hemorrhoids Procedure Review: Thrombosed Hemorrhoids. EM:RAP. EM:RAP.ORG. Published April 2018. Accessed February 21, 2023. https://www.emrap.org/episode/emrapliveapril/procedurereview Zuber TJ. Hemorrhoidectomy for Thrombosed External Hemorrhoids. Am Fam Physician. AAFP. Published 2002. Accessed February 21, 2023. https://www.aafp.org/pubs/afp/issues/2002/0415/p1629.html Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

Episode 018: Heme/Onc Emergencies, Pt. 7: TTP

The Fellow on Call

Play Episode Listen Later Jun 17, 2022

Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further. In this episode, we talk all about our fourth hematologic emergency: thrombotic thrombocytopenic purpura (TTP). Thrombotic thrombocytopenic purpura (TTP):- Be sure to check out episode 009 on thrombocytopenia for a general approach and differential!- New anemia and thrombocytopenia should raise concerns for TTP! Workup: - Peripheral smear - concern for schistocytes. Look at this first! Example of these cells from ASH image bank here- ADAMTS13 level - always draw ASAP before any intervention- Repeat CBC- Reticulocyte count - will have elevated retic count- Citrated platelet count - CMP- PT, PTT, INR- Fibrinogen- Haptoglobin - LDH- Viral serologies Clinical manifestations: - Fever, Anemia, Thrombocytopenia, Renal (AKI), Altered Mental Status- If you see this - the patient is in bad shapeMechanism:- Tiny blood clots form in the body, causing platelet shearing- Loss of ADAMTS13 - This protein normally is responsible for chopping up von Willebrand's factor (vWF)- In the absence of ADAMTS13, vWF multimers are extra long, therefore interacting with platelets/collagen more and causing activation of platelets and clotting system- This causes red blood cell shearing due to small vessel microthrombi (brain, kidneys, heart)- Cytokine release causes fevers Management:- Do not reflexively transfuse platelets; can make situation worse - PLASMIC Score: helps to stratify likelihood of TTP; MDCalc link (https://www.mdcalc.com/plasmic-score-ttp)Treatment: - Plasma exchange: replacing ADATMS13-deficient plasma with ADAMTS13-rich plasma- This is different than plasmapheresis, where we replace plasma with albumin- Steroids: 1mg/kg prednisone daily to stop auto-antibody (against ADAMTS13) production- Confirm with ADAMTS13 levels; if

16 - Subarachnoid Hemorrhage, Pediatric Hepatitis Outbreak, Medical Errors, and More

Health Technology Innovation

Play Episode Listen Later May 11, 2022 87:29

Welcome to Episode 16 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 16 of “The 2 View” – SAH: revisited, pediatric hepatitis outbreak, medical errors, and AHA/ACC heart failure guidelines. SAH - Revisited Headache. American College of Emergency Physicians. Acep.org. Published June 2019. Accessed April 27, 2022. https://www.acep.org/patient-care/clinical-policies/headache/ Ibrahim YA, Mironov O, Deif A, Mangla R, Almast J. Idiopathic Intracranial Hypertension: Diagnostic Accuracy of the Transverse Dural Venous Sinus Attenuation on CT scans. Neuroradiol J. PubMed Central. National Library of Medicine: National Center for Biotechnology Information. Published December 2014. Accessed April 27, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4291803/ Spadaro A, Scott KR, Koyfman A, Long B. Reversible cerebral vasoconstriction syndrome: A narrative review for emergency clinicians. Am J Emerg Med. PubMed.gov. National Library of Medicine: National Center for Biotechnology Information. Published October 4, 2021. Accessed April 27, 2022. https://pubmed.ncbi.nlm.nih.gov/34879501/ Pediatric Hepatitis Outbreak Jetelina K. Severe hepatitis outbreak among children. Your Local Epidemiologist. Published April 26, 2022. Accessed April 27, 2022. https://yourlocalepidemiologist.substack.com/p/severe-hepatitis-outbreak-among-children Multi-Country – Acute, severe hepatitis of unknown origin in children. Who.int. Published April 23, 2022. Accessed April 27, 2022. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON376 Recommendations for Adenovirus Testing and Reporting of Children with Acute Hepatitis of Unknown Etiology. HAN archive - 00462. Cdc.gov. Published April 21, 2022. Accessed April 27, 2022. https://emergency.cdc.gov/han/2022/han00462.asp Medical Errors Dihydroergotamine (DHE) for Migraine Treatment. American Migraine Foundation. Published January 28, 2021. Accessed April 27, 2022. https://americanmigrainefoundation.org/resource-library/dhe-for-migraine/ Kelman B. Former nurse found guilty in accidental injection death of 75-year-old patient. NPR. Published March 25, 2022. Accessed April 27, 2022. https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient. Khan A. Medical Errors in the Emergency Department. SAJEM Editorial. Researchgate.net. Accessed April 27, 2022. https://www.researchgate.net/profile/Abdus-Khan/publication/336838935MedicalErrorsintheEmergencyDepartment/links/5dbae7df4585151435d6e97f/Medical-Errors-in-the-Emergency-Department.pdf Pasquini S. Healthcare Experience Required for PA School: The Ultimate Guide. The Physician Assistant Life. Published February 2, 2015. Accessed April 27, 2022. https://www.thepalife.com/hce-paschool/ AHA/ACC Heart Failure Guidelines Emergency Heart Failure Mortality Risk Grade (EHMRG). MDCalc. Accessed April 27, 2022. https://www.mdcalc.com/emergency-heart-failure-mortality-risk-grade-ehmrg Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published April 1, 2022. Accessed April 27, 2022. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 Ottawa Heart Failure Risk Scale (OHFRS). MDCalc. Accessed April 27, 2022. https://www.mdcalc.com/ottawa-heart-failure-risk-scale-ohfrs Rider I. Evidence Based Disposition in Heart Failure – Who needs to be admitted and who can be discharged? emDOCs.net - Emergency Medicine Education. Published October 5, 2020. Accessed April 27, 2022. http://www.emdocs.net/evidence-based-disposition-in-heart-failure-who-needs-to-be-admitted-and-who-can-be-discharged/ SGEM#170: Don't Go Breaking My Heart – Ottawa Heart Failure Risk Scale. The Skeptics Guide to Emergency Medicine. Published March 5, 2017. Accessed April 27, 2022. https://thesgem.com/2017/03/sgem170-dont-go-breaking-my-heart-ottawa-heart-failure-risk-scale/ Thibodeau J, Turer A, Gualano S, et al. Characterization of a Novel Symptom of Advanced Heart Failure: Bendopnea. ScienceDirect. Sciencedirect.com. Presented November 3, 2012. Accessed April 27, 2022. https://www.sciencedirect.com/science/article/pii/S2213177913004125?via%3Dihub Something Sweet O'Connell A, Greco S, Zhan T, et al. Analyzing the effect of interview time and day on emergency medicine residency interview scores. BMC Med Educ. Published April 26, 2022. Accessed April 27, 2022. https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-022-03388-6 Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

Patients Come First Podcast - Dr. Graham Walker

Patients Come First

Play Episode Listen Later Feb 23, 2022 22:12

This episode of VHHA's Patients Come First podcast features an interview with California-based emergency physician Dr. Graham Walker for a conversation about his work, social media engagement in the misinformation age, the evolution of the MDCalc platform he helped create, and more. Send questions, comments, feedback, or guest suggestions to pcfpodcast@vhha.com or contact us on Twitter or Instagram using the #PatientsComeFirst hashtag.

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Episode 5: To Engage or Not to Engage ft. Dr. Joseph Habboushe

Six Degrees

Play Episode Listen Later Jan 30, 2022 42:11

In Episode 5, To Engage or Not to Engage, Kevin will explore how decision support technologies have the potential to augment provider workflows and enhance clinical decision making with Dr. Joseph Habboushe, CEO and co-founder of MDCalc.

ceo engage mdcalc

Digital Health Technologies: Expert Panel Discussion

Play Episode Listen Later Dec 5, 2021 53:35

This podcast, which was initially recorded as a panel discussion on Innovation Biodesign, has been created by the Montefiore Einstein Innovation Biodesign Training Program. Link - https://einsteinmed.edu/departments/medicine/innovation/biodesign-training/ The podcast's host is Dr. Sunit Jariwala, an Associate Professor of Medicine and Director of Clinical & Research Innovation at Montefiore Einstein. Dr. Jariwala is the Director of Research within the Division of Allergy and Immunology at the Albert Einstein College of Medicine. This podcast's guest presenters – Kurt Yaeger, MD. Neuroendovascular Fellow, Department of Neurosurgery, Mount Sinai Health System. Founder, Karos Vascular. Co-Founder, Mediscribe Jay Graham, MD. Associate Professor, Department of Surgery (Transplant Surgery), Montefiore Health System. Founder, Transplant Hero Joseph Habboushe, MD, MBA. Associate Professor of Emergency Medicine, NYU Langone and Bellevue Medical Centers. CEO and Co-Founder, MDCalc

Episode 73 - Anticoagulants in Afib

Rio Bravo qWeek

Play Episode Listen Later Nov 5, 2021 14:28

Episode 73: Anticoagulation in Afib. When should you start anticoagulation in atrial fibrillation? What medications are appropriate? Virginia Bustamante, Charizza Besmanos and Dr Arreaza discuss this topic. By Charizza Besmanos, MS4; Virginia Bustamante, MS4; and Hector Arreaza, MDCharizza: Hello, welcome to today's episode of Rio Bravo qWeek Podcast. My name is Charizza Besmanos, a 4th year medical student from American University of the Caribbean and I am joined here today by Virginia Bustamante. Virginia: I'm Virginia Bustamante, an incoming 4th year medical student from Ross University. Arreaza: And I'll be here just to make sure that you guys behave during this episode. Charizza: Before we get started on our discussion, I have a quick patient case to share with you. This is a 66-year-old woman who is brought to the ED with sudden onset of severe difficulty speaking and weakness while having breakfast. She has hypertension, hyperlipidemia, severe left atrial enlargement seen on previous ECHO, and is noncompliant with her medications. She is a lifetime nonsmoker and does not drink alcohol. On admission, her blood pressure is 152/90 and pulse is 124/min and irregularly irregular. She is awake and alert but has difficulty finding words while trying to speak. She has severe right lower facial droop and marked weakness and sensory loss in the right arm and mild weakness in right leg. Fingerstick glucose is at 105. ECG shows atrial fibrillation. Acute stroke management is started right away. CT shows occlusion of the left MCA. What management could have prevented this complication? Virginia: This patient clearly has multiple risk factors for thromboembolism events but given her irregularly irregular pulse consistent with atrial fibrillation, she would've warranted long-term anticoagulation to prevent stroke, which she most likely had. Charizza: Exactly. Today's topic is atrial fibrillation, specifically the use of anticoagulation. __________________This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. __________________ Virginia: Anticoagulation is indicated to decrease the risk of thromboembolic events such as ischemic stroke in patients with atrial fibrillation (A-fib). Not all patients receive anticoagulation. Like most things in medicine, you must decide to start anticoagulation when the benefits of decreasing the risk of stroke outweighs the risk of bleeding. So, for assessing the risk of stroke in A-fib, the American College of Cardiology along with American Heart Association and the Heart Rhythm Society published a guideline in the Journal of the American College of Cardiology in 2014 and was recently updated in 2019[1] detailing in which patients anticoagulation is recommended. Charizza: Yes, according to the guideline, “high risk patients” are all patients with valvular A-fib, and those with nonvalvular A-fib with a CHADVASC score of >/= 2 in men or >/= 3 in women, and those with nonvalvular Afib and hypertrophic cardiomyopathy. Those with “medium risk” are patients with nonvalvular Afib with CHAD2VASc score of 1 in men or 2 in women. In these patients, anticoagulation is considered but the risk and benefits are discussed with the patient. Those with “low risk” are patients with CHAD2VASc score of 0 in men or 1 in women and anticoagulation is not routinely recommended in these patients. Can you tell us briefly what CHA2DVASc score is? Virginia: CHA2DS2-VASc score is the stroke risk assessment tool of choice by the AHA/ACC/HRS guideline. It is great because it is a mnemonic. Each letter is assignment 1 point except for 2 criteria. C stands for congestive heart failure, H for HTN defined as >140/90, A2 is for or Age>75 which is for 2 points, D for diabetes, S2 is for stroke or TIA and it's for 2 points, V for vascular disease such as MI, A for age 65-74, S for female sex. Charizza: That certainly makes it easy to remember. Not only that, but you can also find CHA2DS2-VASc score of MDCalc to make it even easier. Virginia: Now that we've established which patients should receive anticoagulation, how do we choose which anticoagulant? Charizza: For this discussion today, I would like to focus on nonpregnant patients. There really are 2 main anticoagulants, DOACs (or the direct oral anticoagulants) and warfarin. DOACs are the direct thrombin INH (dabigatran) and the direct factor Xa INH (rivaroxaban, apixaban, and edoxaban). DOAC is recommended as first-line in the long-term management of nonvalvular afib as trials have shown DOACs are more successful at reducing risk of thromboembolic events and have a lower risk of bleeding than warfarin and warfarin requires INR monitoring with dose adjustments. Although, in patients with valvular Afib, warfarin is preferred. Arreaza: All of them are by mouth. Virginia: Dosing of DOACs depends on the kidney function, so it is important to obtain the creatinine clearance. For dabigatran, the direct thrombin INH, the recommended dose for patients with CrCl >30 mL/min is 150mg PO twice daily based on the results from the RE-LY trial (2), which evaluated the efficacy and safety of dabigatran with warfarin in patients with Afib. For patients with CrCl of 15-30 mL/min, the recommended dose is 75mg PO BID. Those with CrCl 1.5, patient who is > 80years old or body weight

california journal caribbean ucla echo american colleges ml american university tia acute american heart association cardiology s2 bakersfield a2 ecg mca afib inr anticoagulation anticoagulants doac doacs htn ms4 ross university crcl heart rhythm society mdcalc cha2ds2 vasc

The 2 View: Episode 7

What2Know - a Marketing and Communications Podcast

Play Episode Listen Later Jul 25, 2021 85:32

Welcome to Episode 007 (cue the James Bond music please) of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 7 of “The 2 View” A Wolf in Sheep's Clothing Birnbaumer, Diane MD. A Wolf in Sheep's Clothing: Serious Causes of Common Complaints. Advanced Emergency Medicine Boot Camp. September 2019. Las Vegas. Accessed June 29, 2021. Subarachnoid Hemorrhage Carpenter CR, Hussain AM, Ward MJ, et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture with an Exploration of Test Thresholds. Acad Emerg Med. PubMed.gov. Published September 6, 2016. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/27306497/ Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. Published 2012. Accessed June 29, 2021. https://www.ahajournals.org/doi/full/10.1161/str.0b013e3182587839 Headache. Acep.org. Published June 2019. Accessed June 29, 2021. https://www.acep.org/patient-care/clinical-policies/headache/ Hine, J MD, Marcolini, E MD. Aneurysmal Subarachnoid Hemorrhage. EM:RAP CorePendium. Emrap.org. Published September 17, 2020. Accessed June 29, 2021. https://www.emrap.org/corependium/chapter/recTI59VW0TPBpesx/Aneurysmal-Subarachnoid-Hemorrhage Kim YW, Neal D, Hoh BL. Cerebral aneurysms in pregnancy and delivery: pregnancy and delivery do not increase the risk of aneurysm rupture. Neurosurgery. PubMed.gov. Published February 2013. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/23147786/ Marcolini E, Hine J. Approach to the Diagnosis and Management of Subarachnoid Hemorrhage. West J Emerg Med. NCBI. Published February 28, 2019. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404699/ Ogilvy, C MD, Rordorf, G MD, Singer, R MD. Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis. UpToDate. Uptodate.com. Updated February 25, 2020. Accessed June 29, 2021. https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-clinical-manifestations-and-diagnosis?search=subarachnoid%20hemorrhage&source=searchresult&selectedTitle=1~150&usagetype=default&display_rank=1 Ottawa Subarachnoid Hemorrhage (SAH) Rule for Headache Evaluation. Mdcalc.com. Accessed June 29, 2021. https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation Subarachnoid Hemorrhage, no LP. EM:RAP. Emrap.org. Published May 2020. Accessed June 29, 2021. https://www.emrap.org/episode/emrap2020may/subarachnoid Gonococcal Arthritis Klausner, J MD, MPH. Disseminated gonococcal infection. UpToDate. Uptodate.com. Updated January 7, 2021. Accessed June 29, 2021. https://www.uptodate.com/contents/disseminated-gonococcal-infection Li R, Hatcher JD. Gonococcal Arthritis. In: StatPearls. StatPearls Publishing. Published July 26, 2020. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK470439/ Milne, Wm. MD. SGEM#335: Sisters Are Doin' It for Themselves…Self-Obtained Vaginal Swabs for STIs. Thesgem.com. Published June 26, 2021. Accessed June 29, 2021. https://www.thesgem.com/2021/06/sgem335-all-by-myselfself-obtained-vaginal-swabs-for-stis/ Ventura, Y MD, Waseem, M MD, MS. Disseminated Gonococcal Infection: Emergency Department Evaluation and Treatment. Emdocs.net. Published May 17, 2021. Accessed June 29, 2021. http://www.emdocs.net/disseminated-gonococcal-infection-emergency-department-evaluation-and-treatment/ Epiglottitis Abdallah C. Acute epiglottitis: Trends, diagnosis and management. Saudi J Anaesth. Published July-September 2012. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498669/ Ames WA, Ward VM, Tranter RM, Street M. Adult epiglottitis: an under-recognized, life-threatening condition. Br J Anaesth. Oxford Academic. Published November 1, 2000. Accessed June 29, 2021. https://academic.oup.com/bja/article/85/5/795/273886 Dowdy RAE, Cornelius BW. Medical Management of Epiglottitis. Anesth Prog. Published July 6, 2020. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342809/ Farkas, J. Epiglottitis. Emcrit.org. Published December 18, 2016. Accessed June 29, 2021. https://emcrit.org/ibcc/epiglottitis/ Mayo-Smith M. Fatal respiratory arrest in adult epiglottitis in the intensive care unit. Implications for airway management. Chest. PubMed.gov. Published September 1993. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/8365325/ Roberts, J MD, Roberts, M ACNP, PNP. Nasal Endoscopy for Urgent and Complex ED Cases. Lww.com. Published October 28, 2020. Accessed June 29, 2021. https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=110 Wolf M, Strauss B, Kronenberg J, Leventon G. Conservative management of adult epiglottitis. Laryngoscope. PubMed.gov. Published February 1990. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/2299960/ Wellens Syndrome Wellens Syndrom EKG Sign: See full show notes here: https://bit.ly/3eSyzp0 Cadogan M, Buttner R. Wellens Syndrome. Life in the Fastlane. Litfl.com. Published June 4, 2021. Accessed June 29, 2021. https://litfl.com/wellens-syndrome-ecg-library/ Smith S. Wellens' missed. Then returns with Wellens' with dynamic T-wave inversion. Dr. Smith's ECG Blog. Blogspot.com. Published May 4, 2011. Accessed June 29, 2021. http://hqmeded-ecg.blogspot.com/2011/05/wellens-missed-then-returns-with.html?m=1 Wellens Syndrome ECG Recommended Book Resources for the Month Merck. The Merck Manual of Patient Symptoms. (Porter RS, ed.). Merck; 2008. Schaider JJ, Barkin RM, Hayden SR, et al., eds. Rosen and Barkin's 5-Minute Emergency Medicine Consult. 4th ed. Lippincott Williams and Wilkins; 2010. Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Last month we asked you a trivia question regarding the very first NP program – who was the duo that began the program and what was the first NP specialty program? The correct answer was Dr. Loretta Ford and Dr. Henry Silver. The first NP specialty program was pediatrics. We'll be sending Lindsey Harvey, MSN, FNP-BC to the November Original EM Boot Camp Gratis for providing that answer! We can't wait to see you and all of the other registrants in November in Las Vegas! Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to.

history las vegas ms management md wolf treatments adult singer james bond sheep conservatives pac roberts implications diagnosis exploration published clinical guidelines lp stroke mph urgent chest rosen ventura wm msn imaging fastlane acute emergency medicine merck wilkins cerebral np stis medical education neurosurgery uptodate health care professionals pubmed pnp hine blogspot fnp bc medical management acep barkin waseem ncbi published may published october wellens diagnostic accuracy published july disseminated published november emcrit subarachnoid hemorrhage marcolini physical examination acad emerg med oxford academic epiglottitis em rap mdcalc laryngoscope aneurysmal br j anaesth selectedtitle statpearls publishing sgem lippincott williams litfl

Taburcu Ettiğin Hasta Kabusu

Acilci.Net Podcast

Play Episode Listen Later May 11, 2021 8:36

Bumerang Nebulası, Erboğa takımyıldızı yönünde yaklaşık olarak 5.000 ışık yılı uzaklıkta bulunan bir ilkel gezegenimsi bulutsu. Bulutsu, 1 K (−272.15 °C; −457.87 °F) ölçülen sıcaklığıyla evrenin en soğuk yeridir.1 Başlığı okuduktan sonra hepimizin taburcu ettiğimiz hastaları düşünüp kendimizi hissettiğimiz yer... Bir acil hekiminin belki de en büyük kabusu, taburcu ettiği hastanın geri dönmesidir. Taburcu edilen ama şikayetleri geçmeyen - belki de giderek artan - hasta bir bumerang edası ile gelip kafamıza dank eder. Hasta yoğunluğunun çok olduğu hastaneler ya da iş yükünün çok olduğu merkezler bazen istenmeyen sonuçlara yol açabilir. Bu yazıda özellikle acile yeni başlayan arkadaşların kullanabileceği bazı ipuçlarını bir araya toplamaya çalıştım. Bumerang. bazı yörelerindeki kabileler tarafından silah olarak kullanılan yassı bir kesite sahip eğri bir sopa. Acil sağlık hizmeti ihtiyacı 365 gün 24 saat kesintisiz devam eden bir durumdur. Acil servis departmanının sadece hastalara acil bakım sağlaması değil, aynı zamanda sağlayıcıların ve genel olarak toplulukların ihtiyaçlarını da karşılaması beklenmektedir. Ayrıca acil servis, özellikle kırsal topluluklardaki insanlara sağlık hizmetlerinin tek kaynağı olabilir. 2 3 Yani merkeze 50 km bir ilçe hastanesi acil servisinde aile hekimliği hizmeti vermeniz kaçınılmazdır. Yapılan çalışmalar, özellikle kaza sonucu yaralanma oranlarının artması nedeniyle acil sağlık hizmeti kullanımında bir artış olduğunu göstermektedir. Bununla birlikte, özellikle yetersiz kaynaklara sahip ülkelerde acil sağlık sistemlerinin kapasitesi, bu kadar yüksek talebe cevap verecek şekilde yeterince geliştirilmemiştir.4–6 Acil servislerin kalabalıklaşması, ülkemizde ve pandemi sonrası tüm dünyada büyüyen bir sorundur. Kalabalık aciller , hastaların ağrılarının kesilmemesi7, antibiyotik başlamasının aksaması 8 ve akut MI için trombolizin gecikmiş uygulanması9 gibi daha hayati durumlar da dahil olmak üzere düşük kaliteli bakımla ilişkilendirilmiştir. Ek olarak, kalabalıklaşma daha kötü sonuçlarla, hatta artan ölüm oranıyla ilişkilendirilmiştir.10 Acil servisin kalabalıklaşması hastalar, hekimler, sağlık sistemi ve toplum için olumsuz sonuçlara yol açar. Hastalara hizmet sunumundaki gecikme ya da erken taburculuk yalnızca acil servislerin kalitesini tehlikeye atmakla kalmaz, aynı zamanda sonuçlarını daha da kötüleştirebilir. Acil servisin kalabalıklaşması, normların ve hizmet sunum standartlarının ihlaline de yol açabilir ve bu da hastaların gerekli hizmetleri almadan tesislerden ayrılmasına neden olabilir. 11 Kimi nasıl taburcu edeceğiz? Öncelikle hiçbir test ya da yöntemin %100 güvenilir olmadığını ve "hastalık yoktur, hasta vardır." sözünü unutmayacağız. Ayrıntılı bir anamnez, fizik muayene, imkanlar dahilinde laboratuvar testleri ve görüntüleme yöntemleri hastanın şikayetine yönelik ön tanılarımızı kuvvetlendirir. MdCalc ya da Calculate by QxMD gibi skorlama yardımcıları ile de tanı, tedavi ve taburculuk kararlarımızı destekleriz. Örneğin göğüs ağrısı ile acil servisimize başvuran bir hastada kardiyak bir ağrı düşünüyor ancak ST elevasyonu görmüyorsak HEART , GRACE ya da TIMI ile risk değerlendirmesi yapabiliriz. Bu skorların birbirlerine üstünlükleri hakkında Can Özen'in ilgili yazısına buradan ulaşabilirsiniz. HEART Score for Major Cardiac Events Ya da karın ağrısı ile gelen bir hasta için apandisitten pankreatite, sirozdan diyabetik ketoasidoza aklınıza gelebilecek her türlü skorlamayı bulabilirsiniz. Acil serviste bir hasta ile karşı karşıya kaldığımızda hastanın iyiliği için en kısa zamanda ve doğru kararı vermeliyiz. Literatürde klinik karar verme olarak geçen bu karmaşık bir süreç , bilgiyi sentez ederek ayırabilmeyi ve seçeneklerin içinden en iyiyi seçerek uygulamaya koymayı gerektirmektedir.12 Karar verme işlemi, karar veren kişinin farklı seçeneklerle karşı karşıya kaldığı durumlarda, bu seçenekler arasından kendi amaçlarına ve be...

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32. The COVID Mortality Score (VACO)

Stimulus.

Play Episode Listen Later Dec 10, 2020 22:37

The Veterans Health Administration COVID-19 (VACO) Index for COVID-19 Mortality predicts 30 day mortality following a positive test. VACO co-creators Amy Justice MD, PhD and Joseph King Jr, MD, MSCE break down how to use VACO, what it does, and what it doesn’t. We’re also joined by Joe Habboushe MD, CEO of MDCalc, whose online VACO calculator makes using VACO far easier than doing it in your head. Here is a link to the VACO Calculator. Listen on: iTunes Spotify Stitcher We discuss: The Veterans Health Administration COVID-19 (VACO) Index, what it is and how it helps us evaluate patients [01:20]; Why VACO doesn’t include race or BMI [03:40]; Whether VACO can be useful in the ED or the acute setting [08:20]; Potential applications of the VACO index [12:15]; What VACO does not do [18:30]; And more. For complete and detailed show notes, previous episodes, or to sign up for our newsletter: https://www.stimuluspodcast.com/ If you like what you hear on Stimulus and use Apple/iTunes as your podcatcher, please consider leaving a review of the show. I read all the reviews and, more importantly, so do potential guests. Thanks in advance! Interested in sponsoring this podcast? Connect with us here Follow Rob:Twitter: https://twitter.com/emergencypdx Facebook: https://www.facebook.com/stimuluswithrobormanmd Youtube: https://www.youtube.com/c/emergencypdx

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32. The COVID Mortality Score (VACO)

ERCAST

Play Episode Listen Later Dec 10, 2020 22:37

The Veterans Health Administration COVID-19 (VACO) Index for COVID-19 Mortality predicts 30 day mortality following a positive test. VACO co-creators Amy Justice MD, PhD and Joe King MD break down how to use VACO, what it does, and what it doesn’t. We’re also joined by Joe Habboushe MD, CEO of MDCalc, whose online VACO calculator makes using VACO far easier than doing it in your head. Here is a link to the VACO Calculator. Listen on: iTunes Spotify Stitcher We discuss: The Veterans Health Administration COVID-19 (VACO) Index, what it is and how it helps us evaluate patients [01:20]; Why VACO doesn’t include race or BMI [03:40]; Whether VACO can be useful in the ED or the acute setting [08:20]; Potential applications of the VACO index [12:15]; What VACO does not do [18:30]; And more. For complete and detailed show notes, previous episodes, or to sign up for our newsletter: https://www.stimuluspodcast.com/ If you like what you hear on Stimulus and use Apple/iTunes as your podcatcher, please consider leaving a review of the show. I read all the reviews and, more importantly, so do potential guests. Thanks in advance! Interested in sponsoring this podcast? Connect with us here Follow Rob:Twitter: https://twitter.com/emergencypdx Facebook: https://www.facebook.com/stimuluswithrobormanmd Youtube: https://www.youtube.com/c/emergencypdx

covid-19 ceo phd risk testing score index stimulus mortality bmi calculator vaco mdcalc

Networking Is Not a Bad Word - Bunny Ellerin, CEO and Co-founder, NYC Health Business Leaders

Raise the Line

Play Episode Listen Later Aug 3, 2020 30:18

Even though Bunny Ellerin has built a career around bringing people and organizations together -- in fact she's known as "the most connected person in healthcare" -- she still gets apprehensive walking into a room full of business leaders she may not know. While acknowledging that networking is scary for many people, and seen as too transactional for others, she wants her students at Columbia Business School and people in healthcare professions to understand that it's not just about handing out business cards at events. Reaching out with an article recommendation or proactively connecting people who you think would benefit from knowing each other is also "networking". Check out this episode of Raise the Line to find out how, as co-founder and CEO of New York City Health Business Leaders, Ellerin has used this approach to spur innovation in healthcare and help build a thriving digital health scene in New York.

What If You Don't Have a Hunch? - Dr. Joe Habboushe, Co-founder & CEO of MDCalc

Raise the Line

Play Episode Listen Later Jun 24, 2020 20:27

Providers who have treated hundreds of patients with the same problem can develop a "gut sense" of how to proceed. But a new disease like COVID-19 does not allow for such hunches. Dr. Joe Habboushe knows that first hand, having worked on the frontlines in New York City ERs during the worst of the crisis. That's where "decision-support" tools like MDCalc come into play, providing all of the credible available guidance at the fingertips of clinicians. MDCalc, which Habboushe co-founded and leads, is also an instant reference for established diseases and conditions, and the majority of U.S. physicians have come to rely on it to make the best possible decisions and reduce unnecessary care. Check out this episode to find out how that happened, what we can learn from other countries about handling pandemics and how medical training should be changed from this 7th-generation physician.

Battling COVID-19 from the Frontlines: Joseph Habboushe MD, Emergency Physician at NYU & CEO of MDCalc

Play Episode Listen Later May 7, 2020 29:05

Dr. Joseph Habboushe, Emergency Medicine Physician at NYU and CEO of MDCalc, shares his experience of combating COVID-19 from the ground in NYC.

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Telehealth | Heroes in Crisis | Ondansetron for Kids | Pericarditis

JournalFeed Podcast

Play Episode Listen Later Apr 18, 2020

Here is the JournalFeed Podcast for the week of April 13-17, 2020. We cover MDCalc tools for Telehealth, emergency responders in crisis and how to help, two studies on benefit of ondansetron in children, and a pericarditis spoon-feed extravaganza. Special thanks to Lara Fesdekjian for writing theme music!

kids telehealth heroes in crisis pericarditis ondansetron mdcalc

Episode 39 – Discussion with MDCalc on COVID-19 risk scores & NYC

Play Episode Listen Later Apr 2, 2020

Interview with Joe Habboushe, MD, CEO of MDCalc about new COVID-19 tools and his New York City experience. MDCalc's new COVID-19 resource center: https://www.mdcalc.com/covid-19 EBMedicine's COVID-19 article with recent updates: https://www.ebmedicine.net/topics/infectious-disease/COVID-19 Time Stamps: 00:00- Discussion of new tools for COVID-19: calculators, risk factors and odds ratios, labs, etc. 40:02- Discussion of the New York City COVID-19 crisis.

covid-19 ceo new york city interview md risk scores mdcalc

Episode 39 - Discussion with MDCalc on COVID-19 risk scores & NYC

The Curbsiders Internal Medicine Podcast

Play Episode Listen Later Apr 2, 2020

covid-19 ceo new york city interview md risk scores mdcalc

Episode 8: Useful Resources for Medical Practice: Web, Text, & Smartphone Apps

May's Anatomy

Play Episode Listen Later Feb 27, 2020 50:31

In today’s episode I share with you all my favorite web-based, text, and phone applications that have gotten me through nurse practitioner school and clinical rotations. These resources are a cumulation of recommendations from professors, preceptors, peers, and students from various disciplines and they have become staples in my practice. Use each of these measures to help expand your knowledge and act as a guide in your every day practice to help you become the best practitioner you can be! All resources are linked below for your convenience—enjoy! Web-based Resources Natural Medicines: https://naturalmedicines.therapeuticresearch.com/ NIH - National Center for Complementary and Integrative Health: https://nccih.nih.gov/ American Academy of Dermatology - Basic Dermatology Curriculum: https://www.aad.org/member/education/residents/bdc Stanford Medicine: The General Dermatology Exam: Learning the Language: https://stanfordmedicine25.stanford.edu/the25/dermatology.html Bright Futures - Coding for Pediatric Preventative Care, 2019: https://www.aap.org/en-us/documents/coding_preventive_care.pdf Text Resources Anatomy (Quickstudy Academic) The Anatomy Coloring Book Case Files: Family Medicine Fast Facts for Adult Critical Care Apps NIH BMI Calculator: https://apps.apple.com/us/app/nih-bmi-calculator/id446441346 UpToDate: https://apps.apple.com/us/app/uptodate/id334265345 MDCalc: https://apps.apple.com/us/app/mdcalc-medical-calculator/id1001640662 AHRQ ePSS: https://apps.apple.com/us/app/ahrq-epss/id311852560 Epocrates: https://apps.apple.com/us/app/epocrates/id281935788 To try my absolute favorite CBD product line from Cured Nutrition, use code "MAY10" at checkout for 10% off your entire order or simply click the link here Cured Nutrition If you’re interested in consuming slow-release caffeinated vanilla or matcha lattes, or if you’re a coffee drinker who wants a little more collagen and protein in their diet, use code "MAY15" at checkout for 15% off your entire order or simply click the link here Strong Coffee Use my WearFigs code to get a $20 gift card on purchases of $100+ http://fbuy.me/ofl13 For nursing tips, my experiences, and more musings on the show, follow our Instagram @maysanatomypodcast or follow my personal account @mayyazdi This podcast is produced by chase@operationpodcast.com

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In-Flight Emergencies REBOOT

Play Episode Listen Later Oct 7, 2019 40:29

Dominate the most common in-flight emergencies with tools and tips from this classic Curbsiders episode. Our guest, Angelica Zen MD, (formerly an IM Chief Resident at UCLA), recounts a harrowing tale of heroism at 30,000 feet and schools us on how to throw down in an in-flight emergency. We review what’s available in the standard medical kit, common conditions encountered, and the medical legal implications of responding to in-flight emergencies. This episode is a must listen before you next step on a plane. Original air date November 21, 2016. Full show notes https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written, produced and edited by: Matthew Watto MD, FACP Cover Art by: Matthew Watto MD, FACP Hosts: Stuart Brigham MD; Paul Williams MD, FACP; Matthew Watto MD, FACP Guest: Angelica Zen MD Partners Win a prize! Celebrate National Internal Medicine Day and tell us why you’re I.M. Proud. Tell us why you are I.M. Proud and enter the contest by visiting acponline.org/improud to submit your story today! Answer one of the three questions below and share your story on social media using the hashtags #IMProud #NationalInternalMedicineDay, and tag @acpinternists. Prizes will be given out 3 times through June of 2020. The first group of winners will be announced on the first ever National Internal Medicine Day October 28, 2019! What makes you proud to practice internal medicine or one of the I.M. subspecialties? What recent patient experience made you proud to be an internist or subspecialist? How is internal medicine unique from other subspecialties? See us at the CHEST 2019 Annual Meeting in New Orleans! We’ll be doing two live interviews on stage, plus recording two recap episodes to bring you high yield clinical pearls from the conference. Look out for us in our red Curbsiders shirts and say hello. Take a picture with Stuart! Give Paul a hug! Register today https://chestmeeting.chestnet.org/ !!!! Time Stamps 00:00 Cold open; Disclaimer 00:50 Sponsor: ACP’s National Internal Medicine Day 2019 www.acponline.org/improud 01:10 Intro, Guest Bio 02:50 Guest onliner; Wellness tips; Tips for staying up on the literature Pick of the Week*: How Doctors Think (book) by Jerome Groopman; MDCalc app; AHRQ app; Physician’s First Watch 07:30 Sponsor: ACP’s National Internal Medicine Day 2019 www.acponline.org/improud 09:08 Dr. Zen tells her story 19:27 Monitoring your patient in-flight 20:05 Contents of the standard in-flight medical kit 22:10 What Dr. Zen would have done differently 23:05 How to use available resources in-flight 24:20 Medical legal implications 28:07 How to respond to common in-flight emergencies and how to respond 29:35 Syncope and presyncope 31:55 Hypoxia altitude simulation test (HAST) 33:15 Altered mental status 33:52 Anaphylaxis 35:34 Stroke and acute coronary syndrome 36:55 Dr. Zen’s take home points 38:50 Outro *The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra. Goal Listeners will comprehend their role and potential liabilities during in-flight emergencies and effectively utilize available resources for triage, patient care, and decisions about diverting the plane. Learning objectives By the end of this podcast listeners will: Be familiar with the contents of the standard medical kit Think outside the box to identify, improvise and utilize the available resources for patient care Recognize the medical legal consequences of providing emergency medical care on a plane Confidently evaluate and manage common in-flight emergencies using the available resources Disclosures Dr. Zen reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. Citation Zen A, Brigham SK, Williams PN, Watto MF. “#19 In-Flight Emergencies.” The Curbsiders Internal Medicine Podcast https://thecurbsiders.com/episode-list. Original air date November 21, 2016.

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Episode 29 - Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy

Play Episode Listen Later Jun 6, 2019

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO. Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group. Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though. Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%. Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly. Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly. Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players. Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth. Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause. Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic. Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy. Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed. Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January? Jeff: We sure did! Take another listen if that doesn’t ring a bell. Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ. Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias. Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especially prone to surgical causes of abdominal pain including skin infections and surgical leaks. Jeff: For this reason, CT imaging should be done with IV and oral contrast, with those having undergone a Roux-en-Y receiving oral contrast on the CT table. Nachi: Perfect. Let’s move on to evaluation once in the ED! Jeff: As we mentioned a few times already - diagnosis is difficult, a comparison of initial and final diagnosis only has about 50-65% accuracy. For this reason, Dr. C suggests taking a ‘worst first’ approach to forming your differential and guiding your workup. Nachi: And as a brief aside, before we continue… Missed appendicitis is one of the three most common causes of emergency medicine malpractice lawsuits - with MI and fractures being the other two. That being said, you, as a clinician, have either missed appendicitis or likely will in the future. In a study of cases of misdiagnosed appendicitis brought to litigation, several themes recurred. For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. Also, note that in addition to imaging and the physical exam, history is often the key to uncovering the cause of abdominal pain. Nachi: Not to harp on litigation, but in malpractice cases brought up for failure to diagnose abdominal conditions, deficiencies in data gathering and charting were often to blame rather than misinterpretation of data. Jeff: As no shocker here, getting a complete history remains tremendously important in your practice as an emergency clinician. A recurring theme of EMplify for sure. Nachi: In order to really nail this down, consider using a standardized history form -- or memorizing one. An example is shown in Table 1. Standardized forms have been shown to improve patient satisfaction and diagnostic accuracy. Jeff: An interesting question for your abdominal pain patient is to ask about the ride to the hospital. Experiencing pain going over a speed bump has been shown to be about 97% sensitive and 30% specific for appendicitis. So fairly sensitive, but not too specific. Nachi: That’s interesting and may help guide you, but it’s certainly no replacement for CT. And remember that you can have stump appendicitis. This can occur in the appendiceal remnant after an appendectomy and is found in about 0.15% of all appendectomies. Jeff: Alright, so on to the physical exam. Like always, let’s start with vital signs. An elevated temp can be associated with intra abdominal infection, but sensitivity and specificity vary greatly here. Always consider a rectal temp, as these are generally more reliable. Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Jeff: Elevated respiratory rate can be due to pain or subdiaphragmatic irritation. However, it can also be due to hypoxia, sepsis, anemia, PE, or metabolic acidosis, so consider all of those also in your differential. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. In one study, a SI > 0.7 was sensitive for 28-day mortality in sepsis. Jeff: Speaking of HR, tachycardia can be a response to pain, anxiety, fever, blood loss, or sepsis. An irregularly irregular rhythm -- or a fib -- is an important risk factor for mesenteric ischemia in elderly patients. This is important to consider in your differential early as it may guide your imaging modality. Nachi: With vitals done, we can move on to the abdominal exam - it is rare that a serious abdominal condition will present without tenderness in a young adult patient, but remember that the elderly patient may not present with much tenderness at all due decreased peritoneal sensitivity. Abdominal tenderness that is greatest when the abdominal muscles are contracted is likely due to abdominal wall pain. This can be elicited by having the patient lift their head or let their legs off the bed. This finding is known as Carnett sign and is about 95% accurate for distinguishing abdominal wall pain from visceral abdominal pain. Jeff: Though tenderness itself is helpful, the location of tenderness can be misleading. Note that while 80% of patients with appendicitis have RLQ tenderness, 20% don’t. The old 80-20 rule! So definitely don’t let RLQ tenderness be your sole guide! Nachi: Voluntary guarding is due to fear, anxiety, or even a reaction to a clinician’s cold hands. Involuntary guarding (also called rigidity) is more likely to occur with surgical disease. Remember that rigidity may be a less common finding in the elderly despite surgical disease. Jeff: Peritoneal signs are the true hallmark of surgical disease. These include rebound pain, pain with coughing, pain with shaking the stretcher or pain with striking the patient’s heel. Rebound historically has been thought to be pathognomonic for surgical disease, but recent literature hasn’t found it to be all that useful, with one study claiming it has no predictive value. Nachi: As an alternative, consider the “cough test”. Look for evidence of posttussive abd pain (like grimacing, flinching, or grabbing the belly). Studies have found the cough sign to be 80-95% sensitive for peritonitis. Jeff: In terms of other sings elicited during the abdominal exam: The murphy sign, ruq palpation that causes the patient to stop a deep inspiration -- in one study had a sensitivity of 97%, but a specificity of just under 50%. The psoas sign, pain elicited by extending the RLE towards the back while the patient lies on their left side -- in one study had a specificity of 95%, but only had a sensitivity of 16%. Nachi: Neither the obturator sign (pain with internal rotation of the flexed hip) nor the rosving sign (pain in the RLQ by palpating the LLQ) have been rigorously studied. Jeff: Moving a bit further south, from the abdomen to the pelvis - let’s talk about the pelvic exam. Most EM training programs certainly emphasize the importance of the the pelvic exam for women with lower abdominal pain, but some recent papers have questioned its role. A 2018 study involving 288 women 14-20 years old found that the pelvic didn’t increase sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomoniasis when compared with history alone. Another study questioned whether the pelvic exam can be omitted in these patients with an early intrauterine pregnancy confirmed on ultrasound, but it was unable to reach a conclusion, possibly due to insufficient power. Nachi: While Jeff and I do find it valuable to elicit as much as information from the history as possible and take value in the possibility of omitting the pelvic in certain cases in the future, given the current evidence based medicine, we both agree with the author here. Don’t abandon the pelvic for these patients just yet! Jeff: While on this topic, we should also briefly mention a reminder about fitz-hugh-curtis syndrome, perihepatic inflammation associated with PID. Nachi: As for the digital rectal exam, this can certainly be of use when considering and diagnosing prostatitis, perirectal disease, stool impactions, rectal foreign bodies, and gi bleeds. Jeff: And let’s not forget the often overlooked scrotal and testicular exam. In men with abdominal or flank pain, this should always be considered. Testicular torsion often presents with isolated abdominal or flank pain. The scrotal exam will help diagnose inguinal and scrotal hernias. Nachi: Getting back to malpractice case reviews for a minute --- in a 2018 review involving testicular torsion, almost ⅓ of the patients with missed torsion had presented with abdominal pain --- not scrotal pain! In ⅕ of the cases, no testicular exam was performed at all. Also, most cases of missed torsion occured in patients under 25 years old. Jeff: Speaking of torsion, about 6% occur over the age of 31, so have an increased concern for this in the young. Of course, if concerned for torsion, consult urology immediately and consider manual detorsion. Nachi: And if you, like me, were taught to manually detorse by rotating in the lateral or open book direction, keep in mind that in a study of 200 males with torsion, ⅓ had rotated laterally, not medially. Jeff: Great point. And one last quick point here. Especially if you are unsure about the diagnosis, make sure to perform serial exams both in the ED and also in the next few days at their PCP’s office. In one study, a 30 hour later repeat exam for patients discharged with nonspecific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost 25% of patients. Nachi: So that wraps up the physical. Let’s get into diagnostic studies, starting with lab work and everybody’s favorite topic... the cbc. Jeff: Yup, just the other day I was asked by a consultant “what’s the white count.” in a patient with CT proven appendicitis. Man, a small part of my soul dies every time this happens. Nachi: It appears you must have an evidenced based soul then. According to a few studies, anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal WBC. So in some studies, it’s even worse than a coin flip. Jeff: Even worse, in children the CBC is less helpful. In children, an elevated WBC detects a mere 53% of severe abdominal pathology - so again not all that helpful. Nachi: That being said, at the other end of the spectrum, in the elderly, an elevated WBC may imply serious disease. Jeff: So let’s make this perfectly clear. A normal WBC should not be reassuring, but an elevated WBC, especially in the elderly, should be very concerning. Nachi: The CRP is up next. Though not used frequently, it’s still worth mentioning, as there is a host of data on it in the setting of abdominal pain. In one meta analysis, CRP was approximately 62% sensitive and 66% specific for appendicitis. Jeff: And while lower levels of CRP do not rule out positive findings, increasing levels of CRP do predict, with increasing likelihood, the chances of positive findings. Nachi: Next we have lipase and amylase. The serum lipase is the best test for suspected pancreatitis. The amylase adds limited value and should not be routinely ordered. Jeff: As for the lactate. The greatest value of a lactate level is to detect occult shock and sepsis. It is also useful to screen for visceral ischemia. Nachi: And the last lab test we’ll discuss is the UA. The urinalysis is a potentially misleading test. In two studies, 20-30% of patients with appendicitis also had hematuria with leukocytes and bacteria on their UA. In a separate study of those with a AAA, there was an 87% incidence of hematuria. Jeff: That’s pretty troubling. Definitely not great to diagnosis someone with hematuria and a primary GU problem, when their aorta is actually exploding. Nachi: And that’s a great reminder to always avoid premature diagnostic closure. Jeff: Also worth mentioning is that not all ureteral stones present with hematuria. At least 6% have no hematuria on microscopy. Nachi: Alright, so that brings us to imaging. First up: plain films. I’m going to quote this directly from the article since I think it's so important, ‘never rely on plain films to exclude surgical disease.” Jeff: This statement is certainly evidence based as in one study 40% of x-ray findings were inconsistent with the final diagnosis. In another study, 43% of patients with major surgical disorders had either normal or misleading plain film results. So again, the take home here is that XR cannot rule out surgical disease, and should not be routinely ordered except for in specific settings. Nachi: And perhaps the most important of all those settings is in the setting of possible free air under the diaphragm. In this case, an upright chest visualizing the area under the diaphragm would be the test of choice. But again, even this doesn’t rule out surgical disease as free air may be absent on plain films in ⅓ to ½ of patients who have already perfed. Jeff: Next we have everybody’s favorite, the ultrasound. Because of it’s low cost and ease of use, bedside ultrasound is gaining traction. And we’ve cited this and other similar studies in other issues, this is a skill emergency medicine physicians must have in this day and age and it’s a skill they can learn quickly. Nachi: Ultrasound can visualize most solid organs, but it is best suited for the Right upper quadrant and pelvis. In the RUQ, we are looking for wall thickening, pericholecystic fluid, ductal dilatation, and sonographic murphys sign. Jeff: In the pelvis, there is a role for both transabdominal and transvaginal to rule out ectopic and potentially rule in intrauterine pregnancy. I know the thought of performing your own transvaginal ultrasound may sound crazy to some, but we both trained in places where ED TVUS was the norm and certainly wasn’t that hard to learn. Nachi: Ah, the good old days of residency. I’m certainly grateful for the US tech where I am now though! Next up we have CT. CT scans are ordered in just under 30% of patients with abdominal pain. Jeff: It’s worth noting, that while many used to scan with triple contrast - oral, rectal and IV, recent literature has shown that IV contrast alone is adequate for the diagnosis of most surgical conditions, including appendicitis. Nachi: If you’re still working in a shop that scans for RLQ pain with oral or rectal contrast, definitely check out the 2018 american college of radiology appropriateness criteria that states that IV contrast is generally appropriate for assessing the RL. Jeff: And while we are on the topic of contrast, let’s dive a bit deeper into the, perhaps myth, that contrast leads to contrast induced nephropathy. Nachi: This is another really important point. Current data show that being ill enough to be admitted to the hospital is a risk factor for acute kidney injury and that IV contrast for CT does not add to that risk. In 2015, the american college of radiology noted in their manual on contrast media that the concern for the development of contrast induced nephropathy is not an absolute contraindication for using IV contrast. IV contrast may be necessary regardless of the risk of nephrotoxicity in certain clinical situations. Jeff: Ok, so contrast induced nephropathy may be real, but more studies and a definitive statement are still needed. Regardless, if the patient is sick and they need the scan with contrast, don’t hold back. Nachi: I think that’s a fair take home. As another note about the elderly, CT should be almost routine in the elderly patient with acute abdominal pain as it improves accuracy, optimizes appropriate hospitalization, and boosts ED management decision making confidence for this patient group. Jeff: If they are over 65, make sure you chart very carefully why they don’t need a scan. Nachi: Speaking of not needing a scan, two quick caveats on CT before moving to MRI. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Prompt surgical consultation and bedside ultrasound if indicated are both a must in unstable patients. Jeff: The second caveat is on the other end of the spectrum - not all CT scanning is created equally - the interpretation depends on the scanner, the quality of the scan, and the experience and training of the reading radiologist. In one study, nearly 13% of abdominal CT scans may initially be misread. Nachi: So if you’re concerned, consider consultation or an extended ED observation to monitor for any changes in the patient’s status. Jeff: Next up is MRI - MRI has an ever expanding role in the ED. The accuracy of MRI to diagnose appendicitis is very similar to CT, so consider it in all pregnant patients, though ultrasound is still considered first line. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. Jeff: Don’t be reassured by a response to a GI cocktail either - this does not exclude myocardial ischemia. Nachi: Next, let’s talk the role of analgesia in treating the undifferentiated abdominal pain patient. Jeff: While there was formerly a concern of ‘masking the pain’ with opiates, the evidence says otherwise. Pain medicine may even aid in the diagnosis, so definitely don’t withhold it in the setting of acute abdominal pain. Nachi: Wait I get that masking the pain is no longer considered a concern, but how would it aid in the diagnosis? Jeff: Good question. Analgesics might facilitate the gathering of history and allow a more complete physical exam by relaxing the abdominal musculature. Nachi: Ahh that makes sense. So certainly treat pain! Both morphine at 0.1 mg/kg and fentanyl at 1 mic/kg are appropriate analgesics for acute abdominal pain. In those that are a difficult stick, a recent study showed that 2 micrograms/kg of fentanyl via a nebulizer was a safe alternative. Remember, fentanyl is quick on, quick off, which may make it desirable in certain situations. It actually has the shortest time of onset of any opioid. It’s also safer in patients with a “marginal” blood pressure. Jeff: And just like the GI cocktail - response to opiate analgesics does not exclude serious pathology. These patients need serial exams and likely labs and imaging if their pain is so severe. Nachi: Few things are more important prior to discharge of an abdominal pain patient than documenting repeat exams and a PO trial. Jeff: True. You should also consider haloperidol for patients with gastroparesis and cannabinoid hyperemesis as a growing body of literature supports its use in such settings. Check out the August 2018 EMP or EMplify for more details if you’re curious. Nachi: The last analgesic to discuss is our good friend ketamine. Low dose ketamine at 0.3 mg/kg over 15 minutes is gaining traction as the analgesic of choice in many ED’s. Jeff: The key there, is that it must be given over 15 minutes. Ketamine has a great safety profile, but you make it so much safer and a much better experience if you give it slowly. Nachi: Before we get to disposition, let’s talk controversies and cutting edge - and there is just one this month - and that’s the use of the Alvarado score. Jeff: In the Alvarado score, you get two points for RLQ tenderness and 2 points for a leukocytosis over 10,000. You get an additional point for all of the following; rebound, temp over 99.1, migration of pain to the RLQ, anorexia, n/v, and a left shift. The max score is therefore 10. A score of 3 or less make appendicitis unlikely, 4-6 warrants CT imaging, and 7 or more a surgical consultation. Nachi: A 2007 study suggests that using the Alvarado score along with bedside ultrasound might allow for rapid and inexpensive diagnosis of appendicitis. Jeff: I don’t think we should change practice based on this just yet, but more ultrasound diagnosis may be on the horizon. If you want to start using the Alvarado score in your practice, MDcalc has a great easy to use calculator. Nachi: Let’s get to the final section. Disposition! Jeff: As we mentioned at the beginning of this episode, the diagnosis is less important than proper disposition. For patients with suspected ruptured AAA, torsion, or mesenteric ischemia - the disposition is easy - they need immediate surgical consultation and likely operative intervention. Nachi: For others, use the tools we outlined above - ct, us, labs, etc, to help support your decision. Keep in mind, that serial exams are a great tool and of little expense - so make sure to lay your hands on the patient's abdomen frequently, especially when the diagnosis is unclear. Jeff: For those that look well after a work up, with no clear diagnosis, it may be reasonable to discharge them home with prompt follow up, assuming prompt follow up is plausible. The key here is that these patients need good discharge instructions. Check out figure 2 on page 20 for a sample discharge template. Nachi: But if the patient is still uncomfortable, even after a thorough workup, there may be a role for ED observation units. In one study of 220 patients admitted for to ED obs units for serial exams, 39% eventually underwent surgery with only 5% having negative laparotomies. Jeff: This month’s issue wraps up with some super important time and cost effective strategies, so let’s see if we can quickly breeze through some of the most important points before closing out this episode. Nachi: First - limit your abdominal x-rays as they offer limited value and are rarely helpful except in the setting of perforation, when an early upright chest film should be used liberally. Jeff: Next - limit electrolyte testing especially in young adults with nausea, vomiting and diarrhea. In those 18 to 60, clinically significant electrolyte abnormalities occur in only 1% of those with gastro. Nachi: With respect to urine testing, urine cultures are rarely indicated for uncomplicated cystitis in young women. Along similar lines, don’t anchor on the diagnosis of UTI as other lower abdominal conditions often lead to abnomal urine studies. Jeff: In your alcoholic patients, although all should be approached with an abundance of caution, limit testing to repeat abdominal exams in your non-toxic appearing patient who is already tolerating PO. Nachi: For those with suspected renal colic, especially those with a history of renal colic, limit CT use and instead consider ultrasound to look for hydro. This approach is endorsed by ACEPs choosing wisely campaign. Jeff: But as a reminder, this is for low risk patients only. Anyone with signs of infection should also undergo CT imaging. Nachi: And lastly - consider incorporating bedside US into your routine. The US is fast and accurate and compares similarly to radiology, especially in the context of detecting acute cholecystitis. Jeff: Alright, so that wraps up the new material for this episode, let’s close out with some key points and clinical pearls. The peritoneum becomes less sensitive with aging, and peritonitis can be a late or absent finding. Be wary of early diagnostic closure and misdiagnosis with a mimic of a more severe and dangerous pathology. The elderly, immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are all at a higher risk for misdiagnosis. Elderly patients can present without fever, leukocytosis, or abdominal tenderness, but still have surgical abdominal pathology. Consider diagnostic imaging in all geriatric patients presenting with abdominal pain. Consider plain film if you suspect a viscus perforation or for certain foreign body ingestions. Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical, when appropriate. Testicular torsion can present with abdominal pain only. If suspected, consult urology and consider manual detorsion. A normal white blood cell count does not rule out appendicitis or other intra-abdominal pathology. Serum amylase should not be used in your assessment of the abdominal pain patient. Lack of microscopic hematuria does not rule out renal colic. CT of the abdomen with IV contrast alone is enough for most surgical conditions including appendicitis. Oral and rectal contrast does not need to be routinely administered. The 2018 American College of Radiology (ACR) Appropriateness Criteria discuss concern for delay in diagnosis associated with oral contrast use and an increased rate of perforation. There is recent literature to support that IV contrast does not cause nephropathy. The ACR 2015 Manual on Contrast Media states that concern for contrast induced nephropathy is not an absolute contraindication, and IV contrast may be necessary in many situations. Ultrasound can be used to evaluate the aorta, gallbladder, kidneys, appendix, bowel, spleen, pancreas, uterus, and ovaries. Consider bedside ultrasound and emergency surgical consult for all unstable patients with abdominal pain. For stable pregnant patients with concern for appendicitis, start with an ultrasound. If inconclusive, order an MRI. Epigastric pain in an elderly patient should raise concern for ACS. An EKG and troponin should be considered. For analgesia in patients with gastroparesis or cannabinoid hyperemesis syndrome, haloperidol is considered first-line. Low-dose ketamine (0.3mg/kg over 15 minutes) may be a better choice than opiate analgesia for abdominal pain. Nachi: So that wraps up Episode 29! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And last reminder here -The clinical Decision Making in Emergency Medicine Conference is just around the corner and spots are quickly filling up. Don’t miss out on this great opportunity and register today. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0619, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years) 38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations) 41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review) 57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review) 67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review) 83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review) 94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients) 106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)

university strategy man talk pain practice medicine current table impact lack sons emergency studies iv missed experiencing hiv adults aids pe decision making clinical manual assessing retrospective evaluation aaa gi drs oral cbc gu mri elderly american colleges rebound ibs rational acute emergency medicine ketamine wbc emp jama prompt textbooks ultrasounds evidence based unstable xr alvarado uti np cme ua roux disposition pcp serum acs abdominal visceral rl ekg standardized crp involuntary cost effective north carolina school pid acr testicular abdominal pain 3dihub cd4 jagoda show more care ultrasound sbo rle analgesics adhesions jeff it jeff well jeff good mdcalc ruq jeff so jeff for jeff most eb medicine jeff also rlq jeff welcome coney island hospital jeff even jeff great jeff alright jeff definitely jeff before

Episode 28 - Depressed and Suicidal Patients in the Emergency Department: An Evidence-Based Approach

Play Episode Listen Later May 3, 2019

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department. Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression? Nachi: That would certainly be all of our listeners! Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval? Show More v Nachi: Again, just about all of our listeners I’m sure! Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes? Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in. Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University. Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside. Jeff: Quite the team, from a variety of backgrounds. Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt. Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23% Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode. Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable. Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions. Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest. Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks. Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning. Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes. Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD. Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder. Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself. Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.” Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt. Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan. Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%. Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers... Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients. Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men. Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older. Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression. Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide. Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US. Nachi: That’s an incredible amount and much more than I would have guessed. Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals. Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often. Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods. Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another. Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study. Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation. Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality. Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization. Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations. Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions. Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations. Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings. Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise. Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality - how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide. Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt. Jeff: In one study, using this tool doubled the number of suicide-risk cases detected. Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener. Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit. Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it? Jeff: Great question - It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations. Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical. Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression. Nachi: And as you said, we would mention it a few times -- In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression. Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here. Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease. Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing. Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy - urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility. Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility. Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management. Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion. Nachi: That wraps up testing. Let’s move on to treatment. Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable. Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes. Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do. Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling). Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary. Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do. Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts. Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means. Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend. Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths. Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means. Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time. Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling. Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline. Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations. Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there. Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up - perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan. Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though... Nachi: Let’s talk first about special populations - the only one we will discuss this month is military veterans. Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms. Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population. Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death. Nachi: And this is in no way meant to be a knock-on VA ED docs - they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care. Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed. Nachi: Let’s talk controversies and cutting-edge topics from this issue. Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality. Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting. Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression. Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future. Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition. Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED. Jeff: The next controversy is a big one - alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated. Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide. Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED. Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment. Jeff: Very important point - in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines. Nachi: Moving on to the next topic - let’s discuss post discharge patient contact. Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%. Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact. Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors. Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance. Jeff: The last cutting-edge topic to discuss is telepsychiatry. Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner - offering quick psychiatric care to those that never had access. Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated. Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations. Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold. Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches. Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making. Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization. Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed. Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible. Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls. Risk factors for major depression include female gender, young or old age, being divorced or widowed, black or Hispanic ethnicity, poor social support, and substance abuse. The strongest predictor for suicide-related outcomes is history of prior suicidal ideation or suicide attempt. When evaluating a patient with depressive symptoms, try to identify potential secondary causes, as this may influence your management strategy. When assessing for depression, perform a complete history and consider underlying medical causes that may be contributing to their presentation. Consider serum testing for the patient’s psychiatric medications if the medications have known toxic effects. 1. Routine serum testing and urine toxicology testing are not recommended for psychiatric patients presenting to the emergency department. Imaging of the brain should not be ordered routinely in depressed or suicidal patients. Depression places patients at a significantly increased risk for alcohol abuse and dependence. In addition to providing appropriate follow up resources to your depressed patients, emergency clinicians should consider making a brief follow up telephone call to the patient. Telepsychiatry may improve access to mental health providers and allow remote assessment and care from the ED. Suicide risk assessment tools such as C-SSRS, SAFE-T, and ICARE2 can help when deciding on disposition from the ER. It may be necessary to hold a patient against their will if they are at immediate risk of self-harm. Though not routinely administered in the ED for this purpose, psychotropic medications, such as ketamine, have proven helpful in acute depressive episodes. Patients who are actively suicidal should be admitted to a psychiatric observation unit or inpatient psychiatric unit. Nachi: So that wraps up Episode 28! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report) 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book) 15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients) 16. Centers for Disease Control and Prevention. Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects) 97. Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized controlled trial; 24 participants) 100. Griffiths JJ, Zarate CA, Rasimas J. Existing and novel biological therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)

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Episode 161.0 – Opioid Epidemic

Play Episode Listen Later Apr 22, 2019 14:26

A look at the opioid epidemic and what ED providers can do to combat this formidable foe. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Opioid_Epidemic.mp3 Download Leave a Comment Tags: Opioid Dependence, Opioid Free ED Show Notes Consider alternatives to opiates for acute pain NSAIDs Subdissociative ketamine Nerve blocks Curb misuse and diversion through prescribing a short supply and perform I-STOP checks Narcan is not just for acute overdose treatment by EMS or within the ED anymore We can equip patients, family members and friends with Narcan kits prior to discharge In New York state, can prescribe Narcan to patients with near fatal overdoses or who screen positive for an opioid use disorder Intranasal formulation is cheaper and more commonly prescribed than IM Buprenorphine induction can be done in the ED for patients in active withdrawal, as calculated by the COWS score. MDcalc calculator: https://www.mdcalc.com/cows-score-opiate-withdrawal Providers do not need an X-waiver to give a dose of Buprenorphine in the ED for 3 days Home induction can be considered for patients not actively withdrawing but would like to enter medication assisted treatment Some considerations: Contraindicated in patients with severe liver dysfunction and with hypersensitivity reaction to drug Oversedation can occur with concurrent use of benzodiazepines and alcohol Will precipitate withdrawal if concurrently using full opioid agonists Longitudinal care has to be established for patients started on Buprenorphine

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Episode 161.0 – Opioid Epidemic

Just Some Podcast for Advanced Practitioners

Play Episode Listen Later Apr 22, 2019 14:26

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Episode 6: Approach to Chest Pain

EM Student Podcast

Play Episode Listen Later Apr 17, 2019 10:52

In this episode, we'll briefly cover the approach to chest pain. Episode Written by Dr. Brad Schwartz.Recording, Editing/Mixing, and Publishing by Peter Biggane.Software: Audacity (https://www.audacityteam.org/download/)Mics: Brad (Sampson Q2U) and Peter (Audio Technica ATR-2100)Recorded using Zoom H4n Pro via XLR input on 16APR19. References in this episode:Life in the Fast Lane: https://lifeinthefastlane.com/MDCalc: https://www.mdcalc.com/

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#29 - Resources/Tough Love

Play Episode Listen Later Apr 6, 2019 56:24

A frequently asked question from students and new practitioners is "What resources do you use?". So Ben & Tom decided to discuss the resources they use in clinic. Those resources include books, websites, and apps. Links should be in the show notes below. In the "Story You May Have Missed", the guys look at an interesting way one area is trying to contain the measles outbreak. The episode ends with some tough love from the guys. There has been an increasing trend of NPs crowd sourcing a diagnosis on social media and Ben passionately talks about why this needs to stop. Some say that he channels his inner Tom-ness in this rant about NP groups on social media, being "bullied", and crowd sourcing a diagnosis. Resources discussed are: Books Pfenniger & Fowler's Procedures for Primary Care https://amzn.to/2IevnET Websites UpToDate - www.UpToDate.com CDC - www.cdc.gov CDC Zombie Preparedness - https://www.cdc.gov/cpr/zombie/index.htm National Library of Medicine - https://www.nlm.nih.gov/ MdCalc - www.mdcalc.com Apps Epocrates Sanford Guide Antimicrobial Therapy CDC Apps (Antibiotic Treatment, Vaccines, Opiate Prescribing, STD Treatments) ERres ASCCP Eponyms

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The Future of the Emergency Room with Dr. Joe Habboushe (co-founder of MDCalc)

MedChatMonday

Play Episode Listen Later Mar 31, 2019 30:01

The Emergency Room is a constantly evolving environment and now with the option of visiting your local urgent care center - which do you choose? Dr. Ross Kopelman sits down with Dr. Joe Habboushe an Emergency Physician at NYU & Serial Entrepreneur that co-founded MDCalc to explore this very topic. In this podcast you will learn how one of the leading ER doctors in the country perceives the emergency room, his love for the ER, and how MDCalc (the company he co-founded a decade ago) which is widely adopted by healthcare providers has impacted healthcare in this country through evidence based medicine.

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Top 5 GP apps eGPlearning Podblast

eGPlearning Podblast

Play Episode Listen Later Jan 25, 2019 54:50

Watch this session as Andy and Gandhi of the eGPlearning Podblast discuss their top 5 GP apps. Covering a variety of apps that you may want to use in general practice either for yourself or the benefit of your patients. This session also includes some honourable mentions. This session is created as part of the HTN Digital week. To watch the video click here: https://www.youtube.com/watch?v=-inbZVvck-0Subscribe to our Youtube Channel here: https://bit.ly/eGPlearningYTsubscribeContact Andy: https://twitter.com/drawfoster Contact Gandhi: https://linktr.ee/drgandalf52 HTN: https://www.thehtn.co.uk/Andy:Honourable Mention: Omnifocus: https://www.omnigroup.com/omnifocus/ 5: NHS Quicker https://nhsquicker.co.uk/4: Headspace https://www.headspace.com/3: Wysa https://www.wysa.io/2: MyfitnessPal https://www.myfitnesspal.com/1 Onenote http://www.onenote.com/?404&public=1Gandhi:Honourable mention5: MDcalc https://www.mdcalc.com/4: BNF https://www.bnf.org/products/bnfbnfcapp/3: Camscanner https://www.camscanner.com/r1?1315142952: Nottinghamshire LMC https://www.nottinghamshirelmc.co.uk/mobile-app/1: Evernote: https://bit.ly/eGPlearningEvernoteGandhi:Other sessions in this serieshttps://bit.ly/egplearninghtnsocialmediahttps://bit.ly/egplearninghtncpdContact Andy: https://twitter.com/drawfoster Contact Gandhi: https://linktr.ee/drgandalf52 CPD Certificate of engagement: http://bit.ly/egplearninghtncert Subscribe to or follow the eGPlearning platform for more videos, app reviews and content to support technology-enhanced primary care and learning. Facebook - https://www.facebook.com/Egplearning/Twitter - https://twitter.com/egplearningTwitter - https://twitter.com/drgandalf52Website - https://egplearning.co.uk/Support:

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What Canada Can Teach Us About CAT Scans

ERCAST

Play Episode Listen Later Mar 11, 2018 22:25

Joe Habbousche is the CEO of MDCalc, the world's most used online medical calculator. Chances are, you've used it yourself. Joe is a passionate advocate for the practice of evidence based medicine and the proper use of clinical decision tools. In this episode, we dissect one of his favorites: the Canadian CT Head Injury/Trauma Rule Canadian CT Head Injury Rule Derived and validated in a large patient population Overall 8% of patients had positive CTs, but only 1.5% required intervention Two sets of criteria High Risk/Major Criteria Designed to capture patients that went on to require intervention. Medium Risk/Minor Criteria Added on to the high risk criteria to capture those with clinically important brain injury- CT findings that require admission or observation Who does this not apply to? Patients on blood thinners/bleeding disorder Under 16 years old Seizure after trauma No clear history of trauma Obvious penetrating skull injury or obvious depressed fracture Acute focal neurological deficit Unstable vital signs associated with major trauma Returned for reassessment of the same head injury This is a one directional rule Designed to be sensitive but not necessarily specific This decision rule was designed because when CT imaging is done in all comers with head injury, it has very low yield The CT Head Injury/Trauma rule asks, "Can I carve out a cohort of patients who we know will not have a need for this test." If you fall in this group (the cohort that the rule says doesn't need the test), then you don't need the test Here's the one directional part: If you fall outside that group, the group the rule says does not need the test....the rule DOES NOT COMMENT. It is not studying anyone outside the group that has been deemed safe to not have the test done Canadian CT Head Rule Applies to this group of patients Blunt trauma to the head resulting in witnessed loss of consciousness Definite amnesia or witnessed disorientation Initial emergency department GCS score of 13 or greater as determined by the treating physician Injury within the past 24 h High Risk Criteria: Rules out need for neurosurgical intervention Fails rule with any of the following GCS

March 2018; papers of the month

The Resus Room

Play Episode Listen Later Mar 1, 2018 27:08

Welcome to March's papers of the month. We know we're biased but we've got 3 more superb papers for you this month! First up we review a paper looking at oxygen levels in patient's with a return of spontaneous circulation following cardiac arrest, is hyperoxia bad news for this patient cohort as well as the other areas we've recently covered? Secondly we have a look at a paper reviewing the association between time to i.v. furosemide and outcomes in patients presenting with acute heart failure, you may want to have a listen to our previous podcast on the topic first here. Lastly, when you see a pregnant patient with a suspected thromboembolic event, can you use a negative d-dimer result to rule out the possibility? We review a recent paper looking at biomarker and specifically d-dimers ability to do this. We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here. Enjoy! Simon & Rob References & Further Reading Association Between Early Hyperoxia Exposure AfterResuscitation from Cardiac Arrest and Neurological Disability: A Prospective Multi-Center Protocol-Directed Cohort Study. Roberts BW. Circulation. 2018 The DiPEP (Diagnosis of PE in Pregnancy) biomarker study: An observational cohort study augmented with additional cases to determine the diagnostic utility of biomarkers for suspectedvenous thromboembolism during pregnancy and puerperium. Hunt BJ. Br J Haematol. 2018 Time to Furosemide Treatment and Mortality in PatientsHospitalized With Acute Heart Failure. Matsue Y . J Am Coll Cardiol. 2017 MDCALC; Framingham Heart Failure Diagnostic Criteria REBEL.EM; Door to Furosemide in AHF Modified Rankin Scale

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#79 Smarter, Simpler Ways to Fix Healthcare: Dr. Joe Habboushe

How Do We Fix It?

Play Episode Listen Later Nov 30, 2016 32:51

The U.S. spends more than $3 trillion a year on healthcare, or nearly $10,000 a year for every man, woman and child. But are we getting a bang for our buck? In many cases, the answer has to be no. And this goes well beyond the raging debate over Obamacare and whether all Americans should have access to coverage. About a third of money spent on healthcare is now simply wasted or spent on poor decisions, says our guest, emergency room physician and entrepreneur, Doctor Joe Habboushe. The crisis includes clinical waste, excessive prices, fraud and bureaucracy. Dr. Habboushe shares his moving personal story and passion for reducing waste and improving patient outcomes through his work as a physician and as CEO of MDCalc - an online diagnostic app used by about 50% of American doctors. "Let's not get rid of what we do really well and that's drive innovation for the world," says Dr. Joe. "If we focus on waste, we have to look at why healthcare costs a lot and if we want to reduce that how can we do it in a... See acast.com/privacy for privacy and opt-out information.

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Episode 49.0 – Alcohol Withdrawal

Play Episode Listen Later May 30, 2016

This week we take a look at alcohol withdrawal with a focus on recognition and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_49_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Withdrawal, Ativan, Benzodiazipines, Delirium Tremens, Ethanol, Thaimine, Valium Show Notes Yip L. Chapter 77. Ethanol. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e. New York, NY: McGraw-Hill; 2011. EmCrit Podcast: Delirium Tremens Life in the Fast Lane: Alcohol Withdrawal The Poison Review: CPC: alcohol withdrawal with delirium tremens and a significant missed diagnosis EM Updates: Avoid Alcohol Withdrawal Admissions MDCalc:

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Episode 49.0 – Alcohol Withdrawal

Play Episode Listen Later May 30, 2016

new york fastlane cpc final cut ethanol valium ativan delirium tremens alcohol withdrawal mdcalc emcrit podcast em updates

Episode 49.0 – Alcohol Withdrawal