Author- Steve Schenkel, MD MPP Professor of Emergency Mediciner at UMEM:
A recent Annals of Emergency Medicine Publication (here https://www.annemergmed.com/article/S0196-0644(22)01276-8/fulltext) tested a predictive rule for Likelihood to Occupy an Inpatient Bed associated with a common Electronic Health Record.
At the individual patient level, the score performed ok. Depending on the chosen threshold, it traded off sensitivity and specificity and generally became more accurate the longer the patient was in the ED.
The authors and the associated editorial (here https://www.annemergmed.com/article/S0196-0644(22)01401-9/fulltext) suggest a different, potentially more beneficial use: to allow aggregate prediction of admissions across an entire department and therefore prompt earlier planning to prevent crowding on account of boarding.
The takeaway: Administrative prediction rules oriented toward individual patients may be more meaningfully used to predict resource needs, including in-patient beds, across the ED population.
How much screen time after concussion?
Adolescents spent more than 7 hours daily on screen time during the pandemic.
Historically, experts recommended screen time abstinence to various degrees after concussion.
Prior study: RCT of concussion patients (ages 12 to 25) found that those who abstain from screen time for the first 48 hours recovered 4.5 days sooner than those who were permitted screen time.
Population: 633 children and adolescents with acute concussion and 334 with orthopedic injuries aged 8 to 16, recruited from 5 Canadian pediatric emergency departments.
Post concussion symptoms were measured at 7 to 10 days, weekly for three months, and biweekly for three to six months post injury. Screen time was measured.
Results: Screen time was a significant predictor of post concussion symptom recovery with both parent reported somatic and self-reported cognitive symptoms.
There may be an effect of low to moderate screen time (Goldilocks effect) demonstrating that those in the 25th to 50th percentiles had less severe symptoms than those on the higher end of screen time use or those who minimally use of screens!
Low and high screen time were both associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post recovery but not after 30 days.
Conclusion: The association of early screen time with post concussion symptoms is not linear. Recommending moderation in screen time may be the best approach to clinical management.
Children need to strike a balance between avoiding boredom, deconditioning, isolation, and overexerting themselves physically or cognitively.
a 37 year old patient comes in with chest pain, you obtain the following ECG. Is this a STEMI or Pericarditis?
How can you tell? well, you follow the algorithm Dr. Mattu taught us....
The ECG above, if you go through the algorithm you will see that it is most likely pericarditis.
note that PR depression can be transient and you might not see them.
When in doubt, it is not wrong to consult cardiology. Getting serial ECGs also is important, STEMIs will usually evolve.
We hope that you enjoy your Memorial Day!
Don't forget your Sandy Beach Sign vs Barcode Sign of Lung Ultrasound:
Normal lung will have good pleural sliding. When you image the lung with M-Mode it looks like a Sandy Beach.
A lung with a pneumothorax will have poor lung sliding. When you image the lung with M-Mode it looks like a classic barcode or "stratosphere sign."
Make sure that you are on "Lung Mode" or decrease the gain to better image the movement of the pleural line. The negative predictive value for lung sliding on ultrasound is 99%. This means that if you see lung sliding you do not have a pneumothorax in that area. However, lung sliding is affected by certain conditions such as blebs, pulmonary fibrosis, pleural adhesions and right mainstem intubation. So, like any other radiology study, clinically correlate!
Thinking about placing a chest tube or have a patient with multiple rib fractures? Take a look at how to perform a Serratus Anteror Plane Block here: https://www.thepocusatlas.com/thoracoabdominal-blocks#Serratus
Clinician Well-Being and the Patient Experience
Did you know that most patient experience responses are overwhelmingly positive? Rather than focusing all our attention on the bad, let’s focus on the good to promote clinician well-being. See below for a few key points from a recent study on this:
Consider emphasizing positive patient experiences when providing feedback to emergency physicians. It will promote clinician well-being and help improve performance in your practice.
Did you know that you can use the linear probe with pulse wave (PW) doppler over the femoral artery to look for a pulse during CPR pauses?
Well, the researchers of this article took this skill one step further to evaluate if they could use the femoral artery PW doppler while CPR was in progress to look for signs of a pulse.
The authors found that:
- pulsations due to compressions were organized with uniform pulsations.
- when there was also native cardiac activity, the pulsations were nonuniform and may have an irregular cadence.
Although there were several limitations, Arterial doppler was 100% specific and 50% sensitive in detecting organized cardiac activity during active CPR.
Take Home Point: Take a look at your arterial doppler for signs of organized cardiac activity during a resuscitation.
