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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.

Pittfalls in Dvt Management

You’re on your last patient of the day, starting to thinking about which type of sushi you’re going to order later, when the ultrasound comes back. Positive study, you were sure of it, after all, the patient had a hx of cancer and 3 days of progressive leg swelling and pain. He looked like this:

Red Leg Small

You start them on lovenox, admit and run off for sushi.

The next day, you get a call from the chairman, he says “remember that patient you admitted….” Oh Oh…

Continue reading “Pittfalls in Dvt Management” »

Mr. Clean Trial is Here….a Quick Swipe at It.

Question:

-In acute stroke, does the addition of intra-arterial management improve outcomes compared to usual care?

Methodes: 

-Multicenter, randomized, open-label (but blinded end points) in the Netherlands. 502 patients in 16 centers.

-Comparing: (comparing intra-arterial intervention within 6 hours + usual care) vs. usual care.

-Required a radiologically proven intracranial occlusion for study eligibility

-Intervention was arterial catheterization and delivery of a thrombolytic agent, mechanical thrombectomy, or both, within 6 hours (method left up to the interventionist)

-Approx 90% in each group got TPA (considered usual care in this trial).

Results: 

-The primary outcome was distribution of modified Rankin scale at 90 days. These favored the intervention group in all categories except death.

-Regarding patient who were functionally independent with Rankin score of 0-2, the was 32.6% in the intervention group  vs. 19.1% in the control group.

Mr. Clean

 

-There were no differences in serious adverse events during 90 follow up period between groups.

-HOWEVER, there was a significant difference in the number of symptomatic new strokes in a different territory than the original stroke within 90 days in the intervention group (5.6% in intervention group vs. 0.4% control group)

-Also, some have noted that the TPA only group did very poorly in this trial compared to NINDS and IMS-3, which could make the intervention group look artificially superior.

———————————————–

Now, it always comes down to, would you want this for yourself or a loved one? I’m sure you’ll want to read more to decide.

Further Reading:

Original Article:http://www.nejm.org/doi/full/10.1056/NEJMoa1411587#t=articleTop

Opinions and Summaries:

http://www.emlitofnote.com/2014/12/mr-clean-new-golden-age.html

http://stemlynsblog.org/jc-intra-arterial-treatment-stroke/

http://www.neuroicudoc.com/2014/11/the-mr-clean-trial-improved-outcomes.html

Watch the 2 minute NEJM summary video here:

http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMoa1411587&aid=NEJMoa1411587_attach_1&area=aop

Influenza is Here…how Do You Test for It?

Your 60 year old patient says he feels horrible. Fever, chills, body aches. His grandson has similar symptoms last week. His exam is significant for fever of 102, P105, 140/76, SpO2 97%,  upper respiratory congestion, with clear lungs, normal heart sounds and benign abdomen.

Your attending is concerned he has the flu, says: “Hey, lets test for it”. Do you know how to make that happen? From a logistic standpoint?

-The test to order is “Influenza DFA”

-You (the MD) needs to collect it. Go to the Peds side utility room and get a “Floq” swab from the counter and some Hank’s media from the refrigerator. It looks like this:

Img_3157

-Then you have to swab the patient’s nose. Have the patient blow their nose first (you don’t want mucus, you want cells). Take the swab out of the container, place it in their nose. Move straight back posteriorly about half way the distance to the ear until you feel hold up. Rotate the swab several times to get a good sample (about 10-15 seconds in the perfect world). The test is only as good as the sample, so stay in there as long as the patient will tolerate it.

Check out this short video for a demonstration:  https://www.youtube.com/watch?v=DVJNWefmHjE

-Then break the swab off into the Hank’s media. Give it to the patient’s nurse or label it and send it yourself.

-The test takes about 2 hours to come back -

During the Day -> 95% sensitivity 95% specificity against cultures as gold standard (reported by Mt. Sinai labs, although studies have show more like 70-100% and 80-100% sens/spec respectively for this type of test)

During the Night -> Lab will run a rapid test which supposedly has a sensitivity 92-98% and specificity 100% against cultures as gold standard (reported by Mt. Sinai labs, studies quote more like 65-55% sensitivity and 98% specificity). The lab will confirm in the morning with a official DFA if the rapid was negative.

Then the next question arises, what do I do with the information once it results…but let’s talk about that another day.

Further reading:

http://www.pemcincinnati.com/blog/rapid-flu-tests/

Ref:

Gavin, Patrick J., and Richard B. Thomson Jr. “Review of rapid diagnostic tests for influenza.” Clinical and Applied Immunology Reviews 4.3 (2004): 151-172.

 

Yet Another Scary Ekg Finding…

@JoePinero

As if there weren’t enough morphologies and subtleties in the EKG, here is another ekg finding that you should be aware of…

de Winter T-waves

  • 1-3 mm ST-depression upsloping at the J-point in the mid precordial leads leading to tall symmetric T-waves
  • No large studies on the topic
  • Several small case series show correlation with acute LAD occlusion

Continue reading “Yet Another Scary Ekg Finding…” »

Complex Regional Pain Syndrome

@JoePinero

50 yo M hx of NIDDM, recent left shoulder surgery x 4 mo ago for rotator cuff tear, currently presenting with left arm pain from shoulder to hand with swelling and tightness of the left hand and fingers.

Exam:

Well-appearing male holding his left arm at his side with obvious swelling to the hand with tense skin as appears below.
Hand 1

 

Continue reading “Complex Regional Pain Syndrome” »

Carl “Scooter” Mickman


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