Our first interview date of the season is fast approaching - October 23.  We are excited and gearing up for interview season! 

Here are a few highlights of recent resident involvement in national organizations:

• Geoffrey Froehlich, MD is our EMRA Program Representative
• Curtis Knight, MD is our AAEM Vice President's Council Representative
• Kathryn Voss, MD is our DC ACEP Representative
• Jessica Shackman, MD is serving as an SAEM abstract reviewer this year.

MEP at ACEP:

• Oct 15: Our ACEP program dinner in Seattle!

Courses

• Oct 16:  WE-214 Suppressed and Depressed: Immunosuppressants and Immunomodulators in the ED (10:00 AM - 10:50 AM) Faculty: Kevin C. Reed, MD, FACEP
• Oct 16:  WE-237 Aortic Dissection (01:30 PM - 01:55 PM) Faculty: Kevin C. Reed, MD, FACEP
• Oct 17:  TH-277 Antibiotic Abyss (08:00 AM - 08:50 AM) Faculty: Kevin C. Reed, MD, FACEP
• Oct 17:  TH-287 Half-Baked: Emergencies in the Second Trimester of Pregnancy (09:00 AM - 09:50 AM) Faculty: Joelle Borhart, MD
• Oct 17:  TH-326 Third Trimester and Postpartum Disasters (12:00 PM - 01:00 PM) Faculty: Joelle Borhart, MD

New Speaker’s Forum

• Oct 16:  "Traumatic Injuries of the hands and feet: Not always as simple as they seem"
  Seattle Convention Center, Room 2A
  (08:00a-11:00a, 10 minute talk, specific time within the morning session TBD) Faculty: Liz Delasobera, MD

ACEP Research Forum

• Oct 14:  Emergency Department crowding and physician inexperience are synergistically associated with increased physician errors.  (10:45a - 11:45a) Poster 127.  Faculty: Jeffrey Dubin, MD and David Milzman, MD.
• Oct 15:  The effect of emergency department crowding and time of day upon the adherence to early goal directed therapy. (2:30p - 3:30p) Poster 395.  Faculty: Anish Agarwal, MD and Munish Goyal, MD.

Our residents hard at work at the Jay-Z and Justin Timberlake Concert!

Blunt Chest Trauma                                                                              Laura Johnson, MD

• Respect rib fractures in the elderly.  A 2003 study in J Trauma, showed 19.5% vs 9.3% mortality in those age 65 years or older compared to adults less than 65.
• Remember your indications for an urgent thoracotomy:  initial chest tube volume >1500mL, 200mL/hr output over 4 hours, and a massive air leak.
• Blunt Cardiac injury: a normal ECG and troponin I has a NPV of 100%.  If you are concerned for blunt cardiac injury and there is an abnormal ECG or troponin I, admit with telemetry.  2012 EAST Guidelines

Diseases of the Biliary Tract                                                                        Carolyn Phillips, MD

• US has the highest sensitivity for cholelithiasis (compared to CT and MRI), although HIDA has the highest sensitivity to diagnose cholecystitis.
• If a patient with pancreatitis has three or more of Ranson's Criteria consider ICU placement (age >55, WBC >16, glucose >200, AST >250, and LDH >350)

Cardiac Arrest                                                                                                Munish Goyal, MD

Answers at bottom of newsletter

1. A 41 yo female brought in by EMS develops ventricular fibrillation during your initial assessment.  What intervention is most likely to favorably alter her outcome?

   A. Rapid intubation
   B. Effective chest compressions
   C. Defibrillation
   D. IV Vasopressin, epinephrine and methylprednisolone
   E. IV epinephrine

2. A 62 yo male is brought in by EMS in PEA.  The patient is intubated but has not received any medications.  You believe the patient requires a dose of epinephrine.  The best choice is:

   A. 1mg epinephrine IV because it is currently standard of care
   B. 5mg epinephrine IV because more patients get ROSC
   C. 1mg epinephrine IV because it increases survival to hospital discharge
   D. 5mg epinephrine IV because it increases neurologic function
   E. 1mg epinephrine plus 20 IU vasopressin because favorable data in OHCA

An 18yo M with no PMH presents to your ED after having passed out when going up for a lay-up in a basketball game.  He denies recent illness, palpitations, or prior syncopal episode.  In your ED he has no complaints, reporting that he is now feeling normal.

Vitals: T98.4, HR 82, BP 118/72, R 15, RA sat 100%

Exam: He has an unremarkable exam with a normal neurologic exam.  Cardiac examination is normal with no murmurs (both with standing and squatting), rubs, or gallops.

You get the above ECG.  What is your diagnosis?

Thank you Dr. Dave Carlberg and Dr. Kayla Dewey for this presentation

ULTRASOUND REVIEW

You see a 19yo previously healthy G1P0 female with leg swelling, exertional dyspnea, and vaginal bleeding.  She reports vaginal bleeding for 3 months and a positive urine pregnancy test in June with her last menstrual period in late May.  She now has 2 days of lower extremity swelling and dyspnea on exertion.  

Vitals: T98.3, HR 85, BP 153/93, R16, RA sat 99%

Exam: pale appearing. Lungs clear. Heart rapid rate, regular rhythm, no murmurs.  Gravid uterus. Trace bilateral lower extremity edema.

Laboratory Data:
CBC 6>8/25<172
Urine pregnancy test: negative
Serum beta-HCG: >400,000

What is your diagnosis?

Click here to review the US images and make your final diagnosis.

Dr. Michael Ybarra and Dr. Alexander Kheradi meet with Rep. Diane Black (R, TN-6) at AAEM Advocacy Day 2013.

Cardiac Arrest Question Answers

1. Answer - C.  Defibrillation is the most important intervention in a patient who develops VF in front of you.  Time to defibrillation is directly associated with ROSC.  Intubation is not indicated in this patient in the initial phase and may lead to delays to defibrillation and decreased "time on the chest" performing chest compressions, if defibrillation fails.  Chest compressions are important, however, rapid defibrillation is the most important initial intervention.  IV vasopressors are indicated if defibrillation fails.  Current standard of care is IV epinephrine, although the vasopressin, epinephrine, and methylprednisolone combination is intriguing. It has only been studied in IHCA in a limited patient population in Greece; therefore, is of unclear benefit in our patient population.
2. Answer - A.  Current standard of care is 1mg IV epinephrine.  Intravenous epinephrine increases rates of ROSC, likely by increasing afterload, therefore, coronary perfusion pressure.  However, it also causes tissue-level hypoperfusion and may worsen cerebral ischemia.  High dose epinephrine is associated with increased rates of ROSC, however, no change in rates of survival to hospital discharge or survival neurologically intact.  Although the vasopressin, epinephrine, and methylprednisolone combination is intriguing, it has only been studied in IHCA in a limited patient population in Greece; therefore, is of unclear benefit in our patient population.