Filtra per genere
202 - Episode 196: The Critically Ill Infant
0:00 / 0:00
1x
- 202 - Episode 196: The Critically Ill Infant
We discuss an approach to the critically ill infant.
Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/The_Critically_Ill_Infant.mp3
Download
Leave a Comment
Tags: Pediatrics
Show Notes
The Critically Ill Infant: THE MISFITS
Trauma
* ‘T’ in the mnemonic stands for trauma, which includes both accidental and intentional causes.
* Considerations for Non-accidental Trauma:
* Stresses the importance of considering non-accidental trauma, especially given that it may not always present with obvious external signs.
* Anatomical Vulnerabilities:
* Highlights specific anatomical considerations for infants who suffer from trauma:
* Infants have proportionally larger heads, increasing their susceptibility to high cervical spine (c-spine) injuries.
* Their liver and spleen are less protected, making abdominal injuries potentially more severe.
Heart
* 5 T’s of Cyanotic Congenital Heart Disease: Introduces a mnemonic to help remember key right-sided ductal-dependent lesions:
* Truncus Arteriosus: Single vessel serving as both pulmonary and systemic outflow tract.
* Transposition of the Great Arteries: The pulmonary artery and aorta are switched, leading to improper circulation.
* Tricuspid Atresia: Absence of the tricuspid valve, leading to inadequate development of the right ventricle and pulmonary circulation issues.
* Tetralogy of Fallot: Comprises four defects—ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta.
* Total Anomalous Pulmonary Venous Connection (TAPVC): Pulmonary veins do not connect to the left atrium but rather to the right heart or veins, causing oxygen-rich blood to mix with oxygen-poor blood.
* Other Significant Conditions:
* Ebstein’s Anomaly: Malformation of the tricuspid valve affecting right-sided heart function.
* Pulmonary Atresia/Stenosis: Incomplete formation or narrowing of the pulmonary valve obstructs blood flow to the lungs.
* Left-sided Ductal-Dependent Lesions:
* Conditions such as aortic arch abnormalities (coarctation or interrupted arch), critical aortic stenosis, and hypoplastic left heart syndrome are highlighted. These generally present with less obvious cyanosis and more pallor.
* Diagnostic and Management Considerations:
* Routine prenatal ultrasounds detect most cases, but conditions like coarctation of the aorta and TAPVC might not be apparent until after birth when the ductus arteriosus closes.
* Emphasizes the importance of a thorough physical exam: checking for murmurs, assessing hepatosplenomegaly, feeling for femoral pulses, measuring pre- and post-ductal saturations,Wed, 01 May 2024 - 201 - Episode 195: ARDS
We review Acute Respiratory Distress Syndrome
Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/ARDS.mp3
Download
Leave a Comment
Tags: Critical Care, Pulmonary
Show Notes
* Definition of ARDS:
* Non-cardiogenic pulmonary edema characterized by acute respiratory failure.
* Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio <300 mmHg, even with positive end-expiratory pressure (PEEP) >5 cm H2O.
* Severity based on oxygenation (Berlin criteria):
* Mild: PaO2/FiO2 200-300 mmHg
* Moderate: PaO2/FiO2 100-200 mmHg
* Severe: PaO2/FiO2 <100 mmHg
* Epidemiology:
* Occurs in up to 23% of mechanically ventilated patients.
* Mortality rate of 30-40%, primarily due to multiorgan failure.
* Differentiation from Cardiogenic Pulmonary Edema:
* Chest CT shows diffuse edema and pleural effusion in cardiogenic edema; patchy edema, dense consolidation in ARDS.
* Ultrasound may show diffuse B lines in cardiogenic edema; patchy B lines and normal A lines in ARDS.
* Pathophysiology:
* Exudative phase: Immune-mediated alveolar damage, pulmonary edema, cytokine release.
* Proliferative phase: Reabsorption of edema fluid.
* Fibrotic phase: Potential for prolonged ventilation.
* Etiology:
* Direct lung injury (pneumonia, toxins, aspiration, trauma, drowning) and indirect causes (sepsis, pancreatitis, transfusion reactions, certain drugs).
* Diagnostics:
* Comprehensive workup including imaging (chest X-ray, CT), laboratory tests (complete blood count, basic metabolic panel, blood gases), and specialized tests depending on suspected etiology.
* Management Strategies:
* Steroids: Beneficial in certain etiologies of ARDS, with specifics on dosing and duration.
* Fluid Management: Conservative fluid strategy, diuresis guided by patient condition.
* Ventilation: Non-invasive ventilation (NIV) preferred in specific cases; mechanical ventilation strategies to ensure lung-protective ventilation.
* Proning: Used in severe ARDS to improve oxygenation.
* Inhaled Vasodilators: Used for refractory hypoxemia and specific complications like right heart failure.
* Extracorporeal Membrane Oxygenation (ECMO): Considered for severe ARDS as salvage therapy.
* Supportive Care: Includes monitoring and management of complications, nutrition, and physical therapy.
* Ventilation Specifics:
* Tidal volume and pressure settings aim for lung-protective strategies to prevent ventilator-induced lung injury.
* Permissive hypercapnia, plateau pressure, PEEP,Mon, 01 Apr 2024 - 200 - Episode 194: Nitrous Oxide Toxicity
We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview
Hosts:
Stefanie Biondi, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Nitrous_Oxide_Toxicity.mp3
Download
Leave a Comment
Tags: Toxicology
Show Notes
Patient Case Illustration
* Hypothetical case: 21-year-old male with no previous medical history, experiencing a month of progressively worsening numbness, tingling, and weakness. Initially starting in his toes and spreading to his hips, and later involving his hands, the symptoms eventually escalated to the point of immobilization. Despite initially denying drug use, the patient admitted to using 40-60 canisters of nitrous oxide (whippets) every weekend for the last three months.
Background and Recreational Use of Nitrous Oxide
* Nitrous oxide, a colorless, odorless gas with anesthetic properties.
* Synthesized in the 18th century.
* Its initial medical purpose expanded into recreational use due to its euphoric effects.
* Resurgence as a recreational drug during the COVID-19 lockdowns.
* Accessibility and legal status.
Public Misconceptions and Health Consequences
* There are widespread misconceptions about nitrous oxide
* Particularly the belief in its safety and lack of long-term health risks.
* Contrary to popular belief, frequent use of nitrous oxide can lead to significant, sometimes irreversible, health issues.
Neurological Examination and Diagnosis
* Key components of the examination include assessing strength, sensation, cranial nerves, and proprioception, with specific abnormalities such as symmetrically decreased strength in a stocking-glove pattern, upgoing Babinski reflex, and positive Romberg sign being indicative of potential toxicity.
Physical Exam Findings: Upper vs Lower Motor Neuron Lesions
Localize the Lesion- Differential Diagnoses for Extremity Weakness
Localize the Lesion- Differential Diagnoses for Extremity Weakness
Localize the Lesion- Differential Diagnoses for Extremity Weakness
MRI Findings and Subacute Combined Degeneration
* The MRI displayed symmetric high signal intensity in the dorsal columns, a diagnostic feature identified as the inverted V sign or inverted rabbit ear sign.
* Significance of the Inverted V Sign: This MRI sign is pathognomonic for subacute combined degeneration, indicating it is a distinct marker for this condition.
* T2 Weighted Axial Images: The inverted V sign is observed in T2 weighted axial MRI images, which are used to evaluate the presence and extent of demyelination within the spinal cord.
* Interpretation of Hyperintense Signals: Hyperintense signals on T2 weighted images generally indicate demyelination, where the protective myelin sheath around nerve fibers is damaged or destroyed.
* Anatomical Location: The dorsal columns,Fri, 01 Mar 2024 - 199 - Episode 193: Threatened Abortion
We review threatened abortion and the complexities in its care.
Hosts:
Stacey Frisch, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Threatened_Abortion.mp3
Download
One Comment
Tags: OBGYN
Show Notes
Background
* Defined as vaginal bleeding during early pregnancy (before 20 weeks) with a closed cervical os, no passage of fetal tissue, and IUP on ultrasound
* Occurs in 20-25% of all pregnancies.
Initial Assessment and Management
* Priority is to assess patient stability, establish good IV access, FAST may be helpful in identifying some ruptured ectopics early
* Broad differential diagnosis is crucial to avoid mistaking conditions like ectopic pregnancy for other emergencies.
* Importance of a detailed history and physical examination.
Diagnostic Approach
* Essential tests include HCG level, urinalysis, and possibly CBC + blood type/Rh status.
* Rhogam’s use is well-supported in second and third trimester bleeding; however, data is less robust for first trimester bleeding in preventing sensitization
* Importance of interpreting b-HCG with caution and understanding HCG discriminatory zones.
* Use of ultrasound imaging, both bedside and formal, to assess the pregnancy’s status.
Patient Counseling and Management
* Open and honest communication about the prognosis of threatened abortion.
* Addressing psychosocial aspects, including dispelling guilt and myths, and screening for intimate partner violence and mental health issues.
* Recommendations against bedrest and certain activities
* Lack of evidence supporting restrictions on sexual activity.
* Standard pregnancy guidelines: avoiding smoking, alcohol, drug use, and starting prenatal vitamins.
Follow-up and Precautions
* Adopting a wait-and-see approach for stable patients, with scheduled follow-ups for ultrasounds and beta-HCG tests.
* Educating patients on critical warning signs that require immediate medical attention.
* Emphasizing the importance of returning to the hospital if experiencing significant bleeding or other severe symptoms.
Take Home Points
* Threatened Abortion is defined as Experiencing abdominal pain and/or vaginal bleeding during early pregnancy (before 20 weeks), characterized by a closed cervical os and no expulsion of fetal tissue. In these cases, it is important to assess patient stability promptly.
* Keep your differential broad in these cases. The evaluation will in most cases involve a combination of labs and ultrasound imaging.
* Understand that the Rhogam certainly has a role in second and third trimester vaginal bleeding in the Rh-negative patient, and that there is a dearth of good data on its role in the first trimester – it will ultimately be a decision that is made by you, OBGYN, and the patient.Thu, 01 Feb 2024 - 198 - Episode 192: Syncope in Children
We review a general approach to syncope in children.
Hosts:
Brian Gilberti, MD
Ellen Duncan, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Syncope_in_Children.mp3
Download
Leave a Comment
Tags: Cardiology, Pediatrics
Show Notes
* Initial Evaluation and Management:
* Similar initial workup for children and adults: checking glucose levels for hypoglycemia and conducting an EKG.
* The history and physical exam are crucial.
* Dextrose Administration in Children:
* Explanation of the ‘rule of 50s’ for determining the appropriate dextrose solution and dosage for children.
* ECG Analysis:
* Importance of ECG in diagnosing dysrhythmias like long QT syndrome, Brugada syndrome, catecholamine polymorphic V tach, ARVD, ALCAPA, and Wolff-Parkinson-White syndrome.
* Younger children’s dependency on heart rate for cardiac output and the risk of arrhythmias in kids with congenital heart disease.
Condition
Characteristic ECG Findings
Congenital/Acquired
Long QT Syndrome (LQTS)
Prolonged QT interval
Congenital/Acquired
Wolff-Parkinson-White Syndrome (WPW)
Short PR interval, Delta wave
Congenital
Brugada Syndrome
ST elevation in V1-V3, Right bundle branch block
Congenital
Atrioventricular Block (AV Block)
PR interval prolongation (1st degree), Missing QRS complexes (2nd & 3rd degree)
Congenital/Acquired
Supraventricular Tachycardia (SVT)
Narrow QRS complexes, Absence of P waves, Tachycardia
Congenital/Acquired
Ventricular Tachycardia
Wide QRS complexes, Tachycardia
Congenital/Acquired
Arrhythmogenic Right Ventricular Dysplasia (ARVD/C)
Epsilon waves, V1-V3 T wave inversions, Right bundle branch block
Congenital
Hypertrophic Cardiomyopathy (HCM)
Left ventricular hypertrophy, Deep Q waves
Congenital
Pulmonary Hypertension
Right ventricular hypertrophy, Right axis deviation
Acquired
Athlete’s Heart
Sinus bradycardia, Voltage criteria for left ventricular hypertrophy
Acquired
Catecholaminergic Polymorphic VT (CPVT)
Bidirectional or polymorphic VT, typically normal at rest
Congenital
Anomalous Origin of Left Coronary Artery from Pulmonary Artery (ALCAPA)
May be normal, signs of ischemia or infarction in severe cases
Congenital
* History Taking:
* Key aspects include asking about syncope with exertion, syncope after being startled, and syncope after pain or emotional stress.Wed, 03 Jan 2024 - 10min - 197 - Episode 191: Rapid Atrial Fibrillation
We go over the treatment of rapid atrial fibrillation (afib with RVR).
Hosts:
Brian Gilberti, MD
Jonathan Kobles, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Rapid_Atrial_Fibrillation.mp3
Download
One Comment
Tags: Cardiology
Show Notes
Understanding AF with RVR Categories
General AF with RVR: Definition and basic understanding.
Rapid AF with Pre-excitation: Characteristics and complications.
Chronic AF in Critical Illness: Identification and special considerations.
Stability Assessment in AF with RVR
ACLS Protocols: Distinction between unstable and stable patients.
Unstable Patients: Immediate need for synchronized cardioversion, standard dose at 200 J for adults.
Stable Patients: Rate vs. rhythm control strategies, consideration of underlying etiology.
Limitations in Chronic AF: Challenges in patients with AF secondary to critical illness.
ACLS Guidelines and ECG Findings
Tachycardia with a Pulse Approach: Initial assessment guidelines.
ECG Interpretation:
Irregularly Irregular Rhythm: Absence of discernible P waves.
Ventricular Rate: Typically over 100 bpm.
QRS Complexes: Usually narrow, alterations in the presence of bundle branch block or ventricular rate-related aberrancy.
Identifying Pre-Excitation Syndromes: Signs of shortened PR interval and slurred QRS, indication of Wolff-Parkinson-White Syndrome.
AF with Pre-Excitation (WPW Syndrome)
Risk Assessment: Dangers of using AV nodal blockers (BB/CCB, digoxin, adenosine).
Alternative Management: Utilization of procainamide or amiodarone for stable patients, synchronized electrical cardioversion for unstable patients.
Treatment Approaches for AF Types
General Rapid AF:
First Line Agents: Metoprolol vs. Diltiazem.
Metoprolol Considerations: Dosing (5 mg every 10-15 minutes, max 15 mg), benefits in CAD and HF, limitations in asthma/COPD patients.
Diltiazem Advantages: Faster action, suitability in asthma/COPD, typical dosing (0.25 mg/kg initial, followed by 0.35 mg/kg if needed).
Critically Ill Patients: Tailoring treatment to underlying pathology, avoiding typical AF pharmacologic treatments.
Systematic Evaluation of Tachycardia Causes (TACHIES Mnemonic)
Thyrotoxicosis, Alcohol withdrawal, Cardiac issues, Hemorrhage, Intervals (WPW), Embolus, Sepsis.
Application of the mnemonic for a comprehensive approach to differential diagnosis.
Ultrasound in Diagnostic Assessment
Application in Undiagnosed Tachycardia: Identifying EF, pericardial effusion, valvular pathology, and signs of pulmonary embolism.
Fluid Status Evaluation: Use of ultrasound for assessing b-lines in lung scans.
Management of Chronic AF with HD Instability
Fri, 01 Dec 2023 - 196 - Episode 190: Electrical Storm
We discuss Electrical Storm (VT storm) and how to care for the very irritable heart.
Hosts:
Brian Gilberti, MD
Reed Colling, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Electrical_Storm.mp3
Download
Leave a Comment
Tags: Cardiology
Show Notes
Background/Overview of VT:
Definition: What makes it a storm
Three or more sustained episodes of VF, VT, or appropriate ICD shocks in a 24-hour period
Pathophysiology: Understanding the origin and mechanism
Sympathetic drive/adrenergic surge
Underlying pathology: Sodium channelopathies, infiltrative disease like cardiac sarcoidosis, etc.
RF’s / trigger / population (reversible cause in ~25% of patients)
MI
Electrolyte Derangements (emphasis on potassium and magnesium)
New/worsening heart failure
Catecholamine Surge
Drugs (stimulants, cocaine, amphetamines, etc)
QT Prolongation
Thyrotoxicosis
Clinical Presentation:
Symptoms of VT: spectrum of symptoms – from palpitations to syncope to cardiac arrest
Differentiating VT from other potential ER presentations.
Diagnostics in ER:
Electrocardiogram (ECG): Recognizing VT patterns.
Monomorphic vs polymorphic (Torsades) may change management
Wide QRS
Fusion best
Capture beats
Concordance
AV-dissociation
Lab tests: Potassium, magnesium, troponins, TFTs, etc.
Acute Management in the ER:
Hemodynamically stable vs. unstable V
Unstable = cardioversion
Sedation
Catecholamine surge should be considered
No ideal agent
Etomidate or propofol can be considered
Ketamine may worsen irritability
Pharmacological treatments:
Amiodarone
Class III antiarrhythmic
Most studied in VT storm
First line
Beta Blockers
Propranolol
B1 and B2 activity
Non-pharmacological approaches:
Immediate synchronized cardioversion
* IABP / ECMO considered for HD unstable patient
Cath lab if ischemic etiology suspected
Stellate Ganglion Block
Take Home Points
Definition: VT Storm is commonly defined as three or more sustained episodes of ventricular fibrillation, ventricular tachycardia, or appropriate ICD shocks within a 24-hour period.
Varied Presentation: Patients may experience a range of symptoms from palpitations to severe hemodynamic instability.
ECG and Diagnosis: Initial ECG may not show VT; continuous cardiac monitoring or device interrogation may be required for diagnosis.
VT Identification: Look for wide QRS, rate over 100, fusion beats, capture beats, and AV dissociation to identify VT.
Management in Hemodynamic Instability: Cardiovert if t...Wed, 01 Nov 2023 - 195 - Episode 189: Hyperkalemia 2.0
We revisit the topic of Hyperkelamia to update our prior episode from 2015 (pre-Lokelma)
Hosts:
Brian Gilberti, MD
Jonathan Kobles, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hyperkalemia.mp3
Download
2 Comments
Tags: Renal Colic
Show Notes
Introduction
* Background
Physiology:
Normal range and the significance of deviations (>5.5 mEq/L)
Epidemiology:
Prevalence of hyperkalemia in the ER
ESRD missed HD → ECG, monitor
Causes / Risk Factors
Causes
Kidney Dysfunction, Medications, Cellular Destruction, Endocrine Causes, Pseudohyperkalemia
* High-Risk Medications:
* Antibiotics: Bactrim, antifungals
* Calcineurin inhibitors
* Beta-blockers
* ACE/ARB
* K+ Sparing diuretics
* NSAIDs
* Digoxin
* SUX – high risks in neuromuscular disease
Lab errors, hemolysis in samples
VBG vs Chem accuracy
When to repeat a hemolyzed sample
2023 study: Of the 145 children with hemolyzed hyperkalemia, 142 (97.9%) had a normal repeat potassium level. Three children (2.1%) had true hyperkalemia: one had known chronic renal failure and was referred to the ED due to concern for electrolyte abnormalities; the other 2 patients had diabetic ketoacidosis (DKA).
Clinical Presentation / eval
Symptomatic vs. Asymptomatic:
“First symptom of hyperkalemia is death”
If severe, ascending muscle weakness → paralysis
Point at which patients experience symptoms depends on chronicity
>7 mEq/L if chronic and can be lower if acute
Hyperkalemia can be a cause of non-specific GI symptoms
EKG Changes:
ECG findings may be the first marker the ER doc gets that something is wrong
Typical changes:
Peaked T-waves, shortened QT
Lengthening of PR interval and QRS duration
Bradycardia / Junctional rhythm
Hyperkalemia can produce bradycardia without other ECG findings
Ones associated with VT/VF/code,Sun, 01 Oct 2023 - 194 - Episode 188: Vasopressors
We go over the essential and complex topic of vasopressors in the ED.
Hosts:
Brian Gilberti, MD
Catherine Jamin, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vasopressors.mp3
Download
Leave a Comment
Tags: Critical Care
Show Notes
Introduction
* Host: Brian Gilberti, MD
* Guest: Catherine Jamin, MD
* Associate professor of Emergency Medicine at NYU Langone Health
* Vice Chair of Operations
* Triple-boarded in Emergency Medicine, Internal Medicine, and Critical Care Medicine
* Topic: Vasopressors: Essential agents for supporting critically ill patients in the ED
What Are Vasopressors and When to Use Them
* Two primary mechanisms to increase blood pressure:
* Increasing systemic vascular resistance via vasoconstriction
* Increasing cardiac output via augmenting inotropy and chronotropy
* Indicators for vasopressor use:
* MAP <65, systolic BP <90, or significant drop from baseline BP
* Signs of organ dysfunction like altered mental status, decreased urine output, elevated lactate
* Fluid resuscitation either ineffective or contraindicated (e.g., in CHF patients)
Commonly Used Vasopressors in the ED
* Norepinephrine
* Epinephrine
* Vasopressin
* Phenylephrine
Norepinephrine
* Mechanism: Stimulates alpha-1 (vasoconstriction) and beta-1 receptors (increases inotropy & chronotropy)
* Starting Dose: 10 mcg/min, titrate to MAP >65
* Max Dose: No strict limit but usually add a 2nd pressor at 15-20 mcg/min
* Situational Preference: First-line for most cases of shock (septic, undifferentiated, hypovolemic, cardiogenic)
* Pros: Can be infused peripherally via large bore IV
Vasopressin
* Mechanism: Activates V1a receptors causing vasoconstriction
* Dose: Fixed, non-titratable dose of 0.04 units/min
* Situational Preference: Second-line in septic shock
* Concerns: Potential for peripheral ischemia
Phenylephrine
* Mechanism: Stimulates alpha-1 receptors causing vasoconstriction
* Starting Dose: 100 mcg/min, titrate to MAP >65
* Situational Preference: High cardiac output states, tachyarrhythmias, peri-intubation
* Concerns: Increases afterload, can worsen low cardiac output states
Epinephrine
* Mechanism: Stimulates alpha-1, beta-1 and beta-2 receptors
* Starting Dose: 5-10 mcg/min, titrate to MAP >65
* Situational Preference: Anaphylactic shock, septic cardiomyopathy
* Limitations: Can induce tachycardia, may elevate lactate levels
Escalation Strategy in Refractory Shock
* Norepinephrine -> Vasopressin (with stress dose steroids) -> Epinephrine
* Consider POCUS, lactate, central venous saturation, and acid-base status
Fri, 01 Sep 2023 - 193 - Episode 187: Septic Joint in Children
We discuss the diagnosis and management of septic arthritis in the pediatric population.
Hosts:
Brian Gilberti, MD
Ellen Duncan, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Joint_in_Children.mp3
Download
2 Comments
Tags: Infectious Diseases, Pediatrics
Show Notes
General
Pain in joint for pediatric patient has a broad differential, including transient synovitis and septic arthritis
Transient synovitis, also known as toxic synovitis, is a common condition affecting kids aged 3-10 and often occurs after a viral infection. It is typically self-limiting and not considered a serious condition.
Septic arthritis is an infection in the joint space, typically affecting only one joint. It is often difficult to diagnose due to the fact that many patients, particularly under the age of 3, may not be able to localize their pain to a specific joint.
Workup
Diagnostic work-up for septic arthritis begins with blood work, which includes a complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and blood cultures. Lyme disease studies may also be necessary since Lyme disease can cause joint pain.
Patients with transient synovitis typically have mild elevation in inflammatory markers, while those with septic arthritis usually show a significant elevation.
Imaging studies, including X-rays, ultrasound to evaluate for a joint effusion, and MRI to assess for associated osteomyelitis, are also part of the diagnostic approach.
The Kocher criteria, developed specifically for septic arthritis of the hip, are a useful tool for clinical decision-making. The criteria include fever above 38.5 C, inability to bear weight, ESR above 40, and a white blood cell count above 12,000.
1 criterion met = 3% probability of septic arthritis
2 criteria met = 40% probability of septic arthritis
3 criteria met = 93% probability of septic arthritis
4 criteria met = 99+% probability of septic arthritis
If septic arthritis is suspected, orthopedics should be consulted immediately. Joint fluid aspiration is necessary for diagnosis and should not be delayed. The fluid should be sent for cell count, gram stain, glucose, culture, and PCR if available.
Septic arthritis is most commonly caused by bacterial infections, with Staph aureus being the most common organism. In school-age children, other bacteria such as Strep pyogenes, Strep pneumoniae, and Haemophilus influenzae should also be considered. In preschool-aged children, K. kingae is also considered. In older children and neonates, the range of potential bacteria varies.
Management
Tue, 01 Aug 2023 - 9min - 192 - Podcast 186.0: Hypocalcemia
A quick primer on hypocalcemia in the ED.
Hosts:
Joseph Offenbacher, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/hypocalcemia.mp3
Download
4 Comments
Tags: calcium, Critical Care, Endocrine
Show Notes
Swami’s CoreEM Post
Hypocalcemia Repletion:
* IV calcium supplementation with 100-300 mg Ca2+ raises serum Ca2+ by 0.5 – 1.5 mEq
* For acute but mild symptomatic hypocalcemia: 200-1000mg calcium chloride IV or 1-2g IV calcium gluconate over 2 hours
* For severe hypocalcemia: 1g calcium chloride IV or 1-2g IV calcium gluconate IV over 10 minutes repeated q 60 min until symptoms resolve
References:
* Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008; 336:1298.
* Desai TK, Carlson RW, Geheb MA. Prevalence and clinical implications of hypocalcemia in acutely ill patients in a medical intensive care setting. Am J Med 1988; 84:209.
* Goltzman, D. Diagnostic approach to hypocalcemia. UpToDate. UpToDate; Jul 17, 2020. Accessed April 29, 2022. https://www.uptodate.com/contents/plantar-fasciitis
* Kelly A, Levine MA. Hypocalcemia in the critically ill patient. J Intensive Care Med 2013; 28:166.
* Pfenning CL, Slovis CM: Electrolyte Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 125: p 1636-53.
* Swaminathan, A. (2016, January 27). Hypocalcemia. CoreEM. Retrieved April 29, 2022, from https://coreem.net/core/hypocalcemia/
* Vantour L, Goltzman D. Regulation of calcium homeostasis. In: rimer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, 9th ed, Bilezikian JP (Ed), Wiley-Blackwell, Hoboken, NJ 2018. p.163.
Read MoreFri, 29 Apr 2022 - 9min - 191 - Podcast 185.0: Anticoagulation Reversal
How and when to reverse anticoagulation in the bleeding EM patient.
Hosts:
Joe Offenbacher, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/AC_reversal.mp3
Download
3 Comments
Tags: Anticoagulation, Critical Care, Resuscitation
Show Notes
Coagulation Cascade:
Algorithm for Anticoagulated Bleeding Patient in the ED:
Indications for Anticoagulation Reversal:
References:
Baugh CW, Levine M, Cornutt D, et al. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Ann Emerg Med. 2020;76(4):470-485. doi:10.1016/j.annemergmed.2019.09.001
Eikelboom JW, Quinlan DJ, van Ryn J, Weitz JI. Idarucizumab: The Antidote for Reversal of Dabigatran. Circulation. 2015 Dec 22;132(25):2412-22. doi: 10.1161/CIRCULATIONAHA.115.019628. PMID: 26700008.
Fariborz Farsad B, Golpira R, Najafi H, et al. Comparison between Prothrombin Complex Concentrate (PCC) and Fresh Frozen Plasma (FFP) for the Urgent Reversal of Warfarin in Patients with Mechanical Heart Valves in a Tertiary Care Cardiac Center. Iran J Pharm Res. 2015;14(3):877-885.
Fariborz Farsad B, Golpira R, Najafi H, et al. Comparison between Prothrombin Complex Concentrate (PCC) and Fresh Frozen Plasma (FFP) for the Urgent Reversal of Warfarin in Patients with Mechanical Heart Valves in a Tertiary Care Cardiac Center. Iran J Pharm Res. 2015;14(3):877-885.
Palta S, Saroa R, Palta A. Overview of the coagulation system. Indian J Anaesth. 2014;58(5):515-523. doi:10.4103/0019-5049.144643
Siegal DM, Curnutte JT, Connolly SJ, Lu G, Conley PB, Wiens BL, Mathur VS, Castillo J, Bronson MD, Leeds JM, Mar FA, Gold A, Crowther MA. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015 Dec 17;373(25):2413-24. doi: 10.1056/NEJMoa1510991. Epub 2015 Nov 11. PMID: 26559317.
Read MoreFri, 11 Feb 2022 - 21min - 190 - Episode 184.0 Ludwig’s Angina
A primer on this airway/ ID/ ENT emergency.
Hosts: Joe Offenbacher MD, A Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/ludwigs_2.mp3
Download
2 Comments
Tags: Airway, ENT, Infectious Diseases
Show Notes
References:
Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig’s Angina. Ann Maxillofac Surg 2015; 5:168.
Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis 2009; 13:327.
Brook I. Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin North Am. 2007 Jun;21(2):355-91, vi. doi: 10.1016/j.idc.2007.03.014. PMID: 17561074.
Chong W, Hijazi M, Abdalrazig M, Patil N. Respect the Floor of the Mouth. J Emerg Med. 2020 Jul;59(1):e27-e29. doi: 10.1016/j.jemermed.2020.04.015. Epub 2020 May 19. PMID: 32439254.
http://www.emdocs.net/ludwigs-angina-2/
Mohamad I, Narayanan MS. “Double Tongue” Appearance in Ludwig’s Angina. N Engl J Med 2019; 381:163.
Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J. 2004 Mar;21(2):242-3. doi: 10.1136/emj.2003.012336. PMID: 14988363; PMCID: PMC1726306.
Wolfe MM, Davis JW, Parks SN. Is surgical airway necessary for airway management in deep neck infections and Ludwig angina? J Crit Care. 2011 Feb;26(1):11-4. doi: 10.1016/j.jcrc.2010.02.016. PMID: 20537506.
Read MoreThu, 09 Dec 2021 - 9min - 189 - Episode 183.0 Pneumothorax
A quick overview of pneumothorax for the EM physician: the what, why, diagnosis, and treatment.
Hosts:
Joe Offenbacher, MD
Audrey Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumothorax_CoreEM_podcast.mp3
Download
One Comment
Tags: #pneumothorax #FOAMed
Show Notes
Shownotes:
CoreEM Pulmonary Ultrasound Post
References:
Bense L, Lewander R, Eklund G, et al. Nonsmoking, non-alpha 1-antitrypsin deficiency-induced emphysema in nonsmokers with healed spontaneous pneumothorax, identified by computed tomography of the lungs. Chest 1993; 103:433.
Bense L, Wiman LG, Hedenstierna G. Onset of symptoms in spontaneous pneumothorax: correlations to physical activity. Eur J Respir Dis 1987; 71:181.
Brown SGA, Ball EL, Perrin K, Asha SE, Braithwaite I, Egerton-Warburton D, Jones PG, Keijzers G, Kinnear FB, Kwan BCH, Lam KV, Lee YCG, Nowitz M, Read CA, Simpson G, Smith JA, Summers QA, Weatherall M, Beasley R; PSP Investigators. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020 Jan 30;382(5):405-415. doi: 10.1056/NEJMoa1910775. PMID: 31995686.
Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol 2013; 16:351.
Chan KK, Joo DA, McRae AD, et al. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev 2020; 7:CD013031.
Ebrahimi A, Yousefifard M, Mohammad Kazemi H, et al. Diagnostic Accuracy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffos 2014; 13:29.
Gobbel Jr WG, Rhea Jr WG, Nelson IA, Daniel RA. Spontaneous pneumothorax. J Thorac Cardiovasc Surg 1963; 46:331.
Lesur O, Delorme N, Fromaget JM, et al. Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax. Chest 1990; 98:341.
Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005; 33:1231.
Melton LJ 3rd, Hepper NG, Offord KP. Influence of height on the risk of spontaneous pneumothorax. Mayo Clin Proc 1981; 56:678.
Ohata M, Suzuki H. Pathogenesis of spontaneous pneumothorax. With special reference to the ultrastructure of emphysematous bullae. Chest 1980; 77:771.
Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000; 342:868.
Read MoreFri, 29 Oct 2021 - 13min - 188 - Episode 182.0 – Wellens
An interesting back story on this must-not-miss EKG finding in the ED!
Hosts:
Joseph Offenbacher, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/CoreEM_Wellens.mp3
Download
One Comment
Tags: #FOAMed, #wellens, Cardiology, EKG, STEMI
Show Notes
Hosts: Joe Offenbacher MD, Audrey Bree Tse MD
EKG Findings in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.
Table 1 in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.
REFERENCES:
de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.
Lee, M., & Chen, C. (2015). Myocardial Bridging: An Up-to-Date Review. Journal of Invasive Cardiology, 27(11), 521–528.
https://lifeinthefastlane.com/ecg-library/wellens-syndrome/
Lin AN, Lin S, Gokhroo R, Misra D. Cocaine-induced pseudo-Wellens’ syndrome: a Wellens’ phenocopy. BMJ Case Rep. 2017 Dec 14;2017:bcr2017222835. doi: 10.1136/bcr-2017-222835. PMID: 29246935; PMCID: PMC5753703.
Rhinehardt, J., Brady, W. J., Perron, A. D., & Mattu, A. (2002). Electrocardiographic manifestations of Wellens’ syndrome. The American Journal of Emergency Medicine, 20(7), 638–643.https://doi.org/10.1053/ajem.2002.34800
Tandy, TK; Bottomy DP; Lewis JG (March 1999). “Wellens’ syndrome”. Annals of Emergency Medicine. 33 (3): 347–351.PMID 10036351.doi:10.1016/S0196-0644(99)70373-2. (via Wikipedia)
Read MoreWed, 01 Sep 2021 - 8min - 187 - Episode 181.0: Subarachnoid Hemorrhage
We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage.
Hosts:
Mark Iscoe, MD
Brian Gilberti, MD
Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/SAH.mp3
Download
One Comment
Tags: Critical Care, Neurology, Subarachnoid Hemorrhage
Show Notes
Non-contrast head CT showing SAH (Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 22770)
Hunt-Hess grade and mortality (from Lantigua et al. 2015.)
Hunt-Hess grade
Mortality (%)
1. Mild Headache
3.5
2. Severe headache or cranial nerve deficit
3.2
3. Confusion, lethargy, or lateralized weakness
9.4
4. Stupor
23.6
5. Coma
70.5
Ottawa Subarachnoid Hemorrhage Rule, and appropriate population for rule application (from Perry et al. 2017)
Apply to patients who are:
* Alert
* ≥ 15 years old
* Have new, severe, atraumatic headache that reached maximum intensity within 1 hour of osnet
Do not apply to patients who have:
* New neurologic deficits
* Previous diagnosis of intracranial aneurysm, SAH, or brain tumor
* History of similar headaches (≥ 3 episodes over ≥ 6 months)
SAH cannot be ruled out if the patient meets any of the following criteria:
* Age ≥ 40
* Symptom of neck pain or stiffness
* Witnessed loss of consciousness
* Onset during exertion
* “Thunderclap headache” (defined as instantly peaking pain)
* Limited neck flexion on examination (defined as inability to touch chin to chest or raise head 3 cm off the bed if supine)
___________________________
Special Thanks To:
* Dr. Mark Iscoe, MD (Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue)
___________________________
References:
Bellolio MF, Hess EP, Gilani WI, et al. External validation of the Ottawa subarachnoid hemorrhage clinical decision rule in patients with acute headache. Am J Emerg Med. 2015;33(2):244-9.
Carstairs SD, Tanen DA, Duncan TD, et al. Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage. Acad Emerg Med. 2006;13(5):486-492.
Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711-1737.
Czuczman AD, Thomas LE, Boulanger AB, et al. Interpreting red blood cells in lumbar puncture: distinguishing true subarachnoid hemorrhage from traumatic tap. Acad Emerg Med. 2013;20(3):247-256.Thu, 04 Mar 2021 - 19min - 186 - Episode 180.0: Urine Tox Screens
We discuss the (F)utility(?) of ED Utox screens with our very own Dr. Phil DiSalvo.
Hosts:
Bree Tse, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Urine_Drug_Screen_final.mp3
Download
Leave a Comment
Tags: Toxicology
Show Notes
Special Thanks To:
Dr. Philip DiSalvo, MD
Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue
New York City Poison Control Center
References:
Christian MR, et al. Do rapid comprehensive urine drug screens change clinical management in children? Clin Toxicol (Phila). 2017;57:977-980.
Grunbaum AM, Rainey PM (2019). Chapter 7: Laboratory Principles. In Goldfrank’s toxicologic emergencies. New York, NY: McGraw-Hill Education.
Moeller K, Kissack J, Atayee R, Lee K. Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens. Mayo Clinic Proceedings Review. Volume 92, Issue 5, p774-796, May 1, 2017. https://www.mayoclinicproceedings.org/article/S0025-6196(16)30825-4/fulltext
Table 2: Approximate Drug Detection Time in the Urine
Table 4: Summary of Agents Contributing to Results by Immunoassay
Read MoreTue, 12 Jan 2021 - 19min - 185 - Episode 179.0 – Precipitous Breech Deliveries
EM management of the rare but potentially complicated precipitous vaginal breech delivery.
Hosts:
Audrey Bree Tse, MD
Masashi Rotte, MD MPH
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Breesashi_Breech_CoreEM.mp3
Download
One Comment
Tags: Obstetrics, Precipitous Deliveries, Pregnancy
Show Notes
Frank Breech Presentation:
Complete Breech Presentation:
Incomplete Breech (“Footling”) Presentation:
Pinard Maneuver:
Mauriceau Maneuver:
References:
Cunningham FG et al. Breech Presentation and Delivery. Williams Obstetrics, 22nd ed. 2005.
Desai S, Henderson SO. Labor and Delivery and Their Complications. Rosen’s Emergency Medicine, 8e. 2014. Chapter 181.
Gabbe SG et al. Obstetrics: Normal and Problem Pregnancies, 2nd e. 1991. p.479.
Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet Gynecol Clin North Am. 2005; 32: 165.
VanRooyen MJ, Scott J. Emergency Delivery. Tintanelli’s Emergency Medicine, 7th e. 2011. Chapter 105.
http://www.emdocs.net/the-complicated-delivery-what-do-you-do/#:~:text=Deliveries%20that%20occur%20in%20the,in%20denial%20of%20their%20pregnancies.
https://ranzcog.edu.au/womens-health/patient-information-resources/breech-presentation-at-the-end-of-your-pregnancy
https://wikem.org/wiki/Breech_delivery
Read MoreSun, 26 Jul 2020 - 14min - 184 - Episode 178.0 – Graduation Speech by Dr. Goldfrank
The speech given by Dr. Goldfrank at the 2020 NYU / Bellevue Emergency Medicine Graduation Ceremony
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Goldfrank_Graduation_Speech_2020.mp3
Download
Leave a Comment
Tags: Graduation. Goldfrank
Show Notes
Graduation 2020
Lewis R. Goldfrank, MD
June 17, 2020
WELCOME TO THE GRADUATES
Congratulations to a wonderful group of physicians. It is a pleasure to recognize your great accomplishments in the presence of your friends, families, loved ones and the residents and faculty who have learned so much from and with you. I would first like to recognize those of you who are members of the Gold Humanism Honor Society.
There are a remarkable number of awardees in our graduating class of 2020.
CLASS OF 2020
Joe Bennett (R)
Max Berger (R)
Ashley Miller (R)
Leigh Nesheiwat (S)
Kristen Ng (R)
Emily Unks (S)
AND
Arie Francis (R)
Nisha Narayanan (S)
FUTURE PGY-4
Elena Dimiceli (S)
Kamini Doobay (S)
Mark Iscoe (R)
FUTURE PGY-3
Stasha O’Callaghan (S)
Nicholus Warstadt (S)
FUTURE PGY-1
Aaron Bola (S)
Alison (Ali) Graebner (S)
Aron Siegelson (S)
Melissa Socarras (S)
Sarah Spiegel (S)
Thomas Sullivan (S)
Christy Williams (S)
GOLD HUMANISM CORE VALUES
Integrity, Excellence, Compassion, Altruism, Respect, Empathy, Service
These are the values you want as a doctor for yourself or a loved one,
* to have outstanding listening skills with patients
* to be at your side during a medical emergency,
* to have exceptional interest in service to the community,
* to have the highest standards of professionalism
* to integrate a humanistic approach in patient care.
These values are what brought all of you to NYU-Bellevue and that you have honed throughout your training. The remainder of this talk shows how all of you have been successful and demonstrated these values some of you were elected to the Gold Humanism—all of you have achieved humanistic success.
Your personal efforts in the face of uncertainty of the evolution of the pandemic, the inadequate supplies, the hospital and governmental problematic decisions are remarkable. In our country, the President did not mourn the loss of more than a 100,000 human beings and the needs of society. Nor did he provide the leadership and moral support that the country desperately needed to optimally handle this unprecedented crisis. You, in contrast, demonstrate unflappable commitment to address and overcome obstacles to care for your patients, assist your peers, educate and care for your families and friends, while also caring for yourselves. This is a tribute to your humanism. You created essential ways to help patients who were isolated from families and friends during the critical phases of COVID-19.Tue, 30 Jun 2020 - 5min - 183 - Episode 177.0 – Hemoptysis
An overview and management tips of hemoptysis in the ED.
Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hemoptysis.mp3
Download
One Comment
Tags: Critical Care, Pulmonary
Show Notes
OVERVIEW:
Definition:
expectoration/ coughing of blood originating from tracheobronchial tree
Sources:
Bronchial arteries (90%): under systemic circulatory pressure to supply supporting structures of the lung → heavier bleeding
Pulmonary arteries (5%): under low pressure to supply alveoli → milder bleeding
Nonbronchial arteries (5%): intercostal arteries, coronary arteries, thoracic/ upper/ inferior phrenic arteries
Quantification:
Mild: <20mL/ 24h
Massive defined anywhere from >300mL-1L/ 24hr
Mortality: 38% for massive (>500mL/ 24hr) vs 4.5% for nonmassive
Etiology (in adults):
Infectious (most common):
Bronchitis
PNA (necrotizing, lung abscess)
TB
Viral
Fungal
Parasitic
Malignancy:
Primary lung cancer vs metastatic disease
Pulmonary:
Bronchiectasis
COPD
PE/ infarction
Bronchopleural fistula
Sarcoidosis
Cardiac:
Mitral stenosis
Tricuspid endocarditis
CHF
Rheumatological:
Goodpasture Syndrome
SLE
Vasculitis (Wegener’s, HSP, Behcet)
Amyloidosis
Hematological:
Coagulopathy/ thrombocytopenia/ platelet dysfunction
DIC
Vascular:
Pulmonary HTN
AA
Pulmonary artery aneurysm
Aortobronchial fistula
Pulmonary angiodysplasia
Toxins:
Anticoagulation/ aspirin/ antiplatelets
Penicillamine, amiodarone
Crack lung
Organic solvents
Trauma:
Tracheobronchial rupture
Pulmonary contusion
Other:
bronchoscopy/ lung biopsy
Pulmonary artery or central venous catheterization
Foreign body aspiration
Pulmonary endometriosis (catamenial hemoptysis)
Idiopathic (up to 25% of cases)
Pseudohemoptysis:
Sinusitis
Epistaxis
Rhinorrhea
Pharyngitis
URI
Aspiration
GIB
WORKUP:
HPI:
CP, SOB
B symptoms: fever, weight loss, chills, night sweats
Lymphadenopathy
Timeframe: acute vs chronic
Prior lung/ renal/ cardiac disease
Recreational drug/ cigarette/ chemical exposures
travel/ infectious exposure
Medications
Any other sites of bleeding
Precipitating factors
Description of blood clotsMon, 17 Feb 2020 - 14min - 182 - Episode 176.0 – Pneumonia Updates
We go over the recent updates in the workup and management of pneumonia.
Hosts:
Brian Gilberti, MD
Audrey Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumonia_Updates.mp3
Download
Leave a Comment
Tags: Infectious Diseases, Pulmonary
Show Notes
2007 Infectious Diseases Society of America/American Thoracic Society Criteria for Defining Severe Community-acquired Pneumonia
Validated definition includes either one major criterion or three or more minor criteria
* Minor criteria
* Respiratory rate > 30 breaths/min PaO2/FIO2 ratio<250
Multilobar infiltrates Confusion/disorientation
* Uremia (blood urea nitrogen level > 20 mg/dl)
* Leukopenia* (white blood cell count , 4,000 cells/ml)
* Thrombocytopenia (platelet count , 100,000/ml)
* Hypothermia (core temperature , 368 C) Hypotension requiring aggressive fluid
* resuscitation
* Major criteria
* Septic shock with need for vasopressors
* Respiratory failure requiring mechanical ventilation
A special thanks to our Infectious Diseases Editor:
Angelica Cifuentes Kottkamp, MD
Infectious Diseases & Immunology
NYU School of Medicine
Read MoreMon, 27 Jan 2020 - 10min - 181 - Episode 175.0 – Posterior Circulation Stroke
Diagnosing and managing one of our critical diagnoses - posterior stroke.
Hosts:
Mukul Ramakrishnan, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/final_posterior_stroke_podcast_post_edit.mp3
Download
2 Comments
Tags: Neurology, Posterior Stroke
Show Notes
See Dr. Newman-Toker demonstrate the HINTS exam here
Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10
Read MoreMon, 13 Jan 2020 - 15min - 180 - Episode 174.0 – Homelessness
We discuss one of the most complex problems we face – Homelessness
Hosts:
Kelly Doran, MD
Audrey Tse, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Homelessness.mp3
Download
One Comment
Tags: Social Emergency Medicine
Show Notes
Special Thanks To:
Dr. Kelly Doran, MD MHS
Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue
___________________________
References:
Doran, K.M. Commentary: How Can Emergency Departments Help End Homelessness? A Challenge to Social Emergency Medicine. Ann Emerg Med. 2019;74:S41-S44.
Doran, K.M., Raven, M.C. Homelessness and Emergency Medicine: Where Do We Go From Here? Acad Emerg Med. 2018;25:598-600.
Salhi, B.A., et al. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med. 2018;25:577-93.
U.S. Department of Housing and Urban Development, Annual Homeless Assessment Report to Congress. Available at: https://www.hudexchange.info/resource/5783/2018-ahar-part-1-pit-estimates-of-homelessness-in-the-us/
U.S. Interagency Council on Homelessness. Home, Together Federal Strategic Plan to Prevent and End Homelessness. https://www.usich.gov/resources/uploads/asset_library/Home-Together-Federal-Strategic-Plan-to-Prevent-and-End-Homelessness.pdf
Read MoreMon, 16 Dec 2019 - 21min - 179 - Episode 173.0 – Blunt Neck Trauma
We go into one of the more complex injuries – blunt neck trauma.
Hosts:
Audrey Bree Tse, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blunt_Neck_Injuries.mp3
Download
One Comment
Tags: Trauma
Show Notes
Overview
Blunt neck trauma comprises 5% of all neck trauma
Mortality due to loss of airway more so than hemorrhage
Mechanism
MVCs with cervical hyperextension, flexion, rotation during rapid deceleration, direct impact
Strangulation: hanging, choking, clothesline injury (see section on strangulation in this chapter)
Direct blows: assault, sports, falls
Initial Management/Primary Survey
Airway
Evaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromise
Early aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema
Assume a difficult airway
* Breathing
Supplemental oxygen
Assess for bilateral breath sounds
Can use bedside US to evaluate for pneumothorax or hemothorax
* Circulation
Assess for open wounds, bleeding, hemorrhage
IV access
* Disability
Maintain C-spine immobilization
Calculate GCS
Look for seatbelt sign
Secondary Survey
Evaluate for specific signs of vascular, laryngotracheal, pharyngoesophageal, and cervical spinal injuries with inspection, palpation, and auscultation
Perform extremely thorough exam to evaluate for any concomitant injuries (e.g. stab wounds, gunshot wounds, intoxications/ ingestions, etc.)
Types of Injuries
Vascular injury
Overview
Carotid arteries (internal, external, common carotid) and vertebral arteries injured
Mortality rate ~60% for symptomatic blunt cerebral vascular injury
Mechanism
Hyperextension and lateral rotation of the neck, direct blunt force, strangulation, seat belt injuries, and chiropractic manipulation
Morbidity due to intimal dissections, thromboses, pseudoaneurysms, fistulas, and transections
Clinical Features
Most patients are asymptomatic and do not develop focal neurological deficits for days
if Horner’s syndrome, suspect disruption of thoracic sympathetic chain (wraps around carotid artery)
specific screening criteria are used to detect blunt cerebrovascular injury in asymptomatic patients (see below)
Tintinalli 2016
Diagnostic Testing
Gold standard for blunt cerebral vascular injury = MDCTA (multidetector four-vessel CT angiography)Mon, 25 Nov 2019 - 12min - 178 - Episode 172.0 – Ankle Sprains
We dissect one of the most common injuries we see in the ER -- ankle sprains
Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Ankle_Sprains.mp3
Download
3 Comments
Tags: Orthopedics
Show Notes
Background
* Among most common injuries evaluated in ED
* A sprain is an injury to 1 or more ligaments about the ankle joint
* Highest rate among teenagers and young adults
* Higher incidence among women than men
* Almost a half are sustained during sports
* Greatest risk factor is a history of prior ankle sprain
Anatomy
* Bone: Distal tibia and fibula over the talus → constitutes the ankle mortise
* Aside from malleoli, ligament complexes hold joint together
* Medial deltoid ligament
* Lateral ligament complex
* Anterior talofibular ligament
* Most commonly injured
* Weakest
* 85% of all ankle sprains
* Posterior talofibular ligament
* Calcaneofibular ligament
* Syndesmosis
Mechanism of Injury
* Lateral ankle sprains
* Most common among athletes
* ATFL most commonly injured
* Combined with CFL in 20% of injuries
* 2/2 inversion injuries
* Medial ankle sprains
* Less common than lateral because ligaments stronger and mechanism less frequent
* More likely to suffer avulsion fracture of medial malleolus than injure medial ligament
* 2/2 eversion +/- forced external rotation
* Typically landing on pronated foot -> external rotation
* High Ankle sprains
* Syndesmotic injury
* More common in collision sports (football, soccer, etc)
* Grade I
* Mild
* Stretch without “macroscopic” tearing
* Minimal swelling / tenderness
* No instability
* No disability associated with injury
* Grade II
* Moderate
* Partial tear of ligament
* Moderate swelling / tenderness
* Some instability and loss of ROM
* Difficulty ambulating / bearing weight
* Grade III
* Severe
* Complete rupture of ligaments
* Extensive swelling / ecchymosis / tenderness
* Mechanical instability on exam
* Inability to bear weight
Examination
* Beyond visual inspection for swelling, ecchymoses, abrasions, or lacerations
* Palpation
* Pain when palpating ligament is poorly specific but may indicate injury to structure
* Check sites for Ottawa ankle rules to evaluate if there may be an associated fracture with injury
* Posterior edge or tip of lateral malleolus (6 cm)
* Posterior edger or tip of medial malleolus (6 ...Mon, 04 Nov 2019 - 11min - 177 - Episode 171.0 – Vaping Associated Lung Injury
An overview of Vaping Associated Lung Injury (VALI)
Hosts:
Audrey Bree Tse, MD
Larissa Laskowski, DO
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vaping_Associated_Lung_Injury.mp3
Download
2 Comments
Tags: Pulmonary, Toxicology
Show Notes
Why this matters
As of Oct 15, vaping has been associated with acute lung injury in over 1400 people
33 deaths have been confirmed in 24 states
70+% of those with VALI are young men
A large number of patients are requiring ICU/ intubation/ ECMO
4 main ingredients in solvent
+/- Flavor additives
+/- Nicotine or THC (Tetrahydrocannabinol)
Propylene Glycol (PG)
Vegetable Glycerin (VG)
CDC definition of VALI (Vaping Associated Lung Injury)
Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset AND
Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT AND
Absence of pulmonary infection on initial work-up.
No evidence in the medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process).
*Dabbing allows the user to ingest a high concentration of THC. Butane Hash Oil (BHO), an oil or wax-like substance extracted from the marijuana plant, is placed on a “nail” attached to a specialized glass bong called a “rig.” A blow torch is used to heat the wax, which produces a vapor that can then be inhaled to supposedly produce an instantaneous effect.
Pathophysiology
At present, no single compound or ingredient has emerged as the cause, and there may be more than one cause
The only common thread among the cases is that ALL patients reported using e-cig or vaping products
Leading potential toxins:
Vaping products containing THC concentrates: most cases are linked to THC concentrates that were either purchased on the street or from other informal sources (meaning not from a dispensary)
Vitamin E acetate: nutritional supplement safe when ingested or applied to the skin (but likely not when inhaled) has been found in nearly all product samples of NY state cases of suspected VALI
vitamin E acetate is NOT an approved additive at least by NYS Medical Marijuana program
Other potential toxins:
IT CANNOT BE UNDERSTATED that a small percentage of persons w/ VALI have reported exclusive use of nicotine-containing vape products, such as JUUL; as such, we must consider the potential toxicity of standard e-liquid or vape juice
Flavor additives, that exists as chemical aldehydes: irritating and potentially damaging to lung tissue
PG/VG: shown not only to break down to formaldehyde which is a known carcinogen,Mon, 21 Oct 2019 - 16min - 176 - Episode 170.0 – Septic Arthritis
An overview of septic arthritis.
Hosts:
Audrey Bree Tse, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Arthritis.mp3
Download
One Comment
Tags: Infectious Diseases, Orthopedics
Show Notes
Episode Produced by Audrey Bree Tse, MD
Background
Bacteria enters the joint by hematogenous spread due to absence of basement membrane in synovial space from invasive procedures, contiguous infection (e.g. osteomyelitis, cellulitis), or direct inoculation (e.g. plant thorns, nails)
WBCs migrate into joint → acute inflammatory process → synovial hyperplasia, prevents new cartilage from forming, pressure necrosis on surrounding joint, purulent effusion
Why do we care?
irreversible loss of function in up to 10% & mortality rate as high as 11%
Cartilage destruction can occur in a matter of hours
Complications include bacteremia, sepsis, and endocarditis
Etiology
Risk factors: extremes of age, RA, DJD, IVDA, endocarditis, GC, immunosuppression, trauma, or prosthesis
Organisms:
Staph: staph aureus (most common), MRSA, Staph epidermis
N gonorrhea: young healthy sexually active adults
Strep: group A & B
GNRs: IVDA, diabetics, elderly
Salmonella: sickle cell disease
Cutibacterium acnes: prosthetic shoulder infection
Consider mycobacterial & fungal in more indolent courses
Presentation
Typically a single, warm, erythematous, tender joint (#1: knee (50% of cases) → hip, shoulder, ankle)
*Any joint can be involved!
IVDA can involve sacroiliac, costochondral, & sternoclavicular joints
Classic teaching: very painful with ROM, but this is not always present!
Joint usually held in position of maximum joint volume
Prosthetic joints may have less pain than expected for a septic joint given changed anatomy and disrupted nerve endings
In 10-20% of cases, can see polyarticular involvement
GC typically monoarticular but commonly polyarticular
Often have fever & separate infection as well (only see fever in ~60% of cases)
Diagnostics
Arthrocentesis:
Gold standard
Tap joint even if acceptable ROM: septic joints can have normal motion so it does not exclude the diagnosis!
Use ultrasound if possible
Relative contraindications: overlying cellulitis (risk of seeding joint) or severe coagulopathies (weigh risk of creation or worsening of iatrogenic hemarthrosis)
Keep in mind that a “dry tap” may occur due to incorrect needle placement, absent/ minimal joint effusion, ort mechanical obstruction
Note: talk to ortho colleagues if prosthesis present prior to performing arthrocentesis
Mon, 23 Sep 2019 - 11min - 175 - Episode 169.0 – Febrile Seizures
A look at the most common type of seizures in the young pediatric population.
Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Febrile_Seizures.mp3
Download
Leave a Comment
Tags: Pediatrics
Show Notes
Background
* The most common type of seizure in children under 5 years of age
* Occur in 2-5% of children
* In children with a fever, aged 6 months to 5 years of age, and without a CNS infection
* Risk Factors
* 4 times more likely to have a febrile seizure if parent had one
* Also increase in risk if siblings or nieces / nephews had one
* Common associated infections
* Human Herpesvirus 6
* Human Herpesvirus 7
* Influenza A & B
* Simple Febrile Seizure
* Generalized tonic-clonic activity lasting less than 15 minutes in a child 6 months to 5 years of age
* Complex Febrile Seizure
* Lasts longer than 15 minutes, occurs in a child outside of this age range, are focal, or that recur within a 24-hour period.
Diagnostics / Workup
* Gather thorough history and perform thorough physical exam
* Most cases will not require labs, imaging or EEG
* If e/o meningitis, perform LP
* AAP suggests considering LP in:
* Children 6-12 months who are not immunized for H flu type B or strep pneumo
* Children who had been on antibiotics
* For complex seizures, clinician may have a lower threshold for obtaining labs
* Hyponatremia is more common in this group than in the general population.
* LPs are more commonly done by providers, but these are low yield with one study showing bacterial meningitis being diagnosed in just 0.9% (Kimia 2010), all of whom did not have a normal exam or negative cultures.
* Neuroimaging is also exceedingly low yield if the patient returns to baseline (Teng 2006)
* One study that showed that the duration of complex febrile seizure, being greater than 30 minutes, was associated with a higher incidence of bacterial meningitis. (Chin 2005)
* Of they have history and exam concerning for meningitis, they should get an LP
* If they look dehydrated or edematous, you would have more of a reason to get a chemistry
Treatment
* Benzodiazepine if seizure lasted for >5 minutes, either IV or IN
* Supportive care
* Tylenol or motrin if febrile
* Fluids if signs of dehydration
* Antipyretics “around the clock”
* A majority of data show no benefit in preventing recurrence of seizure
* One study (Murata 2018) found that giving tylenol q6h at 10 mg/kg for the first 24 hours following the initial seizure decreased the rate of recurrence when compared to children who did not receive antipyretics.
* NNT here was 7Mon, 26 Aug 2019 - 9min - 174 - Episode 168.0 – Lyme Disease
A review for the emergency physician of this common tick-borne illness.
Hosts:
Audrey Bree Tse, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Lyme_Disease.mp3
Download
Leave a Comment
Tags: Infectious Diseases
Show Notes
Episode Produced by Audrey Bree Tse, MD
Background
* Most common tick-born illness in North America
* Endemic in Northeast, Upper Midwest, northwest California
* 80% to 90% in summer months
Pathophysiology
* Ixodes tick (deer tick) has a 3-stage life cycle (larvae, nymph, adult) & takes 1 blood meal per stage
* Deer tick feeds on an infected wild animal (infected with spirochete Borrelia burgodrferi) then bites humans
* On humans, they typically move until they encounter resistance (e.g. hairline, waistband, elastic, skin fold). It takes 24-48 hrs for B. Burgdorferi to move from the tick to the host
* Pathogenesis: organism induced local inflammation, cytokine release, autoimmunity
* No person to person transmission
Clinical Presentation
Stage 1: Early
* Symptom onset few days to a month after tick bite
* Erythema migrans rash: bulls eye rash seen in more than 90% of patients with Lyme disease (Irregular expanding annular lesion(s))
* Regional adenopathy, intermittent fevers, headache, myalgias, arthralgia, fatigue, malaise
Stage 2: disseminated/ secondary
* Days to weeks after tick bite
* Intermittent fluctuating sx that eventually resolve
* Triad of aseptic meningitis, cranial neuritis, and radiculoneuritis: bell palsy most common
* Cardiac symptoms: tachycardia, bradycardia, AV block, myopericarditis
Stage 3: tertiary/ late
* Symptoms occur >1 year after tick bite
* Acrodermatitis chronic atrophicans: Atrophic lesions on extensor surfaces of extremities (resembles scleroderma)
* Monoarthritis, oligoarthritis (knee > shoulder > elbow)
* GI: Hepatitis, RUQ pain
* Ocular: keratitis, uveitis, iritis, optic neuritis
* Neurological: Chronic axonal polyneuropathy or encephalopathy
Chronic Lyme disease (versus well-accepted Lyme disease sequelae):
* Continuation of symptoms after antibiotics
* Current recommendation for management is supportive care only
Pediatric considerations:
* More likely to be febrile than adults
* Facial palsy accompanied by aseptic meningitis in 1/3
* Untreated kids can develop keratitis
* Excellent prognosis if appropriately treated
History
* Travel, camping, woods, playing under leaves or in wood piles
* Living in endemic area (Northeastern area: Maine to Virginia; upper Midwestern: Wisconsin, Minnesota; Northwest California)
* Endemic in Northern Europe and Eastern Asia as well
* History of tick bite (- 30-50% of patients recall tick bite)Tue, 30 Jul 2019 - 15min - 173 - Episode 167.0 – Malaria
An in depth review of this notorious parasite.
Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Malaria.mp3
Download
Leave a Comment
Tags: Infectious Diseases
Show Notes
Background
* In 2017, there were 219 million cases and 435,000 people deaths from malaria
* Five species: Falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi.
* Falciparum, Vivax and Knowlesi can be fatal
* History of recent travel to Africa (69% of cases in US), particularly to west-Africa should raise suspicion for malaria
Clinical Manifestations
* Average incubation period for Falciparum is 12 days
* 95% will develop symptoms within 1 month
* Clinical findings with high likelihood ratios include periodic fevers, jaundice, splenomegaly, pallor.
* Can also have vomiting, headache, chills, abdominal pain, cough, and diarrhea
* Severe malaria has a mortality of 5% to 30%, even with therapy
* Diagnostic criteria for severe malaria:
Ashley 2018
* Most common manifestations of severe malaria affect the brain, lungs, and kidneys
* Patients with cerebral malaria can present encephalopathic or comatose, some severe enough to exhibit extensor posturing, or seizures
* Can have acute lung injury with a quarter of these patients progressing to ARDS
* Can have AKI from ATN and resultant acidosis
* Labs may be unremarkable but watch for anemia and thrombocytopenia
* Hgb <5 has an OR = 4.9 for death
* Severe thrombocytopenia has an OR = 2.8
* Anemia + Thrombocytopenia has an OR = 13.8 (Lampah 2015, PMID25170106)
* Watch for hypoglycemia
* Be mindful of co-infection with salmonella and HIV
* Obtain BCx, cover with ceftriaxone
Diagnosis
* Blood smear
* Thick smear to increase sensitivity for detecting parasites
* Thin smear for quantifying parasitemia and species
* The first smear is positive in over 90% of cases, but if suspicion is high, it has to be repeated BID for 2-3 days for proper exclusion of malaria (CDC 2019)
Management
* For uncomplicated, non-severe cases, most patients with falciparum should be admitted, especially those with no prior exposure to malaria parasites
* Malarone is one of the first line options
* Check out other suggested regimens from the CDC
* Important to note that when they take this, ensure they take with milk or food containing fat to enhance absorption
* Severe Malaria
Mon, 15 Jul 2019 - 9min - 172 - Episode 166.0 – Acute Otitis Media
A look at this common and controversial topic.
Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Otitis_Media.mp3
Download
Leave a Comment
Tags: Pediatrics
Show Notes
Background:
* The most common infection seen in pediatrics and the most common reason these kids receive antibiotics
* The release of the PCV (pneumococcal conjugate vaccine), or Prevnar vaccine, has made a big difference since its release in 2000 (Marom 2014)
* This, along with more stringent criteria for what we are calling AOM, has led to a significant decrease in the number of cases seen since then
* 29% reduction in AOM caused by all pneumococcal serotypes among children who received PCV7 before 24 months of age
* The peak incidence is between 6 and 18 months of age
* Risk factors: winter season, genetic predisposition, day care, low socioeconomic status, males, reduced duration of or no breast feeding, and exposure to tobacco smoke.
* The predominant organisms: Streptococcus pneumoniae, non-typable Haemophilus influenzae (NTHi), and Moraxella catarrhalis.
* Prevalence rates of infections due to Streptococcus pneumoniae are declining due to widespread use of the Prevnar vaccine while the proportion of Moraxella and NTHi infection increases with NTHi now the most common causative bacterium
* Strep pneumo is associated with more severe illness, like worse fevers, otalgia and also increased incidence of complications like mastoiditis.
Diagnosis
* The diagnosis of acute otitis media is a clinical one without a gold standard in the ED (tympanocentesis)
* Ear pain (+LR 3.0-7.3), or in the preverbal child, ear-tugging or rubbing is going to be the most common symptom but far from universally present in children. Parents may also report fevers, excessive crying, decreased activity, and difficulty sleeping.
* Challenging especially in the younger patient, whose symptoms may be non-specific and exam is difficult
* Important to keep in mind that otitis media with effusion, which does not require antibiotics, can masquerade as AOM
AAP: Diagnosis of Acute Otitis Media (2013)*
* In 2013, the AAP came out with a paper to help guide the diagnosis of AOM
* Moderate-Severe bulging of the tympanic membrane or new-onset otorrhea not due to acute otitis externa (grade B)
* The presence of bulging is a specific sign and will help us distinguish between AOM and OME, the latter has opacification of the tympanic membrane or air-fluid level without bulging (Shaikh 2012, with algorithm)
* Bulging of the TM is the most important feature and one systematic review found that its presence had an adjusted LR of 51 (Rothman 2003)
* Classic triad is bulging along with impaired mobility and redness or cloudiness of TM
Mon, 01 Jul 2019 - 9min - 171 - Episode 165.0 – Foot Fractures
A look at foot fractures – which can be splinted and which may need the OR.
Hosts:
Audrey Bree Tse, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Foot_Fractures.mp3
Download
Leave a Comment
Tags: Orthopedics
Show Notes
Episode Produced by Audrey Bree Tse, MD
Background:
* Why do we care about Jones fractures?
* Propensity for poor healing due to watershed area of blood supply
* Fifth metatarsal fractures account for 68% of metatarsal fractures in adults
* Proximal 5th metatarsal fractures are divided into 3 zones (93% zone 1, 4% zone 2, 3% zone 3)
* Zone 1 (pseudo-Jones):
* Tuberosity avulsion fracture
* Typically avulsion type injuries due to acute episode of forefoot supination with plantar flexion
* Typical fracture pattern is transverse to slightly oblique
* Zone 2 (Jones fracture):
* Fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal
* Typically acute episode of large adduction force applied to forefoot with the ankle plantar flexed
* Zone 3:
* Proximal diaphyseal stress fracture
* Typically results from a fatigue or stress mechanism
Clinical Presentation:
* History of acute or repetitive trauma to forefoot
* Fracture type / pattern closely related to injury location
* Foot often swollen, ecchymotic, very tender to fifth metatarsal +/- crepitus, inability to hear weight
Diagnosis:
* Clinical exam:
* Evaluate skin integrity
* Check neurovascular status
* Evaluate toes/ feet/ ankles/ tib fib/ knees/ hips, involved tendon function, associated adjacent structures (Achilles, ankle ROM/ function, etc)
* 3 XR views: lateral, anteroposterior, 45* oblique
* Acute stress fractures are typically not detected on the standard 3 views; therefore, repeat XRs 10-14d after onset of sx (may see radiolucent reabsorption gap around fracture)
* For more complex mid foot trauma, consider CT to r/o Lisfranc
Treatment:
* Consider classification of fracture, patient demographics & activity level when deciding on treatment
* Tertiary care centers that have access to Orthopedics/Podiatry services
* Consider consultation for “true” Jones fractures, as some cases may be operatively managed acutely and/or for expedited follow-up to be arranged
* If working in community/rural locations: other than patients that present with “open” injuries, concerns for compartment syndrome (almost never), and “high-end”/professional athletes, there are generally no other circumstances that would require expedited transfer to a tertiary care center for immediate further evaluation.
* Less favorable outcomes associated with certain patient factors: female gender, DM, obesity
Mon, 17 Jun 2019 - 14min - 170 - Episode 164.0 – Debriefing
A discussion with Drs. McNamara and Leifer on the essentials and beyond of debriefing
Hosts:
Brian Gilberti, MD
Audrey Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Debriefing.mp3
Download
One Comment
Tags: Resuscitation, Simulation
Show Notes
TAKE HOME POINTS
* Debriefing after a clinical case in the ED is a way to have an interprofessional, reflective conversation with a focus on improving for the next patient. We can debrief routine cases, challenging cases, or even cases that go well.
* Follow a structure when leading a debrief.
* The prebrief sets ground rules and informs the team that the debrief is optional and will only take 3-5 minutes.
* Introduce names and roles
* Then give a one-liner about what happened in the case, followed by a plus/ delta: address what went well and why, then how to improve
* Finally, wrap up with take home points
* Pitfalls to watch out for in clinical debriefing include:
* Avoid siloing or alienating any learners. Learn from all your colleagues on your team- it’s less about medicine and more about interprofessional and systems issues
* Don’t pick on individual performance. It’s not about shaming- it’s about improving patient care
* Avoid “guess what I’m thinking” questions; ask real questions
* Proceed with caution in order to dampen or avoid psychological trauma and second victim syndrome. The learner may ask “was this my fault?”; we never want a learner to feel this way. Ask, what systems supported or did not support you today? Talk about what happened. Avoid shame and blame.
* Have the right values and do it for the right reasons.
ADDITIONAL TOOLS
PEARLS Debriefing Tool
INFO Model:
GUESTS
Dr. Shannon McNamara completed residency in Emergency Medicine at Temple University hospital and fellowship in Medical Simulation at Mount Sinai St. Lukes-Roosevelt. She now is the Director of the Simulation Division in the NYU Department of Emergency Medicine. She’s thrilled to have somehow made a career out of teaching people to talk about their feelings using big computers shaped like people.
Dr. Jessica Leifer attended NYU for medical school and completed her residency training in emergency medicine at Mount Sinai St. Luke’s-Roosevelt. She completed a fellowship in medical simulation at the Mount Sinai Hospital. She is now simulation faculty in the NYU department of Emergency Medicine. Her academic interests include using simulation for patient safety, operations, and improving teamwork.
Read MoreMon, 03 Jun 2019 - 27min - 169 - Episode 163.0 – Croup
A look at one of the most common and potentially concerning upper respiratory infections in children.
Host:
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Croup.mp3
Download
One Comment
Tags: Airway, Infectious Diseases, Pediatrics
Show Notes
Background
* Croup is a viral infection starts in the nasal and pharyngeal mucosa but spreads to the larynx and trachea
* Subglottic narrowing from inflammation
* Dynamic obstruction
* Barking cough
* Inspiratory stridor
* Causes:
* Parainfluenza virus (most common)
* Rhinovirus
* Enterovirus
* RSV
* Rarely: Influenza, Measles
* Age range: 6 months to 36 months
* Seasonal component with high prevalence in fall and early winter
* Differential
* Bacterial tracheitis
* Acute epiglottitis
* Inhaled FB
* Retropharyngeal abscess
* Anaphylaxis
Presentation & Diagnosis
* Classically a prodrome of nonspecific symptoms for 1-3 days with low grade fevers, congestion, runny nose.
* Symptoms reach peak severity on the 4th day
* “Steeple sign” on Xray (subglottic narrowing) present in only 50% of patients with croup
* Assess air entry, skin color, level of consciousness, for tachypnea, if there are retractions / nasal flaring (if present at rest or with agitation) & coughing
* “Westley Croup Score” (https://www.mdcalc.com/westley-croup-score)
* Chest wall retractions
* Stridor
* Cyanosis
* Level of consciousness
* Air entry
Management
* Mild Croup
* Occasional barking cough, but no stridor at rest and mild to no retractions
* Tx: Single dose of dex
* Has been shown to improve severity and duration of symptoms
* Route is not particularly important, whether it’s PO, IV or IM
* Chosen route should aim to minimize agitation in the patient that might worsen their condition
* May be managed at with supportive care
* Humidifiers (NB: there isn’t good evidence supporting the use of humidifiers)
* Antipyretics
* PO fluids
* Moderate Group
* May have stridor at rest, mild-moderate retractions but no AMS and will not be in distress.
* Tx: Dex + Racemic Epinephrine
* Racemic epinpehrine will start to work in about 10 minutes
* Effects last for more than an hour
* Severe group
* Receives the same initial therapy as the moderate group with dex and race epi
* Pts with worrisome signs: stridor at rest, marked retraction, cyanosis and/or lethargy
* Heliox (a combinations of 70-80% helium + 20-30% oxygen) may be attempted
...Mon, 20 May 2019 - 6min - 168 - Episode 162.0 – Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED
https://media.blubrry.com/coreem/content.blubrry.com/coreem/SJS.mp3
Download
Leave a Comment
Tags: Critical Care, Dermatology
Show Notes
Episode Produced by Audrey Bree Tse, MD
* Rash with dysuria should raise concern for SJS with associated urethritis
* Dysuria present in a majority of cases
* SJS is a mucocutaneous reaction caused by Type IV hypersensitivity
* Cytotoxic t-lymphocytes apoptose keratinocytes → blistering, bullae formation, and sloughing of the detached skin
* Disease spectrum
* SJS = <10% TBSA
* TEN = >30% TBSA
* SJS/ TEN Overlap = 10-30% TBSA
* Incidence is estimated at around 9 per 1 million people in the US
* Mortality is 10% for SJS and 30-50% for TEN
* Mainly 2/2 sepsis and end organ dysfunction.
* SJS can occur even without a precipitating medication
* Infection can set it off especially in patients with risk factors including HIV, lupus, underlying malignancy, and genetic factors
* SATAN for the most common drugs
* Sulfa, Allopurinol, Tetracyclines, Anticonvulsants, and NSAIDS
* Anti-epileptics include carbamazepine, lamictal, phenobarb, and phenytoin
* Can have a curious course
* Hypersensitivity reaction can develop while taking medication, or even one to four weeks after exposure
* In pediatric population, mycoplasma pneumonia and herpes simplex have been identified as precipitating infections
* Patients often have a prodrome 1-3 days prior to the skin lesions appearing
* May complain of fever, myalgias, headaches, URI symptoms, and malaise
* Rash may be the sole complaint
* Starts as dark purple or erythematous lesions with purpuric centers that progress to bullae
* Skin surrounding the lesions detaches from the dermis with just light pressure (Nikolsky Sign)
* Up to 95% of patients will have mucous membrane lesions
* ~85% will have conjunctival lesions
* Symptoms: Burning or itching eyes, a cough or sore throat, pain with eating, pain with urinating or defecating
Source: JAMA Dermatol. 2017
* Differential Diagnosis: SSSS, autoimmune bullous diseases, bullous fixed drug eruption, erythema multiforme, thermal burns, phototoxic reactions, and TSS
* SJS is a clinical diagnosis
* Basic workup: CBC, chemistry panel, LFTs, and a UA
* Treatment
* Supportive care
* IV fluid repletion guided by TBSA affected, as well as electrolyte, protein, and energy supplementation
Mon, 06 May 2019 - 9min - 167 - Episode 161.0 – Opioid Epidemic
A look at the opioid epidemic and what ED providers can do to combat this formidable foe.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Opioid_Epidemic.mp3
Download
Leave a Comment
Tags: Opioid Dependence, Opioid Free ED
Show Notes
* Consider alternatives to opiates for acute pain
* NSAIDs
* Subdissociative ketamine
* Nerve blocks
* Curb misuse and diversion through prescribing a short supply and perform I-STOP checks
* Narcan is not just for acute overdose treatment by EMS or within the ED anymore
* We can equip patients, family members and friends with Narcan kits prior to discharge
* In New York state, can prescribe Narcan to patients with near fatal overdoses or who screen positive for an opioid use disorder
* Intranasal formulation is cheaper and more commonly prescribed than IM
* Buprenorphine induction can be done in the ED for patients in active withdrawal, as calculated by the COWS score.
* MDcalc calculator: https://www.mdcalc.com/cows-score-opiate-withdrawal
* Providers do not need an X-waiver to give a dose of Buprenorphine in the ED for 3 days
* Home induction can be considered for patients not actively withdrawing but would like to enter medication assisted treatment
* Some considerations:
* Contraindicated in patients with severe liver dysfunction and with hypersensitivity reaction to drug
* Oversedation can occur with concurrent use of benzodiazepines and alcohol
* Will precipitate withdrawal if concurrently using full opioid agonists
* Longitudinal care has to be established for patients started on Buprenorphine
* SAMHSA’s Buprenorphine practitioner locator site: https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator
* Buprenorphine Induction Pamphlet
Read MoreMon, 22 Apr 2019 - 14min - 166 - Episode 160.0 – Measles
In this episode, we discuss the recent measles outbreak and how ED providers can best prepare to treat this almost vanquished foe.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Measles_Final_Cut.mp3
Download
One Comment
Tags: Infectious Diseases, Pediatrics
Show Notes
Episode Produced by Audrey Bree Tse, MD
References:
CDC Measles for Health Care Providers. https://www.cdc.gov/measles/hcp/index.html#lab.
Gladwin M, Trattler B. Orthomyxo and Paramyxoviridae. In: Clinical Microbiology Made Ridiculously Simple. 4th ed. Miami, FL: MedMaster, Inc; 2009: 240-243.
Hussey G, Klein M. A Randomized, Controlled Trial of Vitamin A in Children with Severe Measles. N Engl J Med. 1990; 323: 160-164.doi: 10.1056/NEJM199007193230304.
Nir, Sarah Mailin and Gold, Michael. “An Outbreak Spreads Fear: Of Measles, of Ultra-Orthodox Jews, of Anti-Semitism.” New York Times [New York City] 03/29/2019. https://www.nytimes.com/2019/03/29/nyregion/measles-jewish-community.html
A massive thanks to:
Shweta Iyer, MD: NYU Langone 3rd year Pediatric Emergency Medicine Fellow.
Jennifer Lighter, MD: Assistant Professor of Pediatric Infectious Diseases, NYU School of Medicine.
Michael Mojica, MD: Associate Professor of Pediatric Emergency Medicine, NYU Langone Medical Center.
Michael Phillips, MD: Chief Hospital Epidemiologist, NYU Langone Medical Center.
Read MoreMon, 08 Apr 2019 - 12min - 165 - Episode 159.0 – Acute Decompensated Heart Failure
In this episode, we discuss acute decompensated heart failure and how to best manage these dyspneic patients in the ED.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_ADHF.mp3
Download
Leave a Comment
Tags: Cardiology, Respiratory
Show Notes
* Features that increase the probability of heart failure. (Wang 2005)
* B-lines seen in pulmonary edema.
* Positioning of ultrasound probe in BLUE protocol. (Lichtenstein 2008)
Read MoreFri, 22 Mar 2019 - 5min - 164 - Episode 158.0 – Boxer’s Fracture
In this episode, we discuss Boxer's fractures and how to best manage them in the ED.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Boxer_s_Fracture_eq.m4a
Download
One Comment
Tags: Orthopedics, Trauma
Podcast Video
https://youtu.be/UreET5eLHas
Show Notes
Background:
* 40% of all hand fractures
* A metacarpal fracture can occur at any point along the bone (head, neck, shaft, or base)
* “Boxer’s” fractures classically at neck
* Most common mechanism: direct axial load with a clenched fist
* Most common metacarpal injured is the 5th
* A majority of these injuries are isolated injuries, closed and stable
Examination:
* Ensure that this is an isolated injury
* May note a loss of knuckle contour or shortening
* A thorough evaluation of the skin is important
* Patients may also have fight bites and require irrigation and antibiotics
* Tender along the dorsum of the affected metacarpal
* Evaluate the range of motion as the commonly seen shortening results in extension lag
* For every 2 mm of shortening there is going to be a 7 degree decrease in ability to extend the joint
* Check rotational alignment of digits with the MCP and PIP at 50% flexion.
* Partially clench their fist and ensure that the axis of each digit converges near the scaphoid pole / mid wrist
* Deformity is often seen due to the imbalance of volar and dorsal forces
* Dorsal angulation
* AP, lateral and oblique views should be obtained on XR
* The degree of angulation is estimated with the lateral view
* NB: Normal angle between the metacarpal head and neck is 15 degrees
Management:
* Most may be splinted with an ulnar gutter splint
* Must be closed, not significantly angulated, and not malrotated
* When splinting, place the wrist in slight extension, MCP (knuckles) at 90 degrees and the DIP and PIP in a relaxed, slightly flexed position
* A closed reduction is indicated if there is significant angulation
* “20, 30, 40” rule
* If angulation is more than:
* 20 in the middle finger metacarpal
* 30 in the ring finger metacarpal
* 40 in the pinky finger metacarpal
* Analgesia with a hematoma block or ulnar nerve block
* Reduction technique: https://www.aliem.com/2013/01/trick-of-trade-reducing-metacarpal/
Referral:
* May have mild deformity or decreased functionality and strength in hand grip after this injury
* Emergent evaluation if:
* Open fractureFri, 08 Mar 2019 - 5min - 163 - Episode 157.0 – Farewell
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_157_0_Final_Cut.m4a
Download
5 Comments
Read MoreMon, 13 Aug 2018 - 2min - 162 - Episode 156.0 – Updates in Community Acquired Pneumonia
This week we dive into a recent article highlighting a major update in the treatment of community acquired pneumonia (CAP)
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_156_0_Final_Cut.m4a
Download
Leave a Comment
Tags: CAP, Macrolides, Pulmonary
Show Notes
Read More
REBEL EM: Update in Community Acquired Pneumonia (CAP) Treatment – Macrolide Resistance
Moran GJ, Talan, DA; Pneumonia, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 76: p 978-89.
Haran JP et al. Macrolide resistance in cases of community-acquired bacterial pneumonia in the emergency department. J Emerg Med 2018. PMID: 29789175
Mandell LA et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27–72. PMID: 17278083
Arnold FW et al. A worldwide perspective of atypical pathogens in community-acquired pneumonia. AmJ Respir Crit Care Med 2007;175:1086–93. PMID: 17332485
Read MoreMon, 30 Jul 2018 - 5min - 161 - Episode 155.0 – Journal Update
This week we discuss three recent articles looking at esmolol in refractory VF, c-spine clearance and antibiotics after abscess drainage
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_155_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Cardiac Arrest, Cervical Spine, Esmolol, I+D, Infectious Diseases, Journal Club, MRSA, Refractory VF, Trauma
Show Notes
Read More
REBEL EM: Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses
Bryan Hayes at ALiEM: Sulfamethoxazole-Trimethoprim for Skin and Soft Tissue Infections: 1 or 2 Tablets BID?
The SGEM: SGEM#164: Cuts Like a Knife
Core EM: Antibiotics in the Treatment of Smaller Abscesses
EM Nerd: The Case of the Pragmatic Wound
REBEL EM: Refractory ventricular fibrillation
Resus.ME: Esmolol for Refractory VF
Read MoreMon, 23 Jul 2018 - 12min - 160 - Episode 154.0 – Femoral Shaft Fractures
This week we review femoral shaft fractures with a focus on assessment and analgesia
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_154_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Femoral Nerve Blocks, Orthopedics
Show Notes
Read More
Orthobullets Femoral Shaft Fracture
Rosen’s Emergency Medicine Concepts and Clinical Practice(link)
Tintinalli’s Emergency Medicine(link)
Femoral Nerve Block video (link)
Read MoreMon, 16 Jul 2018 - 5min - 159 - Episode 153.0 – Morning Report Pearls VI
More amazing pearls from our Bellevue morning report series.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_153_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Alcohol Intoxication, Discitis, ESRD, Necrotizing Fasciitis
Show Notes
Read More
Core EM: Spinal Epidural Abscess
REBEL EM: Cauda Equina Syndrome
Radiopaedia: Discitis
LITFL: Necrotizing Fasciitis
REBEL Cast: Episode 50 – Intoxicated Patients Can Equal Badness
Read MoreMon, 09 Jul 2018 - 9min - 158 - Episode 152.0 – Penetrating Neck Trauma
This week, we discuss penetrating neck trauma and some pearls and pitfalls in management.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_152_0_Final_Cut.m4a
Download
One Comment
Tags: Neck Trauma, Trauma
Show Notes
REBEL EM: Penetrating Neck Injuries
Zone 1
Zone 2
Zone 3
Anatomic Landmarks
Clavicle/Sternum to Cricoid Cartilage
Cricoid Cartilage to the Angle of the Mandible
Superior to the Angle of the Mandible
Anatomic Structures in Zone
Proximal Common Carotid Artery
Carotid Artery
Vertebral Artery
Subclavian Artery
Vertebral Artery
Distal Carotid Artery
Vertebral Artery
Jugular Vein
Distal Jugular Vein
Lung Apices
Pharynx
Salivary and Parotid Glands
Trachea
Trachea
Cranial Nerves IX – XII
Thyroid
Esophagus
Spinal Cord
Esophagus
Larynx
Thoracic Duct
Vagus Nerve
Spinal Cord
Recurrent Laryngeal Nerve
Spinal Cord
Hard + Soft Signs of Major Aerodigestive or Neurovascular Injury
Hard Signs
Soft Signs
Airway Compromise
Hemoptysis
Expanding or Pulsatile Hematoma
Oropharyngeal Blood
Active, Brisk Bleeding
Dyspnea
Hemorrhagic Shock
Dysphagia
Hematemesis
Dysphonia
Neurologic Deficit
Nonexpanding Hematoma
Massive Subcutaneous Emphysema
Chest Tube Air Leak
Air Bubbling Through Wound
Subcutaneous or Mediastinal Air
Vascular Bruit or Thrill
Crepitus
WTA Management Algorithm for Penetrating Neck Injury (Sperry 2013)Mon, 02 Jul 2018 - 14min - 157 - Episode 151.0 – Cauda Equina Syndrome
This week we discuss the difficult to diagnose and high morbidity cauda equina syndrome.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_151_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Back Pain, Cauda Equina
Show Notes
Take Home Points
Cauda equina syndrome is a rare emergency with devastating consequences
Early recognition is paramount as the presence of bladder dysfunction portends bad functional outcomes
The presence of bilateral lower extremity weakness or sensory changes should alert clinicians to the diagnosis. Saddle anesthesia (or change in sensation) and any bladder/bowel changes in function should also raise suspicion for the disorder
MRI is the diagnostic modality of choice though CT myelogram can be performed if necessary
Prompt surgical consultation is mandatory for all patients with cauda equina syndrome regardless of symptoms at presentation
Read More
EM Cases: Best Case Ever 11: Cauda Equina Syndrome
OrthoBullets: Cauda Equina Syndrome
Radiopaedia: Cauda Equina Syndrome
Perron AD, Huff JS: Spinal Cord Disorders, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 106: p 1419-30.
References
Lavy C et al. Cauda Equina Syndrome. BMJ 2009; 338: PMID: 19336488
Todd NV. Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurg 2005;19:301-6 PMID: 16455534
Read MoreMon, 25 Jun 2018 - 5min - 156 - Episode 150.0 – Journal Update
This week we review some recent publications on steroids in pharyngitis and the VAN assessment in stroke.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_150_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Pharyngitis, Steroids, VAN Assessment
Show Notes
Read More
The SGEM: SGEM #203: Let Me Clear My Sore Throat with a Corticosteroid
Core EM: Corticosteroids in Pharyngitis – Systematic Review + Meta-Analysis
REBEL EM: Does it Take a VAN to Identify Emergency Large Vessel Occlusion (EVLO) in Ischemic Stroke?
REBEL EM: Stroke Workflow in 2018
Stroke Workflow 2017 (REBEL EM)
References
Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials BMJ 2017; 358 :j3887. PMID: 28931508
Teleb MS et al. Stroke vision, aphasia, neglect (VAN) assessment – a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. J Neurointervent Surg 2017; 9(2): 122-6. PMID: 26891627
Read MoreMon, 18 Jun 2018 - 8min - 155 - Episode 149.0 – Simplified Approach to Peds Trauma
This week the podcast features a lecture from Dr. Frosso Admakos - Assistant Residency Director at Metropolitan Hospital in NYC
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_149_0_Final_Cut.m4a
Download
One Comment
Tags: All NYC EM, Pediatrics, Trauma
Show Notes
Take Home Points
While peds traumas and severe traumas are uncommon, stay cool and collected – you’ve run many resuscitations in the past and resuscitating a kid is no different. You’ve got this
When it comes to access, think 1, 2 IO. 2 shots at a peripheral line and if you don’t get it, go to IO
Tachycardia should be assumed to be compensated shock until proven otherwise. Don’t write tachycardia off as anxiety
Failed airway approach – place an 18 gauge catheter into the neck – hopefully through the cricothyroid membrane and bag through that. If you still have difficult getting an airway from above, consider a retrograde intubation over a wire
Read More
University of Maryland EM: Retrograde Intubation
Read MoreMon, 11 Jun 2018 - 15min - 154 - Episode 148.0 – ACEP VTE Clinical Policy 2018
This episode reviews the highlights from the recent ACEP clinical policy on acute VTE management in the ED.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_148_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Deep Venous Thrombosis, DVT, PE, Pulmonary Embolism, VTE
Show Notes
Take Home Points
The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing.
Age-adjusted D-dimers are ready for use and it doesn’t matter if your assay uses FEU (cutoff 500) or DDU (cutoff 250). For FEU use an upper limit of 10 X age and for DDU use an upper limit of 5 X age.
For now, subsegmental PEs should continue to routinely be anticoagulated even in the absence of a DVT. Keep an eye out for more research on this area.
Although outpatient management of select PE patients (using sPESI or Hestia criteria) may be standard practice, the evidence wasn’t strong enough for ACEP to give it’s support
Patients with DVT can be started on a NOAC and discharged from the ED
sPESI Tool (MDCalc.com)
PERC Decision Tool (MDCalc.com)
Read More
REBEL EM: ACEP Clinical Policy on Acute VTE 2018
Core EM: PE Rule-Out Criteria RCT
Core EM: Age-Adjusted D-dimer (Using D-dimer Units)
Core EM: Age Adjusted D-dimer in PE – The ADJUST-PE Trial
REBEL EM: Is It PROER to PERC It Up
References
ACEP Clinical Policies Subcommittee. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71(5): e59-109. PMID: 29681319
Jaconelli T, Eragat M, Crane S. Can an age-adjusted D-dimer level be adopted in managing venous thromboembolism in the emergency department? A retrospective cohort study. European journal of emergency medicine : official journal of the Eur Soc Emerg Med. 2017. PMID: 28079562
Freund Y et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA 2018; 319(6): 559-66. PMID:Mon, 04 Jun 2018 - 10min - 153 - Episode 147.0 – Salicylate Toxicity
This episode reviews the identification and management of patients with salicylate toxicity.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_147_0_Final_Cut.m4a
Download
4 Comments
Tags: Aspirin, Salicylate, Toxicology
Show Notes
Take Home Points
Always consider salicylate toxicity:
In patients with tachypnea, hyperpnea, AMS and clear lungs
In the presence of an anion gap metabolic acidosis with a respiratory alkalosis
Treat salicylate toxicity by alkalinizing the blood and urine to increase excretion
Avoid intubation until absolutely necessary. If you do have to intubate, minimize apneic time and consider awake intubation and nake sure your ventilator settings match the patient’s necessary high minute ventilation
Think about chronic salicylate toxicity in unexplained altered mental status, tachypnea or metabolic acidosis in elderly
Know indications for hemodialysis in salicylate toxic patients
Read More
REBEL EM: Salicylate Toxicity
LITFL: Salicylates
Wiki EM: Salicylate Toxicity
Rebel EM: Acute Salicylate Toxicity, Mechanical Ventilation, and Hemodialysis
* Mosier JM et al. The Physiologically Difficult Airway. The western journal of emergency medicine. 16(7):1109-17. 2015. PMID: 26759664
Read MoreMon, 28 May 2018 - 10min - 152 - Episode 146.0 – Morning Report Pearls V
More pearls from our fantastic morning report series at Bellevue.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_146_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Endocarditis, Ludwig's Angina, Penetrating Neck Trauma
Show Notes
Take Home Points
In patients with neck pain, consider Ludwig’s angina particularly if they have any swelling, fever, truisms or respiratory difficulty. Consider early airway management and get your consultants involved early for operative management
Endocarditis is a tricky diagnosis and will often be subtle. Any patient with a prosthetic valve and a fever has endocarditis until proven otherwise. Suspect it in any patient with fever and a murmur, get lots of cultures and remember that TEE is the gold standard but, TTE is highly specific
Finally, penetrating neck trauma. Patients with hard signs – airway compromise, ongoing brisk bleeding, an expanding/pulsatile hematoma, neurologic compromise, shock or hematemesis should go directly to the OR and don’t probe the wounds!
Hard Signs in Penetrating Neck Injury (Sperry 2013)
Management Algorithm for Penetrating Neck Injury (Sperry 2013)
Read More
LITFL: Ludwig’s Angina
Core EM: Infective Endocarditis
EM Cases: Endocarditis and Blood Culture Interpretation
Sperry JL et al. Western Trauma Association Critical Decisions in Trauma: Penetrating Neck Trauma. J Trauma Acute Care Surg 2013; 75(6): 936-41. PMID: 24256663 [OPEN ACCESS]
Read MoreMon, 21 May 2018 - 7min - 151 - Episode 145.0 – All NYC EM 14 Pearls
This week we discuss some pearls from the 14th All NYC EM Conference.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_145_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Documentation, Major Trauma, Massive Transfusion Protocol
Show Notes
All NYC EM Conference
Read More
Core EM: Episode 77.0 – Give TXA Now!
Read MoreMon, 14 May 2018 - 10min - 150 - Episode 144.0 – Acute Rhinosinusitis
This week we dive into rhinosinusitis exploring the recommendations of who needs antibiotics and who doesn't.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_144_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Acute Bacterial Sinusitis, ENT, Sinusitis
Show Notes
Take Home Points
Acute rhinosinusitis is a clinical diagnosis
The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics
Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement.
Read More
Core EM: Acute Rhinosinusitis
TheNNT.com: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults
TheNNT.com: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis
Read MoreMon, 07 May 2018 - 9min - 149 - Episode 143.0 – Testicular Torsion
This week we review the presentation, examination and diagnosis of testicular torsion.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_143_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Acute Scrotal Pain, Torsion, Urology
Show Notes
Take Home Points
Consider the diagnosis of testicular torsion in all patients with acute testicular pain
Testicular torsion is a surgical emergency that requires immediate urologic consultation to increase the rate of tissue salvage.
History, physical examination and ultrasound are all flawed in making the diagnosis. The gold standard is surgical exploration
Consider manual detorsion in patients where consultation will be delayed
Show Notes
Core EM: Testicular Torsion
Ben-Israel T et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28:786-789.
Sidler D et al. A 25-year review of the acute scrotum in children. S Afr Med J. 1997;87(12) 1696-8. PMID:
Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID:
Ban KM, Easter JS: Selected Urologic Problems; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 99: p 1326-1356.
Read MoreMon, 30 Apr 2018 - 9min - 148 - Episode 142.0 – Morning Report Pearls IV
This week we discuss more pearls from our morning report conference on APE, SAH and caustic ingestions.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_142_0_Final_Cut.m4a
Download
Leave a Comment
Tags: APE, Cardiology, Caustic Ingestions, CHF, SAH, SCAPE, Subarachnoid Hemorrhage, Toxicology
Show Notes
Take Home Points
In patients with APE, give high-dose nitro to decrease after load and preload quickly. 400-500 mcg/min for the first 4-5 minutes is my standard approach
Consider DSI to facilitate pre-oxygenation. Ketamine is your go to drug here
A NCHCT performed within 6 hours of symptom onset is extremely sensitive for ruling out SAH but, nothing is 100%. If you’ve got a high-risk patient, you should still consider LP
Patients with caustic ingestions can have rapidly deteriorating airways. Prepare early and be ready to take over the airway at a moments notice
Read More
Core EM: Acute Pulmonary Edema
EMCrit: Sympathetic Crashing Acute Pulmonary Edema (SCAPE)
EMCrit: Delayed Sequence Intubation
Core EM: Setting Up Non-Invasive Ventilation
The SGEM: Thunderstruck (Subarachnoid Hemorrhage)
Friedman BW. Managing Migraine. Ann Emerg Med 2017; 69(2): 202-7. PMID: 27510942
Read MoreMon, 23 Apr 2018 - 7min - 147 - Episode 141.0 – Journal Update
This week we discuss some recent publications relevant to EM: ADRENAL, Idarucizumab and Time to Furosemide.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_141_0_Final_Cut.m4a
Download
Leave a Comment
Tags: ADRENAL, CHF, Corticosteroids, Furosemide, Idarucizumab, Journal Club, Journal Update, Sepsis
Show Notes
Read More
Core EM: Idarucizumab for Reversal of Dabigitran
Core EM: Idarucizumab for Reversal of Dabigitran II
First10EM: Idarucizumab: Plenty of Optimism, Not Enough Science
EM Lit of Note: The Door-to-Lasix Quality Measure
EMS MED: When It’s More Complicated Than A Tweet: Door-To-Furosemide And EMS
REBEL EM: Door to Furosemide (D2F) in Acute CHF . . . Really?
emDocs.net: Furosemide in the Treatment of Acute Pulmonary Edema
Core EM: Door-to-Furosemide Time
References
Pollack et al. Idarucizumab for dabigitran reversal – full cohort analysis. NEJM 2017; 377(5): 431-41. PMID: 28693366
Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized with Acute Heart Failure J Am Coll Cardiol 2017; 69(25): 3042-51. PMID: 28641794
Read MoreMon, 16 Apr 2018 - 11min - 146 - Episode 140.0 Disutility of Orthostatics in volume Loss
This week we discuss the disutility of orthostatic vital signs as a diagnostic tool in patients with suspected volume loss.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_140_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Cardiology, Orthostatic Hypotension
Show Notes
Summary: Based on the limited available evidence, it’s unlikely orthostatic vital sign measurement can be used to determine which patients have volume loss and which do not. The baseline prevalence of orthostatic vital signs is common and patients will not always develop orthostatic vital signs in response to volume loss. Therefore, there will both be patients who are orthostatic by numbers without volume loss and there will be patients with volume loss who are not orthostatic by numbers. Symptoms, with the exception of inability to stand to have orthostatics performed, are not useful either.
Bottom Line: Based on the low overall sensitivity of orthostatic vital sign measurements, they should not be used to influence clinical decision making.
Read More
REBEL EM: Orthostatic Hypotension in Volume Depletion
References:
Skinner JE et al. Orthostatic heart rate and blood pressure in adolescents: reference ranges. J Child Neuro 2010; 25(10): 1210-5. PMID: 20197269
Stewart JM. Transient orthostatic hypotension is common in adolescents. J Pediatr 2002; 140: 418-24. PMID: 12006955
Ooi WL et al. Patterns of orthostatic blood pressure change and the clinical correlates in a frail, elderly population. JAMA 1997; 277: 1299-1304. PMID: 9109468
Aronow WS et al. Prevalence of postural hypotension in elderly patients in a long-term health care facility. Am J Cardiology 1988; 62(4): 336-7. PMID: 3135742
Witting MD et al. Defining the positive tilt test: a study of healthy adults with moderate acute blood loss. Ann Emerg Med 1994; 23(6): 1320-3. PMID: 8198307
McGee S et al. The rational clinical examination. Is this patient hypovolemic. JAMA 1999; 281(11): 1022-9. PMID: 10086438
Johnson DR et al. Dehydration and orthostatic vital signs in women with hyper emesis gravidarum. Acad Emerg Med 1995; 2(8): 692-7. PMID: 7584747
Read MoreMon, 09 Apr 2018 - 7min - 145 - Episode 139.0 – Ear Foreign Body Removal
This week we welcome back Andy Little from Doctors Hospital in Columbus, Ohio to chat about ear foreign body removal.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_139_0_Final_Cut.m4a
Download
Leave a Comment
Tags: ENT, Foreign Body
Show Notes
Read More
DiMuzio J, Deschler, DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol. 2002; 23(4):473-5. PMID: 12170148
Leffler S et al. Chemical immobilization and killing of intra-aural roaches: an in-vitro comparative study. Ann Emerg Med. 1993; 22(12):1795-8. PMID: 8239097
ALiEM: Trick of the Trade: Ear Foreign Body Removal with Modified Suction Setup
Read MoreMon, 02 Apr 2018 - 13min - 144 - Episode 138.0 – EEMCrit Pearls
This week we review pearls from the EEMCrit conference back in January 2018.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_138_0_Final_Cut.m4a
Download
Leave a Comment
Tags: BRASH, Hyperkalemia, TTP, Ventricular Tachycardia, VTach
Show Notes
Show Notes
Core EM: Procainamide vs Amiodarone in Stable Wide QRS Tachydysrhythmias (PROCAMIO)
PulmCrit: Myth-Buesting: Lactated Ringers is Safe in Hyperkalemia, and Is Superior to NS
PulmCrit: BRASH Syndrome
Read MoreMon, 26 Mar 2018 - 11min - 143 - Episode 137.0 – How to Build a Great Presentation
This podcast discusses an 8 step process for building better presentations.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_137_0_Final_Cut.m4a
Download
One Comment
Show Notes
Resources:
P Cubed Presentations
Presentation Zen
Presentation Zen: Simple Ideas on Presentation Design and Delivery
Keynotable
Read MoreMon, 19 Mar 2018 - 35min - 142 - Episode 136.0 HIV Related Infections in the ED
This week we discuss some pearls and pitfalls when caring for HIV+ patients in the ED.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_136_0_Final_Cut.m4a
Download
One Comment
Tags: AIDS, HIV, Infectious Diseases, PCP, TB, Tuberculosis
Show Notes
HIV Associated Infections Based on CD4 Count (cooperhealth.org)
Total Lymphocyte Count = (% lymphocytes x WBC count)/100
TLC 1200 cells/mm3 correlated with CD4 count of < 200 cells/mm3 with a maximal sensitivity of 72.2%, and specificity of 100%
TLC1500 cells/mm3 correlated with CD4 count of 200 – 499 cells/mm3 with a maximal sensitivity of 96.7% and specificity of 100%
TLC 1900 cells/mm3 correlated with CD4 count of ≥ 500 cells/mm3 with a maximal sensitivity of 98.5% and specificity of 100%
Show Notes
REBEL EM: REBEL Cast Episode 1 – Total Lymphocyte Count as a Surrogate Marker for CD4 Count
LITFL: HIV and AIDS
References
Obirikorang C et al. Total Lymphocyte Count as a Surrogate Marker for CD4 Count in Resource-Limited. BMC Infectious Diseases Journal 2012; 12 (128): 1 – 5. PMID: 22676809
Read MoreMon, 12 Mar 2018 - 9min - 141 - Episode 135.0 – Occult Causes of Non-Response to Vasopressors
This podcast reviews how clinicians should think about patients who's shock isn't responding to our typical management options.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_135_0_Final_Cut.m4a
Download
One Comment
Tags: Critical Care, Resuscitation, Shock, Vasopressors
Show Notes
Read More
Core EM: Occult Causes of Non-Response to Vasopressors
Emergency Medicine Updates: Hypotension: Differential Diagnosis
EMCrit: Steroids in Septic Shock – PRE-ADRENAL
The Bottom Line: Steroids in Sepsis
EMCrit: RUSH Exam
Read MoreMon, 05 Mar 2018 - 10min - 140 - Episode 134.0 – Morning Report Pearls III
More pearls from our fantastic morning report series.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_134_0_Final_Cut.m4a
Download
2 Comments
Tags: ALL, Altered Mental Status, Hyperleukocytosis, Hyponatremia, Leukostasis
Show Notes
Take Home Points
1. When seeing patients with AMS, think of the 5 broad categories of pathologies – VS abnormalities, toxic-metabolic, infectious causes, CNS abnormalities and, lastly as a diagnosis of exclusion – psychiatric issues
2. In kids with AMS, think of zebra diagnoses and toxic ingestions and remember that primary psychosis is rare
3. Patients with ALL are susceptible to developing hyperleukocytosis. If the WBC is > 100K, think about getting hematology on the line to initiate chemo induction and leukopheresis
4. Always think about electrolyte disorders, particularly hypoNa in patients with global AMS. Remember to treat severe hypoNa w/ hypertonic saline and, to correct slowly as to avoid ODS
Read More
LITFL: HSV Encephalitis
EM Cases: Episode 60 – Emergency Management of Hyponatremia
Core EM: Severe Hyponatremia
Core EM: Episode 58: Hyponatremia
Read MoreMon, 26 Feb 2018 - 7min - 139 - Episode 133.0 – Initial Trauma Assessment
This week we dive in to the initial trauma assessment.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_133_0_Final_Cut.m4a
Download
Leave a Comment
Tags: ABCDEs, Trauma
Show Notes
Take Home Points
* Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures
* Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team
* Complete the primary survey (ABCDEs) and address immediate life threats
* Round out your assessment with a good medical history and remember to complete a comprehensive head-to-toe exam
Read More
Shlamovitz GZ, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007;50(1):25-33, 33.e1. PMID: 17391807
ER Cast: Gunshot to the Groin with Kenji Inaba
EM:RAP: Do We Still Need The C-Collar?
YouTube: Death of the Dinosaur: Debunking Trauma Myths by Dr. S.V. Mahadevan
REBEL EM: Is ATLS wrong about palpable blood pressure estimates?
Life in the Fast Lane: Digital rectal exam (DRE) in trauma
Read MoreMon, 19 Feb 2018 - 18min - 138 - Episode 132.0 – Air Embolism
This week we dive into the rare but potentially fatal, and difficult to diagnose, air embolism.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_132_0_Final_Cut.m4a
Download
2 Comments
Tags: Air Embolism, Central Lines, Hyperbaric Oxygen
Show Notes
Take Home Points
Air embolism is a rare but potentially fatal complication of central line placement and some surgical procedures and of course of as the result of barotrauma.
Recognizing the signs and symptoms of air embolism can be tricky because it will look like any other ischemic process. Consider air embolism if you have a patient that rapidly decompensates after placement of a central line, the most likely culprit for those of us in the ED.
Treatment should focus on supportive cares. Give supplemental O2, IV fluids and hemodynamic support and consider hyperbarics and cardiopulmonary bypass for the super sick patient.
Show Notes
Core EM: Air Embolism
Blanc et al. Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation. Intensive Care Med. 2002; 28(5): 559-63. PMID 12029402
Read MoreMon, 12 Feb 2018 - 8min - 137 - Episode 131.0 – Spontaneous Bacterial Peritonitis (SBP)
This week we explore the presentation, diagnosis and management of SBP.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_131_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Gastroenterology, Infectious Diseases, SBP
Show Notes
Take Home Points
SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis
An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever
Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL)
Read More
Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205.
REBEL EM: Spontaneous Bacterial Peritonitis
EMRAP: C3 Live Paracentesis Video
LITFL: Spontaneous Bacterial Peritonitis
SinaiEM: SBP Pearls
REBEL EM: Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)?
Core EM: Episode 123.0 – Paracentesis Journal Update
Read MoreMon, 05 Feb 2018 - 8min - 136 - Episode 130.0 – Morning Report Pearls II
Another set of high-yield pearls coming out of our morning report conferences.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_130_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Babesiosis, Carbon Monoxide, Doxycycline, Myasthenia Gravis, Tick-Borne Illnesses
Show Notes
Take Home Points
Non-specific viral syndromes are usually just that, a viral syndrome but, be cautious as a number of more serious ailments can present similarly. This includes tick borne illnesses, acute HIV and carbon monoxide
Doxycycline is safe in kids. The dental staining seen with tetracycline is specific to that drug, not the class. If doxy is the best drug for the disease, use it.
Lots of meds can lead to a myasthenia gravis exacerbation. Carefully review meds before prescribing for interactions
Read More
CDC: Research on Doxycycline and Tooth Staining
Core EM: Episode 96.0 – Carbon Monoxide Poisoning
Sinai EM: Succinycholine in Myasthenia Gravis
Read MoreMon, 29 Jan 2018 - 6min - 135 - Episode 129.0 – Toxic Alcohols
We welcome Meghan Spyres back to the podcast to discuss toxic alcohol ingestion diagnosis and management.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_129_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Ethylene Glycol, Fomepizole, Methanol, Toxic Alcohols, Toxicology
Show Notes
Take Home Points
* Suspect a toxic alcohol in any patient with a large osmol gap or a large anion gap metabolic acidosis and consider treating these patients empirically.
* Fomepizole is the critical antidote for toxic alcohol ingestions but, patients are likely going to require dialysis as well.
* Call your local poison control center if you suspect a toxic alcohol ingestion to help guide management.
Read More
LITFL: Toxic Alcohol Ingestion
ER Cast: Mind the Gap: Anion Gap Acidosis
FOAMCast: Episode 43 – Alcohols
Read MoreMon, 22 Jan 2018 - 20min - 134 - Episode 128.0 – Hip Dislocations
This week, we sit down with Billy Goldberg - senior faculty at NYU/Bellevue, to discuss some nuances of hip dislocation management.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_128_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Orthopedics, Trauma
Show Notes
Read More
Core EM: Hip Dislocation
OrthoBullets: Hip Dislocation
EMin5: Hip Dislocation
Read MoreMon, 15 Jan 2018 - 17min - 133 - Episode 127.0 – Idiopathic Intracranial Hypertension
This week we talk about the subacute headache and the dangerous, can't miss diagnoses of cerebral venous thrombosis and IIH
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_127_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Cerebral Venous Sinus Thrombosis, Headache, Neurology
Show Notes
Take Home Points
Keep IIH and CVST on the differential for patient’s coming in with a subacute headache, particularly if they have visual or neuro symptoms.
Consider an ocular ultrasound! It’s quick, shockingly easy to do, and can help point you toward a diagnosis you may have otherwise overlooked. I have made it my practice now to include a quick look in the physical exam of my patients with a concerning sounding headache or a headache with neurologic symptoms.
Consider IIH particularly in an overweight female of child bearing age with a subacute headache, but remember patients outside that demographic can have IIH as well.
Consider CVST in a patient with a thrombophilic process like cancer, pregnancy or the use of OCPs or androgens or in a patient with a recent facial infection like sinusitis or cellulitis.
Read More
WikEM: Idiopathic Intracranial Hypertension
WikEM: Ocular Ultrasound
Sinai EM Ultrasound – Pseutotumor Cerebri
Read MoreMon, 08 Jan 2018 - 14min - 132 - Episode 126.0 – Flexor Tenosynovitis
This week we discuss the uncommon but must make diagnosis of flexor tenosynovitis
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_126_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Hand, Kanavel Signs, Orthopedics, Soft Tissue Infections
Show Notes
Take Home Points
Think about flexor tenosynovitis in a patient with atraumatic finger pain. They may have any combination of these signs:
Tenderness along the course of the flexor tendon
Symmetrical swelling of the finger – often called the sausage digit
Pain on passive extension of the finger and
Patient holds the finger in a flex position at rest for increased comfort
Give antibiotics to cover staph, strep and possibly gram negatives.
Get your surgeon to see the patient, while we can get the antibiotics started, these patients need admission and may require surgical intervention.
Infographic
by Dr. Y. Jay Lin
Read More
Mailhot T, Lyn ET: Hand; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 50: p 534-571
OrthoBullets: Pyogenic Flexor Tenosynovitis
Ped EMMorsels: Flexor Tenosynovitis
Read MoreMon, 18 Dec 2017 - 8min - 131 - Episode 125.0 – Morning Report Pearls I
This week we discuss some critical pearls and teaching points from our morning report conference.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_125_0_Final_Cut.m4a
Download
One Comment
Tags: Fluoroquinolones, Pneumonia, Spleen
Show Notes
FOAMCast: Episode 17 – The Spleen!
Read MoreMon, 11 Dec 2017 - 5min - 130 - Episode 124.0 – Metformin-Associated Lactic Acidosis
This week we discuss a quick case leading into the management of MALA.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_124_0_Final_Cut.m4a
Download
2 Comments
Tags: Metformin, Toxicology
Show Notes
Take Home Points
In patients with shortness of breath and clear lungs, consider metabolic acidosis with respiratory alkalis as a potential cause
Suspect MALA in any patient on metformin who presents with abdominal pain, nausea and vomiting and/or AMS
Patients with MALA will have a low pH, a high-anion gap metabolic acidosis and high lactate levels
Call your tox consultant to assist with management which will focus on fluid resuscitation with isotonic bicarbonate and dialysis
Read More
Bosse GM. Antidiabetics and Hypoglycemics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Accessed October 31, 2017
LITFL: Metformin-Associated Lactic Acidosis
LITFL: Metformin
The Poison Review: 6 Pearls About Metformin and Lactic Acidosis
Read MoreMon, 04 Dec 2017 - 5min - 129 - Episode 123.0 – Paracentesis Journal Update
This week we dive into a recent journal article questioning whether we should tap all ascites.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_123_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Albumin, Cirrhosis, Paracentesis, SBP, Spontaneous Bacterial Peritonitis
Show Notes
Take Home Points
SBP is a difficult diagnosis to make clinically. While patients may have the triad of fever, abdominal pain and increasing ascites, they are far more likely to only have 1 or 2 of these symptoms
In patients admitted to the hospital with ascites, consider performing a diagnostic paracentesis on all patients as limited literature shows an association with decreased mortality and, the procedure is simple and low risk
Once you get the fluid, focus on the cell count: WBC > 500 or PMN > 250 should prompt treatment with a 3rd generation cephalosporin and albumin infusion
Gaetano et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. Journal of Gastroenterology and Hepatology 2016. PMID: 26642977
Read More
EMRAP: C3 Live Paracentesis Video
LITFL: Spontaneous Bacterial Peritonitis
SinaiEM: SBP Pearls
REBEL EM: Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)?
Approach to the Diagnosis and Treatment of SBP (University of Washington)
Read MoreMon, 27 Nov 2017 - 6min - 128 - Episode 122.0 – True Knee Dislocations
This week we discuss the tibio-femoral knee dislocation focusing on identification of the dangerous complications.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_122_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Knee Dislocation, Orthopedics, Popliteal Artery
Show Notes
Take Home Points
Up to 50% of true knee dislocations will spontaneously reduce prior to arrival. Be suspicious of a dislocation in any patient who describes the joint moving out of place or if they have significant swelling, joint effusion or ecchymosis despite normal X-rays
In all patients with suspected dislocation, perform a neurovascular exam immediately as popliteal artery injury is common. If they’ve got an absent DP or PT pulse, reduce immediately and get a CT angiogram as quickly as possible to assess for popliteal injuries
If distal pulses are intact, you can either do ABIs and if normal, observe and repeat them or get a CTA. If the ABI is abnormal or the patient had an absent or decreased pulse at any point, get the CTA
Read More
OrthoBullets: Knee Dislocation
Radiopaedia: Knee Dislocation
EM: RAP: Obese Patient and Knee Dislocations
Core EM: True Knee and Patellar Dislocations
Read MoreMon, 20 Nov 2017 - 7min - 127 - Episode 121.0 – Pancreatitis
This week we dive into the diagnosis and management of pancreatitis in the ED
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_121_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Gastroenterology, GI, Pancreatitis
Show Notes
Ranson’s Criteria for Pancreatitis-Associated Mortality (Rosen’s)
Take Home Points
Pancreatitis is diagnosed by a combination of clinical features (epigastric pain with radiation to back, nausea/vomiting etc) and diagnostic tests (lipsae 3x normal, CT scan)
A RUQ US should be performed looking for gallstones as this finding significantly alters management
The focus of management is on supportive care. IV fluids, while central to therapy, should be given judiciously and titrated to end organ perfusion
Patients will mild pancreatitis who are tolerating oral intake and can reliably follow up, can be discharged home
Read More
Hemphill RR, Santen SA: Disorders of the Pancreas; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 91: p 1205-1226
PulmCrit: The Myth of Large-Volume Resuscitation in Acute Pancreatitis
PulmCrit: Hypertriglyceridemic Pancreatitis: Can We Defuse the Bomb?
Read MoreMon, 13 Nov 2017 - 13min - 126 - Episode 120.0 – Bites and Stings
This week we discuss common bites, stings and envenomations.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_120_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Bee Sting, Black Widow, Brown Recluse Spider, Hymenoptera
Show Notes
Take Home Points
The most common bites and stings you will see are by bees and ants. These can present as a local reaction, toxic reaction, anaphylaxis or delayed reaction. For all of these, treat with local wound care and epinephrine for any systemic symptoms.
The brown recluse spider is found in the Midwest and presents as local pain and swelling but carries the risk of a necrotic ulcer
The black widow spider is found all around the US and presents with either localized or generalized muscle cramping, localized sweating and potentially tachycardia and hypertension. Treatment is symptom management with analgesics and benzos.
The bark scorpion usually presents with localized pain and swelling, but particularly in children, may present with a serious systemic presentation including jerking muscle movements, cranial nerve dysfunction, hypersalivation, ataxia and opsoclonus, which is the rapid, involuntary movement of the eyes in all directions. Treatment is supportive cares, but remember to call your poison center to ask about antivenin.
Read More
WikEM: Brown Recluse Spider Bite
WikEM: Black Widdow Spider Bite
WikEM: Hymenoptera Stings
Read MoreMon, 06 Nov 2017 - 8min - 125 - Episode 119.0 – Journal Update
This week we review 4 articles discussed in our conference in the last month.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_119_0_Final_Cut.m4a
Download
Leave a Comment
Tags: ACS, AMI, Cardiac Arrest, Cardiology, Oxygen, Pediatrics, POCUS, Syncope
Show Notes
Take Home Points
Tachycardia in peds patients at discharge was associated with more revisits but not with more critical interventions. If your workup is reassuring, isolated tachycardia in and of itself shouldn’t change your disposition.
Supplemental O2 is not necessary in the management of AMI patients with an O2 sat > 90% and, may be harmful
Until further study and prospective validation has been performed, we’re not going to recommend embracing the Canadian decision instrument on predicting dysrhythmias after a syncopal event.
Finally, our agreement on what cardiac standstill is isn’t great. We need a unified definition going forward to teach our trainees and for the purposes of research.
Read More
Core EM: ED POCUS in OHCA – The REASON Study
ALiEM: Management of Syncope
EM Nerd: The Case of the Liberated Radicals
ScanCrit: O2 Not Needed in Myocardial Infarction
Core EM: Predicting Dysrhythmia after Syncope
Gaspari R et al. Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital and in-ED Cardiac Arrest. Resuscitation 2016; 109: 33 – 39. PMID: 27693280
References
Wilson PM et al. Is Tachycardia at Discharge from the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study.Ann Emerg Med. 2017. PMID: 28238501
Hofmann R et al. Oxygen Therapy in Suspected Acute Myocardial Infarction. NEJM 2017. PMID: 28844200
Thiruganasambandamoorthy V et al. Predicting short-term risk of arrhythmia among patients with syncope: the Canadian syncope arrhythmia risk score. Acad Emerg Med 2017. PMID: 28791782
Hu K et al. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers.Mon, 30 Oct 2017 - 124 - Episode 118.0 – Acute Cholangitis
Part II of II on gallbladder disorders finishing up with acute cholangitis.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_118_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Gallbladder, Gastroenterology, General Surgery, GI
Show Notes
Take Home Points
Cholangitis is an acute bacterial infection of the bile ducts resulting from common bile duct obstruction and is potentially life-threatening (mortality 5-10%, acute bacterial infection of the bile ducts
Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic. Look for RUQ tenderness with peritoneal signs and fever
A normal ultrasound does not rule out acute cholangitis
Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery)
Read More
Radiopaedia: Acute cholangitis
Core EM: Cholangitis
Read MoreMon, 23 Oct 2017 - 7min - 123 - Episode 117.0 – Acute Cholecystitis
Part I of II on gallbladder pathology starting with cholecystitis.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_117_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Gallbladder, Gastroenterology, General Surgery, GI
Show Notes
Take Home Points
Acute cholecystitis is an inflammation of the gallbladder and is a clinical diagnosis. Imaging can be helpful but US and CT can both have false negatives.
Lab tests are insensitive and non-specific and, as such, they can neither rule in or rule out the diagnosis.
Treatment focuses on fluid resuscitation when indicated, supportive care, antibiotics and surgical consultation for cholecystectomy
Although uncommon, be aware that patients can develop gangrene, necrosis and perforation as well as frank sepsis and require aggressive resuscitation
Read More
Core EM: Acute Cholecystitis
Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205.
Leschka S et al. Chapter 5.1: Acute abdominal pain: diagnostic strategies In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008.
Menu Y, Vuillerme MP. Chapter 5.5: Non-traumatic Abdominal Emergencies: Imaging and Intervention in Acute Biliary Conditions In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008.
Read MoreMon, 16 Oct 2017 - 9min - 122 - Episode 116.0 – Button Battery Ingestion
This podcast discusses the presentation and management of button battery ingestions in kids.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_116_0_Final_Cut.m4a
Download
One Comment
Tags: Button Battery, GI, Pediatrics
Show Notes
NBIH Button Battery Ingestion Algorithm
Button Battery XR (scielo.br)
Take Home Points
Button battery ingestions are extremely dangerous. Necrosis, perforation and erosion into vessels can occur in as little as 2 hours
ALL esophageal button batteries should be removed within 2 hours of presentation to minimize mucosal damage
Consider button battery ingestion in children presenting with dysphagia, refusal to eat and hematemesis
Co-ingestion of a button battery with a magnet requires emergency removal regardless of where it is in the GI system
Read More
National Capital Poison Center: NBIH Button Battery Ingestion Triage and Treatment Guideline
Pediatric EM Morsels: Button Battery Ingestion
St. Emlyn’s: Button Batteries – Hide and Seek in the Emergency Department
ENT Blog: Lithium Disc Battery Danger for Kids
Read MoreTue, 10 Oct 2017 - 9min - 121 - Episode 115.0 – Wernicke’s Encephalopathy
This week we sit down with toxicologist Meghan Spyres to talk about Wernicke's Encephalopathy.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_115_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Alcohol Abuse, Thiamine, Toxicology, Wernicke's Encephalopathy
Show Notes
Take Home Points
* Consider the diagnosis in all patients with nutritional deficiencies, not just alcoholics.
* Look for ophthalmoplegia, ataxia and confusion in patients that have risk factors for thiamine deficiency.
* Don’t think that it can’t be Wernicke’s because the triad isn’t complete; any two of the components (dietary deficiency, oculomotor abnormalities, cerebellar dysfunction or altered mental status) makes the diagnosis.
* Treat Wernicke’s with an initial dose of 500 mg of thiamine IV and admit for continued parenteral therapy.
Read More
LITFL: Thiamine Deficiency
EMRAP: Remember to Take Your Vitamins
ALiEM: Mythbusting the Banana Bag
Read MoreMon, 02 Oct 2017 - 12min - 120 - Episode 114.0 – Evaluation of the Alcohol Intoxicated Patient
This week we discuss the initial approach to assessment of the alcohol intoxicated patient.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_114_0_Final_Cut.m4a
Download
One Comment
Tags: Alcohol Intoxication, Chronic Alcoholism, Wernicke's Encephalopathy
Show Notes
Take Home Points
Chronic drinkers and even just acutely intoxicated patients are at risk of many medical emergencies including life threatening trauma, infections, metabolic derangements and tox exposures. Don’t dismiss them as “just drunk”
Undress these patients and perform a thorough head to toe examination, focusing on looking for e/o trauma and infection. Get as much history as you can and be sure to ask about their drinking habits and etoh w/d hx to risk stratify them in your brain
Always check FS glucose and replete glucose as needed.
Consider giving your chronic intoxicated patients thiamine injections semi-regularly to prevent WE, and look for e/o the triad in your patients as it can be easily overlooked and deadly if missed!
Read More
EM Docs: EM@3AM Alcohol Intoxication
EM Updates: Emergency Management of the Agitated Patient
Life in the Fastlane: Ethanol Intoxication, Abuse and Dependence
Read MoreMon, 25 Sep 2017 - 14min - 119 - Episode 113.0 – Preeclampsia + Eclampsia
This podcast takes a deep dive into the presentation, diagnosis and management of preeclampsia and eclampsia.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_113_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Eclampsia, Hypertensive Disorders of Pregnancy, Obstetrics, Preeclampsia
Show Notes
Take Home Points
Suspect preeclampsia in any pregnant women presenting with epigastric/RUQ pain, severe or persistent headache, visual disturbances, nausea or vomiting, shortness of breath, increased edema or weight gain
Evaluate for preeclampsia by looking at the blood pressure, urine for protein and obtaining a panel to evaluate for HELLP syndrome
Severe preeclampsia and eclampsia are treated with bolus and infusion of MgSO4
Emergency delivery is the “cure” for preeclampsia and eclampsia. Consult obstetrics early for an evaluation for delivery
Don’t forget to consider preeclampsia and eclampsia in the immediate postpartum period
Read More
Core EM: Preeclampsia and Eclampsia
LITFL: Preeclampsia and Eclampsia
LITFL: Eclampsia
EM Curious: ED Management of Severe Preeclampsia
Houry DE, Salhi BA. Acute Complications of Pregnancy. In: Marx, J et al, ed. Rosen’s Emergency Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014: 178: 2282-2302
Read MoreMon, 18 Sep 2017 - 10min - 118 - Episode 112.0 – Herpes Zoster
This week we discuss the presentation and management of herpes zoster.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_112_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Infectious Diseases, Varicella
Show Notes
Take Home Points
Classically, herpes zoster will present with rash and pain in a dermatomal distribution
Immunocompromised patients are at greater risk for significant complications of zoster, including visceral dissemination and zoster ophthalmicus
Appropriate therapy includes antiviral therapy within 72 hours of onset of symptoms and analgesia for acute neuritis
Disseminated zoster and zoster ophthalmicus threatening sight should be treated with IV antivirals
Read More
Emergency Medicine Ireland: Tasty Morsels of EM 073: FRCEM Varicella
Life in the Fast Lane: Herpes zoster ophthalmicus
Core EM: Herpes Zoster
Read MoreMon, 11 Sep 2017 - 6min - 117 - Episode 111.0 – Snake Bites
This week we discuss the presentation and management of native US snake bites with Dr. Meghan Spyres
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_111_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Rattlesnakes, Snake Bites, Snake Envenomation, Toxicology, Vipers
Show Notes
Read More
ALiEM: Envenomations: Initial Management of Common US Snakebites
Read MoreMon, 04 Sep 2017 - 17min - 116 - Episode 110.0 – Advanced RSI Topics
This week we dive into some advanced topics in RSI including patient positioning and pre-intubation resuscitation.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_110_0_Final_Cut.m4a
Download
One Comment
Show Notes
Take Home Points
Bed up head elevated position for intubation may reduce intubation related complications.
Patients who are hypotensive or at risk of hypotension should be aggressively resuscitation prior to intubation with fluids and liberal use of pressors
Shock patients would be intubated with decreased induction agent dose, preferably ketamine, and increased paralytic dose.
Bed-Up-Head-Elevated Positioning
Show Notes
EMCrit: Podcast 104 – Laryngosocpe as a Murger Weapon (LAMW) Series – Hemodynamic Kills
Life in the Fastlane: Intubation, hypotension and shock
Core EM: Bed Up Head Elevated Position for Airway Management Video
REBEL EM: Critical Care Updates: Resuscitation Sequence Intubation – Hypotension Kills (Part 1 of 3)
ALiEM: The Dirty Epi Drip: IV Epinephrine When You Need It
emDocs: Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI
Swaminathan A, Mallemat H. Rocuronium Should Be the Default Paralytic in Rapid Sequence Intubation. Ann Emerg Med 2017. PMID: 28601274
Khandelwal N et al. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016; 122(4): 1101-7. PMID: 26866753
Read MoreMon, 21 Aug 2017 - 9min - 115 - Episode 109.0 – Renal + GU Emergencies
This week we discuss some quick pearls from our conference covering an array of renal and GU pathologies.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_109_0_Final_Cut.m4a
Download
Leave a Comment
Tags: GU, Renal, Urology
Show Notes
Read More
Core EM: Testicular Torsion
Core EM: Podcast Episode 92.0 – Dialysis Emergencies
Al Sacchetti: ED Repair of Bleeding Dialysis Shunt
EM: RAP: Episode 107 – Dialysis Emergencies
EMBlog Mayo Clinic: How to Stop a Post-Dialysis Site Bleeding
emDocs: Managing Fistula Complications in the Emergency Department
References
Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID: 22217895
Read MoreMon, 14 Aug 2017 - 7min - 114 - Episode 108.0 – Intubation in In-Hospital Cardiac Arrest
Should we intubate patients in cardiac arrest? We discuss this topic and some basics of running a good arrest.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_108_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Advanced Airway Management, Cardiac Arrest, Critical Care, Resuscitation
Show Notes
Take Home Points
Intra-arrest intubation does not appear to improve outcomes. For most patients, support with BVM, or possibly an LMA, is adequate.
Instead of securing an advanced airway, focus on the two things that clearly make a difference in outcomes – good compressions and defibirillation
Good compressions should be fast and hard and you must minimize interruptions in compressions to minimize interruptions in perfusion
Don’t forget that a great resuscitation requires great preparation. Take whatever time you have to discuss with your team and assign roles.
Read More
Rebel EM:In-hospital Cardiac Arrest – The First 15 Minues
Core EM: Proper Defibrillator Pad Placement + Dual Sequential Defibrillation
REBEL EM: Beyond ACLS: Cognitively Offloading During a Cardiac Arrest
REBEL EM: Beyond ACLS: POCUS in Cardiac Arrest
REBEL EM: Beyond ACLS: CPR, Defibrillation and Epinephrine
REBEL EM: Beyond ACLS: Pre-Charging the Defibrillator
Read MoreMon, 31 Jul 2017 - 10min - 113 - Episode 107.0 – Angioedema
Prompted by the recent CAMEO trial publication on icatibant, we dive into angioedema with a focus on airway management.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_107_0_Final_Cut.m4a
Download
Leave a Comment
Tags: ACE Inhibitors, Allergy/Immunology, Angioedema, Icatibant
Show Notes
Take Home Points
Airway management is paramount, expect a challenging intubation and consider controlling the airway early
When controlling the airway, consider an awake approach and fiberoptics if available. Always be prepared for the can’t intubate, can’t oxygenate scenario with a double set up.
If the patient has urticaria and pruritus, the process is likely histamine mediated and will respond to typical anaphylaxis treatment
Finally, observe the patient for progression of swelling and don’t forget to stop the inciting medication
Read More
Core EM: Angioedema
EMCrit: Podcast 145 – Awake Intubation Lecture from SMACC
ERCast: Angioedema
REBEL EM: Icatibant Doesn’t Improve Outcomes in ACE-I Induced Angioedema
The SGEM: Icatibant Bites the Dust – For ACE-I Induced Angioedema
Read MoreMon, 24 Jul 2017 - 8min - 112 - Episode 106.0 – Procedural Sedation and Analgesia II
This week we drop into some of the nitty gritty on PSA including preparation and patient assessment as well as discuss some common pitfalls.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_106_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Pitfalls, Procedural Sedation, PSA
Show Notes
Take Home Points
Always perform a full pre-PSA evaluation including an airway assessment. Time of last meal shouldn’t delay your sedation based on the best available evidence.
Always do a complete setup including consideration of different agents, dosage calculations, preparation of airway equipment and reversal agents.
PSA serious adverse events are rare but you still must be prepared for them. Careful agent selection and dosing can help prevent issues but, know your outs.
If apnea develops, do some basic maneuvers before you reach for the BVM or laryngoscope. Remember OOPS as in “oops, my patient went apneic.” Oxygen on, pull the mandible forward and sit the patient up. This fixes most issues
Show Notes
Core EM: Procedural Sedation and Analgesia Resources
EM Updates:Emergency Department Procedural Sedation Checklist v2
REBEL EM: Complications of Procedural Sedation
Bellolio MF et al. Incidence of adverse events in adults undergoing procedural sedation in the emergency department: a systematic review and meta-analysis. Acad Emerg Med 2016; 23: 119-34. PMID: 26801209
Read MoreMon, 17 Jul 2017 - 111 - Episode 105.0 – Initial Antibiotic Choice in Cellulitis
This week we dissect a JAMA article on the whether it's necessary to add TMP-SMX to cephalexin in the treatment of uncomplicated cellulitis
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_105_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Cellulitis, IDSA, Infectious Diseases, MRSA
Show Notes
SSTI Flow Diagram (Stevens 2014)
EM Lit of Note: Double Coverage, Cellulitis Edition
Pharm ER Tox Guy: Uncomplicated Cellulitis? Consider Strep-Only Coverage
Core EM: Cellulitis
Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis 2014; 59(2): e10-52. PMID: 24973422
Read MoreMon, 10 Jul 2017 - 110 - Episode 104.0 – Procedural Sedation and Analgesia
This week we dive into the various common agents used in procedural sedation and analgesia in the ED.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_104_0_Final_Cut.m4a
Download
2 Comments
Tags: Anesthesia, Critical Care, Procedural Sedation, PSA
Show Notes
Show Notes
Core EM : Parenteral Benzodiazepines
Core EM: Procedural Sedation and Analgesia Resources
EM Updates: Ketamine Brain Continuum
First 10 EM: Managing laryngospasm in the emergency department
Read MoreMon, 03 Jul 2017 - 109 - Episode 103.0 – Priapism
This week we talk about priapism focusing on emergency department management.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_103_0_Final_Cut.m4a
Download
One Comment
Tags: GU, Priapism, Urology
Show Notes
Read More
Dr. Mutara Jubara: Ultrasound Guided Dorsal Penile Nerve Block
McCollough M, Sharieff GQ: Genitourinary and Renal Tract Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 174: p 2205-2223.
Davis JE, Silverman MA. Urologic Procedures; in Roberts JR: Roberts and Hedges’ Clinical Procedures in Emergency Medicine, ed 6. 2014, (Ch) 55: p 1113-1154
Govier FE et al. Oral terbutaline for the treatment of priapism. J Urol 1994;151: 878-9. PMID: 8126815
Priyadarshi S. Oral terbutaline in the management of pharmacologically induced prolonged erection. Int J Impot Res. 2004;16:424-426. PMID: 14999218
Read MoreMon, 26 Jun 2017 - 108 - Episode 102.0 – Valsalva Maneuver in SVT
This week we welcome Andy Little onto the show to discuss the modified Valsalva maneuver for breaking SVT.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_102_0-AVNRT_Final_Cut.m4a
Download
Leave a Comment
Tags: Adenosine, AVNRT, Cardiology, SVT, Tachydysrhythmia
Show Notes
Read More
Rebel EM: The REVERT Trial – A Modified Valsalva Maneuver to Convert SVT
SGEM: This is a SVT and I’m Gonna Revert It Using a Modified Valsalva Manoeuvre
Appelboam A et al. Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias (REVERT): A Randomised Controlled Trial. Lancet 2015. PMID: 26314489
Read MoreMon, 19 Jun 2017 - 107 - Episode 101.0 – Major Burns
This week we dive into some of the initial considerations in the resuscitation of major burn patients.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_101_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Carbon Monoxide, Cyanide, Major Burns, Trauma
Show Notes
Take Home Points
Be prepared to intubate early, the patency of the airway can decline quickly and without warning. If there is any concern for burns to face/neck or smoke inhalation, consider taking control of the airway early.
Review the rule of 9s and the parkland formula to direct your large volume fluid resus. Remember the parkland formula directs you to use 4 mL x %TBSA x weight (kg). Half in the first 8 hours and the second half over the next 16 hours. Given the large volume here it’s probably best to use LR or another balanced solution.
Do a thorough trauma eval to make sure you don’t miss any other injuries and be sure to watch for developing compartment syndrome
And last, consider the need to treat for CO and/or cyanide poisoning. Poor cardiac function, cardiac arrest or a high lactate can be clues to cyanide poisoning and just start 100% O2 while you wait for a co-ox, since CO tox is pretty likely.
Rule of 9’s
Read More
MD Calc: Parkland Formula for Burns
LITFL: Trauma! Major Burns
LITFL: Releasing the Roman Breast Plate
Parvizi D et al. The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: things to keep in mind. Burns 2014; 40: 241-5. PMID: 24050977
Hettiaratchy S, Dziewulski P. ABC of Burns: Introduction. BMJ 2004; 328: 1366-8. PMID: 15178618
Hettiaratchy S, Papini R. ABC of Burns: Initial Management of a Major Burn: I – Overview. BMJ 2004; 328: 1555-7. PMID: 15217876
Hettiaratchy S, Papini R. ABC of Burns: Initial Management of a Major Burn II – Assessment and Resuscitation . BMJ 2004; 329: 101-3. PMID: 15242917
Read MoreMon, 12 Jun 2017 - 106 - Episode 100.0 – Our 100th Episode!
It's been 2 years and 100 podcasts. Jenny and Swami take a minute to talk about the Core EM project and our future directions.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_100_0_Final_Cut.m4a
Download
One Comment
Read MoreMon, 05 Jun 2017 - 105 - Episode 99.0 – Journal Update
This week we discuss 3 articles recently reviewed in our conference - LOV-ED study, Validation of Step-By-Step and Therapeutic Hypothermia.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_99_0_Final_Cut.m4a
Download
Leave a Comment
Tags: ARDS, Cardiac Arrest, Lung Protective Ventilation, Mechanical Ventilation, OHCA, Step-By-Step Protocol, Therapeutic Hypothermia, TTM
Show Notes
Take Home Points
The step-by-step approach to managing febrile infants is a reliable decision instrument to identify patients at low risk for invasive bacterial infections. Caution in the group of patients 22-28 days of age.
The LOV-ED study shows an association between employing a lung-protective ventilation strategy in the ED and decreased complications from mechanical ventilation. Best available evidence says that we should embrace this approach in the ED.
Cooling to 33 degrees is no better than cooling to 36 degrees. However, shooting 36 degrees is more difficult than we may have thought. We have to continue to be vigilant about maintaining patients in the target temperature range and avoiding fever.
The Step-By-Step Algorithm
Lung-Protective Ventilation Protocol (LOV-ED Study)
Read More
The SGEM: SGEM #171: Step-by-Step Approach to the Febrile Infant
REBEL EM: The Benefit of Lung Protective Ventilation in the ED Should Be LOV-ED
Taming the SRU: A Crack in the Ice? An In-Depth Breakdown of the TTM Trial
References
Gomez B et al. Validation of the Step-by-Step Approach in the Management of Young Febrile Infants. Pediatrics. 2016 Aug. PMID: 27382134
Fuller BM et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med 2017. PMID: 28259481
Bray JE et al. Changing target temperature from 33oC to 36oC in the ICU management of out-of-hospital cardiac arrest: a before and after study. Resuscitation 2017; 113: 39-43. PMID: 28159575
Read MoreMon, 29 May 2017 - 104 - Episode 98.0 – Cardioversion in Recent Onset AF
This week we delve into the argument for cardioversion in recent-onset AF as well as the logistics of getting it done.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_98_0_Final_Cut.m4a
Download
Leave a Comment
Tags: Atrial Fibrillation, Atrial Flutter, Cardiology, Cardioversion
Show Notes
Read More
Core EM: Podcast 64.0 – Rate Control in AF
Core EM: Recent Onset Atrial Fibrillation
Core EM: 30-Day Outcomes After Aggressive AF Management in the ED
The SGEM: SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol
References
Nuito I et al. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA 2014; 312(6): 647-9. PMID: 25117135
Stiell IG et al. Association of the Ottawa aggressive protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation and flutter. Can J Emerg Med 2010; 12(3): 181-91. PMID: 20522282
Stiell IG et al. Outcomes for Emergency Department Patients with Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals. Ann Emerg Med 2017. PMID: 28110987
Read MoreMon, 22 May 2017 - 103 - Episode 97.0 – Methemoglobinemia
This week we discuss the rare but life-threatening methemoglobinemia with a focus on recognition and use of the antidote.
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_97_0_Final_Cut.m4a
Download
2 Comments
Tags: Methemoglobin, Toxicology
Show Notes
Take Home Points
MetHb –emia occurs as a results of various medications including amyl nitrite, dapsone, nitroprusside, phenazopyridine, sodium nitrite and topical anesthetics like benzocaine
Patients will present with cyanosis, short of breath, fatigue, dizziness, weakness and ultimately CNS depression and death at higher concentrations.
If you have a cyanotic/hypoxic patient that does not respond to supplemental oxygen, be concerned for MetHb and send a co-oximetry panel.
If the level is <25% and the patient is asymptomatic you can observe, but if the level is >25% or the patient is symptomatic, you will treat with the antidote methylene blue given as a bolus of 1-2 mg/kg over 5 minutes
And as always, make sure to call your local poison center to get your toxicologists involved. They can help with dosing, and they are also an important player of the public health component in cases such as these, to make sure this is an isolated incident and we don’t have a repeat of the 11 blue men situation.
Price DP. Chapter 127. Methemoglobin Inducers. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e New York, NY: McGraw-Hill; 2011. Accessed April 19, 2017.
Methemoglobinemia Signs and Symptoms
Methemoglobinemia Treatment
Read MoreMon, 15 May 2017
Mostra altri episodi
5Podcast simili a <nome>
Conversations ABC listen- Global News Podcast BBC World Service
- El Partidazo de COPE COPE
- Herrera en COPE COPE
- The Dan Bongino Show Cumulus Podcast Network | Dan Bongino
- Es la Mañana de Federico esRadio
- La Noche de Dieter esRadio
- Hondelatte Raconte - Christophe Hondelatte Europe 1
- Dateline NBC NBC News
- 財經一路發 News98
- La rosa de los vientos OndaCero
- Más de uno OndaCero
- La Zanzara Radio 24
- L'Heure Du Crime RTL
- El Larguero SER Podcast
- Nadie Sabe Nada SER Podcast
- SER Historia SER Podcast
- Todo Concostrina SER Podcast
- 安住紳一郎の日曜天国 TBS RADIO
- アンガールズのジャンピン[オールナイトニッポンPODCAST] ニッポン放送
- 辛坊治郎 ズーム そこまで言うか！ ニッポン放送
- 飯田浩司のOK! Cozy up！ Podcast ニッポン放送
- 吳淡如人生實用商學院 吳淡如
- 武田鉄矢・今朝の三枚おろし 文化放送PodcastQR
![アンガールズのジャンピン[オールナイトニッポンPODCAST]](https://is1-ssl.mzstatic.com/image/thumb/Podcasts126/v4/a3/d0/03/a3d0036b-fb99-56ad-928e-2fdabbea43b6/mza_8898289893618631728.jpg/300x300bb.jpg)
