Welcome to the Mount Sinai Emergency Medicine Residency Website.

Here you will find information regarding rotation schedules, academic resources, wellness and facts about our program and residents. Check out our bios and photos. Please also visit the Emergency Department's official residency website. This site is intended for Mount Sinai EM residency purposes only, and no information on these pages is intended or should be construed as medical advice. Read more.

A Modified Valsalva for Svt

Although clinical practice may differ, vagal maneuvers are still the first step in attempting to convert supraventricular tachycardia (SVT) to sinus rhythm prior to adenosine. The reason why they are rarely attempted is because of relatively low (5-20%) success rates.

A recent study published in The Lancet describes a method of Valsalva maneuver which has improved success rates significantly. In this study (the REVERT trial), 433 patients presenting with SVT (AVNRT or undetermined narrow complex tachycardia) were randomized to either performing their modified Valsalva or the standard Valsalva maneuver. Atrial fibrillation/flutter were excluded from the study.

The standard maneuver involved having the patient sit at 45 degree angle in the stretcher and to blow into a standard manual manometer tube at a pressure of 40mmHg for 15 seconds while on a cardiac monitor. The modified maneuver proceeded exactly the same as the standard maneuver, except after the patient’s Valsalva maneuver was completed patients were placed flat and their legs were raised at 45 degrees for an additional 15 seconds. This was designed to increased venous return during the relaxation phase of the vagal maneuver. Cardiac rhythms were checked 60 seconds later.

The results of the trial were positive. In the control group, only 17% converted to sinus rhythm. In the intervention group, 43% converted to sinus rhythm. As a result, significantly less adenosine was given in the intervention group. No serious adverse events were reported in either group, although the modified maneuver group did experience more non-serious adverse events than the control group (9 vs 21 including sinus tachycardia, PVCs, musculoskeletal pain, headache, shortness of breath). 86% patients were found to have AVNRT and 6-7% patients were noted to have undetermined narrow complex tachycardia. Of note, 6% of patients were found to have atrial flutter during their management, presumably because AF with 2:1 conduction is difficult to distinguish from AVNRT in the emergency department.

The researchers go as far as to suggest that their modified Valsalva should be used a standard approach to SVT vagal maneuvers given the significant increase in conversion success rates and lack of apparent risk or cost involved.

For more information and a video showing the manometry setup and modified Valsalva maneuver check out http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61485-4/abstract (open access)


Appelboam A et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015. PMID 26314489


Arytenoid Cartilage Dislocation

Your patient with respiratory failure was successfully intubated and admitted to the MICU. Two weeks later he comes back to the ED complaining of persistent hoarse voice and dysphagia. He states he was extubated 1 week prior and was told his symptoms would resolve but they hadn’t. What could be going on?

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Serum Sickness

Serum sickness is an often overlooked entity when considering the differential diagnosis of a febrile patient. This is a brief overview on the history and management of a patient who presents with signs and symptoms of this disorder:

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We’ve Got a Pumper Here!

Hemostasis is an essential step in wound management. Most commonly, bleeding is caused by lacerated subdermal plexus and superficial veins which can be controlled with pressure alone. When lacerations are especially deep, an artery may also be affected. In these situations, special maneuvers are often necessary to obtain adequate hemostasis.

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Studying for Boards/inservice with Foam

By @benazan

Book Foam White

Free Open Access Medical education (FOAM) began as medium for accelerated knowledge translation of cutting edge medical knowledge and as a virtual community of practice for ED physicians. As it matures, it’s grown to include many excellent sources of core content material that can be used by residents to learn the basics of Emergency Medicine and yes, to study for boards and inservice exams.

Here are my recommendations for FOAM for inservice/board studying. Keep in mind that many of these resources are great material for longitudinal study and don’t work well for cramming. So start early. Remember spaced recall is KEY to retaining knowledge. The other caveat is that what is largely missing in the FOAM community is high quality board review questions. ALiEM and their Chief incubator are working on fixing that issue.


  • Individual Sources:
    • EM Basic – Great podcast for junior resident to get their feet wet with emergency medicine thinking. Great review sheets.
    • FOAMCastEntertaining, short blasts of core content, with a few board review questions from Rosh Review included accompanying blog posts.
    • CoreEM  – The new kid on the block, with great core content blog posts and podcasts.
    • EM Cases – Is a treasure trove of EM core content. A good place to start is their EM Cases Summaries.
    • emDocs  – An ever expanding series of high yield core content articles, with a review card style question bank to boot.
    • Stemlyns Blog and Podcast – A great mix of core review and advance topics from our friends from across the pond.
  • Content Aggregators / MOOCs:
    • ALiEMU – Offers a great material via it’s Capsules series focused on pharmacology and AIR series composed on monthly high yield FOAM topics with board review style questions
    • Foambase.org – A searchable database of FOAM resources organized by category, learner level, media type.
  • Review Card Based: 
    • EMupdates.com – 1412 board review “EMCards” on core content emergency medicine topics by Dr. Reuben Strayer. I know people who have downloaded them and put them in an idevice flashcard app.
    • BoringEM – In addition to being a great blog for core EM review, Dr. Brent Thoma has “Boring Cards” ~1000 core content review cards ready to download (need to download phone flashcard app)

FOAMish (free to EMRA members):

  • EMRAP – Fantastic core content podcast. Review sheets and, little known, 20 board review questions a month!
  • EMedHome – Great monthly free podcast by Amal Mattu (all topics) and access to many core topic review lectures.
  • EBMedicine.net –  Review articles on core EM topics with review/board questions at the end of each article.

Not FOAM but a great deals:

  • HippoEM – If you’re already a member of EMRA, you can get an even better deal than the regular ‘resident’ price, $189 per year with EMRA resident discount.


Disclosures: I, Dr. Benjamin Azan, take no money from any of the services/blogs/podcasts above. I am a founder of Foambase.org and also an assistant editor at aliem.com. FoamCAST was co-founded by a Sinai EM resident (Dr. Jeremy Faust). Dr. Reuben Strayer is an attending at a Mount Sinai Affiliate hospital. EB Medicine is a publication managed by Dr. Andy Jagoda, chair of the Mount Sinai Emergency department.


Greg Fernandez, MD