Providence

 

Clinical Posts and Updates

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Forms/Guidelines

Warfarin Nomogram, 5mg Infective Endocarditis Guideline ED Referral Form
Warfarin Nomogram, 10mg Medical Clearance for Psychiatry Illness Affecting Work/Travel
Acetaminophen Nomogram Skin & Soft Tissue Infections Form 4 (Mental Health)
Code MI Meds UTI Guidelines Form 5 (Mental Health)
COPD Antibiotics PHC Antibiogram 2011  
Acute Heart Failure Pathway PE Algorithm  
Asthma Adult Pathway Peak Flow Adult Male Peak Flow Adult Female
Asthma Peds Pathway Peak Flow Children Stroke Pathway
CAP pathway Sepsis Protocol 2012 Trauma Guidelines
CAP Abx Guideline Appendicitis Protocol Surge Policy

Blood and Body Fluid Exposure

Non-Occupational PEP (NPEP) Algorithm NPEP Fact Sheet
Post Exposure Prophylaxis (PEP) Poster HIV Risk Assessment

Rules/ Resources

Ottawa Ankle Rule Ottawa Knee Rule Peak Flow Calculator
Canadian CT Head Rule Canadian C-Spine Rule Nexus C-Spine Rule
Well's DVT Criteria Well's PE Criteria PERC Rule
CURB 65 Pneumonia Severity Index SF Syncope Rule
Glasgow-Blatchford GI Bleed Centor Pharyngitis Score TIMI Score for UA/NSTEMI
ABCD2 for TIA Alvarado Appy Score King's College APAP Severity
WikEmerg UpToDate Google EM Search
The NNT E2E CMA Clinical Resources

Weekly Reading List

The Weekly Reading List

... and we're back...

So, 2 months off for Summer, St Paul's Emergency Medicine Update, the birth of my second child.  Things have been quiet here, but not on the Webs.

At ICEM 2012, a group of EM and SoMe (Social Media) thought leaders put their heads together over a pint of Guiness (it was Dublin after all) to come up with the next step in Medical Education in the Wild West we call the Internet.  Thus was born FOAM (Free Open Access Meducation). This was 'shortened' to FOAMed. The goal was/is to provide a loose structure and enhanced usability to the array of EMCC (Emergency Medicine and Critical Care) blogs, podcasts, tools, and resources available on the Web, and to harness that bounty to improve Medical Education. Don't take my word for it, check out the originators:

The first 2 big tools to help harness all this are:

emgoogle.com - a Google Custom Search Engine (created by yours truly) that ONLY searches EMCC blogs, podcasts, tools and Journals. This is a good first filter, and if you don't find what you need, then you can resort to the full Google.

foamem.com - a realtime RSS feed of all the known EMCC blogs and podcasts.  You can visit the site to see the latest, or subscribe to their integrated, single stream RSS feed.

So, welcome to #FOAMed !

Okay, but what else happened?  Here is a smattering of other good stuff from the web:

Ultrasound for Subclavian Lines - you can do that?  Yes you can!

Dr Ves at CasesBlog points us to the new Guidelines for Management of Acute Bacterial Sinusitis (it's not sexy but it is important)

Does this overdose need dialysis? Review of Extracorporeal Removal Techniques for the Poisoned Patient

Urine Drug Screening - Useful? Part One focusses on Benzos, Part Two on Opiates.

Have you been given a Field Note by a FM resident? Want to know What's up?

Is that cut 'too old' to close? Are you sure? (Journal Link)

ENLS -Emergency Neurological Life Support (What to do in the first critical hour of a neurological emergency). This is a new 'Advanced Life Support' course, but the Protocols and the background info are FREE!  Yay FOAMed.

Erowid - more than anyone needs to know about Psychoactive substances... from a slightly different point of view.

Are you scared of CROCODILEs? A new approach to Pt Safety with Learners in the driver's seat.

Finally, this is just cool!


Enjoy the weekend.

Weekly Reading List

ReadingList

If I say 'it was another busy week on the Internet', will you get that it is ALWAYS a busy week on the Internet?  Let's get at it then.

First, a bit of a rant from Simon Carley at StEmlyn's about the generally poor state of teaching (and use) of Clinical Skills - Does anyone use Ophthalmoscopes anymore?

Staying with a theme, Sinaiem.org gives us a great synopsis of The Value of Symptoms and Signs in the Emergent Diagnosis of Acute Coronary Syndromes. [The original paper in Resuscitation (2010) is by Richard Body, Simon Carley et al of St Emlyn's - are we getting why this is called social NETWORKING?]

Since we seem to need a refresher on H&Ps and Clinical skills, I will bring the JAMA Rational Clinical Exam Series to your attention once again. [You can access it by using the Library VPNEMLitofNote highlights the latest in the Series When Do Patients Need Blood Cultures?

Here are a few more Skill/Tool related items:

Everything you wanted to know about Capnography (ETCO2 monitors) but were afraid to ask.

The Trauma Professional reminds you that not all pts need O2 - to treat the Pt not the numbers.

Femoral lines are Dirty... or are they?

Got no IV Access, a Central Line seems excessive, and the EX-IO is out of batteries?  Try the 'Peripheral IJ' (There is Gold in the Comments here, so read the whole thing)

Compartment Syndrome is Scary, but so is the Stryker.  The cure for Fear is Education.

Ventilator-Associated Pneumonia is an ICU problem... yer not off the hook just yet - Good Care Downstairs may mean No VAP Upstairs.

I mentioned the new Anticoagulation Guidelines in this weeks Journal Club, and now the fine folks at ALiEM have updated their Paucis Verbis Card for Overanticoagulation and Supratherapeutic INR. [You can get all the PV Cards Here.] St Emlyn's has a great post reminding us why this is important - You Snooze you Ooze.

A few more gems, then I am done:

ALiEM has a new blogger, Brian Hayes PharmD (an ED Pharmacist), and he starts by debunking the Cephalosporin/Penicillin cross-reactivity myths.

Resus.me reminds us that COPD exacerbations can impact more than the lungs.

The Poison Review reminds us that Tylenol is not just Acetaminophen anymore.

US Physics and Knobology made ridiculously easy... mostly.

Finally, if you simply have to have more to read this weekend, the latest R&R in the FastLane is out and full of researchy goodness.

 

I have more, but even I am going cross-eyed.  Watch for a Special post with a Philosphical bent next week.

 

Featured Resource

This week I feature 2 sites I find very useful for clinical decision making and teaching.

First is MDCalc, a great online medical calculator with a primary focus on Emergency Medicine and Critical Care.  You will find it featured prominently in this site's Clinical Links Rules/Resources section.

Second is the NNT.  the NNT turns a critical and analytic eye to landmark research, reviews and meta-analyses.  In a nutshell, they evaluate each paper and then calculate a Number Neede to Treat (or Harm) for the intervention.  The Traffic Light infographic at the top of each review gives you a Go/No Go/Caution advisory about the paper's findings.  Then there is a detailed explanation of how they reached their conclusions. See how they do it all here.

They have also begun to review Diagnostic Tests (Likelihood Ratios) and Risk Assessments.

The thread connecting the 2 sites is Graham Walker (@grahamwalker) an MD/geek extraordinaire, who created both sites.  He is worth a follow on Tumblr and Twitter.

Virtual Journal Club - Evidenced Based Management of Anticoagulation

JournalClub

 

Okay, so no big trials or local research this week.  Instead a recent Review of the management of Anticoagulation and it's attendant complications.  Published in the Chest supplement on Antithrombotic Therapy and Prevention of Thrombosis, this atricle provides an 'Evidence-Based' approach to the issue.  How well the authors do at presenting a balanced approach to the Evidence is something I hope we can discuss.  In any case it appears to be the most current and authoritative recommendations on Anticoagulation and Anticoagulation-related Emergencies.

Evidence-Based Management of Anticoagulant Therapy:  Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Weekly Reading List

ReadingList

 

Another busy week on the 'Tubes.

Let's start with a great look at where EM is, where we came from, and how little has changed (and why this is probably a good thing).  Javier Benitez (Twitter, and now blogging at Academic Life in EM) gives us a 2 part (Part 1, Part 2) look back at Peter Rosen's seminal "The Biology of Emergency Medicine" from 1979! The original paper can be downloaded here.

Next a few for the learners:

If you don't already use these, you should - JAMA's Rational Clinical Exam Series.  This week, Does This Adult Patient With Suspected Bacteremia Require Blood Cultures?

The British Journal of Sports Medicine (twitter) has a YouTube Channel filled with great Clinical Exam videos.

Another Checklist from Dr Strayer at EMUpdates - ED Procedural Sedation and Analgesia

Crossing over from the Learners to the staff, a couple of excellent posts on Journal Clubs and How to make them Effective, from the StEmlyn's crew.

Now for the 'Well that's Interesting" moment of the day - it works here, and apparently elsewhere too: the Vancouver Chest Pain Rule in Tehran.

From the UK we get Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies.

This is a hopeful story from the US DEA (how often do you hear that?) Nationwide Synthetic Drug Takedown - 19 million packets of synthetic drugs seized and $36 million in cash. Hopefully we get to reap the benefits of that...

Staying with drugs, Graham Walker (twitter) found this website StreetRx.  Not sure how I feel about this... thoughts?

After that, a bit of an antidote (literally) - Lipid emulsion therapy for poisonings: a review

Finally a bit of food for thought on Shellfish Safety - this news release about Shellfish Toxins led me to this BCCDC Advisory. From there we get an overview of DSP (a new entity), not to be confused with PSP (old, but still terrifying).

That's it for this week. Enjoy the weekend!

Featured Resource - Free Emergency Medicine Talks

This week we highlight Free Emergency Medicine Talks.  Not flashy or sexy, just 2000+ MP3s of EM talks from the best National and International Emergency Medicine Conferences.  Joe Lex from Temple University School of Medicine takes digital recorders to almost every major EM conference and records the lectures.  His residents decided that those lectures needed to be shared, and Free Emergency Medicine Talks was born.

For example, almost every session at ICEM 2012 (Dublin) was recorded and can be found here.

That's it. Emergency Medicine talks.  Free.

Enjoy!

Virtual Journal Club - Coronary CTA

JournalClub

This may seem like a bit of a cop out, but I hope not. I put the ROMICAT II study on the reading list last week, but I think the topic needs a bit more exploration.  As pointed out by EM Lit of Note here, there are now 3 high quality ED based studies on the use of CCTA to help us rule out ACS in low risk patients - ROMICAT II, CT STAT, and ACRIN PA. [Note: if you think we should explore others in this forum, please let me know so I can link to them.]

While there seems to be utility in clearing these pts from the ED earlier than our traditional method (still one of the best and most efficient in the world - seriously), the evidence indicates that we may be robbing Peter to pay Paul (higher downstream testing/consultations/costs, plus the radiation issue minimal though it may be).

Are we using this test in the most effective manner possible, or is CCTA still a test in search of its proper cohort as suggested by the ROMICAT II Editorial?

Weekly Reading List

Reading List

 

Well the InterWebs were on fire this week. Here are some of the gems:

ROMICAT-II (Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography) provides fuel for the CCTA fire. (Thanks to Dr Harris for pointing this one out).

The AHA is out with an Update on the Management of US/NSTEMI (it replaces the 2007 Update).

While on about the heart, did you know that recent caffeine ingestion reduces the sensitivity to Adenosine?  Ya do now.

Last heart post - a case this week prompted me to learn more about ECGs in Athletes the good and the bad (from the European Heart Journal).

Staggered (ie not a single dose) Tylenol overdoses are difficult to prognosticate.  The SOFA score tries.

To change course a bit, try this philosophical rant about how we practice Medicine - On Evidence, Education, Errors, Ego and Expert intuition.

Need more soul searching and introspection?  Does Palliative Care belong in the ED? (news article)

And now back to the hard stuff.  From Resus.me comes a reminder that Head Injury does not Predict  Cervical Spine injury.

Speaking of head injury, the folks from Glasgow have a new score, this time for Upper GI Bleeds - the Glasgow Blatchford Score (as seen in the NICE Guidelines I featured last week).  The folks at St. Emlyns have picked it apart for us in 2 parts (Part 1 & Part 2).

There are new World Allergy Organization Guidelines for the assessment and management of anaphylaxis.  The link is to the abstract because of a paywall.  You should be able to get to it using your UBC Library account, or the full text is available on Medscape (free signup required).

Finally, because it is the weekend, and many of you like to visit our local food spots, check on the VCH Restuarant Closure list before you head out.  It is also useful to see if your Gastro pt ate somewhere questionable recently.

 

There it is.  Enjoy the weekend!

Featured Resource - ECG-palooza!

ecg

This week I want to feature 3 great ECG resources:

Stephen Smith (an Emerg doc at Hennepin County ED in Minnesota and an expert on ECGs and Cardiology - see his CV) runs Dr Smith's ECG Blog.  There are regular updates on ECG basics and esoterica. This is the best bang for your buck on ECG education.

Amal Mattu (Emerg doc at UMEM in Maryland, and another ECG guru as well as an EM:RAP veteran) posts weekly short videos about challenging ECG findings on his Tumblr.

For a more comprehensive, textbook-like, resource see the ECGPedia (from the Netherlands, but all in English).  This one is great for the learners, and for reviewing the basics, especially physiology.

Virtual Journal Club - the ADAPT 2h Chest Pain Rule Out

Virtual Journal Club

 

The ADAPT Trial is an observational study from Oz/NZ which looks uses TIMI 0, and negative Trop I at 0 and 2 hours as a Low Risk Chest Pain rule out.  I will direct you to 2 slightly different takes on the study below.

I will note here that I discussed this with our Chest Pain Pathway author, Dr Scheuermeyer. He ran our cohort of patients from the validation study using the ADAPT criteria.  Our study missed NO (that is zero) events.  Using the ADAPT criteria on our cohort would have resulted in six (6) missed events. 

Here are the reviews of the ADAPT trial from EM Lit of Note and (the new and quite excellent) St Emlyn's from the EM group in Manchester.

Read the paper (free at the JACC site here), and then the posts above. There is also an Editorial that accompanies the JACC paper, found here.  Please post your comments here once you have digested those.