Category Archives: Resources

proBNP cutoffs

A few people were asking for a quick reference regarding age related proBNP cutoffs.

Embedded below are links to both the PRIDE and ICON-RELOADED trials which investigated proBNP cutoffs in the emergency department.

In summary:

The optimal age-independent cutoff for ruling out acute heart failure is <300 pg/ml

The optimal age-adjusted cutoffs for ruling in acute heart failure are:

<50 years old – 450 pg/ml

50-75 years old – 900 pg/ml

>75 years old – 1800 pg/ml

doi_10.1016_j.amjcard.2004.12.032

Accidental Hypothermia

Given the current weather it seems appropriate to post some guidance for patients suffering significant cold exposure. Below are concise guidelines from OSU medical center  and the Wilderness Medical Society (pre-hospital).  Both have useful information in regards to management along the spectrum of exposure. 

OSU Management of Accidental Hypothermia

ECMO TRANSFERS

At this time we are referring all all ECMO transfers to Montefiore’s Cardiothoracic Surgical ICU.  Although most ECPR cases are not typically candidates for on-site cannulation and transfer, in some rare hypothermic cases (eg. young patient, short downtime) there may be an exception. 

To initiate possible transfer first call 718-920-ECMO and provide the following: Patient name, Diagnosis and Location.  The transfer center will connect you with a CT surgeon with whom you can discuss the case and decide whether the patient is a candidate for potential transfer.

If ECMO is deemed appropriate, next call the AOD in order to initiate the emergency credentialing process for the surgeon.

EXCLUSIONS to CPR

Appropriate situations in which to terminate efforts for performing CPR in hypothermic patients with cardiac arrest:

  • Body is frozen solid (cannot perform chest compressions, no chest recoil)
  • Obvious non-survivable injury (eg. Decapitation, truncal transection, incineration/decomposition of whole body)
  • Airway obstruction (snow/ice) with downtime greater than 1 hour (more for avalanche victims than urban recoveries)

PROCEDURES

Thoracic lavage should be reserved only for pulseless patients.  A few variations of the procedure are possible including single and dual tube methods.  A good review can be found here THORACIC LAVAGE

Thank you to Neil Dubey and Mark Andreae for their help with this post.

Accidental Exposure in the ED – needlestick/splash

Steps to follow in the event of a needle stick or body fluid exposure  (updated 4/13/21)

 

  1. Protect and discard all sharps. Immediately notify the attending. Wash the exposure site with soap and water (or if eye splash, use water irrigation.)
  2. Ask the attending to draw HIV and hepatitis serologies from the source patient with their permission and record the MRN.
  3. Inform the charge nurse of your unit and request an incident report. If after hours (5pm-8am) or the charge nurse doesn’t have the document, contact AOD (4-HELP).
  4. Fill out the indecent report (It will need to be signed by the provider who sees you)
  5. Get evaluated by an MD or APP (PA/NP):
    1. During business hours (8a-4p M-F) go to Employee Heath (4-3030) with your incident report form and tell them what happened.
    2. After hours and weekends register at internal triage in the ED to open an ED visit. Confirm that the clerk listed “worker’s comp.”
  6. What test should you have done?
    1. Baseline CBC, BMP, LFTs
    2. HIV, Hepatitis B/C serologies, HCV RNA PCR.
  7. Should you start PEP? That depends on the situation. You should discuss the risks/benefits of starting PEP with your provider. If starting PEP, they should give you 1 week supply of the appropriate medications.
  8. Follow up
    1. If the source patient is known to be positive for HIV or hepatitis B or C, you should be scheduled for an appointment with ID “ambulatory referral to EL Virology” for the next business day.

Otherwise;

  1. If you were seen in OHS, they will help arrange your follow up.
  2. If you were seen in the ED, go to OHS during walk-in hours listed on their door on the next business day – earlier is better. 

Note: Rotating residents (including MSSM) should make their first visit at Elmhurst OHS if the incident occurred at Elmhurst.

  1. Make a copy of the incident report for yourself.
  2. Give the incident report to Fabio Martich (B1-27) to be sent to OHS. Note: If you don’t complete an incident report you are going to receive a bill from the city that cannot be voided without the report.

 

If you have any questions, please contact ED leadership.

Palliative Care

For  quick, concise clinical info at the bedside on palliative care (want to manage dyspnea in a dying patient, have a conversation about code status, prognosticate in a patient with advanced cancer…)

EPERC Fast Facts

Amazing resource for all things EM and pal care

IPAL-EM     

Want to improve your communication skills?  The site below was created for oncologists but the skill set is universal. Watch the videos for a great demonstration of these skills in action!

Oncotalk

The creators of Oncotalk also wrote a terrific book, Mastering Communication with Seriously Ill Patients: balancing honesty with empathy and hope, if you want to go a step further.

Want to significantly improve your palliative care knowledge and skills?

EPEC-EM course

Palliative Care Goal Setting Pocket Card