High-Risk Cardiovascular Emergencies - NSTEMI - DOACs - Blunt Cardiac Injury
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High-Risk Cardiovascular Emergencies (Trauma CME and Pharmacology CME)

This resource, delivered in online digital format, includes three courses on high-risk cardiovascular presentations encountered by emergency clinicians: non–ST-segment elevation myocardial infarction, patients taking direct oral anticoagulant agents, and blunt cardiac injury. Also included are two video recordings from the 2019 ResusEM conference featuring expert presentations on current topics in cardiac emergencies. Includes 4 AMA PRA Category 1 Credits™ per course, including 4 trauma credits and 4 pharmacology credits, for a total of 12 credits.

Course Modules

We hope you enjoy this course! If you have any questions, our Customer Service Team is here to help Monday - Friday, 9:00am-5:30pm EST, and can be reached at 678-366-7933 or ebm@ebmedicine.net

Authors

Julianna Jung, MD, MEd, FACEP
Associate Professor of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
Sharon Bord, MD, FACEP
Assistant Professor Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD
Patrick Maher, MD
Assistant Professor, Emergency Medicine and Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY
Emily Taub, MD
Department of Emergency Medicine and Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY
Eric J. Morley, MD
Associate Professor, Clinical Director, Department of Emergency Medicine, Deputy Chief Medical Informatics Officer, Stony Brook Medicine, Stony Brook, NY
Bryan English, MD
Assistant Professor, Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, NY
David B. Cohen, MD, FACEP
Associate Professor, Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, NY
William F. Paolo, MD
Associate Professor, Residency Program Director, SUNY Upstate Medical University, Syracuse, NY

Peer Reviewers

Michael Gottlieb, MD
Assistant Professor, Department of Emergency Medicine, Director of Emergency Ultrasound, Rush University Medical Center, Chicago, IL
Bradley Shy, MD
Visiting Associate Professor, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Medical Director, Adult Emergency Department, Denver Health and Hospital Authority, Denver, CO
Dowin Boatright, MD, MBA, MHS
Assistant Professor, Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
Natalie Kreitzer, MD, MS
Assistant Professor of Emergency Medicine, Neurocritical Care, and Stroke, University of Cincinnati, Cincinnati, OH
Isaac Tawil, MD, FCCM
Associate Professor, Critical Care and Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
Jennifer Maccagnano, DO, FACOEP
Assistant Professor, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY; Emergency Medicine Attending Physician, Brookdale Hospital Medical Center and Maimonides Medical Center, Brooklyn, NY
Ashley Norse, MD, FACEP
Associate Chair of Operations, Department of Emergency Medicine, University of Florida Health Jacksonville, Jacksonville, FL

Product Details

Publication Date: May 1, 2020

CME Information: Included as part of the 12 credits, this CME activity is eligible for 4 Trauma CME and 4 Pharmacology CME credits, subject to your state and institutional approval. Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME. Credit Designation: EB Medicine designates this enduring material for a maximum of 12 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. High-Risk Cardiovascular Emergencies (Trauma CME and Pharmacology CME) is approved by the American College of Emergency Physicians for 12 hours of Category I credit per issue. High-Risk Cardiovascular Emergencies (Trauma CME and Pharmacology CME) has been reviewed and is acceptable for up to 12 Prescribed credits by the American Academy of Family Physicians. Credits may be claimed for one year from the date of the issue. High-Risk Cardiovascular Emergencies (Trauma CME and Pharmacology CME) is eligible for 12 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.

Table of Contents

Course 1: Management of Non–ST-Segment Elevation Myocardial Infarction

  1. Abstract
  2. Opening Cases
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
    3. Cardiac Monitoring
  9. Diagnostic Testing
    1. Electrocardiogram
      1. ST-Segment Elevations
      2. ST-Segment Depressions
      3. Wellens Syndrome
      4. Left Bundle Branch Block and Sgarbossa Criteria
      5. de Winter Pattern
      6. Left Main Pattern
    2. Troponin
      1. High-Sensitivity Troponin
    3. Risk Stratification
    4. Imaging Studies
  10. Treatment
    1. Anti-Ischemic Therapies
      1. Supplemental Oxygen
      2. Analgesia
    2. Antiplatelet Therapies
    3. Anticoagulant Therapies
    4. Beta Blockers
    5. Statins
    6. Ischemia-Guided Strategy Versus Early-Invasive Management Strategy
  11. Special Populations
    1. Women Patients
    2. Black Patients
    3. Young Patients
    4. Diabetic Patients
    5. Cocaine-Associated Myocardial Infarction
  12. Controversies and Cutting Edge
    1. Copeptin as a Biomarker for Acute Coronary Syndromes
  13. Disposition
  14. Summary
  15. Time- and Cost-Effective Strategies
  16. Risk Management Pitfalls for Management of NSTEMI in the Emergency Department
  17. Case Conclusions
  18. Clinical Pathways
    1. Clinical Pathway for Risk Stratification for STEMI and NSTEMI in the Emergency Department
    2. Clinical Pathway for Management of NSTEMI in the Emergency Department
  19. Tables and Figures
    1. Table 1. American Heart Association/ American College of Cardiology Classes of Recommendation and Levels of Evidence
    2. Table 2. Clinical Features of Type 1 and Type 2 Myocardial Infarction
    3. Table 3. Differential Diagnosis of Chest Pain
    4. Table 4. Sgarbossa Criteria
    5. Table 5. HEART Score for Suspected Acute Coronary Syndromes
    6. Figure 1. Anterior STEMI on Electrocardiogram
    7. Figure 2. ST Depressions
    8. Figure 3. Wellens Pattern
    9. Figure 4. Sgarbossa Criteria
    10. Figure 5. Modified Sgarbossa Criteria
    11. Figure 6. The de Winter Pattern
    12. Figure 7. Left Main Pattern
  20. References

Course 2: Management of Patients Taking Direct Oral Anticoagulant Agents

  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Pathophysiology
  6. Mechanisms and Comparison of Direct Oral Anticoagulants
    1. Direct Thrombin Inhibitor
    2. Factor Xa Inhibitors
      1. Rivaroxaban
      2. Apixaban
      3. Edoxaban
      4. Betrixaban
  7. Prehospital Care
  8. Emergency Department Evaluation
  9. Diagnostic Studies
    1. Imaging Studies
      1. Computed Tomography
      2. Ultrasound
    2. Laboratory Studies
      1. General Testing
      2. Prothrombin Time/ International Normalized Ratio and Partial Thromboplastin Time
      3. Anti-Factor Xa Activity Levels
      4. Thrombin Time
      5. Ecarin Clotting Time
  10. Treatment
    1. General Principles
    2. Specific Reversal Agents
      1. Idarucizumab
      2. Coagulation Factor Xa (Recombinant), Inactivated-zhzo (Andexanet Alfa)
    3. Nonspecific Reversal Agents
      1. Prothrombin Complex Concentrate
      2. Activated PCC (Factor VIII Inhibitor Bypassing Activity)
      3. Recombinant Factor VIIa (rFVIIa)
      4. Fresh-Frozen Plasma
    4. Adjunct Therapies
      1. Activated Charcoal for Oral Agents
      2. Tranexamic Acid
      3. Vitamin K
      4. Hematology Consultation/Transfer
  11. Special Circumstances/Populations
    1. Patients With Valvular Disease
    2. Pregnant, Breastfeeding, and Pediatric Patients
    3. Patients With Renal Impairment
  12. Controversies and Cutting Edge
    1. Treatment of Ischemic Stroke in Patients Taking Direct Oral Anticoagulants
    2. Scoring Systems for Bleeding Risk
    3. Hemodialysis for Dabigatran Removal
    4. Viscoelastic Testing
    5. Ciraparantag
  13. Disposition
    1. Patients Currently Taking Direct Oral Anticoagulants
    2. Emergency Department Initiation of Direct Oral Anticoagulants
  14. Summary
  15. Risk Management Pitfalls for Patients Taking Direct Oral Anticoagulant Agents
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway for Management of Hemorrhage in Patients Taking Direct Oral Anticoagulant Agents
  19. Tables and Figures
    1. Table 1. Comparison of Pharmacokinetics/Pharmacodynamics of Direct Oral Anticoagulant Agents
    2. Table 2. Key Elements From the History and Physical Examination of Patients on Direct Oral Anticoagulant Agents
    3. Table 3. Scoring Systems for Bleeding Risk
    4. Figure 1. Clotting Factor Cascade and Site of Action of Oral Anticoagulant Agents
  20. References

 

Course 3: Diagnosis and Management of Blunt Cardiac Injury

  1. Abstract
  2. Case Presentation
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Epidemiology
  6. Differential Diagnosis
    1. Cardiac Wall Rupture
    2. Septal Injuries
    3. Valvular Injuries
    4. Coronary Artery Injury
    5. Pericardial Injury
    6. Dysrhythmias
    7. Conduction Blocks
    8. Commotio Cordis
    9. Myocardial Contusion
    10. Aortic Root Injuries
  7. Prehospital Care
    1. Hospital Destination
    2. Level of Care
    3. Providing Comfort and Alleviating Pain During Transport to the Emergency Department
    4. Rapid Identification of Blunt Cardiac Injury With Ultrasound
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Laboratory Testing
    2. Electrocardiogram
    3. Electrocardiogram and Troponin Testing
    4. Chest X-Ray
    5. Focused Assessment With Sonography in Trauma (FAST) Examination
    6. Computed Tomography
    7. Echocardiogram
  10. Treatment
    1. Transfusion and Fluids
    2. Operative Management
    3. Dysrhythmia
    4. Myocardial Infarction
    5. Pain Management Strategies
  11. Special Circumstances
    1. Sternal Fractures
  12. Controversies and Cutting Edge
    1. Advanced Cardiac Imaging
  13. Disposition
    1. Emergent Transfer to the Operating Room
    2. Admission for Observation
  14. Discharge
  15. Summary
  16. Risk Management Pitfalls in Blunt Chest Trauma
  17. Time- and Cost-Effective Strategies
  18. Case Conclusions
  19. Clinical Pathway for Management of Emergency Department Patients With Suspected Blunt Cardiac Injury
  20. Tables and Figures
    1. Table 1. Eastern Association for the Surgery of Trauma – Levels of Recommendation
    2. Table 2. Differential Diagnosis of Chest Pain Following Blunt Chest Trauma
    3. Table 3. Physical Examination Findings in Blunt Cardiac Injury
    4. Figure 1. Pericardial Effusion on Chest X-Ray
    5. Figure 2. Pericardial Effusion on Ultrasound and Noncontrast Chest Computed Tomography
    6. Figure 3. Sternal Fracture and Myocardial Contusion on Magnetic Resonance Imaging
  21. References

 

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