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.

Management of Traumatic Subarachnoid Hemorrhage

Prioritization of following steps is based on individual patient needs:

1. Assess stability
- stabilize
- neuroprotective intubation as needed

2. Determine secondary damage
- neuro exam, including GCS
- CT scan

3. Treat (may begin simultaneously with 1 and 2)
- reverse anticoagulation as necessary
- prevent potential seizures
- minimize cerebral edema
- normocapnic, normothermic, normotensive, normovolemic, normal oxygenation
- minimize sympathetic surge
- may need ICP (CPP) monitoring (remember CPP = MAP – ICP)

Some pointers:
Hypertonic saline is preferred to mannitol
Hyperventilation is no longer a mainstay therapy unless the patient is hypercapnic or herniating
Elevate the head of the bed to 1/2 the length of the head of the bed (or 30 degrees)
Consider high dose barbiturates or fentanyl/propofol for inducing a medical coma, intubating where necessary

Haddad and Arabi. Critical care management of severe traumatic brain injury in adults. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:12
Peds Neuroprotective Strategies

 

Medical Statistics – a Primer on Concepts

Medical statistics review (assuming some basic familiarity):

Mean (average), median (middle number), mode (most common number)

Sensitivity and specificity depend on a specific, pre-determined test. Also, they do NOT depend on prevalence of the condition being tested for.
Positive predictive value and negative predictive value depend on the prevalence of the condition being tested for.

Odds ratio: People who have A,B,C are x times more or less likely to have a certain condition/outcome.
Relative risk: People who have A,B,C are x times more or less at risk to have a certain condition/outcome.
The key difference is that relative risk depends on the prevalence of the condition/outcome. In the situation that the condition/outcome is rare, odds ratio and relative risk approach equivalence.

Equations and examples of these and more medically relevant statistical concepts. 

Continue reading “Medical Statistics – a Primer on Concepts” »

The Normotensive Pulmonary Embolism Patient

Early death (within 7-30 days) in PE patients is concerning. It is relatively easy to identify high-risk PE patients, defined by abnormal vitals SBP < 90 or drop in SBP by 40 for at least 5 min.

Normotensive patients with poor prognostic indicators include (statistically significant odds ratios):
- SBP between 90-100 (OR 2.45)
- HR > 110 (OR 1.87)
- elevated cardiac enzymes (OR 2.49)
- RV dysfunction (abnormal RV function on echo or RV dilation on echo or CT) (2.28)

Patients who have biomarkers for heart strain and RV dysfunction may benefit from some form of interventional therapy:
- lower (half) dose fibrinolytic therapy for patients < 75 years of age
- local, catheter-delivered, ultrasound-assisted thrombolysis

Other things to note:
- intubation increases intrathoracic pressure, which may decrease venous return and further worsen R sided dysfunction
- extracorporeal membrane oxygenation can help temporize heart and lung collapse where available but is not definitive management
- heparin is still mainline therapy for normotensive patients with PE but without any indications of RV dysfunction or no elevated biomarkers

Sanchez O, Planquette B, Meyer G. Management of massive and submassive pulmonary embolism: focus on recent randomized trials. Curr Opin Pulm Med. 2014 Jul 15.

Criteria for St Segment Elevation

Different criteria exist based on gender, age, and ethnicity:

- new 1 mm of STE in 2 contiguous leads except for V2-V3
- 2 mm of STE in V2-V3 in men > or = 40
- 2.5 mm of STE in V2-V3 in men < 40
- 1.5 mm STE in V2-V3 in women
- strongly consider serial EKG with chest pain patients

many examples of STEMIs and non-STEMIs

Circulation.2009; 119: e241-e250Published online before print February 19, 2009,doi: 10.1161/​CIRCULATIONAHA.108.191096 (details differences w/ ethnicity)
Am Heart J. 2013 Jan;165(1):50-6. doi: 10.1016/j.ahj.2012.10.027. Epub 2012 Nov 21.  (evidence for serial EKGs)

Young Female with Hemoptysis

A 24 year old female from Europe presents with progressive shortness of breath and hemoptysis. O2 sat is 94%. CXR is clear. PSH includes silicone implants in gluteal area. Meds include OCPs. Travel from Eastern Europe 2 months ago. D-dimer is negative. CTA is negative for embolus. What is the diagnosis?

Continue reading “Young Female with Hemoptysis” »


Archives

Categories