Heart Failure Risk Scale and Atrial Fibrillation

This week we had the pleasure of welcoming a guest speaker for grand rounds, prominent EM researcher and well-known clinical decision rule/tool expert from Ottawa, Dr. Ian Stiell. The focus of his talk was on the Canadian Heart Failure Risk Scale and atrial fibrillation, with some personal travel blogging and joking scattered throughout. Beginning with its derivation and subsequent validation, Dr. Stiell provided a background to the current phase of study that Queen’s will be a part of, the revision and validation of the Canadian Heart Failure Risk Scale. Approximately 1 million people are seen in the ED annually in Canada for acute heart failure, 40-60% of which are admitted to the hospital.  The Heart Failure Risk Score hopes to provide guidance and standardize practice for ED physicians across the country with respect to admission decisions in this population.  The group had a rich discussion about factors included, surprises found in the literature, and predicted utility of the tool. Dr. Stiell pointed out that in order to find out whether this tool will change practice, an implementation trial would have to ensue – stay tuned! In the meantime, check out the score and look for the bright yellow forms to fill out on your next shift in the ED!

The Canadian Heart Failure Risk Scale

Dr. Stiell finished his talk with a review of his work on management of acute atrial fibrillation and flutter. Refer to the updated Canadian CV Society Guidelines for the latest (see algorithm below). Dr. Stiell is now working with CAEP to adapt these guidelines to the ED – stay tuned!

BONUS feature: Dr. Stiell sold us on two new phone applications to check out – The Ottawa Rules Application and Thrombosis.

Thanks for coming Dr. Stiell (@EMO_Daddy)!

 

 

Mass Gatherings and ED Ultrasound

On February 2 we had the pleasure of welcoming back Dr. Colin Bell, a recent FRCP EM grad, all the way from Denver for a talk on ED Ultrasound and hearing some more stories from Dr. Terry O’Brien.

The legendary TOB started the morning off with a talk on mass gatherings, using the last Tragically Hip concert as an example. He took us through the planning, equipment, personnel involved, and lessons learned on the day. Our crew of one nurse (thanks Patti!), multiple residents, staff physicians, and essential administrative assistants provided excellent care and diverted 35 people away from the crowded hospital. EMS was instrumental in the success of the event as well. Kingston’s population received an additional 25, 000 that day!

Here are some resources on mass gatherings to take a look at in preparation for the next big event:

Colin Bell then took us through ‘The Second Phase of POCUS’, illustrating the growing utility of ED ultrasound with a few key cases in which management was altered based on bedside images. It is an exciting time for POCUS and is becoming more of an essential adjunct to diagnostic workups in the ED, especially when time is of utmost importance.

Don’t be shy to ask Colin about the cool new initiatives he is taking part in across the border – he also has some interesting stories to tell practicing EM in an entirely different context than we see here in Kingston.

Here is a reminder of a previous post in which we included a number of valuable online resources for ED ultrasound.

 

Thyroid Emergencies and CBME EPAs

On January 25th Dr. Andrew Hall gave us a reminder the concept of CBME and what it will look like next year. Dr. Heidi Wells followed with an excellent overview of Thyroid disorders encountered in the ED.

Andrew re-iterated the model of CBME and how it will fit into our emergency medicine program starting July 2017. He provided a list of the current entrustable professional activities (EPAs) for emergency medicine and a rich discussion ensued. Overall, it is an exciting time in medical education and Andrew convinced me that our already great program will only get better with this shift towards an outcomes-based, learner centered model! Feel free to ask Dr. Hall all about it, or refer to the PGME website for more information.

Heidi then took us through an approach to thyroid disorders in the ED – with tons of clinical pearls and important take home points to use on your next shift. See the infographic below for a summary of the key messages, and click here for a downloadable pdf version:

Interestingly, Queen’s wasn’t the only institution focused on thyroid disorders that week – the twittersphere was lighting it up!

In true FOAMed spirit, check these resources from the Bold City EM program in Jacksonville, Florida on endocrine, metabolic and nutrition themed topics. Thanks Bold City EM!

 

Exploring the Spectrum of Burnout to Wellness

Just in time for #CAEPWellness2017 Mikayla presented at Grand Rounds on the topic of Burnout to Wellness.She presented a great deal of literature on the topic and made a convincing case for finding ways to help each other thrive.

My favourite part of the presentation was when she displayed word clouds made from our group’s responses to a quick survey she had sent ahead of time. The words below represent how our group manifests burnout.

Better yet was her forward-looking, optimistic look at how we might thrive! Mikayla highlighted some things our department already does and pointed to a couple of other institutions and online discussions on the topic including the ALiEM Journal Club “Thriving, Not surviving, in Residency“. This word cloud displays the strategies that our group uses to get and stay well.

At the end of the day as institutions, friends, colleagues, peers, and individuals we have the ability to support each other in being the best version of ourselves possible. At QEmerg we will continue to find ways, big and small, to navigate the spectrum of burnout to thriving.

Check out information about International Emergency Medicine Wellness Week with lots of available resources and important discussions here. Please add your favourite wellness hacks below!

Grand Rounds: don’t RUSH ortho

In this week’s edition of Grand Rounds Zack performed a quick review of the RUSH exam for undifferentiated shock and Theresa outlined some easy to miss orthopaedic injuries. Below are a few resources on both below! 

The RUSH Exam

In the patient with undifferentiated shock you can use the power of the ultrasound to evaluate the “Pump, Tank and Pipes” or the HI-MAP. See the EMCrit post from the original creators.

rush-exam

For a super primer on the RUSH/HI-MAP exam check out this video from 5 minute soon here or this post from ALiEM.

Happy scanning with our new high frequency probe!!!

Easy to Miss Ortho Injuries

There is far too much to cover from Theresa’s awesome review on this topic. I’ve decided to highlight a couple of the injuries that she mentioned with links to the resources about those injuries for some quick reading.

There is a spectrum of scapholunate injuries that are easy to miss. These range from scapholunate dissociation (widening of the scapholunate joint) to peri-lunate dislocation to lunate dislocation.

The posterior shoulder dislocation can be easy to miss. Keep your eye for the lightbulb sign. Maybe we can consider using ultrasound for catching the diagnosis?

The lateral elbow x-ray is your friend. Keep your eye out for signs of occult fracture in this view.

I really appreciated Theresa’s discussion of the Ottawa Ankle rule. She reminded us that these rules can help assess the need for imaging but the components do not make up a complete or thorough ankle exam. Remember to check the proximal fibular head and examine the whole ankle and foot.

Theresa’s 10 Commandments for Ortho Injuries

  1. Know what you are looking for
  2. Obtain proper, perpendicular views, multiple views and specific views
  3. Be aware of specific, occult and dislocation radiographic signs
  4. Know what “normal looks like”
  5. Avoid being distracted
  6. Develop a systematic approach to xrays
  7. Use cognitive forcing strategies – (i.e. always document snuffbox tenderness and DRUJ findings in wrist exams)
  8. ALWAYS obtain post reduction films
  9. Examine the joint above and below
  10. History and physical trump ALL. Examine, image, re-examine.

 

 

Grand Rounds: Pediatric Rashes

This week, Dr. Aaron Ruberto (otherwise known as Mr. Trebek), took us through an exciting and informative game of Jeopardy to teach us about Pediatric Rashes. The ultimate winner was Dr. Eve Purdy, but we all ‘won’ a ton of relevant and always difficult trivia regarding common and serious pediatric rashes encountered in the ED. See the infographic below as a reminder of the basics to use as an approach to these skin conditions in practice. If you have specific questions, I’m sure Aaron would be happy to provide his expert opinion.

gr-sept-29

You can download a pdf of the above summary here: Grand Rounds Sept 29.

You can also check out the following resources to practice your pediatric rashes:

Staff Rounds:

Dr. Nici Rocca presented an interesting case for staff rounds before Aaron took to the mic, reminding us to keep necrotizing fasciitis on our differential as one of the time sensitive, high mortality infections not to miss in the ED! She provided a description of a recent case she had in the ED of an older woman who presented with refractory cellulitis, pain out of proportion, and a history of femoral popliteal bypass. She reminded us of the risk factors (diabetes, vascular insufficiency, trauma, etc.), the physical exam (pain out of proportion, induration beyond visible cellulitis, crepitus, erythema, bullae, necrosis ecchymosis), and the importance of rapid referral to a surgeon as definitive treatment. Imaging can be done but should not delay treatment – CT or MRI are best. Piptazo + Vancomycin OR Clindamycin + Ampicillin + Vancomycin are good empiric regimes to start in the ED. Penicillin + Clindamycin can be used if you are sure it is a type 2 monomicrobial infection with streptococcus! In the end the patient above ended up having a graft infection for which she was placed on antibiotics and taken to the OR to remove the infected graft and repeat her bypass.

Summer Series: the Art of Regional Anesthesia

This is the final summer series post for 2016! We ended the season with a great session on nerve blocks followed by an adventure to the Agnes Etherington Art Centre for a session on art appreciation.

Below is an infographic, created by Andrew Helt, that can act as a quick reminder of the types of nerve blocks that you can use. You can check out Vault Ultrasound or keep Joey’s sheet handy by taking a picture of it and adding it as a favourite on your phone for more in-depth reminders at the point of care.

regional-anesthesia regional-anesthesia

After learning about nerve blocks we headed across campus to Agnes Etherington. If you haven’t had the opportunity to check it out you should go! The curators were setting up new installations while we were there so it is sure to be enjoyable.  In case you are skeptical about this as a component of our academic curriculum, I will direct you to these resources discussing the value of humanities in medical education here, here and here.

The summer series was a great introduction (for some) and return (for others) to the foundations of emergency medicine. We are looking forward to the academic year ahead!

Grand Rounds: Chemical Asphyxiation

And here it is – the long awaited last grand rounds post of the school year! On June 23, Dr. Sharleen Hoffe provided a great summary of 3 types of chemical asphyxiation that may be encountered in the Emergency Department: carbon monoxide poisoning, methemoglobinemia, and cyanide toxicity. She gave a fantastic presentation full of practical tips and interesting tid bits – did you know that both the EMS Lifepaks and our special co-oximetry device (found in section A) test for COHb at the bedside? Our regular bedside monitors do not have this capability, but our lab sure does. Don’t forget to ask for the COHb and MetHb along with the blood gas if you are suspicious for either – both of these can be added to the VBG/ABG and will be back within 15 minutes!

Check out the infographic summary below for a quick overview of Sharleen’s talk. Pick her brain about it next time you are on shift together – she has tons of knowledge to share.

June 23 Grand Rounds

To download a pdf of this infographic, click here: June 23 Grand Rounds

Critically Appraised Topic Project: Point of Care Ultrasonography (POCUS) versus Radiology Ultrasonography (RUS) to rule in acute cholecystitis for adult patients presenting to the emergency room with right upper quadrant pain

Dr. Rowan Henry presented his CAT project this week instead of staff rounds, providing an excellent overview of the literature available to compare POCUS and RUS for the diagnosis of cholecystitis in the emergency department. After an extensive literature search, Rowan presented a summary of the most relevant studies, 4 prospective observational studies with small sample sizes, to guide our clinical decisions. The bottom line: POCUS was found to be comparable to RUS with respect to sensitivity and specificity for the diagnosis of acute cholecystitis in adults with right upper quadrant pain.

The question that was brought up by Rowan and the audience was, ‘what should be the gold standard for diagnosis in acute cholecystitis?’ We all know that even RUS is not 100%. Will this change your practice pattern? Rowan is no longer in Kingston, but would have a lot to contribute to a rich discussion about his interpretation of the literature if you can find him.

 

 

Summer Rounds: Ultimate Introduction to Ultrasound

The posts over the summer months are going to change in format! The structure of our academic program in the summer is such that we cover core topics and skills in emergency medicine in weekly, daylong sessions. We will either pick something interesting from the session to focus on or provide a look at some available online resources for each session.

Our first 2016 summer series session was an ultrasound extravaganza to give the newcomers to QEmerg a feel for ultrasound, the basic concepts and get them ready to start acquiring scans. It also gave those with some experience the chance to practice and teach as well! We covered the aorta scan, subxiphoid view, FAST and gyne scans. Thanks to Louise, Joey and Connor for putting on an awesome session with tons of hands on time! If you had fun on the day here are a few neat articles and resources you might want to check out.

  • SonoMojo provides an outlined curriculum of basic ultrasoScreen Shot 2016-07-08 at 10.56.15 AMund skills with links to podcasts and videos to brush up on the basics. I especially like their cheat sheets for a quick reminder.
  • One Minute Ultrasound is an app that provides quick
    reminders of key landmarks and techniques.
  • Matt and Mike’s ultrasound podcast is great or check out their awesome iBOOK “Introduction to Bedside Ultrasound”  complete with videos, it truly is an unreal learning tool.
  • Tons more FREE ultrasound resources are outlined on this LITFL blog post

Feel free to add your favourite ultrasound resources in the comments section below but don’t forget, none are a substitute for hands on probe time with teachers showing you the ropes! Happy scanning!

Grand Rounds: Ischemic Stroke

This week Dr. Allison Lainey provided us with an excellent overview of acute ischemic strokes, delving into the evidence behind our current practice with tissue plasminogen activator (tPA) and looking forward to the changes that are occurring with the introduction of endovascular therapy (EVT). I was certainly intrigued and with a recent claim of “the biggest thing ever to happen to neurology”, it will be interesting to watch our practice evolve in the emergency department.

Allison finished her presentation reminding the audience that although EVT is looking quite promising, we shouldn’t forget about the intervention with the best evidence for improving outcomes – rehabilitation on multidisciplinary, dedicated stroke units. Try to catch her before she heads to Peterborough as a staff to discuss her thoughts on the current state and future of stroke management!

gr-june-16

To download a pdf of this infographic click here: June 16 Grand Rounds.

Critically Appraised Topic Project: Should we be using an age adjusted D-dimer in the emergency room to rule out pulmonary embolism?

Instead of staff rounds, Dr. Mike Mason presented his CAT project on the utility of an age adjusted D-dimer to rule out PE. He took us through a complete summary of the literature, concluding that age adjusted D-dimers increase specificity with a minimal and acceptable decline in sensitivity in low risk patients. According to Dr. Jeff Kline, adjusted D-dimers are ready for prime time!

Refer to the ADJUST-PE Study for more information, and a prospective validation study of this test. Mike reminded us all that regardless of the adjustment, D-dimer is only useful as a rule out test in patients with a low risk of PE in the first place.