Congratulations to Dr. Mike Ybarra - the 2014 American Academy of Emergency Medicine National Young Educator of the Year!  

Resident and faculty oral presentations at the Mid-Atlantic SAEM in February:

1. Khan T, Kappler S, Pittman M, Pate J.  Sickle Cell Disease in the Adult Emergency Department:  A Structured Protocol to Improve Pain Control and Length of Stay for Vaso-Occlusive Pain Crises.  SAEM Mid-Atlantic Regional Conference, Philadelphia, PA.
2. Dall T, Tainsh V, Tefera E, Goyal M.  Initial Cardiac Rhythm and Pulse on ED Arrival is Associated with Survival Rates in Patients Who Suffer Out of Hospital Cardiac Arrest.  SAEM Mid-Atlantic Regional conference, Philadelphia, PA

Congratulations to our faculty for their upcoming CORD presentations:

1. Love JN, Smith J, Weizberg M,  Doty C, Garra G, Avegno J, Howell JM.  The Council of Emergency Medicine Residency Directors Standardized Letter of Recommendation:  Program Directors Perspective.  Council of Emergency Medicine Residency Directors, Academic Assembly, New Orleans, LA.  March 2014. 
2. Bhat R, Graham A, Davis J, Maloy K.  The Milestones Dashboard-A Novel tool for Resident Evaluation and Amalgamation of Milestones.  Council of Emergency Medicine Residency Directors, New Orleans, LA.  March 2014.
3. Bhat R, Garg, M, Goyal N, Levine B, Oyama L, Broder J, Omron R, Visconti A, Takenaka K, Park Y.  Predictors of Success in EM Residency: A multicenter Study.  Council of Emergency Medicine Residency Directors, New Orleans, LA.  March 2014.
4. Doty C, Roppolo L, Seamon J, Willis J, Asher S, Taft S, Graham A, Bhat R.   How Does Your EM Program Structure Your Clinical Competency Committee?  Council of Emergency Medicine Residency Directors, New Orleans, LA.  March 2014.
5. Kitaura J, Lane DR.  A Formal Mentorship Program Improves Quality and Access.  Council of Emergency Medicine Residency Directors, New Orleans, LA.

Winter Retreat Skiing

Intimate Partner Violence: Strangulation                            Heather Devore, MD

• Ask often.  68% have no symptoms; 50% have no external signs
• Five questions to ask:

1. Trouble breathing? Assess risk of delayed airway compromise
2. Cough or change in voice? Assess for underlying structural injuries
3. LOC or near LOC? Assess compromise of blood flow to brain
4. Bowel/bladder incontinency? Objective indicator of asphyxia
5. Sense of doom? Assess extent of strangulation

• Mild symptoms: Observe at home (if someone else at home) or 4-vessel CTA
• Moderate symptoms: 4-vessel CTA.  Positive: Admit to trauma.  Negative: observe 4 hours in ED.
• High risk: Admit to trauma

Oncologic Fever                                                            Jeffrey Dubin, MD

• Neutropenia = ANC < 500
• If febrile: Blood/urine cultures, UA, CXR, CBC, BMP and others as indicated
• Low risk patients can be managed at home: MASCC Score greater than or equal to 21.
• Treatment: Ceftazidime (or equivalent).  Add Vancomycin if suspect gram positive.  Consider Clindamycin for anaerobic coverage.

Third Trimester Disasters: Preeclampsia                            Joelle Borhart, MD

• Preeclampsia: BP>140/90.  
• Proteinuria no longer needed if other signs of end organ damage.  Absence of ketones on UA only has 34% negative predictive value.
• Edema is also no longer part of the formal definition
• Control of BP: Goal is to stabilize at 140/90.  No single agent is superior according to a 2013 Cochrane Review
• Severe preeclampsia (BP>160/110, platelet <100k, Cr>1.1, LFTs>2x normal, HA, epigastric/RUQ pain, oliguria, pulmonary edema): Seizure prophylaxis with Magnesium Sulfate.  2010 Cochrane Review
• Steroids for fetal lung maturity if between 24 and 34 weeks: betamethasone or dexamethasone

This is a 57 year old woman with history of HTN and smoking who presented to the ED with intermittent anterior chest pain for several days, now worsening over the course of several hours.  She also had nausea, SOB, and diaphoresis.

What would you do?  Click here to see what happened

Thank you Dr. Jonathan Davis for providing this interesting case and Dr. David Hager for the review!

ULTRASOUND REVIEW

A 61yo F with no previous medical history, presents with chest pain:  two episodes of chest pressure, nonradiating, pain is pleuritic, triggered by walking/exertion and relieved with rest.  Associated palpitations, shortness of breath.
 

Vitals: T 36.1    HR 103    BP 119/65    O2 99% on RA 

Exam: Mild distress noted. Lungs clear. Heart with irregular rhythm, diastolic murmur. Abdomen nontender. 2+ lower extremity edema bilaterally.

ECG: irregular rhythm, new T wave inversions in inferior and lateral leads.

Initial concern for acute coronary syndrome with new onset arrhythmia.  Later, bedside ultrasound performed to investigate potential causes for diastolic murmur, chest pain.  Bedside ECHO shown in following slides, performed by Drs. Alex Shuster and Kerri Layman

Click here for further images and a review of the technique

Thank you Dr. Brianne Steele, Ultrasound Fellow, for this presentation!