In relation to Episode 13 on The Found Down Patient with Dr. Brian Steinhart and Dr. David Carr, we present here, the second of our new 5 minute 'Best Case Ever' series. Dr. Steinhart's found down patient In Episode 13 The Found Down Patient, Dr. Helman presents 4 challenging cases of patients who present with altered mental status to Dr. Carr and Dr. Steinhart, who give us loads of key pearls and intriguing controversy in the evaluation and treatment of these difficult patients. [wpfilebase tag=file id=370 tpl=emc-play /] [wpfilebase tag=file id=371 tpl=emc-mp3 /]

In Part 2 of this episode on ACLS Guidelines - Atropine, Adenosine & Therapeutic Hypothermia, Dr. Steven Brooks and Dr. Michael Feldman discuss the removal of Atropine from the PEA/Asystole algorithm, the indications and dangers of Adenosine in wide-complex tachycardias, pressors as a bridge to transvenous pacing in unstable bradycardias, and the key elements of post cardiac arrest care including therapeutic hypothermia and PCI. They answer questions such as: In which arrhythmias can Amiodarone cause more harm than good? Is there any role for transcutaneous pacing for asystole? When should Bicarb be given in the arrest situation? In what situations is Atropine contra-indicated or the dosage need to be adjusted? How has the widespread use of therapeutic hypothermia currently effected our ability to prognosticate post-arrest patients? What are the indications for PCI and thrombolysis in the cardiac arrest patient? Should we be using therapeutic hypothermia in the non-Vfib arrest patient? What is the best method for achieving the target temperature for the patient undergoing therapeutic hypothermia? and many more......

In Part 1 of this episode on the latest ACLS Guidelines, Dr. Steven Brooks and Dr. Michael Feldman review and debate what's new and what's controversial in the the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Within the frameworks of Cardiocerebral Rescusitation and the 3 phase model of rescucitation (electrical, circulatory and metabolic), they discuss the importance of high quality CPR, the de-emphasis on early ventilation and the utility of continuous quantitative waveform capnography. Dr. Brooks and Dr. Feldman answer questions such as: of all the therapeutic manoeuvres we do for the cardiac arrest patient, which ones have been shown to improve survival to hospital discharge? What is the evidence for chest compression machines? What is the utility of bedside ultrasound in the cardiac arrest patient? Why is cardiac arrest survival to discharge in Seattle the best in the world? Should we be performing 'hands-on defibrillation'? and many more.....

In this episode on Cognitive Decision Making & Medical Error, Dr. Doug Sinclair, CMO of St. Michael's Hospital and Dr. Chris Hicks show us that, while the ED physician's knowledge base may play a small part in predicting medical error, more important might be how we understand and reflect upon our decision-making processes, how we communicate with our staff and patients, and how we cope with the ED environment and shift work. Medical error is the 6th leading cause of death in North America, and despite huge advances in imaging technology and lab testing as well as an explosion of EM literature in recent years, the misdiagnosis rate detected through autopsy studies has not changed significantly over the past century. Studies on diagnostic error in emergency medicine have shown error rates between 1 and 12%, and it's been suggested that cognitive error, or some flaw in the decision making process (as apposed to a lack of knowledge), is present in about 95% of these cases. Dr. Sinclair and Dr. Hicks elucidate for us how to identify and understand cognitive decision making and medical error, and how we can improve our decision making, reduce medical error and optimize the care of our patients.

In Part 2 of this episode on Trauma Pearls & Pitfalls Dr. Dave MacKinnon and Dr. Mike Brzozowski go through key management strategies and controversies surrounding head, neck, chest, abdominal, pelvic and extremity trauma, followed by a discussion on how best to prepare the trauma patient for transfer to a trauma centre.

In this episode on Trauma Pearls and Pitfalls, Dr. Dave MacKinnon and Dr. Mike Brzozowski discuss the latest in trauma controversies. In Part 1 they give us some key pearls and pitfalls on traumaairway management, the value of the C-spine collar, how to clear the C-spine, vascular access options in trauma, 'Damage Control Rescuscitation', the best resuscitation fluids to use including hypertonic saline, hemostatic drugs such as Tranexamic Acid in trauma, the vulue, or lack thereof, of Recombinant Factor 7a in trauma, and the use of Prothrombin Complex Concentrates in trauma.

Nontraumatic Eye Emergencies are seldom very satisfying for the emergency physician to manage. However, with systematic approach and timely management they can save a patient's vision. Dr. George Porfiris and Dr. Simon Kingsley discuss four non-traumatic eye emergency presentations. The painful red eye, the painless red eye, acute painful loss of vision and acute painless loss of vision. Several cases are discussed in which an accurate diagnosis and timely ED management are of critical importance in order to prevent permanent vision loss and significant morbidity. A systematic approach to the eye examination is described with particular attention to important maneuvers such as the swinging flashlight test. The utility of ED ultrasound of the eye is debated, and a discussion around systemic diseases that cause eye problems provides fodder for many clinical pearls.

There are so many emergency airway controversies in emergency medicine! Dr. Jonathan Sherbino, Dr. Andrew Healy and Dr. Mark Mensour debate dozens of these controversies surrounding emergency airway management. A case of a patient presenting with decreased level of awareness provides the basis for a review of the importance, indications for, and best technique of bag-valve-mask (BVM) ventilation, as well as a discussion of how best to oxygenate patients. This is followed by a discussion of what factors to consider in deciding when to intubate and some of the myths of when to intubate. The next case, of a patient with severe head injury who presents with a seizure, is the fodder for a detailed discussion of Rapid Sequence Intubation (RSI). Tips on preparation, pre-oxygenation and positioning are discussed, and some great debates over pre-treatment medications, induction agents and paralytic agents ensues. The new concept of Delayed Sequence Intubation is explained and critiqued. They review how to identify a difficult airway, how best to confirm tube placement and how to avoid post-intubation hypotension. In the last case of a morbidly obese asthmatic they debate the merits of awake intubation vs RSI vs sedation alone in a difficult airway situation and explain the best strategies of ventilation to avoid the dreaded bradysystlolic arrest in the pre-code asthmatic. Finally, some key strategies to help manage the morbidly obese patient's airway effectively are reviewed.

The whole playing field changes with pregnant patients in the emergency department. When you're faced with one of the Medical and Surgical Emergencies in Pregnancy that we'll cover in this episode, there are added challenges and considerations. Dr. Shirley Lee and Dr. Dominick Shelton discuss a challenging case of a pregnant patient presenting to the emergency department with shortness of breath and chest pain. They review those diagnoses that the pregnant patient is at risk for and discuss the challenges of lab test interpretation and imaging algorithms in the pregnant patient. Next, they walk us through the management of cardiac arrest in the pregnant patient. In another case of a pregnant patient who presents with abdominal pain and fever, they discuss strategies to minimize delays in diagnosis to prevent serious morbidity and mortality. The pros and cons of abdominal ultrasound, CT and MRI are reviewed as well as the management of appendicitis, pyelonephritis and septic abortion in pregnant patients.

Transient Ischemic Attack (TIA) can be difficult to diagnose. It's unclear who to work up. It's challenging if the patient is already taking blood thinners. Dr. Walter Himmel and Dr. Daniel Selchen discuss the key historical and physical examination maneuvers to determine whether patients with neurologic complaints have had a TIA or whether they have had a TIA mimic. They review the 3 best risk stratification rules including the ABCD2 Score to help us determine who needs to be admitted and who needs timely investigations to reduce vascular morbidity and mortality. The reasoning behind which patients require urgent carotid imaging, echocardiograms and advanced imaging such as CT Angiogram is explained, and the best medication choices are reviewed, as well as the indications for Clopidogrel, Aggrenox, Warfarin, Heparin and carotid endarterectomy in the managment of Transient Ischemic Attack. In the second part of the episode, a simple and practical approach to the patient with dizziness is presented, and a discussion on which patients with dizziness need urgent work-up and treatment for vertebrobasilar TIA.