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About Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
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Patwari Academy videos: Anticoagulation and reversal agents

Screen Shot 2013-06-26 at 5.11.08 AM

Bleeding in general is bad. Bleeding while on anticoagulants is VERY bad. Dr. Rahul Patwari reviews the pathophysiology of coagulation, the various reversal agents, and treatment approaches we can use. In this five-part series where all videos are less than 10 minutes, Rahul goes from the basic physiology of coagulation all the way to the complex reasoning and approaches to reversing anticoagulants. These are worth a quick look and review.

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By |2019-01-28T21:57:58-08:00Jun 30, 2013|Heme-Oncology, Patwari Videos, Tox & Medications|
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Trick of the Trade: Got a shoulder dislocation? Park it

ShoulderDLxray

Myriad techniques exist to reduce shoulder dislocations, which includes scapular rotation, Hennepin, Snowbird, Cunningham, and Legg maneuvers. They are nicely reviewed at ShoulderDoc.co.uk. You can also supplement any technique with ultrasound-guided intraarticular lidocaine for improved pain control.

Recently, Dr. Jay Park (Beth Israel Medical Center in New York) contacted me about his novel approach to shoulder reduction which anatomically makes sense. If his animation video doesn’t convince you, check out the video of an actual reduction.

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By |2019-01-28T21:59:02-08:00Jun 25, 2013|Orthopedic, Tricks of the Trade|
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Welcome new blog team member: Dr. Matt Astin

Welcome superstar Dr. Matt Astin to the ALiEM blog family. Matt is the Clinical Assistant Professor of EM and IM at Medical Center of Central Georgia, Mercer University School of Medicine. We’re incredibly happy here to add him as our new secret weapon in the social media and FOAM arena. After having met him in real-life at this past SAEM meeting, I can’t imagine a better fit for this team. Welcome! Follow him on Twitter: @mastinmd.

Here is brief bio by Matt:

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By |2019-09-10T14:03:22-07:00May 28, 2013|Life|
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PV Card: Contraindications to Thrombolytics in Stroke

thrombolytics stroke

This Paucis Verbis (PV) card is an updated version of the PV card on Contraindications to Thrombolytics for CVA from September 10, 2010, based on the Stroke 2013 AHA/ASA new guidelines that were just published.1 Some changes include…

  1. There is new mention of new anticoagulants in the market with additional absolute exclusion criteria.
  2. A blood glucose < 50 mg/dL has been upgraded from a relative exclusion to an absolute exclusion criteria. There is no more mention of glucose > 400 mg/dL as an exclusion criteria.
  3. Seizure at onset of presentation has moved from an absolute to a relative risk.
  4. Post-AMI pericarditis is no longer a relative exclusion criteria.

PV Card: Contraindications for Thrombolytics in Stroke


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. Jauch E, Saver J, Adams H, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. [PubMed]
By |2021-10-06T19:58:38-07:00May 23, 2013|ALiEM Cards, Neurology, Tox & Medications|
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PV card: Early repolarization vs STEMI on ECG

You are handed an ECG for a 50 year old man with moderate chest pain for 2 hours now and no associated symptoms typical for ACS, PE, aortic dissection, or any other red flags of chest pain. He has no prior ECG’s on file.

  • Is this early repolarization or ST elevation MI?
  • Should I activate the cardiac catheterization lab?

Image courtesy of Dr. Steve Smith at HQMedEd-ecg.blogspot.com

Here are some great literature-based pearls compiled by Dr. Jason West (@JWestEM), an EM resident from Jacobi/Montefiore.

PV Card: ECG – Early Repolarization vs ST Elevation MI


Adapted from [1–7]
Go to ALiEM (PV) Cards for more resources.

Furthermore, there is a formula to differentiate early repolarization vs STEMI, per Dr. Smith’s publication6:

(1.196 x STE60V3) + (0.059 x QTc) – (0.326 x RA V4)

  • STE60V3 = STE elevation height at 60 msec (1.5 small boxes) after the J-point in lead V3 (mm)
  • QTc = The computer-read QTc interval
  • RA V4 = R wave amplitude in lead V4 (mm)

A result of > 23.4 is predictive of a LAD occlusion causing a STEMI, rather than early repolarization.

P.S. The above ECG image shows early repolarization.

References

  1. Brady W, Syverud S, Beagle C, et al. Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment. Acad Emerg Med. 2001;8(10):961-967. [PubMed]
  2. Brady W, Perron A, Syverud S, et al. Reciprocal ST segment depression: impact on the electrocardiographic diagnosis of ST segment elevation acute myocardial infarction. Am J Emerg Med. 2002;20(1):35-38. [PubMed]
  3. Smith S. Upwardly concave ST segment morphology is common in acute left anterior descending coronary occlusion. J Emerg Med. 2006;31(1):69-77. [PubMed]
  4. Larson D, Menssen K, Sharkey S, et al. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298(23):2754-2760. [PubMed]
  5. Nfor T, Kostopoulos L, Hashim H, et al. Identifying false-positive ST-elevation myocardial infarction in emergency department patients. J Emerg Med. 2012;43(4):561-567. [PubMed]
  6. Smith S, Khalil A, Henry T, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. 2012;60(1):45-56.e2. [PubMed]
  7. Chung S, Lei M, Chen C, Hsu Y, Yang C. Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED. Am J Emerg Med. 2013;31(5):825-829. [PubMed]
By |2021-10-08T09:16:44-07:00May 16, 2013|ALiEM Cards, Cardiovascular, ECG|
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