Core EM - Emergency Medicine Podcast

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 cm) Base of fifth metatarsal Navicular bone Acute ATFL rupture / Grade III Sprain 90% chance of this injury if hematoma and localized tenderness with palpation present on exam over this ligament Anterior drawer test Assess for anterior subluxation of talus from the tibia Ankle in relaxed position, distal extremity is stabilized with one hand while the other cups the heel to apply anterior force Compare to contralateral side Difficult to determine if there is an acute rupture at this point and may be more easily diagnosed in subacute phase (4-5 days after injury) Ability to perform exam adequately limited by pain, swelling and potential muscle spasm Talar tilt test If applying inversion force to ankle and there is excessive mobility → calcaneofibular ligament Thompson test Can be performed if there is concern for concomitant Achilles tendon injury Do not miss a Maisonneuve fracture by palpating proximally about the fibular ahead as forces may be transmitted through the syndesmosis Squeeze test – pressure just proximal to ankle If elicits pain → concern for syndesmotic injury Diagnostics X-rays indicated if unable to rule out using Ottawa Ankle Rules Sn (Up to 99.6) (one of the best validated tools we use in the ER) May have trouble applying rule if there is question of patients ability to sense pain (diabetic neuropathy), in which case obtain radiographs Treatments RICE Crutch train so they can be weight bearing a tolerated Ideally initiate within first 24 hours of injury Ice 15-20 minutes q2-3h over the first 48 hours or until swelling improves NSAIDs Topical and PO are better than placebo We do not know if PO is superior to topical NSAIDs Early mobilization / Functional Rehab (sample patient instructions here) Work to restore range of motion, strength, proprioception For Grade I and II, can begin as soon as the patient can tolerate and ideally within 1 week of the injury Patients return to work sooner, decreased chronic instability, less recurrent injuries Dorsiflexion, plantarflexion, and perform foot circles as well as toe curls, inversion and eversion as tolerated Proprioception Balancing on wobble board Continue exercises until patient is able to return to activities at full capacity, without pain Immobilization High re-injury rates and important to protect against this Grade I No immobilization required +/- Ace wrap Grade II Aircast brace Ensure patient understands that they should still partake in rehabilitation exercises Grade III Data conflicts RCT, multicenter study comparing aircast brace, compression bandage, Bledsoe immobilization boot and below-knee cast for 10 days Ankle function at 3 months Cast group had most improvement No difference at 9 months in function or complications May be institu

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, but also to produce lipoid pneumonia in rat lungs Some devices are easily manipulated to increase the capacity to produce vapor; increasing these settings may impact heating temperature, metabolic breakdown, and release of microscopic metal particles Lungs are multifunctional, including serving as an immune organ: lungs cleave proteins of all of the bacteria, viruses and other pathogens we are exposed to and inhale daily human studies on those that are chronic e-cig users or vapers have revealed that these products are shifting the balance of proteases and antiproteases in our lungs such that the proteases are destroying native lung tissue similar to how traditional cigarettes cause COPD Many potential reactions: NEJM article in references: details four radiographic phenotypes essentially reflecting different pathologic changes Long-term Effects Long term effects are unknown (some pts have required home oxygen on discharge) Risk for recurrence or relapse, especially if repeat exposure Presentation 95% of pts have had pulmonary sxs (cough, cp, dyspnea) 77% of pts have had GI sxs (abd pain, n/v/d) 85% of pts w/ constitutional sxs (f/c, weight loss) 57% w/ hypoxia (O2 < 95%) Unfortunately auscultation has been unreliable and poorly sensitive Workup There is no specific test or marker for dx, so VALI is still considered a dx of exclusion Labs: CBC ESR/CRP (93% w/ elevated ESR) LFTs (50% w/ transaminitis) ABG: hypoxia Imaging: CXR: typically shows bilateral infiltrates, although not always and there have even been some cases w/ unremarkable chest XR (so high degree of clinical suspicion in any person p/w hypoxia) CT: ground glass opacities, typically bilaterally Management Dispo: 96% of cases required hospitalization Any pt w/ hypoxia, respiratory distress, or comorbidities Outpatient only if: no hypoxia or respiratory distress, reliable followup within 48h and good social support (keep in mind that some patients w/ mild symptoms of first presentation deteriorated rapidly within 48h) Empiric treatments for pneumonia inc abx, antivirals Steroids (methylpred 60mg q6h, based on how index cases in Illinois were managed) Case reports have documented improvement Mechanism: blunting of inflammatory response Aggressive supportive care Special Thanks To: Dr. Larissa Laskowski, DO Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC He

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 Ortho team may want to perform the arthrocentesis themselves because scar tissue formation and altered anatomic relationships make the procedure more challenging Usually want to perform washout in OR plus/ minus antibiotic spacer Send fluid for protein, glucose, cell count with differential, gram stain, culture, and crystals Often see decreased glucose and elevated protein The presence of crystals does not rule out septic arthritis No clear number of synovial WBCs to define septic arthritis, but in general: >30 to 50K/ mm3 synovial WBCs with PMN predominance (>75%) seen in septic arthritis A 2011 meta-analysis suggests +LRs of 4.7 (95% CI = 2.5 to 8.5) and +LR of 13.2 (95% CI = 3.6 to 51.1) for a sWBC count of >50L × 109 or >100K, respectively Use the synovial WBC count plus the whole clinical picture to rule in or out the diagnosis of septic arthritis (do not use the synovial WBC in isolation) Different threshold for prosthetic joints: WBC > 1100 or >64% PMNs = septic arthritis Gram stains only identify causative organisms 1/3 of the time Culture negative arthrocentesis can be seen in cases where abx have been given prior to arthrocentesis, or in TB/ brucella/ nocardia/ other indolent organisms like fungi Labs: No studies have demonstrated an acceptable sensitivity or overall diagnostic accuracy of peripheral WBC count for SA, but usually see leukocytosis with left shift ESR and CRP are reasonably sensitive but there is no cutoff that significantly increases or decreases the pretest probability UA, urine cultures, blood cultures: send even if no fever Blood cultures are positive in 50-70% of nonGC SA If GC suspected, do GC NAAT from throat/ rectal/ urethral/ cervical discharge Imaging: XRs: effusion, baseline status of joint, contiguous osteomyelitis, fractures, foreign body US: effusion CT, MRI: not really used in ED Differential Viral arthritis RA gout/ pseudogout HIV associated arthritis Reactive arthritis Lyme Osteo Septic bursitis Trauma Treatment Septic arthritis is an orthopedic emergency! Needs IV abx + often washout of the joint Hold abx as much as possible prior to tap unless pt is unstable or tap cannot be performed easily Initiate empiric IV antibiotic therapy prior to definitive cultures based Transition to organism-specific antibiotic therapy once culture sensitivities result Start empiric abx based on gram stain if available (in non-=GC SA, grain stain is positive in 50% of cases

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 7 Questionable whether we can generalize these findings from a single ED in Japan. No role for antiepileptics Prognosis High rate of recurrence (~1/3) within 1 year of initial seizure Risk increases for Younger age at which they had initial seizure Lower temperature at which they had seizure If initial febrile seizure was prolonged, more likely that the next will be prolonged 1-2% develop epilepsy for simple febrile seizure, slightly above risk of general population 5-10% develop epilepsy for complex febrile seizure Follow up with PMD Generally, peds neuro follow up is not necessary References Chin RF, Neville BG, Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child. 2005;90(1):66-9. Kimia A, Ben-Joseph EP, Rudloe T, Capraro A, Sarco D, Hummel D, et al. Yield of lumbar puncture among children who present with their first complex febrile seizure. Pediatrics. 2010;126(1):62-9. Murata S, Okasora K, Tanabe T, Ogino M, Yamazaki S, Oba C, et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. 2018;142(5). Patel N, Ram D, Swiderska N, Mewasingh LD, Newton RW, Offringa M. Febrile seizures. BMJ. 2015;351:h4240. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013;54(12):2101-7. Stapczynski, J. S., & Tintinalli, J. E. (2016). Tintinalli’s emergency medicine: A comprehensive study guide, 8th Edition. New York: McGraw-Hill Education. Subcommittee on Febrile S, American Academy of P. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-94. Teng D, Dayan P, Tyler S, Hauser WA, Chan S, Leary L, et al. Risk of intracranial pathologic conditions requiring emergency intervention after a first complex febrile seizure episode among children. Pediatrics. 2006;117(2):304-8. Warden CR, Zibulewsky J, Mace S, Gold C, Gausche-Hill M. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003;41(2):215-22. A special thanks to our editors: Michael A. Mojica, MD Director, Pediatric Emergency Medicine Fellowship Bellevue Hospital Center Christie M. Gutierrez, MD Pediatric Emergency Medicine Fellow Columbia University Medical Center Morgan Stanley Children’s Hospital New York Presbyterian   Read More

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) Flu like illness in summer Rash: https://www.cdc.gov/lyme/signs_symptoms/rashes.html Joint complaints Cardiac complaints Neurologic complaints Careful search for tick Diagnosis Labs CBC (leukocytosis, anemia, thrombocytopenia) ESR: most common lab abnormality (>30 mm/hr) Chem 7 LFTs: commonly elevated especially GGT Cultures not typically indicated LP when meningeal signs (CSF: pleocytosis, elevated protein, CSF spirochete ABs). LP function is more to rule out other etiologies of meningitis rather than diagnose Lyme meningitis given that lyme PCR and lyme Ab index are not very accurate. Serological Testing Serological testing is not always warranted because of the very high incidence of false positive results Serologies are not useful in acute phase (<30 days of infection) because they are negative; it takes several weeks to develop enough antibodies for either test below (ELISA or Western Blot) Acute Lyme is a clinical diagnosis and does not need laboratory testing, especially in endemic areas such as NY If pretest probability is high (symptoms consistent with Lyme + epidemiological background), say patients with CN palsy, meningitis, carditis, or migratory large joint arthritis, then serologies can be very helpful Do not test if patients in endemic areas with potential tick exposure present with EM — just treat with antibiotics Do not test if patients in endemic areas present with no history of tick exposure or only nonspecific symptoms Test if you have high suspicion of lyme without EM PCR is highly specific and sensitive but not available for routine use. There are two tests you need to use together: 1) ELISA: this detects antibodies to lyme bacteria (borrelia burgdorferi) in your blood, BUT it can’t distinguish between borrelia and similar bacteria (even sometimes normal flora that lives in you). In addition, IgM response takes 1-2 weeks while IgG response takes 2-4 weeks. If ELISA is positive or equivocal, then you move onto the: 2) Western blot test: this looks for antibodies not to the whole organism, but to the basic building blocks of the lyme bacteria — the individual proteins, BUT many types of bacteria use the same building blocks. So the CDC says that the Western Blot test must detect IgG antibodies to 5 out of the 10 proteins. See figure 2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918152/ Two-tiered testing has sensitiv

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, PMID 25170106) 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 Resuscitative efforts directed at affected organ Can deteriorate rapidly Initiate IV Artesunate if high level of suspicion Requires call to CDC: CDC Malaria Hotline: (770) 488-7788 or (855) 856-4713 (toll-free) Monday–Friday 9am–5pm EST – (770) 488-7100 after hours, weekends, and holidays Benzodiazepines for seizures Be judicious with fluids as this can precipitate pulmonary edema and cerebral edema a/w increased mortality in children at 48 hour (Maitland 2011, PMID: 21615299; Hanson 2013, PMID: 23324951) Take Home Points This is going to be a diagnosis that is mainly made through a thorough history, and pay particular attention to those with recent travel to West-Africa The incubation period for falciparum is 12 days, but there is a range of weeks and we should consider Malaria when consistent symptoms develop within 1 month of travel to an endemic area Typical signs and symptoms for uncomplicated malaria are periodic fevers, jaundice, pallor Be mindful of end organ involvement, such as cerebral edema, ATN, and pulmonary edema; these cases are considered to be severe and treated differently than uncomplicated malaria Uncomplicated cases should get Malarone or Coartem Severe cases require IV Artesunate Be judicious with your fluid resuscitation as this can harm our patients References Centers for Disease Control and Prevention. CDC Parasites – Malaria. 2019 https://www.cdc.gov/parasites/malaria/index.html (7 July 2019, date last accessed) Ashley EA, Pyae Phyo A, Woodrow CJ. Malaria. Lancet. 2018;391(10130):1608-21. Hanson JP, Lam SW, Mohanty S, Alam S, Pattnaik R, Mahanta KC, et al. Fluid resuscitation of adults with severe falciparum malaria: effects on Acid-base status, renal function, and extravascular lung water. Crit Care Med. 2013;41(4):972-81. Lampah DA, Yeo TW, Malloy M, Kenangalem E, Douglas NM, Ronaldo D, et al. Severe malarial thrombocytopenia: a risk factor for mortality in Papua, Indonesia. J Infect Dis. 2015;211(4):623-34. Lokken KL, Stull-Lane AR, Poels K, Tsolis RM. Malaria Parasite-Mediated Alteration of Macrophage Function and Increased Iron Availability Predispose to Disseminated Nontyphoidal Salmonella Infection. Infect Immun. 2018;86(9). Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-95. Park SE, Pak GD, Aaby P, Adu-Sarkodie Y, Ali M, Aseffa A, et al. The Relationship Between Invasive Nontyphoidal Salmonella Disease, Other Bacterial Bloodstream Infections, and Malaria in Sub-Saharan Africa. Clin Infect Dis. 2016;62 Suppl 1:S23-31. Tintanelli, Judith E., et al. Tintinalli’s Emergency Medicine:

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 Mild bulging of the tympanic membrane AND (grade C) Recent onset (48hrs) Ear pain (verbal child) Holding, tugging, rubbing of the ear (non-verbal child) OR Intense erythema of the tympanic membrane * The diagnosis should not be made in the absence of a middle ear effusion (grade B) Treatment Options A strategy of “watchful waiting” in which children with acute otitis media are not immediately treated with antibiotic therapy, has been endorsed by the American Academy of Pediatrics. Who gets antibiotics? Depends on age, temperature, duration of otalgia, laterality / otorrhea, and access to follow up Get’s antibiotics: <6 months: Treat 6 months to 2 years: Treat Exception, AAP permits initial observation: unilateral AOM with mild symptoms (mild ear pain, <48h, T <102.2) But know that there is a high rate of treatment failure (Hoberman 2013) >2: Treat Unless they have mild symptoms and it’s unilateral, you can observe for 48-72 hours Why do we give antibiotics? Demonstrated reduction in pain, TM perforations, contralateral episodes of AOM They are no walk in the park, with increased adverse events (vomiting, diarrhea, rash) Two well-designed clinical trials (2011) randomized approximately 600 children meeting strict diagnostic criteria for acute otitis media to receive Augmentin or placebo. These studies demonstrated a significant reduction in symptom burden and clinical failures in those who received antibiotics. The authors conclude that those patients with a clear diagnosis of acute otitis media would benefit from antibiotic therapy AAP AOM Treatment Algorithm Antibiotic Selection High-dose amoxicillin in most (for now) Amoxicillin should not be used if the patient has received Amoxicillin in the past 30 days, has concomitant purulent conjunctivitis (likely H flu) or is allergic to penicillin. beta lactamase resistant antibiotic should be used. Amoxicillin clavulanate or 2nd or 3rd generation cephalosporins (including intramuscular ceftriaxone). Patients with a history of type 1 hypersensitivity reactions to penicillin should be treated macrolides. Studies on duration of therapy have shown better results with 10-day duration in children younger than 2 years and suggest improved efficacy in those 2-5 years. For patients old

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 Surgical: Different modalities of surgery: Intramedullary screw Bone graft Closed reduction and fixation with K-wire ORIF (all +/- need for bone graft) Surgery likely recommended for displacement >10 degrees of plantar angulation or 3-4 mm of translation in any plane Indications for OR: Neck and shaft fractures with >10 degrees plantar angulation or 3mm of displacement in any plane with insufficient closed reduction Avulsion fractures (zone one) with >3 mm of displacement or comminuted Zone two fractures: displaced zone two fractures require operative management. For acute non displaced Jones fractures, consider early intramedullary screw fixation in athletes (studies have shown return to sport ~ 8 weeks, weight bearing within 1-2 weeks) Zone three fractures (diaphyseal stress fractures) in athletes Nonoperative: All non displaced fifth metatarsal fractures can be treated non operatively Non displaced zone 1 fractures: protected weight bearing/ symptomatic care in short leg walking cast, air-boot, posterior splint, or compression wrap/ rigid shoe until discomfort subsides Zone 2 and 3 fractures are more complex because they often result in prolonged healing time and potential for delayed/ nonunion Acute zone 2 fractures: nonweightbearing in short leg cast for 6-8 weeks Acute zone 3 fractures: nonweightbearing in short leg cast for up to 20 weeks With respect to athletes: repeat fracture after surgical treatment of Jones fracture can occur after healing and screw removal; thus it is recommended that the screw be left in until the end of the athlete’s career References: Bowes J, Buckley R. Fifth metatarsal fractures and current treatment. World J Orthop. 2016;7(12):793–800. Published 2016 Dec 18. doi:10.5312/wjo.v7.i12.793 Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006 Mar; 27(3): 172-4. Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 2004;35 Suppl 2:SB77–SB86. Tham W, Sng S, Lum YM, Chee YH. A Look Back in Time: Sir Robert Jones, ‘Father of Modern Orthopaedics’. Malays Orthop J. 2014;8(3):37–41. doi:10.5704/MOJ.1411.009 Thomas JL, Davis BC. Three-wire fixation technique for displaced fifth metatarsal base fractures. J Foot Ankle Surg. 2011;50:776–779. ______________________ LISFRANC SHOW NOTES: Intro: Can’t miss diagnoses: needs stat ortho 20% miss rate Can be dislocation, fracture, fracture

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 More

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 There is limited evidence to support the role of heliox in croup, NB: Pt may require higher levels of oxygen than the 20-30% mixture may provide Intubation Anticipate edema narrowing the airway Consider starting with a tube that is 0.5 to 1 mm smaller than size typically used Disposition: Patients without stridor at rest or respiratory distress can be generally discharged from the ED If epinephrine is given, patients should be monitored for 2-4 hours for reemergence of symptoms as the medication wears off Take Home Points Croup usually affects children within the age range of 6 months to 36 months with the most common cause being parainfluenza virus Given the symptom overlap, we must consider more concerning diagnoses, including bacterial tracheitis, in these patients, especially if they are ill appearing or traditional therapies are ineffective All patients benefit from a one-time dose of dexamethasone and, if racemic epinephrine is given, the patient should be observed for at least 3 hours If intubation is required, anticipate a narrowed airway   Parent Article: https://coreem.net/core/croup/ by Dr. Pankow Read More

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 Consider protecting airway if significant oral mucosal involvement Stop the offending agent (if there is one) Advanced wound care and pain control Consults: Derm to do a biopsy, +/- ophthalmology, gyn / urology to prevent strictures or contractures Consider transferring to a burn center Dispo: Low threshold for ICU admission SCORTEN ( max of 7 points) 1 point each for Age over 40 Current cancer >30% body surface area affected HR >120 BUN >28 Glucose >240 Bicarb <20 Score of 2 points or higher should -> ICU Take Home Points SJS may begin like the flu, with lesions appearing 1-3 days after the prodrome starts Have to have a high suspicion for SJS because it is deadly. It’s a clinical diagnosis — derm biopsy is supportive A thorough history and physical exam are key. Remember the characteristic rash and bullae, and always look in the mouth and eyes. Ask about dysuria, sore throat, and eye irritation, as well as preceding medications or infections. Think SATAN! Prompt supportive care focused on ABCs and IVF repletion are critical. These patients can get sick really fast, so consider an ICU or burn unit. References: Barrett W. Quick Consult: Symptoms: Rash, Dysuria, and Mouth Sores. Emergency Medicine News. 41(4): 15-16, April 2019. Bivins H, Comes J. Stevens-Johnson Syndrome. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 2015; 1076-1077. Ergen EN, Hughey LC. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. JAMA Dermatol.2017;153(12):1344. doi:10.1001/jamadermatol.2017.3957 Gerull R, Nelle M, Schaible T. Toxic epidermal necrolysis and Stevens-Johnson syndrome: A review. Crit Care Med. 2011; 39:1521-1532. Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Current Perspectives on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Clin Rev Allergy Immunol. 2018;54(1):147-76. McNeil, D. (2019). Measles Cases Surpass 700 as Outbreak Continues Unabated. [online] Nytimes.com. Available at: https://www.nytimes.com/2019/04/29/health/measles-outbreak-cdc.html [Accessed 6 May 2019]. Mustafa SS, Ostrov D, Yerly D. Severe Cutaneous Adverse Drug Reactions: Presentation, Risk Factors, and Management. Curr Allergy Asthma Rep. 2018;18(4):26. Read More

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 More

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 More

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 More

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 fracture Neurovascular compromise Follow up: Refer to hand specialist Within 1 week if fractures of 4thand 5thmetacarpals with angulation 3 to 5 days if the 2ndand 3rd metacarpalsare affected Immobilized for three to four weeks in splint Healing may take up to six weeks Take Home Points: This is one of the most common fractures we will see as emergency physicians When evaluating these patients, ensure that this are no other more severe, life-threatening injuries, and pay particular attention to the skin exam so that you do not miss a fight-bite Reductions may be required if there is significant angulation, which is guided by the 20, 30, 40 rule Finally, emergent specialist evaluation is indicated if there is an open fracture or evidence of neurovascular compromise Read More

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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 More

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 More

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 More

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 More

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) Read More

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 More

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 More

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 More

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: 29450523 Read More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More