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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 Different Approach to Central Line Placementu

Today’s pearl comes to you directly from Dr. Reuben Strayer (emupdates.com) and I think is particularly applicable to resident learners.  The traditional teaching for CVC placement has involved needle puncture and stabilization of said needle followed by detaching the syringe and threading a wire.  Many, typically less experienced providers (i.e. residents), have a tendency to move the needle (even while attempting to keep it stable) while removing the ultrasound or while unscrewing the syringe.  This process often dislodges the needle making it impossible to threat the wire.  A technique that has been around for some time, but is underutilized, is the wire through catheter technique, which allows you to thread a catheter over the needle so that it remains stable inside the vein, rather than having to perform the more difficult task of stabilizing the needle.  The two techniques are demonstrated in the video attached to the link that follows.  Also, do not forget your confirmatory techniques, which are discussed in the video as well.  Without further ado, the soothing voice of Dr. Strayer.

http://emupdates.com/2015/07/11/a-better-central-line-technique-wire-through-catheter/

Post Cardiac Arrest Care

According to the American College of Cardiology(ACC), based on guidelines published this month, there is a shift in the post cardiac arrest care algorithm.  The prior guidelines from 2013 have a Class I recommendation for performing immediate heart catheterization for PCI for the management of comatose patients with STEMI after out of hospital cardiac arrest.  Prior to now there were no recommendations for post arrest patients who did not have STEMI.  The ACC guidelines now push for immediate catheterization for patient’s who do not have unfavorable resuscitation features (discussed in the table provided) after discussion with our cardiology colleagues.  This may drastically change post-arrest care as the majority of post-arrest patients do not have STEMI on EKG.  The data supporting catheterizing non-stemi post-arrest patients is more limited, but data suggests that about 25% of patient’s without STE will have an occlusion upon cath and about 60% will have significant obstructive lesions.  One study evaluating early invasive treatment in the management of non-stemi post-arrest patients found that there was better long term survival  (60% vs 40.4% [p = 0.005]) and a more favorable neurological outcome (60.0% vs 39.7% [p = 0.004]) when implementing the invasive strategy.

Read more at the following link:

http://rebelem.com/beyond-acls-cpr-cath-new-accaha-cardiac-arrest-algorithm/

Continue reading “Post Cardiac Arrest Care” »

I’ve Got a Lump

45 y  male with no known medical problems presents to the emergency department complaining of tender lump to left axillary region worsening over the last 2 days.  Pt notes that over the last 3 days he had also been having subjective fevers, chills, and HA.  Pt has never had similar issues in the past.  States that he did recently come to the Northeast after moving from Colorado.  On exam patient has stable vitals other than fever to 102.1.  Pt’s left axilla has tender, non-fluctuant, mass with surrounding erythema.    A picture of the axilla is shown below.

Bubonic Plague

 

What’s the diagnosis? Continue reading “I’ve Got a Lump” »

Do Less

A 4 y female arrives to ED accompanied by mother after witnessed mechanical fall off out of stroller (approximately 3.5 feet high) with head hitting linoleum floor.  Mom states that the child cried immediately afterwards and never experienced LOC.  Denies n/v.  Now acting normally.  Physical exam is remarkable only for a small, left parietal scalp hematoma, but no laceration.  Neurologic exam is WNL.  With the provided information what should be your next step?  Discharge home? Observe the patient? CT head?

Continue reading “Do Less” »

Respiratory Failure

As we all know, NiPPV is a well established practice and therapy of choice in patients with COPD and CHF exacerbations.  It is typically used in patients with hypercarbic respiratory failure.  But for those patients who come to the ED with pure hypoxemic respiratory failure (in say, someone with pneumonia) is there a better way to oxygenate them when standard nasal cannula isn’t doing the trick and you want to avoid intubation?  According to 2 recent studies high flow nasal cannula may provide the answer.  In comparing NiPPV to standard oxygen delivery therapy to high flow nasal cannula the intubation rates did not differ significantly, but appear to be lower in the high flow NC group.  Additionally, the 90 day mortality rate was significantly lower and ventilator free days were increased in the the high flow NC group compared to the other two.  The other benefit is that there was less patient discomfort in the high flow NC group.

It is important to note that high flow nasal cannula should probably only be thought of as a potential first line therapy for purely hypoxemic respiratory failure.   NPPV remains first line in hypercarbic respiratory failure.

To read these studies go to the following:

http://dx.doi.org/10.1056/NEJMoa1503326

http://dx.doi.org/10.1001/jama.2015.5213

 

Leslie Pendery, MD


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