6.6.19 Conference Summary

EM/IM Conference: Atrial Fibrillation with RVR

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-EM: Dr. Colin McCloskey, EM/Intensivist-

  • Why do we care? associated with 2-5x increased risk of death

  • Primary vs reactive process (consider sepsis, ACS, electrolyte/endocrine)

  • Approach to management depends on the patient

    • Unstable —> synchronized cardioversion

      • 200 J, A-P pad placement, hemodynamically-neutral procedural sedation

    • Stable-ish but you’re worried —> amiodarone 150 bolus + infusion /digoxin  0.5mg + mag 4.5g

      • LOWMAGH- synergistic effect when mag added to AV nodal blockers (lower dose with fewer side effects)

    • Stable, >48 hrs or <48 hrs with follow up —> rate control +/- anticoagulation

      • AFFIRM & RACE trials demonstrated no survival benefit between rate vs rhythm control); rhythm control tended to be associated with more adverse effects

      • RACE-7 (wait & see vs early cardioversion —> wait & see approach not inferior to early cardioversion; most pts convert to sinus rhythm spontaneously

    • Stable, <48 hrs without follow up — chemical vs electrical cardio version +/- anticoagulation

  • Rate control agents

    • Diltiazem is faster

    • Avoid CCB if reduced EF or ACS

    • Avoid BB If asthma

  • Anticoagulation?

    • CHA2DS2-VASc score (afib stroke risk) vs HAS-BLED score for major bleeding risk


-IM: Dr. Joshua Clevenger, Cards Fellow-

  • Primary vs reactive process (there are many exacerbating/causative factors!!)

  • Acute management — stable vs unstable (vitals, EKG, mental status, perfusion)

    • Determine causative/exacerbating factors & address reversible ones

    • Cardiovert if unstable (200J)

    • Rate vs rhythm control (AFFIRM, RACE - see above)

  • Rate control agents

    • Beta blockers - rapid acting, titratable

      • Caution use if sick sinus syndrome, AV nodal delay, severe COPD, cariogenic shock, hypotension, recent cocaine use

      • If using IV metoprolol, dose q6-8 hrs (not q12)

    • Calcium channel blockers

      • Disadvantage: negative inotrope + chronotrope

      • Contraindicated in heart failure

    • Digoxin

      • Can be helpful with rate control in hypotensive pts but takes hours to work so less optimal for immediate effect

      • Contraindicated in AV nodal disease or for long use in pts with renal dysfunction

  • Rhythm control

    • Amiodarone

      • Many adverse effects, potentially causes long QT

      • Great post-CABG

  • Anticoagulation? - Look at risk factors for stroke/TIA, VTE - CHADS2VASc Score

    • Increased risk for stroke if lack of or inadequate anticoagulation

    • Warfarin - good efficacy but requires frequent monitoring

    • DOACs - consider high BMI when determining doses (are they being underdosed?)



Transition to Attendinghood - Dr. Sarah Tehranisa

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  • Supervision of residents

    • Each learns at a different pace

    • Elicit something they’re working on

    • Give more leniency as they progress

  • Supervision of APPs

    • Know local group/state laws and expectations

    • When in doubt, do more

    • It is ok to change plans

    • Ultimately, you are responsible

  • RVUs

    • Components of documentation

    • Exam complexity

    • Critical care time - starts at 30 minutes (anything less is level 5 visit)

      • Time performing procedures or CPR does NOT count (these are separately billable procedures)

    • Financial

      • Disability insurance

      • Loans

      • Retirement



Pregnancy in the Community - Dr. Sam Houng, PGY2

  • Transfer?

    • Emergency Medical Treatment and Active Labor Act (EMTALA)

      • Do not transfer if patient is unstable, delivery if imminent or there is inadequate time to safely transfer patient to another hospital before delivery, transfer puts mother or unborn child at risk

    • ACOG Committee Opinion - ensure stability of laboring pregnant pt and do not transfer if it poses a threat to mother/child

  • Labor

    • True labor

    • Show - discharge of mucous plug

    • Spontaneous ROM

    • Braxton-Hicks contractions - brief, irregular in timing

  • Evaluation of labor

    • Is this true labor? (vs Braxton hicks)

    • Abd exam, nitirazine test, POCUS - fetal lie (transverse generally unsafe for SVD)

    • Vaginal exam (effacement, station, dilation)

    • Fetal heart tracing - rate (normal HR 100-160), accels, early/late decels, variability

Cardinal movements of labor

  • Complications

    • Shoulder dystocia

      • Attempt McRoberts, suprapubic pressure, Wood’s screw maneuver, posterior shoulder delivery, etc.

    • Breech presentation

      • Attempt delivering posterior hip then anterior hip

      • Consider episiotomy

    • Postpartum hemorrhage (atony, GU trauma most common)

      • Fundal massage, uterotonics, blood products as indicated

    • Cord prolapse

      • Elevate presenting part, place knee-chest or deep Trendelenberg, avoid cord manipulation

      • Emergent c-section if possible

    • Third trimester bleeding

      • Placental abruption, placenta previa, vasa previa

    • Uterine inversion

  • Perimortum c-section

  • Newborn evaluation - within 1st 60 sec ( “golden minute”)

    • Dry, warm, position, suction, ABCs, etc.


Pediatric Headache in the ED

- Dr. Steve Steiner, Peds Neurologist Akron Children’s

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  • TIming is key in obtaining history

    • Acute recurrent and chronic progressive tend to be more concerning

    • Chronic non-progressive - tend to be less concerning

    • New daily persistent

  • Primary vs secondary headaches

    • Primary - migraine, tension, etc

      • Stress, anxiety, sleep, skipping meals, etc

    • Secondary - often more serious

      • Infection, Inflammatory, vascular, mass, increased ICP

  • Red flags

    • Progressive pattern

    • Sudden onset

    • Increased with straining/coughing/sneezing

    • Systemic sx

    • Secondary risk factors: immunosuppressed, hypercoagulable state, genetic/rheum/neurocutaneous disorder, etc

    • Neurologic signs/sx

    • New or different headache

    • Sleep-related (i.e. worse in morning)

    • Age ≤ 5 yrs

  • Comprehensive neuro exam

    • Mentation, cranial nerves (extraocular movements, visual fields, fundoycopic exam, symmetry), motor (strength, flex neck), sensory, reflexes, cerebellar, gait, nystagmus (>3 beats is abnormal)

  • If concerned about badness?

    • CT vs MRI

      • CT - rapidly assess for blood, mass effect

      • MRI - much more sensitive - inflammation, structural lesion, stroke, clot, vascular anomaly

    • LP

  • Management is etiology-dependent. Ensure patient stability. Follow institution protocols