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What Do The Changes To The ACS Trauma CME Requirements Mean For the Future Of Trauma Education? November 29, 2018

Posted by Robin Wilkinson in : Uncategorized , add a comment

You’ve probably heard the American College of Surgeons (ACS) has loosened the requirement for trauma CME for ABEM-Boarded Physicians.

To say that the majority of emergency physicians welcomed the change would be an understatement. We recently conducted a survey of our subscribers who collectively characterized the ACS revisions as a reprieve from an ever-changing list of professional requirements that seems only to grow longer. At the same time, many recognized ongoing trauma education is critical to ensure appropriate care and there was confusion over what exactly the new rules are and who they do, and don’t, apply to.

The question on everyone’s mind is: What do the ACS trauma CME requirements changes mean for ongoing trauma education exactly?

We interviewed leaders in emergency medicine including Graham T. McMahon, MD, MMSC, Lee Shockley, MD, MBA, and many more to dig into the new ACS trauma CME requirements. Download our free report and find out more about the changes to the ACS trauma CME requirements as well as what they mean for you and the future of trauma education.

Get your copy: Next-Level Emergency Trauma Care To Surpass “Merit-Badge Medicine”
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Case Conclusion — Shock in the Emergency Department March 6, 2014

Posted by Andy Jagoda, MD in : Uncategorized , add a comment

Recap of March’s Case: You are working in the ED late one evening when an 82-year-old man is brought in by his son. His son reports that earlier today, his father had been in his usual state of health, but this evening he found his father confused, with labored breathing. He is delirious and unable to answer questions. A focused physical examination demonstrates tachycardia without extra heart sounds or murmurs, right basilar crackles on lung auscultation, a benign abdomen, and 1+ lower extremity pitting edema. You establish intravenous access with a peripheral catheter and send basic labs. A further history obtained from the son reveals that his father has congestive heart failure with a low systolic ejection fraction, as well as a history of several prior myocardial infarctions that were treated with stent placement. As you consider this case, you ask yourself whether this patient is in shock, and if he is, what are the specific causative pathophysiologic mechanisms?

Case Conclusion: You rapidly determined that the patient was in shock. Although his blood pressure was within acceptable limits, he had clear clinical evidence of impaired end-organ perfusion as evidenced by altered mental status (impaired cerebral perfusion) and respiratory insufficiency. While you recognized the possibility of a cardiogenic process contributing to his presentation, the majority of the clinical data supported an infectious process (specifically, a right lower lobe pneumonia) resulting in a systemic inflammatory response and distributive pathophysiology due to septic shock. You administered a bolus of 30 mL/kg of lactated Ringer’s. You requested a comprehensive laboratory panel be sent, including CBC, chemistries and renal function analyses, arterial blood gas, serum lactate concentration, and blood cultures. You ordered a chest x-ray to better characterize his presumptive pneumonia. Because the patient was in shock due to sepsis, you ordered empiric broad-spectrum antibiotics based on your hospital’s antibiogram – in this case you elected to administer vancomycin 15 mg/kg (as the patient’s renal function is not yet known) and cefepime 2 gm IV. Despite these interventions, his blood pressure progressively decreased in the setting of an increasing temperature and worsening oxygenation. Given his clinical deterioration, you made the decision to intubate him and initiate mechanical ventilation with low-tidal-volume ventilation. Then, you placed a left subclavian central venous line and initiated a continuous infusion of norepinephrine, titrated for a MAP goal of > 65 mm Hg. His laboratory studies demonstrated leukocytosis (WBC 27 x 109/L), thrombocytopenia (90 x 109/L), acute renal failure (creatinine 3.1 mg/dL), and a lactic acidosis (lactate 7.2 mmol/L, bicarbonate concentration of 16 mmol/L, and base excess of -10 mEq/L). After receiving high-quality, evidence-based care in the ED, he was admitted to the MICU in critical condition, but ultimately made a full and uneventful recovery.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about shock in the ED? Simply click the links below:

Cardiotoxicity January 29, 2014

Posted by Andy Jagoda, MD in : Uncategorized , 19comments

Late one evening, a 32-year-old woman is brought to your ED via EMS after her boyfriend found her slumped over in a chair. He states that they were arguing last evening and that she was quite upset. Her boyfriend provides a medical history significant for migraine headaches, and he knows that she is taking verapamil for the same. Her fingerstick glucose is normal, and she has a heart rate of 28 beats/min and a blood pressure of 74/36 mm Hg. Consider what the best initial step in management for this patient would be — Is there a role for GI decontamination? What about hemodialysis?

Submit your diagnosis in the comments box below, and be sure to check back on February 8 to see if you were correct!

Case Conclusion — Urinary Retention Complications January 6, 2014

Posted by Andy Jagoda, MD in : Uncategorized , add a comment

Case 1:

A quick physical examination revealed only a distended bladder for the 72-year-old man. A urethral catheter was placed, and 700 mL of urine was obtained, with much relief for the patient. Not forgetting the patient’s presentation and his stumble while changing stretchers, you decided to perform a thorough neurological examination, and you found nearly absent rectal tone and absence of sensation and vibration below T11. Urgent MRI confirmed your diagnosis of spinal cord compression. You consulted neurosurgery, and the patient was admitted for decompressive laminectomy and eventual chemotherapy.

Case 2:

After taking the history of the 46-year-old febrile woman with HIV and giving her a thorough physical examination, you performed a rectal examination, which showed good rectal tone and no evidence of obstruction. You then performed a pelvic examination (with a chaperone present), and it showed vesicular lesions suggestive of herpes. Adequate pain control was achieved. Ultrasound showed a fully distended bladder. You gave the patient acetaminophen, IV acyclovir, and IV fluids, and you started cardiorespiratory monitoring. You performed complete bladder decompression using a 16F Foley and sent the urine for urinalysis and culture. The urinalysis returned positive for white blood cells, so you gave her IV ceftriaxone and admitted her to medicine for IV antibiotics, IV fluids, and antivirals.

Congratulations to this month’s winners!  You will receive a free copy of the latest issue of Emergency Medicine Practice: An Evidence-Based Approach To Emergency Department Management of Acute Urinary Retention. If you did not win this month, you can still read part of the issue — click here to download a free copy of this month’s Risk Management Pitfalls!

“Afebrile patient with a swollen knee…” Case Conclusion May 7, 2012

Posted by Andy Jagoda, MD in : Uncategorized , add a comment

The Conclusion Is…

You remembered from your evidence-based review of the literature that there is no serum blood test that can adequately rule out septic arthritis, so the patient’s history and exam warranted arthrocentesis. After laying the patient flat and partially flexing the knee with a pillow, you guided the needle medially under the patella and you aspirated watery, but cloudy, material. A point-of-care sLactate came back quickly at 15 mmol/L, and removed any ambiguity — this was a septic joint. While synovial culture and Gram stain (and blood cultures) were sent, along with sWBC and pre-op labs, you initiated IV antibiotics — vancomycin and ceftriaxone. Then you called up the orthopedist and asked him to prepare the OR.

Congratulations to  Dr. Lalitha, Dr. Averick, Dr. Karagöz, Dr. Piebalga, and Dr. Dube— this month’s winners of the exclusive discount coupon for Emergency Medicine Practice For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Monoarticular Arthritis, purchase this issue.

Afebrile patient with a swollen knee… April 30, 2012

Posted by Andy Jagoda, MD in : Uncategorized , 27comments

A middle-aged man with diabetes and hypertension has been waiting patiently to be seen, with a complaint of right knee pain and swelling that has gradually progressed over several hours. There is no history of trauma, recent or remote, but he describes several goutlike episodes of pain in both feet in recent years, which improved with rest and NSAIDs. He was triaged as an ESI4, and the waiting room is packed. Fortunately, the charge nurse comments on how uncomfortable he looks and he is brought into the ED for evaluation. The patient is afebrile, but the knee is hot, beefy red, and swollen. The ED is over-capacity and the patient’s history is reassuring, so you consider keeping him in a chair. But that knee looks impressive and you wonder if your plan is aggressive enough.

What do you do next?

(Enter to win a discount coupon for an Emergency Medicine Practice subscription by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is May 6th.)

“A case of Rhabdomyolysis…” Case Conclusion March 6, 2012

Posted by Andy Jagoda, MD in : Uncategorized , add a comment

The Conclusion Is…

The patient had clearly developed pneumonia, which was unsuccessfully treated from the previous hospitalization, and nowhttp://www.ebmedicine.net/empblog/wp-admin/post.php?post=40&action=edit&message=1 presented with severe sepsis. You treated her with broad-spectrum antibiotics, taking into account her risk for gram-negative bacteria, and started crystalloid infusion to support her hemodynamically. You found that the she had developed rhabdomyolysis from sepsis and had already developed acute renal failure, with a BUN:Cr ratio concerning for myoglobinuria-induced renal failure. You checked the urine pH, which was 4.6, and switched her normal saline to 0.45% saline with 2 ampules sodium bicarbonate per liter to alkalinize the urine to a pH > 6.5. You continued early goal-directed therapy, performed endotracheal intubation to decrease her work of breathing, and consulted your intensive care unit for admission.

Congratulations to  Dr. Hugo, Dr. Anda, Dr. Achacoso, Dr. Cohen, and Dr. Peschanski— this week’s winners of Emergency Medicine Practice’sRhabdomyolysis: Advances In Diagnosis And Treatment!” For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Rhabdomyolysis, read this issue.

Welcome To “What’s Your Diagnosis?” October 26, 2011

Posted by Andy Jagoda, MD in : Uncategorized , add a comment

Welcome to EB Medicine’s “What’s Your Diagnosis” blog! We created “What’s Your Diagnosis” to be a fun way for emergency clinicians to test their knowledge of challenging clinical cases. One ED patient presentation will be posted each month, with the case conclusion posted one week later including a link to a full text article on the topic. Post your guess to the diagnosis before we share the conclusion, and then see if you got it right!

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