#FOAMed of the Week: POCUS for distal radius fractures via WesternSono

Lovely vodcast from WesternSono introducing you to distal radius reduction review using Point Of Care Ultrasound (POCUS) and also using POCUS in haematoma blocks. A great way to develop my skills in US which could be transferable into other areas eg sternal US.

In the future I imagine telling the medical students anecdotes about how we used to irradiate patients to see if the fracture was back to normal while pulling my portable US out of my pocket........ *drifts off into day-dream*

#FOAMed of the Week: @HEFTEMCAST turns medical comedy on its head in their podcast on needle thoracostomy

OK......, if black humour isn't your thing then maybe the video isn't entertaining.........HOWEVER the Team at heftemcast.co.uk have done a very interesting review of a resus classic - the needle thoracostomy. Could we be doing it at a better site?

Check their webpage: http://www.heftemcast.co.uk/needle-thoracostomy/ for all the show notes and evidence plus subscribe and rate the podcast.

Or listen below to get an idea (but really just go to the site....)

#FOAMed of the Week: Sepsis v3.0 with Merv Singer via.......Everyone + EMCrit

New sepsis definitions were released in Febuary and got a mixed reception in the FOAMed world. 

Thankfully EMCrit pulls together some useful reading to get you up to speed with things: 

Firstly you could read the (free) JAMA paper .

Secondly you can read or download various FOAMed discussions on the topic: 

AND finally you should definitely listen to the EMCrit interview with the lead author Merv Singer, where all this info was cribbed from!

#FOAMed of the Week: Best Case Ever- Low Risk Pulmonary Embolism from @EMCases

Great thought provoking discussion about how we use decision rules in the ED. Featuring Dr. Salim Rezaie of R.E.B.E.L. EM.  

EM Cases produce excellent meducation podcasts from Canada. Their work is great quality, highly recommended and needs to be on your commuting podcast list!

Check out the EM Cases website for the shownotes and subscribe to the podcast.

Keep up the good work!

#FOAMed of the week: Too Sick for Surgery by @SteveMathieu75 via SMACC Podcasts

Another great podcast from SMACC Chicago exploring decision making in patients 'too sick for surgery'. In a nutshell, admission to ITU for optimisation rarely helps hard outcomes. Its either high risk surgery or discussion around palliation. 

For SMACC podcasts the easiest way to listen is to:

Apple: subscribe via itunes

Android: download the SMACC APP

#FOAMed of the Week: 5 ECG Patterns you must know via rebelem.com

REBEL-EM is a fantastic source of blogs and podcasts, helping you to stay in touch with the latest mutterings in the hallways of EM......Check it out for the proper post with all the images!

Background: The electrocardiogram (ECG) is one of the most useful diagnostic studies for identification of acute coronary syndrome (ACS) and acute myocardial infarction (AMI). The classic teaching is ST-segment elevation myocardial infarction (STEMI) is defined as symptoms consistent with acute coronary syndrome (ACS) + new ST-segment elevation at the J point in at least 2 anatomically contiguous leads of at least 2mm (0.2mV) in men or at least 1.5mm in women in leads V2 – V3 and/or at least 1mm (0.1mV) in other contiguous leads or the limb leads, in the absence of a left bundle branch block, left ventricular hypertrophy, or other non-acute MI ST-segment elevation presentations. Unfortunately, the ECG may be non-diagnostic in nearly half of all patients who initially present with AMI. There are also STEMI equivalent patterns that are caused by occlusion of the coronary arteries that place a significant portion of the left ventricle at jeopardy and result in poor outcomes. This review article focused on 5 under recognized high-risk ECG patterns in the ACS patient that result in poor outcomes including malignant dysrhythmias, higher rates of cardiogenic shock, and death.

First Diagonal Branch of the Left Anterior Descending Artery Occlusion

  • The 1st diagonal branch (D1) of the LAD supplies blood to the anterolateral wall of the left ventricle
  • Look for:
    • STE in aVL and V2
    • Upright T-waves in aVL and V2
    • ST-Depression and inverted T waves in Inferior Leads (III and aVF)
  • STE in aVL and V2 + lack of STE in other precordial leads = 89% PPV for MI of the anterior wall caused by a D1 lesion

De Winter’s T Waves

  • Concerning for proximal LAD occlusion (Present in 2% of patients)
  • Look for:
    • Upsloping ST-Depression at J Point in leads V1 – V4 without STE
    • Tall, Symmetric T-Wave in leads V1 – V4
    • STE in lead aVR +/- aVL

Left Main Coronary Artery Occlusion

  • Look for:
    • STE in lead aVR AND/OR
    • Widespread ST-Depression
  • In one study STD in leads I, II, and V4 – V6 + STE in aVR present in 90% of patients with greater than 70% stenosis of the LMCA

Wellens’ Syndrome

  • Concerning for proximal critical high grad LAD occlusion
  • Consider Wellens’ if:
    • Active (or recent) angina chest pain
    • Minimal or no cardiac biomarker elevation
    • Absence of pathologic precordial Q waves
    • Minimal or lack of STE (<1mm)
    • No loss of precordial R-wave progression
    • Characteristic T-wave abnormalities
  • Two Types of Wellens’ Syndrome:
    • Type A (25% of cases) consists of biphasic t waves
    • Type B (75% of cases) consists of deep symmetric t waves
  • Provocative Stress Testing could prove to have disastrous consequences resulting in AMI and fatal dysrhythmias
  • AMI can occur within a mean of 6 – 8.5d after admission, but a mean of 21.4d after symptoms
  • T-wave changes may be transient or resolve with medical management
  • Look for:
    • Deeply inverted T-waves in leads V1 – V4 OR
    • Biphasic T-waves in leads V1 – V4

Posterior Wall AMI

  • Concerning for occlusion of either distal left circumflex artery or PDA of right coronary artery
  • If you see STD in leads V1 – V3, the next thing to do is get a posterior ECG with leads V7 – V9 to help differentiate posterior AMI vs Anterior Ischemia
  • Look for:
    • Horizontal (flat) ST-Depression in leads V1 – V3
    • Prominent R-wave in leads V1 – V2
    • Upright T-wave in leads V1 – V3


Clinical Bottom Line: It is important to recognize the above 5 patterns as these are high risk ACS patients because a significant portion of the left ventricle is at jeopardy.  Only 4 of the above diagnoses require activation of the cath lab immediately and the 5th requires consultation of interventional cardiology.

Cath Lab Activation:

  • 1st Diagonal Branch of the Left Anterior Descending Artery Occlusion
  • de Winter’s T Waves
  • Left Main Coronary Artery Occlusion
  • Posterior STEMI

Interventional Cardiology Consultation:

  • Wellens’ Syndrome

#FOAMed of the Week: Modified Sgarbossa Criteria via REBEL EM

Salim Rezaie and the crew at R.E.B.E.L EM have kindly published a nice appraisal of a recent Retrospective study seeking to externally validate the Modified Sgarbossa Criteria. These rules guide interpretation of ECG ischaemia in LBBB.

This article gives a useful run down of the criteria and how to use them, as well as taking us through a critical appraisal - useful for anyone approaching FCEM. 

Check out the blog here: Modified Sgarbossa Criteria: Part Deux

#FOAMed of the Week: The Semantics of End of Life Discussions via EMcrit.org


Great Post and Podcast from Scott Weingart featuring Ashley Shreves on the practical steps to introduce these discussions in an ED setting. 

End of Life Conversations are Hard

We stumble, we stutter, we say things that derail the discussion when we have a patient at the end of life. But how do we learn to do better? We model good behavior. But in order to do that we need to hear good discussions. I listened to Ashley Shreve’s amazing SMACC Chicago talk: What is a Good Death?

After listening, I wanted to bring Ashley back on to really get into the nitty-gritty of the semantics of End of Life discussions. Ashley has been on the EMCrit podcast before discussing Critical Care Palliation. Now lets hear from here again…

Tidbits I pulled out of the Podcast

The three patients that will spur Ashley to try to have these discussions:
1. Advanced Cancer or Terminal Disease with Instability
2. Advanced Frailty/Dementia with Instability
3. Advanced Physiological Age (>85 y/o) with Instability
Start with, “I’m so worried about your family member,” and see the response
Then, “Tell me how things have been going with your family member”
Technique: Ask, Tell, Ask, Tell
Know the trajectories of care for the diseases we deal with
Does that mean you will do nothing? No, we actually want to intensify the treatment, with a focus on peace and dignity
We don’t want to artificially prolong the dying process
Vitalists comprise 5-10% of the population, you are unlikely to convince these folks in the ED
What if things don’t get better?
— http://emcrit.org/podcasts/semantics-end-of-life-discussions/

#FOAMed of the Week New Years Resolution: Papers of January via @HEFTEMCAST. Keep your EM current in 2016!

This year I solemnly swear to keep up to date with the latest in EM literature......
— Me, every year......

Thankfully this year the wonderful team from @HEFTEMCAST are here to make that promise a little easier to keep. A new feature gives us a monthly summary of the most recent EM relevant journal articles with a little bit of critical appraisal along the way. 

You can listen to the podcast below, but far better is to subscribe to the podcast (itunes/pocketcasts  etc) and check out the website for a written summary.

Finally theres LOADS more out there in the #FOAMed world to make keeping up to date a breeze. Blogs and podcasts, get 'em on your feed reader or follow on twitter to get the latest EM research brought to your phone or tablet. Easy. 

Here's a recommended list: Life in the fast lane Research & Reviews, EM Literature of Note, Annals of EM Audio Summary, St Emlyn's Journal Club, The Bottom Line, the Skeptics Guide to EM, and EM Nerd.......actually theres loads more but I have to stop somewhere!

Happy 2016!!

#FOAMed of the Week: Dizziness Made Easy via @PeterJohns84 and @RCEMFOAMed

OK.......actually this is more than one FOAMed article.......but its going to get your understanding of vertiginous dizziness off to the right start. From here you can start to think about the HINTS exam with more confidence, helping us differentiate central from peripheral causes of vertigo. 

First up watch these 2 excellent videos from Peter Johns, an Emergency Physician in Ottowa. Differentiating between Acute Vestibular Syndrome and BPPV is the biggest contribution we can make to the patient's care. This can be done just on the history.

Then a brilliant video from Michael Kim a UK EM trainee showing a Neuro SpR performing a Hallpike, Epley and your new best friend: THE SEMONT MANOEUVRE. The video won't embed here so go to RCEMFOAMed.co.uk to see it and the explanatory notes.

#FOAMed of the week: Acute Traumatic Coagulopathy by Karim Brohi via SMACC14

With pre-hospital blood coming to South East Scotland its past time to find out why we're making such a fuss about it..... PLUS see below to get the low down on ROTEM!

Karim Brohi highlights the pitfalls of fluid resuscutation and the deadly spiral of coagulopathy in severe trauma.
— http://www.smacc.net.au/2014/08/acute-coagulopathy-of-trauma-by-brohi/

See Practical-Haemostasis.com's guide to TEG and ROTEM, plus watch the video below (technically its about TEG but similar principles). Boths links from the ever amazing: Life in the fast lane.

#FOAMed of the Week: Pseudoaxioms and Dogmalysis, from SMACC15, Via ICN

Another talk from SMACC Chicago, this time from David Newman covering some favourite subjects.  Reminding us why we should know the evidence behind medical lore (and remain sceptical of wannabe new medical lore). Make sure you listen 'til the end, to include how medical students and junior doctors should handle #FOAMed Dogmalysis........

He and his wife, Ashley Shreaves, produced a number of brilliant podcasts on critical appraisal and EBM on SMART-EM which played a huge part in my passing my FRCEM.  

He also started the EBM website theNNT which produces EBM summaries on a variety of topics and is well worth checking out once you've got your basic stats in your head. 

Finally please listen to the monthly podcast Drs Newman and Shreaves produce for the Annals of Emergency Medicine Audio Summary. It's easy (and entertaining) listening and helps keep you up to date with latest publications. 

The Podcast:

#FOAMed of the Week: Sepsis SMACCdown via EMcrit

SMACC Chicago, brought to your armchair in dark n stormy Edinburgh. Viva la #FOAMed

An all-star panel discuss the burning issues in sepsis right now. Hosted by Chris Nickson and I, the conversation on the controversial aspects of sepsis was lubricated with on-stage alcohol (my idea!)

Mervyn Singer (research guru, sepsis expert and self-proclaimed Sex-God) and Paul Marik (iconoclast and dogma-basher) reveal just how hard it is to describe what sepsis is. Flavia Machado (intensivist and researcher) brings common sense and the perspective from South America, representing middle-income countries. Kath Maitland (author of FEAST, African-based paediatrician and clinical trialist) talks about sepsis management issues in Africa, where sepsis strikes its biggest global impact. Heavyweight researcher and clinician John Myburgh, argues that the word “sepsis” should be removed from our language and turns the paradigm on its head, arguing for a more pragmatic approach to sepsis management. Simon Finfer (crit care clinician, clinical trialist, voice of reason) describes the history, the good, the bad and the ugly about the Surviving Sepsis Guidelines, and some of the controversy surrounding them.

There’s a fascinating, very high level discussion on antibiotics which is not as clear cut as you might imagine. You couldn’t discuss fluids without talking about fluids and this panel features several world experts on this topic. Kath Maitland’s insights from FEAST, combined with the opinions of the rest of the panel will hopefully leave you an informed agnostic.
— http://emcrit.org/podcasts/sepsis-smaccdown/