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”

D-dimer for aortic dissection: the evidence

An overview of the evidence for D-dimer use in the diagnosis of aortic disection

I am really excited to announce that we are starting a new format on the EMCases Journal Jam podcast series. The plan is to take important questions about everyday clinical practice and do a deep dive into the literature to provide you with the most evidence based answer we can come up with. Most importantly, we are adding new (or, I suppose you might argue, our first ever) talent to the series: the brilliant @EMNerd_ himself, Dr. Rory Spiegel!

The first episode has just gone live. Our question: Is there a role for D-dimer testing in the workup of aortic dissection in the emergency department? I would suggest the podcast as the more entertaining and succinct way to get an answer, but because of time restraints and our desire not to bore you to death, we did not discuss every single study in the podcast. What follows are my notes for the podcast – a brief review of all the original literature I could find on the topic, arranged by year of publication. Continue reading “D-dimer for aortic dissection: the evidence”