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Emergency Medicine Readiness Elective. April 7. 2014. Today’s Agenda. EM Concepts Chest Pain Sepsis Axioms. What Makes Emergency Medicine Special ?. Digital processing Packets of information Not in sequential order Multiple interruptions Constant reprioritization.
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Emergency Medicine Readiness Elective April 7. 2014
Today’s Agenda • EM Concepts • Chest Pain • Sepsis • Axioms
What Makes Emergency Medicine Special? • Digital processing • Packets of information • Not in sequential order • Multiple interruptions • Constant reprioritization
What Makes Emergency Medicine Unique? • Digital processing • Emphasis on the bad diagnoses
What Makes Emergency Medicine Unique? • Digital processing • Emphasis on the bad diagnoses • Categorization into bins
CHEST PAIN POSSIBLE ACS STEMI DEFINITE ACS
Multinomial logistic regression • Dependent variable is categorical (what category is patient in?) • Independent variables can be both continous (e.g. temperature) or categorical (e.g. sex) • This is what we do.
What Makes Emergency Medicine Unique? • Digital processing • Emphasis on the bad diagnoses • Categorization into bins • People are sick until proven otherwise • Our null hypothesis is that the patient is not sick and we try to disprove it. • Griffen’srule: lab results and imaging results can not make a patient less sick.
What Makes Emergency Medicine Unique? • Focus on disposition • “Every patient has a direction and a velocity”. • “What do you want to do for this patient”
What Makes Emergency Medicine Unique? • Focus on disposition • We are pattern recognizers
What Makes Emergency Medicine Unique? • Focus on disposition • We are pattern recognizers • We think fast – and slow • Heuristics • Dual process theory
What Makes Emergency Medicine Unique? • Focus on disposition • We are pattern recognizers • We think fast – and slow • We are Bayesian probalists.
Bayesian Probablility • To evaluate the probability of a hypothesis, the Bayesian probabilist specifies some prior probability, which is then updated in the light of new, relevant data.
What Makes Emergency Medicine Unique? • Focus on disposition • We are pattern recognizers • We think fast – and slow • We are Bayesian probalists. • We understand systems • We are not independent • Hospital based • As good as the systems around you • “Independent ED group”
Chest Pain • Acute Coronary Syndrome • Aortic Dissection • Pulmonary Embolus • Pneumothorax • Boerhaave syndrome • Myocarditis • Pericarditis • Trauma • Peptic ulcer, cholecystitis, pancreatitis • Pleurisy • GERD • Herpes Zoster • Hyperventilation • Costochondral pain • Chest wall strain
Chest Pain • Acute Coronary Syndrome • Aortic Dissection • Pulmonary Embolus • Pneumothorax • Boerhaave syndrome • Myocarditis • Pericarditis
Chest Pain • Acute Coronary Syndrome • Aortic Dissection • Pulmonary Embolus • Pneumothorax • Boerhaave syndrome • Myocarditis • Pericarditis
Patient #1 • This is a 47 year old male with a history of hypertension presenting to the ED with complaint of chest pain beginning 11 hours prior to arrival. • The pain is now better but was located in the lower chest and did not radiate. It has been intermittent through the day, at times associated with some mild diaphoresis but no other symptoms.
Patient #1 • The patient did have one episode of transient paresthesias of his left hand and had a brief episode of paresthesia of his left leg without any weakness. • He stated that this rapidly resolved when he “walked it off”. • No extremity weakness. No focal neuro findings. • Other than the hypertension, PMH is unremarkable.
Patient #1 continued • EKG with sinus rhythm, no diagnostic ST or T wave changes • Laboratory testing negative including cardiac markers. • The patient had some epigastric discomfort on palpation which was completely relieved with Mylanta and Viscous xylocine. • The patient was hypertensive in the ED.
Patient #1 • As a precaution he was placed in the chest pain protocol to have myocardial infarction ruled out and a stress dobutamine echocardiogram performed.
Patient #1 • Four hours after arrival, the patient complained of chest and epigastric pain. A repeat EKG showed marked bradycardiawith rate of 45. The patient was taken out of the chest pain protocol and Cardiology consulted. The patient’s pain became more intense and moved to the upper abdomen, a CT scan of the abdomen with IV and oral contrast was obtained.
Patient #1 • The CT showed a dissection of the lower thoracic and abdominal aorta with extension of the dissection into the origin of the superior mesenteric artery and with extensive dissection into the left common iliac artery.
