The Mount Sinai journal of medicine, New York
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Review
New diagnostic and treatment modalities for pulmonary embolism: one path through the confusion.
Pulmonary embolism is one of the greatest diagnostic challenges in emergency medicine. New techniques and strategies constantly arise for the diagnosis and treatment of this disease. A review of the new diagnostic and treatment modalities for pulmonary embolism (PE) suggests that it should be suspected in any patient with unexplained dyspnea, tachypnea, or chest pain. ⋯ Both heparin and low molecular weight heparin are equally effective initial treatments for stable patients with suspected or confirmed PE. Because accurate screening and identification of pulmonary embolism frequently requires more than a single test, knowledge of existing diagnostic techniques allows an evidence-based strategy for diagnosis. New therapeutic choices may benefit patients with confirmed pulmonary embolism.
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The diagnosis and management of blunt cardiac injury, formerly known as myocardial contusion, has challenged clinicians for decades. Caused primarily by motor vehicle collisions, significant blunt cardiac injury carries a high mortality rate. ⋯ A literature search using the MEDLINE database was performed to compose a review of epidemiology, diagnostic intervention, and therapeutic approach. The results of the search indicate that, along with a high index of suspicion, utilizing a combination of electrocardiogram, troponin, and echocardiography for appropriate patients may improve the diagnosis, risk stratification and disposition of patients sustaining blunt cardiac injury.
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Out-of-hospital cardiac arrest (OOH-CA) is a leading cause of mortality and the focus of significant research. Recent studies provide new evidence that may change our management of OOH-CA and improve outcomes. The findings of two recently published studies of OOH-CA are reviewed in this article. ⋯ The study demonstrated that vasopressin is similar to epinephrine for OOH-CA due to ventricular fibrillation or pulseless electrical activity, and superior to epinephrine for the initial treatment of asystolic arrest; it also demonstrated that the combination of vasopressin and epinephrine is superior to epinephrine alone in the treatment of refractory, out-of-hospital cardiac arrest. Studies on alternative CPR techniques and adjunctive devices for CPR were also reviewed. We conclude that pre-hospital access to defibrillators and the use of vasopressin in the management of asystole hold promise for improving survival for patients with out-of-hospital cardiac arrest.
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Randomized Controlled Trial
The role of patient-controlled apparatus for sedation in the emergency department.
Hand trauma is a fairly common cause of emergency unit admissions. Various analgesic and sedative agents are used to decrease pain and anxiety during minor surgical procedures for hand trauma patients and provide more comfortable conditions for the surgeon. The aim of this study was to investigate the potential role of patient-controlled sedation (PCS) during surgical procedures done under local anesthesia for hand trauma in the emergency department. ⋯ The two regimens did not differ with respect to hemodynamic changes, sedation levels and patient satisfaction. Therefore, PCS may be an acceptable alternative for surgical procedures performed using local anesthesia.
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Comparative Study
Comprehensive educational performance improvement (CEPI): an innovative competency-based assessment tool.
The focus of competency-based training is on outcomes, specifically well-trained residents. Our goal is to help move resident assessment away from content- and process-based factors and towards measures of mastery of practice. Doing so requires reorganizing and reprioritizing elements of the training program. We describe our attempt to shift the priorities of our program (the primary care internal medicine residency of the Mount Sinai School of Medicine [Elmhurst] Program) towards the desired outcomes of the medical resident, faculty, institution, and program as a whole. These outcomes are based on the six core competencies of graduate medical education (medical knowledge, patient care, interpersonal and communication skills, professionalism, systems-based practice, and practice-based learning and improvement). We call this process "comprehensive educational performance improvement" (CEPI). ⋯ The CEPI process has a number of strengths. It allows for the concurrent assessment of each learning element with its intended outcomes, enabling us to simultaneously assess its outcome and its programmatic value. It effectively integrates the cognitive aspects of a program element with its clinical aspects, along with the input of evaluators at various levels. Finally, it helps train faculty members in an evidence-based approach to the curriculum.