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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.

My Head Hurts

35 y F presents to ED with sudden onset worst headache of life starting 3 hours ago.  Refractory to treatment with excedrin.  No history of Migraines.  Concern for SAH. What is your management algorithm to rule out SAH?  Do you CT/LP?

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Orthopedic Injuries

34 y M with right midfoot swelling and pain after injuring while playing football.  The patient describes a hyper-plantarflexion mechanism.  Physical exam notable for bruising to medial plantar foot and diffuse swelling to dorsal midfoot with tenderness to palpation.  XR is seen below:

Lisfranc No Arrows

What is the diagnosis?

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Exertional Syncope

23 y M presenting to ED with episode of syncope while playing soccer this afternoon.  Endorses preceding palpitations, but denies any associated CP/diaphoresis/n/v/sob.  EKG is as follows:

Arvd

What is the diagnosis?

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A Different Approach to Central Line Placement

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/

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Leslie Pendery, MD


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