First in a series of presentations for medical students going into Emergency Medicine and interns starting out on the cardinal presentations. A must study before your rotation!!
Download the PDF show notes here!
Journal Club Podcast for April 20
Abscesses: Lancing the myths! This podcast and the journal club answer the following questions:
Irrigate and abscess: yes or no?
Pack an abscess: yes or no?
Antibiotics for an abscess: yes or no?
Ultrasound an abscess: yes or no?
Inject lido or lido/tetra patch: which is better?
With the usual tangential flight of ideas that accompanies these ‘casts – such as what was buffered lidocaine and why don’t we bother using it anymore?
Here are the articles – at the end is the study by Jerry Hoffman (okay so it was an abstract) that showed that buffered lidocaine was not worth much to the patient.
Talan DA et al. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess N Engl J Med. 2016 Mar 3;374(9):823-832.
Alsaawi et al. Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: a systematic review of the literature. Eur J Emerg Med 2015
Tornay et al Heated versus buffered lidocaine and the pain on local injection: A comparative study Annals of Emergency Medicine 1994 , Vol. 23, Issue 3, p629
Small study that showed most patients would not pay $2 for buffered lidocaine. “Heating a solution of lidocaine with epinephrine reduces the pain of local injection, but buffering with bicarbonate is more effective in this regard. The value of this difference to the patient may be minimal”
Electrical Storm aka Refractory V Tach by Dr Rachel Wenzel Drexel EM3
Be a stud med student in 3 mins! Guaranteed!
Tips on EM presentations skills
Michael Pasirstein MD
Why
Students have already had a few years of being taught by other departments how to do an oral presentation, but it may not be applicable to EM.
Majority of the student and resident educational interactions with attending physicians in EM occur during oral presentation.
Student evaluation is directly linked to how well the student presents.
About the article
The authors are using their success to assist learners present all pertinent information in under 4 minutes
History of the Oral presentation
Earliest mention of the oral presentation is from the dean of the New Orleans Medical School, Erasmus Fenner, in 1846, though it seems intuitive that doctors and learners have been communicating with oral presentations much longer than about 200 years.
In 2003, the SNAPPS format of presentations was developed at Case Western Reserve University School of Medicine. This format was designed for outpatient oral presentations. The SNAPPS method focuses on
- brief patient summaries
- Narrowing DDx of 2-3 etiologies
- Analyzing information to determine the most likely cause of chief complaint
- Probing the attending for knowledge
- Planning pt management
- Selecting an issue for self-directed learning
Students noted that:
Effective presenters alter the way they present but had difficulty describing how, making it difficult for novices to mimic
EM
The origins of the oral presentation and the recent studies noted previously are not EM specific
In EM we:
- Assume every patient has an emergent condition
- Have multiple undifferentiated patients at once
- Prioritize patients
- Have incomplete patient data
EM Oral Presentations – How are we different?
- CC
- HPI
- Meds/allergies
- PE
- Summary statement
- Assessment and plan
What is minimized are
- PMHx,
- PSHx
- Soc Hx
- FmHx
- ROS
Essentially, the HPI should include all the pertinent information from those areas that are minimized.
Earlier learners will still have items that are positive in the ROS, as they may not be aware of what is pertinent and what is not.
To further improve speed, the student should include only pertinent positives and negatives on physical exam.
The 3 Minute Emergency Medicine Medical Student Presentation: A variation on a theme.
the-3-minute-emergency-medicine-medical-student-presentation-a-variation-on-a-theme-pdf-
K2 Krash
K2 Krash – what to do?
What is the K2 Krash – it’s the phenomenon of hypotension and bradycardia after a synthetic cannabinoid overdose. Typically an overdose with hypotension and bradycardia is a life-threatening phenomenon, for example calcium channel blockers and beta blockers. K2 crash seems to be less life-threatening and responds well to fluid resuscitation unlike other poisonings with the same cardiovascular effect.
I suggest you follow Leon Gussow’s tip on managing hypotension in overdoses – scan the IVC and fill up the tank until the respiratory collapse of the IVC is replaced with a plump IVC and then add pressors if needed or wait out the metabolism of the synthetic cannabinoid. Typically the clinical course of hypotension is less than six hours.
We do know that the K2 Krash is the result of stimulus of the CB1 receptor. We also know that endogenous cannabinoids are released by platelets and macrophages during sepsis. Whether they in fact have a protective effect remains to be seen, but they appear to result in vasodilation of the brain and coronary vasculature. Perhaps that’s why K2 Krash appears to be a relatively benign event once it resolves.
Here’s a great article on cannabinoid induced hypotension.
Cannabinoid-Induced Hypotension and Bradycardia J Pharmacol Exp Ther-1997-Lake-1030-7
A nice case series on synthetic cannabinoid overdoses – about half of which demonstrated bradycardia and hypotension. Synthetic Cannabinoid Abuse in Adolescents: A Case Series
Also a discussion on how synthetic cannabinoids play a role in sepsis. Platelet- and macrophage-derived endogenous cannabinoids are involved in endotoxin-induced hypotension
Enjoy and let me know what you think!
The Hot Stove League of EM/Tox 