Welcome to Flipping EM, our flipped classroom case-based learning conference activity! Each conference module we will post clinical cases for your consideration and each learner level (PGY1, 2, 3) will be asked to answer a question about the cases. In order to aid your response, links to journal articles will accompany each question. You will be responsible for reading the articles for your level’s assigned questions and developing an answer to the questions (feel free to seek out other resources as well!). During our scheduled conference time, we will break up into small groups of 6-9 residents (2-3 residents per level in each group) with a faculty facilitator. Each level of learner will discuss their question and corresponding articles and teach the rest of the small group what they learned with the other group members adding their input. Below you will find the cases for this edition which focuses on Hematology and Oncology. Please be prepared to discuss your articles and questions by conference on 9/22/16!
66 M BIBA after found down. Patient arrives to the ED unresponsive. You quickly establish a definitive airway and 2 large bore IVs. VS: BP=160/95, HR=65, R=18, O2=98%. After completing the primary survey, the patient is sent to CT for a head scan.
PGY 1: While the patient is in CT, his wife arrives and tells you that he is on one of those “newfangled blood thinner pills.” Describe the mechanism of action and pharmacological properties for both factor Xa inhibitors (i.e. rivaroxaban) and direct thrombin inhibitors (i.e. dabigatran).
PGY 2: The patient’s wife recalls that he was started on anticoagulation for a previous “blood clot.” Review the use of factor Xa inhibitors and direct thrombin inhibitors for the treatment of venous thromboembolism and compare them to alternative therapies in terms of effectiveness and complications. What other indications are there for the use of this class of medications?
- Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies
- Treatment of Acute Venous Thromboembolism With Dabigatran or Warfarin and Pooled Analysis
PGY 3: You find in the EHR that the patient is prescribed rivaroxaban. The CT shows a large ICH with midline shift. You immediately page Neurosurgery. What strategies would you employ to reverse the effects of the rivaroxaban and manage the hemorrhage? What would you do differently if the patient was prescribed dabigatran?
- Practical considerations in emergency management of bleeding in the setting of target-specific oral anticoagulants (requires library login)
- Specific antidotes against direct oral anticoagulants: A comprehensive review of clinical trials data (requires library login)
- Reversal of Rivaroxaban and Dabigatran by Prothrombin Complex Concentrate A Randomized, Placebo-Controlled, Crossover Study in Healthy Subjects
24 F h/o Sickle Cell Disease ℅ chest, back, and b/l lower extremity pain since yesterday. The pain is described as severe (10/10). Denies fever, cough, abdominal pain. Patient reports symptoms are similar to prior pain crises and asks you for 6mg of intravenous hydromorphone.
VS: T: 99.5F, BP: 125/80, HR: 85, RR: 20, O2: 96%
PGY 1: Describe your management strategy for acute painful crises in sickle cell disease. What adjunctive therapies would you consider and when would you employ them?
- Pain management for sickle cell disease in children and adults (requires library login)
- Management of the acute painful crisis in sickle cell disease- a re-evaluation of the use of opioids in adult patients
PGY 2: What complications related to sickle cell disease should you consider and how would you identify them in the ED?
PGY 3: Upon checking a rectal temperature and CXR, the patient is found to have a fever of 102F and a RLL infiltrate. Describe the pathophysiology, diagnosis, and management of acute chest syndrome.
Feel free to utilize additional resources to support your responses and further the discussion of the topics raised in the cases! Please leave any questions or comments below. Thanks!