EM Lyceum - A Novel Method to Encourage Academic Debate and Teaching Amongst Faculty and Residents Whitney K. Bryant, MD, MPH Anand Swaminathan, MD, MPH

Disclosures

What the hell is a Lyceum?

The Reality Clinical shifts, especially in most over-extended academic EM centers, are chaotic Clinical shifts, especially in most over-extended academic EM centers, are chaotic The practice of EM varies widely from hospital to hospital, and even attending to attending within a residency program The practice of EM varies widely from hospital to hospital, and even attending to attending within a residency program The balance of education versus service can feel skewed for residents The balance of education versus service can feel skewed for residents

The Goal Incorporate evidence-based teaching and nuanced academic debate into the clinical environment Incorporate evidence-based teaching and nuanced academic debate into the clinical environment Ensure uniform resident exposure to this, even if “off-service” that month Ensure uniform resident exposure to this, even if “off-service” that month Promote relevant, enjoyable, and succinct faculty teaching during shifts Promote relevant, enjoyable, and succinct faculty teaching during shifts

The Curriculum Developed in collaboration between residents and faculty at Bellevue/NYU Hospital Center Developed in collaboration between residents and faculty at Bellevue/NYU Hospital Center Controversial topics in EM chosen Controversial topics in EM chosen Can be used to start resident-initiated debate, as a background for mini-lectures, or as a stand-alone lesson plan. Can be used to start resident-initiated debate, as a background for mini-lectures, or as a stand-alone lesson plan.

Curriculum Logistics Curriculum team discusses potential topics and questions, reviewing the literature for areas of practice variation or deviation from evidence-based practice Curriculum team discusses potential topics and questions, reviewing the literature for areas of practice variation or deviation from evidence-based practice New Topic Roll Out – 1 st Wednesday of the month New Topic Roll Out – 1 st Wednesday of the month Questions and key articles sent to attendings the Sunday before Questions and key articles sent to attendings the Sunday before

Curriculum Logistics Posters placed in all clinical areas Posters placed in all clinical areas Residents encouraged to discuss questions with attendings, empowering and enlisting them to pilot their own education Residents encouraged to discuss questions with attendings, empowering and enlisting them to pilot their own education

POSTERS

Acute Coronary Syndrome 1.What anti-coagulants and/or anti-platelet agents do you use in a patient with a STEMI? In an NSTEMI? 2.How do you identify and manage patients with unstable angina? 3.How do you risk stratify patients with chest pain? Do you use any clinical decision rules? 4. How reassuring is a recent (< 1 year) negative stress test in managing a patient with chest pain? How about a recent “normal” cath (i.e., < 30% blockage, no intervention)?

Hyperkalemia 1.What are the EKG changes associated with hyperkalemia? Do these changes occur in a predictable order? 2.What is the role of kayexylate in the treatment of hyperkalemia? 3.Is there a threshold serum potassium level or EKG finding that triggers you to administer calcium? How do you give calcium when you use it? 4.When do you re-dose patients after treating them for hyperkalemia?

“ANSWERS”

“Answers” Look for as much high quality evidence as we can find Look for as much high quality evidence as we can find Create “answers” based on the best evidence and group consensus Create “answers” based on the best evidence and group consensus Where there is minimal evidence, we use expert opinion Where there is minimal evidence, we use expert opinion Distributed via and in conference Distributed via and in conference

What is the role of Kayexalate in the treatment of hyperkalemia? Kayexalate (Sodium Polystyrene Sulfate) is a cation- exchange resin that was approved in 1958 as a treatment for hyperkalemia. It is believed to help exchange sodium for potassium in the colon and thus encourage excretion of potassium from the body. Kayexalate (Sodium Polystyrene Sulfate) is a cation- exchange resin that was approved in 1958 as a treatment for hyperkalemia. It is believed to help exchange sodium for potassium in the colon and thus encourage excretion of potassium from the body. Although this drug has been used for a number of years as an adjunct to more acute treatments, there are two potential problems with its use. Although this drug has been used for a number of years as an adjunct to more acute treatments, there are two potential problems with its use.

What is the role of Kayexalate in the treatment of hyperkalemia? Firstly, there is little to no evidence that Kayexalate effectively reduces serum potassium levels. The two original studies promoting its use, often cited in literature, were published in the New England Journal of Medicine in These two trials were completed without any controls, multiple confounding variables, a lack of statistical analysis, and demonstrated minimal if any effect of Kayexalate on serum potassium levels (Scherr, 1961 & Flinn 1961). Firstly, there is little to no evidence that Kayexalate effectively reduces serum potassium levels. The two original studies promoting its use, often cited in literature, were published in the New England Journal of Medicine in These two trials were completed without any controls, multiple confounding variables, a lack of statistical analysis, and demonstrated minimal if any effect of Kayexalate on serum potassium levels (Scherr, 1961 & Flinn 1961). Furthermore, a recent study in 1998 also failed to demonstrate a statistically significant difference in serum potassium levels at 4, 8, and 12 hours after administration of 30g Kayexalate with sorbitol, compared to controls (Gruy-Kapral, 1998). Furthermore, a recent study in 1998 also failed to demonstrate a statistically significant difference in serum potassium levels at 4, 8, and 12 hours after administration of 30g Kayexalate with sorbitol, compared to controls (Gruy-Kapral, 1998).

Discuss the Utility of Pretreatment Agents in RSI. Atropine: This drug is most commonly used in pediatric patients (particularly < 2 years of age) to attenuate reflex bradycardia associated with succinycholine administration in RSI. The idea is that kids tolerate tachycardia very well but do poorly with bradycardia. The dose of atropine for pretreatment is 0.01 mg/kg IV (minimum dose is 0.1 mg). Atropine: This drug is most commonly used in pediatric patients (particularly < 2 years of age) to attenuate reflex bradycardia associated with succinycholine administration in RSI. The idea is that kids tolerate tachycardia very well but do poorly with bradycardia. The dose of atropine for pretreatment is 0.01 mg/kg IV (minimum dose is 0.1 mg). Although it continues to be recommended, randomized control trials have shown no difference in the rate of bradycardia in pediatric patients receiving succinycholine whether they got atropine or not (McAuliffe, 1995). Most airway "gurus" have dropped atropine as a recommendation for pretreatment but suggest having it at the bedside in case bradycardia occurs. Although it continues to be recommended, randomized control trials have shown no difference in the rate of bradycardia in pediatric patients receiving succinycholine whether they got atropine or not (McAuliffe, 1995). Most airway "gurus" have dropped atropine as a recommendation for pretreatment but suggest having it at the bedside in case bradycardia occurs.

Discuss the Utility of Pretreatment Agents in RSI. Fentanyl: Fentanyl pretreatment is thought to attenuate the sympathetic response to direct laryngoscopy. This sympathetic response can drive up heart rate and blood pressure and so may be detrimental to patients, especially those patients with ischemic heart disease, aortic dissections etc. Fentanyl: Fentanyl pretreatment is thought to attenuate the sympathetic response to direct laryngoscopy. This sympathetic response can drive up heart rate and blood pressure and so may be detrimental to patients, especially those patients with ischemic heart disease, aortic dissections etc. The dose required for full attenuation is mcg/kg but this large a dose may cause significant hypertension. Doses as low as 2- 3 mcg/kg will produce some attenuation and are more reasonable for RSI purposes. The dose required for full attenuation is mcg/kg but this large a dose may cause significant hypertension. Doses as low as 2- 3 mcg/kg will produce some attenuation and are more reasonable for RSI purposes. Important to note that the use of opioids in pretreatment for head trauma is an area of controversy. The Walls text recommends it, but be aware there is some evidence to suggest that it may increase ICP in patients with head injury (de Nadal, 1998). Important to note that the use of opioids in pretreatment for head trauma is an area of controversy. The Walls text recommends it, but be aware there is some evidence to suggest that it may increase ICP in patients with head injury (de Nadal, 1998).

Discuss the Utility of Pretreatment Agents in RSI. Lidocaine: Lidocaine pretreatment is also believed to attenuate the response to direct laryngoscopy but instead of sympathetic response the response is bronchoconstriction and increased intracranial pressure. Lidocaine: Lidocaine pretreatment is also believed to attenuate the response to direct laryngoscopy but instead of sympathetic response the response is bronchoconstriction and increased intracranial pressure. The evidence for this is incomplete at best, but many argue there is little downside to a dose of lidocaine in this situation. A 2001 literature review by Robinson and Clancy found no evidence that pretreatment with lidocaine in patients with head injury undergoing RSI improved neurological outcomes. The evidence for this is incomplete at best, but many argue there is little downside to a dose of lidocaine in this situation. A 2001 literature review by Robinson and Clancy found no evidence that pretreatment with lidocaine in patients with head injury undergoing RSI improved neurological outcomes. The dose for both reactive airway disease and increased ICP is 1.5 mg/kg IV. The dose for both reactive airway disease and increased ICP is 1.5 mg/kg IV.

Web Page Launched in August 2011 Launched in August 2011 Free, includes downloadable versions of the posters, easy to print and use in your department Free, includes downloadable versions of the posters, easy to print and use in your department

Future Directions Involvement of non-Bellevue residents and attendings in topic development Involvement of non-Bellevue residents and attendings in topic development Creation of blog/chat on a regular basis to discuss/debate topics remotely Creation of blog/chat on a regular basis to discuss/debate topics remotely Development of strategy to analyze impact of topics on actual management Development of strategy to analyze impact of topics on actual management

Acknowledgements Whitney Bryant, MD, MPH Whitney Bryant, MD, MPH Audrey Wagner, MD Audrey Wagner, MD Salil Bhandari, MD Salil Bhandari, MD Meghan Spyres, MD Meghan Spyres, MD Lewis Goldfrank, MD Lewis Goldfrank, MD

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