Would you choose adenosine?

Comparing adenosine to calcium channel blockers in the management of SVT

Hi sir. My name is Dr. Morgenstern. That racing feeling in your chest… it’s something we call SVT. That just means that you heart is going too fast. I’m going to get it slowed down for you. All that silly stuff we just did – getting you to blow in a syringe and raising your legs above your head – that sometimes works, but honestly, I have never seen it work myself. It’s time to stop asking you to “bear down” and move on to using medications to slow your heart down. Right now, your blood pressure is fine and you have no other problems, so we have a few options.

Option number one is a medication that works about 90% of the time, but it causes a horrible feeling when it is given. Some people describe it as chest pain. Others say is feels like they are going to die. Most people tell me it is the worst thing they have ever experienced.

Option number two is a medication that works closer to 100% of the time and doesn’t cause any pain at all.

Which would you prefer?

Continue reading “Would you choose adenosine?”

Embedding decision tools into the electronic record

Last week I picked up a chart at work. It was a 25 year old woman who had sneezed very hard and developed some right sided rib pain. She had waited about 2 hours to see me after being sent in from a walk in clinic with a note asking me to “rule out PE” because the pain was, unsurprisingly, pleuritic. She had normal vital signs. She had an x ray done at the walk in clinic that ruled out pneumothorax. She had no history of or risk factors for VTE. She had a Well’s score of 0. She was PERC negative. Continue reading “Embedding decision tools into the electronic record”

Interventional therapy for acute ischemic stroke: the evidence

A summary of the evidence for endovascular therapy in stroke

In part 2 of our EM Cases Journal Jam, we explored the literature looking at endovascular therapy for acute ischemic stroke. (Part 1 on the evidence for thrombolytics can be found here.) The studies of interventional therapy for stroke tend to get broken down into the early (negative) studies and the later (positive) studies. For consistency, I’ll use the same break down. Continue reading “Interventional therapy for acute ischemic stroke: the evidence”

Thrombolytics for stroke: The evidence

A summary of the evidence for (or against) thrombolytics for stroke

Thrombolytics for stroke: undoubtedly the biggest controversy in emergency medicine. Also, the topic of this week’s Emergency Medicine Cases Journal Jam podcast. Rory Spiegel, Anton Helman, and I take a deep dive into the evidence. Why would we do this? No, it isn’t just that we have too much time on our hands. The journal jam podcast exists because we truly believe it is important to understand why we do what we do, both to ensure we are always providing the best care for our patients, but also so that we can explain that care to our patients. The evidence for (or against) thrombolytics is important precisely because the topic is so controversial. You will hear arguments on both sides. So will your patients. It is only through a familiarity with the studies, their strengths, and their weaknesses, that you will be able to decide for yourself what the evidence really shows and guide your patients to the best decision for their circumstances.

What follows are the notes I made while preparing for the podcast. First, I review the major randomized controlled trials looking at thrombolytics for stroke. That is followed by a discussion of the things I think are important to consider when trying to interpret this data. (Many folks might want to skip straight to this discussion section.) Continue reading “Thrombolytics for stroke: The evidence”

Quick PESIT update

By now, everyone has (unfortunately) heard about the PESIT trial. Given the many commentaries in the FOAM community, we are all familiar with the many reasons that the widely quoted 1 in 6 figure probably does not apply to our patients. If you need a reminder, I summarize the paper as part of this post, or you can read a more elegant post by Rory Spiegel here. For me, the biggest issue was that PESIT never passed the sniff test. We see a ton of syncope patients. There are massive syncope databases. And nowhere have we seen massive numbers of patients returning with PE.

A research letter was just published yesterday in JAMA that gives us another take on the issue: Continue reading “Quick PESIT update”

Ultrasound for pediatric forearm fractures (SGEM HOP)

The most recent episode of the SGEM hot of the press series came out today. The article we reviewed was looking at the utility of point of care ultrasound in pediatric forearm fractures:

Poonai N, Myslik F, Joubert G et al. Point-of-care Ultrasound for Nonangulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes. Acad Emerg Med. 2017. Continue reading “Ultrasound for pediatric forearm fractures (SGEM HOP)”

The Ottawa heart failure risk scale

A new episode of the SGEM hot off the press just went up. Ken and I spoke to Ian Stiell about his Ottawa heart failure risk scale.

Reference: Stiell et al. Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative NT-proBNP. AEM March 2017

Continue reading “The Ottawa heart failure risk scale”