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A quick overview of pneumothorax for the EM physician: the what, why, diagnosis, and treatment.
Joe Offenbacher, MD
Audrey Tse, MD
Tags: #pneumothorax #FOAMed
CoreEM Pulmonary Ultrasound Post
Bense L, Lewander R, Eklund G, et al. Nonsmoking, non-alpha 1-antitrypsin deficiency-induced emphysema in nonsmokers with healed spontaneous pneumothorax, identified by computed tomography of the lungs. Chest 1993; 103:433.
Bense L, Wiman LG, Hedenstierna G. Onset of symptoms in spontaneous pneumothorax: correlations to physical activity. Eur J Respir Dis 1987; 71:181.
Brown SGA, Ball EL, Perrin K, Asha SE, Braithwaite I, Egerton-Warburton D, Jones PG, Keijzers G, Kinnear FB, Kwan BCH, Lam KV, Lee YCG, Nowitz M, Read CA, Simpson G, Smith JA, Summers QA, Weatherall M, Beasley R; PSP Investigators. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020 Jan 30;382(5):405-415. doi: 10.1056/NEJMoa1910775. PMID: 31995686.
Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol 2013; 16:351.
Chan KK, Joo DA, McRae AD, et al. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev 2020; 7:CD013031.
Ebrahimi A, Yousefifard M, Mohammad Kazemi H, et al. Diagnostic Accuracy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffos 2014; 13:29.
Gobbel Jr WG, Rhea Jr WG, Nelson IA, Daniel RA. Spontaneous pneumothorax. J Thorac Cardiovasc Surg 1963; 46:331.
Lesur O, Delorme N, Fromaget JM, et al. Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax. Chest 1990; 98:341.
Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005; 33:1231.
Melton LJ 3rd, Hepper NG, Offord KP. Influence of height on the risk of spontaneous pneumothorax. Mayo Clin Proc 1981; 56:678.
Ohata M, Suzuki H. Pathogenesis of spontaneous pneumothorax. With special reference to the ultrastructure of emphysematous bullae. Chest 1980; 77:771.
Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000; 342:868.
Episode 182.0 – Wellens
An interesting back story on this must-not-miss EKG finding in the ED!
Joseph Offenbacher, MD
Audrey Bree Tse, MD
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Tags: #FOAMed, #wellens, Cardiology, EKG, STEMI
Hosts: Joe Offenbacher MD, Audrey Bree Tse MD
EKG Findings in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.
Table 1 in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.
de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.
Lee, M., & Chen, C. (2015). Myocardial Bridging: An Up-to-Date Review. Journal of Invasive Cardiology, 27(11), 521–528.
Lin AN, Lin S, Gokhroo R, Misra D. Cocaine-induced pseudo-Wellens’ syndrome: a Wellens’ phenocopy. BMJ Case Rep. 2017 Dec 14;2017:bcr2017222835. doi: 10.1136/bcr-2017-222835. PMID: 29246935; PMCID: PMC5753703.
Rhinehardt, J., Brady, W. J., Perron, A. D., & Mattu, A. (2002). Electrocardiographic manifestations of Wellens’ syndrome. The American Journal of Emergency Medicine, 20(7), 638–643. https://doi.org/10.1053/ajem.2002.34800
Tandy, TK; Bottomy DP; Lewis JG (March 1999). “Wellens’ syndrome”. Annals of Emergency Medicine. 33 (3): 347–351. PMID 10036351. doi:10.1016/S0196-0644(99)70373-2. (via Wikipedia)
We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage.
Mark Iscoe, MD
Brian Gilberti, MD
Bree Tse, MD
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Tags: Critical Care, Neurology, Subarachnoid Hemorrhage
Non-contrast head CT showing SAH (Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 22770)
Hunt-Hess grade and mortality (from Lantigua et al. 2015.)
1. Mild Headache
2. Severe headache or cranial nerve deficit
3. Confusion, lethargy, or lateralized weakness
Ottawa Subarachnoid Hemorrhage Rule, and appropriate population for rule application (from Perry et al. 2017)
Apply to patients who are:
≥ 15 years old
Have new, severe, atraumatic headache that reached maximum intensity within 1 hour of osnet
Do not apply to patients who have:
New neurologic deficits
Previous diagnosis of intracranial aneurysm, SAH, or brain tumor
History of similar headaches (≥ 3 episodes over ≥ 6 months)
SAH cannot be ruled out if the patient meets any of the following criteria:
* Age ≥ 40
Symptom of neck pain or stiffness
Witnessed loss of consciousness
Onset during exertion
“Thunderclap headache” (defined as instantly peaking pain)
Limited neck flexion on examination (defined as inability to touch chin to chest or raise head 3 cm off the bed if supine)
Special Thanks To:
* Dr. Mark Iscoe, MD (Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue)
Bellolio MF, Hess EP, Gilani WI, et al. External validation of the Ottawa subarachnoid hemorrhage clinical decision rule in patients with acute headache. Am J Emerg Med. 2015;33(2):244-9.
Carstairs SD, Tanen DA, Duncan TD, et al. Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage. Acad Emerg Med. 2006;13(5):486-492.
Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711-1737.
Czuczman AD, Thomas LE, Boulanger AB, et al. Interpreting red blood cells in lumbar puncture: distinguishing true subarachnoid hemorrhage from traumatic tap. Acad Emerg Med. 2013;20(3):247-256.
Urine Tox Screens
We discuss the (F)utility(?) of ED Utox screens with our very own Dr. Phil DiSalvo.
Bree Tse, MD
Brian Gilberti, MD
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Special Thanks To:
Dr. Philip DiSalvo, MD
Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue
New York City Poison Control Center
Christian MR, et al. Do rapid comprehensive urine drug screens change clinical management in children? Clin Toxicol (Phila). 2017;57:977-980.
Grunbaum AM, Rainey PM (2019). Chapter 7: Laboratory Principles. In Goldfrank’s toxicologic emergencies. New York, NY: McGraw-Hill Education.
Moeller K, Kissack J, Atayee R, Lee K. Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens. Mayo Clinic Proceedings Review. Volume 92, Issue 5, p774-796, May 1, 2017. https://www.mayoclinicproceedings.org/article/S0025-6196(16)30825-4/fulltext
Table 2: Approximate Drug Detection Time in the Urine
Table 4: Summary of Agents Contributing to Results by Immunoassay
Episode 179.0 – Precipitous Breech Deliveries
EM management of the rare but potentially complicated precipitous vaginal breech delivery.
Audrey Bree Tse, MD
Masashi Rotte, MD MPH
Tags: Obstetrics, Precipitous Deliveries, Pregnancy
Frank Breech Presentation:
Complete Breech Presentation:
Incomplete Breech (“Footling”) Presentation:
Cunningham FG et al. Breech Presentation and Delivery. Williams Obstetrics, 22nd ed. 2005.
Desai S, Henderson SO. Labor and Delivery and Their Complications. Rosen’s Emergency Medicine, 8e. 2014. Chapter 181.
Gabbe SG et al. Obstetrics: Normal and Problem Pregnancies, 2nd e. 1991. p.479.
Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet Gynecol Clin North Am. 2005; 32: 165.
VanRooyen MJ, Scott J. Emergency Delivery. Tintanelli’s Emergency Medicine, 7th e. 2011. Chapter 105.
Episode 178.0 – Graduation Speech by Dr. Goldfrank
The speech given by Dr. Goldfrank at the 2020 NYU / Bellevue Emergency Medicine Graduation Ceremony
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Tags: Graduation. Goldfrank
Lewis R. Goldfrank, MD
June 17, 2020
WELCOME TO THE GRADUATES
Congratulations to a wonderful group of physicians. It is a pleasure to recognize your great accomplishments in the presence of your friends, families, loved ones and the residents and faculty who have learned so much from and with you. I would first like to recognize those of you who are members of the Gold Humanism Honor Society.
There are a remarkable number of awardees in our graduating class of 2020.
CLASS OF 2020
Joe Bennett (R)
Max Berger (R)
Ashley Miller (R)
Leigh Nesheiwat (S)
Kristen Ng (R)
Emily Unks (S)
Arie Francis (R)
Nisha Narayanan (S)
Elena Dimiceli (S)
Kamini Doobay (S)
Mark Iscoe (R)
Stasha O’Callaghan (S)
Nicholus Warstadt (S)
Aaron Bola (S)
Alison (Ali) Graebner (S)
Aron Siegelson (S)
Melissa Socarras (S)
Sarah Spiegel (S)
Thomas Sullivan (S)
Christy Williams (S)
GOLD HUMANISM CORE VALUES
Integrity, Excellence, Compassion, Altruism, Respect, Empathy, Service
These are the values you want as a doctor for yourself or a loved one,
* to have outstanding listening skills with patients
* to be at your side during a medical emergency,
* to have exceptional interest in service to the community,
* to have the highest standards of professionalism
* to integrate a humanistic approach in patient care.
These values are what brought all of you to NYU-Bellevue and that you have honed throughout your training. The remainder of this talk shows how all of you have been successful and demonstrated these values some of you were elected to the Gold Humanism—all of you have achieved humanistic success.
Your personal efforts in the face of uncertainty of the evolution of the pandemic, the inadequate supplies, the hospital and governmental problematic decisions are remarkable. In our country, the President did not mourn the loss of more than a 100,000 human beings and the needs of society. Nor did he provide the leadership and moral support that the country desperately needed to optimally handle this unprecedented crisis. You, in contrast, demonstrate unflappable commitment to address and overcome obstacles to care for your patients, assist your peers, educate and care for your families and friends, while also caring for yourselves. This is a tribute to your humanism. You created essential ways to help patients who were isolated from families and friends during the critical phases of COVID-19.
Core content doesnt get any better
A brilliant and concise look at truly essential EM topics. Essential listening for all EM Docs.
The Swami strikes again
An excellent series of podcasts, done by The Swami, whom most people interested in EM Foamed will at least have heard of.
Good coverage of most topics, well structured and interesting podcasts.