Core EM - Emergency Medicine Podcast

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 More

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 More

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 More

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. Ann Emerg Med 2017. PMID: 28870394 Read More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

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 More

This week we do a brief review on recognizing CO monoxide poisoning and expertly managing it. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_96_0_Final_Cut.m4a Download Leave a Comment Tags: CO, Inhaled Toxins, Toxicology Show Notes Take Home Points CO poisoning happens most often from common are accidental exposures from faulty home heaters, camp stoves and indoor use of gas powered generators, structure fires and intentional exposure like in suicide attempts. Patients with a mild exposure will present with symptoms like headache, nausea, vomiting, dizziness, vision blurring, palpitations, confusion or myalgias. More severe exposures may produce Altered mental status. seizures, coma, dysrythmias, myocardial ischemia, metabolic acidosis, syncope and vital sign abnormalities including hypotension and, eventually, cardiac arrest. To help distinguish the vague symptoms of a patient who may have chronic exposure ask about things like whether symptoms improve in different environments or whether they have sick pets, as human viral illness generally don’t affect our dogs and cats. If you’re concerned about CO send a co-ox panel. City dwellers may have a baseline carboxyhemoglobin of 1-2% and smokers around 6-10% but others should really have no carboxyhemoglobin. Treatment is supplemental O2 which can be stopped when symptoms improve. For severe symptoms and for pregnant patients, consider hyperbarics to prevent long term sequelae and to protect the fetus. As always, consider discussing the case with your local poison center to help decide whether a patient warrants transfer for hyperbarics. LITFL: Carbon Monoxide Poisoning EMCrit: Podcast 122 – Cardiac Arrest after the Toxicology of Smoke Inhalation with Lewis Nelson FOAMcast: Episode #1: EMCrit Episode #122 – Cyanide and Carbon Monoxide Toxicity Nelson LS, Hoffman RS: Inhaled Toxins, 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) 159: p 2036-2045. Tomaszewski C. Chapter 125. Carbon Monoxide. 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. Read More

This week we discuss the identification, prevention and treatment of local anesthetic systemic toxicity. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_95_0_Final_Cut.m4a Download 6 Comments Tags: Antidote, Bupivicaine, Intralipid, Lidocaine, Toxicology Show Notes LITFL: Local Anesthetic Toxicity Wiki EM: Local Anesthetic Systemic Toxicity References: Schwartz DR, Kaufman B. Local Anesthetics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Neal JM et al, American Society of Regional Anesthesia and Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med 2012;37:16–8. PMID: 22189574 Cao D et al. Intravenous lipid emulsion in the emergency department: a systematic review. J Emerg Med 2015; 48(3): 387-97. PMID: 25534900 Read More

This week we talk about mammal bites - dogs, cats and humans - with a focus on wound closure, antibiotics and rabies prophylaxis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_94_0_Final_Cut.m4a Download Leave a Comment Tags: Infectious Diseases, Mammal Bites, Rabies Show Notes EM:RAP: Animal Bites – A Short Board Review EM:RAP: Episode 107 Mammalian Bites Rebel EM: Medical Myths in the Management of Dog Bites CDC: Rabies Info References Chen E et al. Primary Closure of Mammalian Bites. Acad EM 2000; 7(2): 157- 162. PMID: 10691074 Paschos NK et al. Primary closure versus non-closure of dog bite wounds. A radomised controlled trial. Injury 2014 45(1): 237-40. PMID: 23916901 Medeiros IM, Saconato H. Antibiotic prophylaxis for mammalian bite (Review). Cochrane Database of Systematic Reviews 2008 (3); PMID: 11406003 Read More

This week we cover a workshop from our conference on CNS infections focusing on meningitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_93_0_Final_Cut.m4a Download 3 Comments Tags: Bacterial Meningitis, CNS Infections, Infectious Diseases, Meningitis, Neurology Show Notes CSF Analysis (LITFL) EM Lyceum: Viral Meningitis “Answers” EM RAP: Meningitis LITFL: Bacterial Meningitis LITFL: CSF Analysis The NNT: Glucocorticoid Steroids for Bacterial Meningitis References Attia J et al. Does this adult patient have acute meningitis. JAMA 1999; 281(2): 175-81. PMID: 10411200 Brouwer MC et al. Corticosteroids for acute bacterial meningitis (review). Cochrane Database Syst Rev 2015. PMID: 26362566 Cooper DD, Seupaul RA. Is adjunctive dexamethasone beneficial in patients with bacterial meningitis? Ann Emerg Med 2012; 59(3): 225-6. PMID: 22088494 de Gans J et al. Dexamethasone in adults with bacterial meningitis. NEJM 2012; 347(20): 1549-57. PMID: 12432041 Hasbun R et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. NEJM 2001; 345(24): 1727-34. PMID: 11742046 Sakushima K et al. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. J Infection 2011; 62: 255-62. PMID: 21382412 Tunkel AR et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39: 1267-84. PMID: 15494903 Read More

This week we discuss some of the many dialysis-related emergencies we frequently see in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_92_0_Final_Cut.m4a Download One Comment Tags: Dialysis, ESRD, Nephrology Show Notes Take Home Points On any dialysis patient, make sure to do a good assessment of their access site. If it’s a fistula, assess for a thrill, for any warmth/induration/erythema and make sure they have distal sensation and perfusion. If it’s a catheter, evaluate for any signs of infection—so warmth, erythema or discharge. Bleeding is a big concern. If the patient is bleeding from their access, start with direct pressure to the bleeding site, then move on to topical thrombotic agents and if needed throw a figure 8 stitch with a 5-0 proline on a non-cutting needle. Peritoneal dialysis patients are at risk for bacterial peritonitis. In a PD patient that appears infected, get a peritoneal fluid sample and start antibiotics Dialysis patients are susceptible to dialysis disequilibrium syndrome which can present as altered mental status, focal neurological deficits or even frank coma or seizures after dialysis. Make sure to consider a broad differential in these patients and start with a solute load such as an amp or two of D50 while starting your work up. Core EM: Hyperkalemia Core EM: Episode 7.0 – Hyperkalemia + Rate Control in AFib 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 Read More

This week we discuss a recent article in Annals of EM on contrast induced nephropathy and whether the phenomena is real or dogma. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_91_0_Final_Cut.m4a Download Leave a Comment Tags: AKI, CIN, Contrast Induced Nephropathy, Journal Update Show Notes ACR Table on CIN – FOAMCast FOAMCast: Episode 65 – Contrast Induced Nephropathy and Genitourinary Trauma REBEL EM: Contrast Induced Nephropahty: Fact or Myth Core EM: Acute Kidney Injury is not Associated with IV Contrast Use in the ED EM Lit of Note: Punching Holes in CIN EMCrit: Do CT Scans Cause Contrast Nephrophathy? EM Lit of Note: Punching Holes in CIN EM Docs: Contrast-Induced Nephropathy – Confounding Causation Read More

This week we dive into acute rhinosinusitis focusing on diagnosis and discussing the absence of utility for antibiotics in most patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_90_0_Final_Cut.m4a Download Leave a Comment Tags: ENT, Rhinosinusitis, Sinusitis, URI Show Notes Take Home Points Sinusitis is a clinical diagnosis. Patients typically present with purulent nasal discharge and facial pain or other URI symptoms. The vast majority of patients with acute rhino sinusitis will be viral in nature and will not benefit from antibiotics Patients with prolonged symptoms, more than 7-10 days, without improvement or continued fevers past 2-3 days should be considered for antibiotic treatment as should those who are immunocompromised. Show Notes Melio FR, Berge LR. Upper Respiratory Tract Infections, 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) 75: p 965-79. The NNT: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults The NNT: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Lemiengre MB et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012. PMID: 23076918 Ahovuo-Saloranta A et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2008. PMID: 18425861 Read More

This week we discuss the ED management of anterior and posterior epistaxis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_89_0_Final_Cut.m4a Download 3 Comments Tags: ENT, Epistaxis, Nose Bleeds, TXA Show Notes Take Home Points The first step is managing epistaxis is solid pressure. This means holding a tight pinch just distal to the nasal bones and hold, without peaking, for at least 5 minutes. This will stop a good deal of the bleeding. If you need to do more, start by soaking gauze in either oxymetazoline or epinephrine, mix in some lidocaine to help with anesthesia, pack the nare with that and add on some compression. Hope fully this stops the bleeding enough that you can see a good bleeder and perform cautery. Third line of treatment would be to try some soaked gauze, but this time with TXA. Can’t hurt to try! And then last resort is of course packing. Here make sure the patient is anesthetized with some lidocaine, lubricate the packing well and apply horizonally, no vertically as we are often tempted. Epistaxis Tray Show Notes LITFL: Epistaxis Core EM: Podcast 18.0 – Influenza Testing and Epistaxis REBEL EM: Do Patients with Epistaxis Managed by Nasal Packing Require Prophylactic Antibiotics EM Lyceum: Epistaxis, “Answers” Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013; 31: 1389-92. PMID: 23911102 Read More

This week, we review a simplified approach to determining the rhythm on an EKG with a tachydysrhythmia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_88_0_Final_Cut.m4a Download One Comment Tags: Atrial Fibrillation, AVNRT, SVT, Tachycardias, Tachydysrhythias, Ventricular Tachycardia Show Notes Take Home Points When looking at a tachy rhythm that isn’t sinus tach, quickly differentiate by determining if the QRS complexes is narrow or wide and then determine if the rhythm is regular or irregular. This approach quickly drops the rhythm into 1 of 4 boxes and makes rhythm determination much easier Each of those 4 categories has a small set of rhythms included. Narrow and irregular – AF, Aflutter with variable block or MFAT. Narrow and regular – SVT or Aflutter. Wide and irregular – Torsades, VF, AF with aberrancy or a BBB. Wide and regular – VTach, SVT with aberrancy or SVT with a BBB. If you see wide and regular, the top 3 diagnoses are VT, VT and VT. Assuming VT and treating for that will almost never send you astray Read More EM: RAP: Episode 84 – Tachycardia Core EM: A Simplified Approach to Tachydysrhythmias Core EM: Atrioventricular Nodal Reentry Tachycardia Core EM: Ventricular Tachycardia Core EM: Recent-Onset Atrial Fibrillation Simplified Approach to Tachydysrhythmias Diagnosis Tachydysrhythmias Therapeutic Algorithm Torsades de Pointes Torsades de Pointes Read More

This week we discuss two recent journal articles - the POKER trial and the ketorlac analgesic ceiling https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_87_0_Final_Cut.m4a Download Leave a Comment Tags: Ketamine, Ketofol, ketorlac, POKER, Propofol, PSA Show Notes Take Home Points The POKER trial examined the difference between propofol and ketofol when it comes to adverse respiratory events. They found no significant difference between the groups. Given the increased risk of medication errors using two medication instead of one, you may want to avoid the mixture. Ketorolac has an analgesic ceiling effect lower than you may have thought. When comparing IV doses of 10mg, 15mg and 30mg they found no difference in analgesic effect. Given the risks of side effects may increase with higher doses, you may want to stick to the lower 10mg dose. RebelEM: The POKER Trial: Go All in on Ketofol? St. Emlyn’s: JC: Is Ketofol with the hassle? Core EM: Propofol vs. Ketofol in PSA EM: RAP: Just Enough Ketorlac RebelEM: The Ketorolac Analgesic Ceiling Core EM: Parenteral Ketorlac Dosing Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. PubMed ID: 27460905 Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. PubMed ID: 27993418 Read More

Do patients with 1st trimester bleeding need to get anti-D immunoglobulin if they're Rh negative? We dive into the topic this week. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_86_0_Final_Cut.m4a Download Leave a Comment Tags: Early Pregnancy, Obstetrics, RhoGam, Vaginal Bleeding Show Notes Take Home Points An Rh negative woman can become alloimmunized to Rh antigen if exposed to blood from an Rh positive fetus. Theoretically, this alloimmunization can occur even in early pregnancy While anti-D immune globulin has clearly been shown to be beneficial in preventing alloimmunization in 2nd and 3rd trimester pregnancy, there is no evidence supporting use specifically in the 1st trimester Despite the absence of evidence, RhoGam administration has become routine in many places. At this time, it’s advisable to follow local practice patterns regarding which patients should be given RhoGam. References ACOG Practice Bulletin. Prevention of Rh D Alloimmunization. Int J Gynaecol Obstet 1999; 66(1): 63-70. PMID: 10458556 Recommendations reaffirmed in 2016 Hahn SA et al. Clinical Policy: Critical Issues in the Initial Ealuation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med 2012; 60(3): 381-419. PMID: 22921048 Hannafin B et al. Do Rh-Negative Women with First Trimester Spontaneous Abortions Need Rh Immune Globulin. Am J Emerg Med 2006; 24: 487-9. PMID: 16787810 Visscher RD, Visscher HC. Do Rh-Negative Women with an Early Spontaneous Abortion Need Rh Immune Prophylaxis? Am J Obstet Gynecol 1972; 113(2): 158-65. PMID: 4623673 Read More

This week we discuss three common complications of delivery: cord prolapse, nuchal cord and shoulder dystocia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_85_0_Final_Cut.m4a Download Leave a Comment Tags: Cord Prolapse, Nuchal Cord, Obstetrics, Shoulder Dystocia Show Notes Take Home Points If you have a patient with a cord prolapse, elevate the presenting part to take pressure off the cord, place the patient in trendelenburg and fill the bladder. Then, redline it to the OR for a c-section. Nuchal cord is common but likely not too dangerous. Just gently unwrap the umbilical cord and the fetus should be just fine Shoulder dystocia isn’t common but it’s a true emergency as the fetus can suffer severe hypoxia or death. You’ve got a bout 5 minutes to deliver. Immediately call for help from OB, place a foley catheter to drain the bladder and place the mom’s legs so that her knees are pressed into her chest. This helps to open up the pelvis and give more room for the shoulder to be delivered. If that doesn’t work, you can try the wood’s screw maneuver or place the mom on all 4s. If you’ve got an OR ready, pushing the head back in is also an option but only if you have an OR available Read More Core EM: Shoulder Dystocia emDocs: The Complicated Delivery: What You Can Do Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82. PMID: 24360351 Read More

This week we look at TBI and discuss some of the pitfalls and pearls in early management of traumatic ICH. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_84_0_Final_Cut.m4a Download 2 Comments Tags: Head Injury, Hyperosmolar Therapy, ICH, Resuscitation, RSI, TBI, Trauma Show Notes Take Home Points If you get a heads up from EMS on an incoming trauma, take the lead time you get to clearly delineate everyone’s roles to help ensure the resuscitation runs smoothly. In the severe TBI patient, the key is in preventing secondary injury to the brain. We do this by guarding against hypoxia, hypercarbia, hypotension and aspiration. Max your pre-ox, get the ETT in quickly to prevent oxygenation and ventilation issues and keep the head up if possible Hypotension is rarely seen in isolated head trauma. If the patient is or becomes hypotensive, reassess for any sources of hemorrhagic shock that may have been missed and consider whether the meds you gave may have caused the problem. Hypertension is much more common and despite extensive research, we haven’t shown that dropping the patient to normal levels is beneficial. Keeping the SBP < 180 seems reasonable but check your local protocol as well. If the patient’s ICP spikes or your concerned about herniation, administer mannitol or hypertonic saline and get your neurosurgeon to the bedside since the patient is gonna need decompression Finally, make sure to reverse any anticoagulant the patient may have on board as this will hopefully prevent hematoma expansion. Read More emDocs: Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI Core EM: Podcast 31.0 – Rocuronium vs. Succinylcholine Core EM: Intensive Blood Pressure Lowering in Intracerebral Hemorrhage (ATACH-2 Trial) PulmCCM: Hyperosmolar Therapy for Increased Intracranial Pressure (Review) EM Cases: Episode 89 – DOACs Part 2: Bleeding and Reversal Agents Hopper AH. Hyperosmolar therapy for raised intracranial pressure. NEJM 2012; 367(8): 746-52. PMID: 22913684 Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014; 28(6): 821-7. PMID: 24859931 Zeiler FA et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014; 21(1): 163-73. PMID: 24515638 Read More

This week we discuss a bit about back pain and specifically, lumbar radiculopathy with a focus on causes and red flags. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_83_0_Final_Cut.m4a Download One Comment Tags: Back Pain, Low Back Pain, Musculoskeletal, Steroids Show Notes Read More St. Emlyn’s: Back to Basics: Back Pain in the ED Edlow JA. Managing nontraumatic acute back pain. Ann Emerg Med 2015; 66: 148-53. PMID: 25578887 Goldberg H et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA 2015; 313 (19): 1915-23. PMID: 25988461 Friedman BW et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 2015; 314 (15): 1572-80. PMID: 26501533 Read More

This week we discuss the ED management of seizures focusing on treatment and workup particularly of a 1st seizure episode. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_82_0_Final_Cut.m4a Download Leave a Comment Tags: Neurology, Seizure, Status Epilepticus Show Notes Take Home Points Get a detailed history to tease out whether the patient had a seizure or a syncopal event. Regardless, get an EKG on 1st time seizures in case it was actually syncope. BZDs are first line therapy for seizure termination. If you don’t have IV access, go with 10 mg of midazolam or 2-4 mg of lorazepam IM Always review the 5 main categories for causes of seizures in order to make sure you’re not missing anything. Those categories once again are vital sign abnormalities, CNS infections, toxic/metabolic issues, CNS space occupying lesions including masses and bleeds and finally epilepsy. In patients with a first time seizure without a particular cause and return to baseline neurologic status, there’s unlikely to be any benefit to a NCHCT or to starting an AED. Scheduling close follow up with a neurologist is very reasonable. The key is to do a thorough examination and make sure you’re not missing a subtle abnormality. Finally, in status epilepticus hit the patient with 2-3 hefty doses of BZDs and if the seizure is still ongoing, strongly consider moving to propofol and intubation in order to rapidly control the seizure activity. Read More Core EM: Parenteral Benzodiazepines LITFL: Seizure EMCrit: Podcast 155 – Status Epilepticus with Tom Bleck First10EM: Management of Status Epilepticus in the Emergency Department Huff SJ et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Seizures. Ann Emerg Med 2014; 43(5): 605-25. PMID: 15111920 Read More

This week, the podcast features a talk on Visualization given at the All NYC EM conference in October 2016. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_81_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, Human Factors, Performance Psychology, Sports Psychology Show Notes Read More EMCrit: EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria Read More

This week we feature a short primer on penetrating chest trauma focusing on circulation first over airway and breathing. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_80_0_Final_Cut.m4a Download Leave a Comment Tags: ED Thoracotomy, EFAST, Resuscitative Thoracotomy, Trauma, Ultrasound Show Notes Take Home Points Don’t rush to the airway. In most situations, you have some time so resuscitate before you intubate. Give blood products and get the BP up a bit to give yourself a little better physiologic situation in which to intubate. Start your massive transfusion immediately if the patient is shocked. There’s always a delay in getting products but the earlier you start, the shorter the delay. Include US in your primary survey. Your E-FAST should start with the cardiac window, then go to the lungs and then, finally, the abdomen. This order focuses on finding pathology you can fix immediately. If the patient is shocked and peri-arrest or recently lost vitals, open the chest and look for a fixable injury. Start with opening the pericardium to relieve tamponade, identify and repair cardiac wounds and cross clamp the aorta. Read More Larry Mellick: Open Thoracotomy Video EMCrit: Podcast 081 – An Interview on Severe Trauma with Karim Brohi LITFL: Penetrating Chest Trauma EM:RAP: How to Crack the Chest EM: RAP: Stabbed in the Chest Read More

This week we discuss facial trauma and the disasters it can cause to your airway management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_79_0_Final_Cut.m4a Download 2 Comments Tags: Airway, Cricothyroidotomy, RSI, Trauma Show Notes Take Home Points In a patient with significant head and neck trauma, EACH step of the airway management can be more difficulty. BVM may be hard, LMA may be hard, RSI may be hard, so don’t be afraid to ask for help early. Decide whether the patient has an actual obstruction of their airway. If they are obstructed above the larynx, don’t bother with your usual airway maneuvers, go directly to the surgical airway. When you do attempt RSI, have double suction and multiple airway techniques set up. This is the time to have your friend standing at your side, scalpel in hand and ready to move directly down the difficult airway algorithm if trouble arises. Finally, consider keeping the patient awake and preserving their own respiratory drive as it may give you more time to secure the airway. Read more LITFL: Facial Trauma LITFL: Airway in Maxillofacial Trauma EMCrit: Real Surgical Airway Read More

This week we discuss the OXYGEN-ICU trial exploring the effect of excess oxygen on ICU mortality. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_78_0_Final_Cut.m4a Download Leave a Comment Tags: Critical Care, ICU, OXYGEN-ICU Study Show Notes Read More The Bottom Line: Normal Oxygen Versus Hyperoxia in the Intensive Care Unit (ICU) (OXYGEN-ICU) ScanCrit: Avoid the Oxygen Reflex REBEL EM: July 2015 REBEL Cast References Giradis M et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 316(15):1583-1589. 2016. PMID: 27706466 Meyhoff CS et al. PROXI Trial Group. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009; 302(14):1543-1550. PMID: 19826023 Stub D et al. AVOID Investigators. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150. PMID: 26002889 Read More

This week the podcast features a talk Jenny Beck-Esmay gave at the 11th All NYC EM Conference entitled "Give TXA Now!" https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_77_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, CRASH-2, Massive Transfusion Protocol, MATTERS, Trauma, TXA Show Notes Take Home Points Giving TXA provides a significant mortality benefit to the any trauma patient requiring massive transfusion with an NNT = 7 for mortality TXA must be given early. Give within 1 hour of injury if possible but the benefit remains up to 3 hours out TXA administration: 1 gram as a bolus followed by 1 gram over the next 8 hours Show Notes Intensive Care Network: Karim Brohi on TXA in Trauma EMCrit: Podcast 67 – Tranexamic Acid (TXA) Core EM: CRASH-2 Tranexamic Acid in Major Trauma References CRASH-2 trial collaborators. Effects of tanexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a ransomised placebo-controlled trial. Lancet 2010; 376: 23-32. PMID: 20554319 Guerriero C et al. Cost-effectiveness analysis of administering tranexamic acid to bleeding trauma patients using evidence from the CRASH-2 trial. PLoS One 2011; 6(5): e18987. PMID: 21559279 Ker K et al. Avoidable mortality from giving tranexamic acid to bleeding trauma patients: an estimation based on WHO mortality data, a systematic literature review and data from the CRASH-2 trial. BMC Emerg Med 2012; 12:3. PMID: 22380715 Morrison JJ et al. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) Study. Arch Surg 2012; 147 (2): 113-9. PMID: 22006852 Read More

This week we discuss Lisfranc injuries with a focus on a diagnostic pathway and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_76_0_Final_Cut.m4a Download Leave a Comment Tags: Lisfranc Fracture, Lisfranc Injury, Orthopedics, Trauma Show Notes Take Home Points A Lisfranc injury is a midfoot injury that results in displacement of one or more of the metatarsal bones from tarsus. XR will show widening of the space between the 1st and 2nd metatarsals. Getting contralateral XR may help you identify this. Even if you don’t see that widening on the XR, the patient could still have a Lisfranc injury. If they cannot walk due to pain, get a weight bearing XR or CT scan to look further. Once the injury is identified, the patient must be strict non-weightbearing. Place them in a posterior splint and get orthopedics involved either in the ED or for prompt follow up as the patient will probably need surgery. Foot Bones (Google Images) Normal Foot X-ray Series (Case courtesy of Dr Andrew Dixon, Radiopaedia.org. From the case rID: 36688) Lisfranc Injury AP X-ray (Radiopaedia Image #1: Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. From the case rID: 10919) Divergent Lisfranc Injury Read More LITFL: Eponymous Fractures Radiopaedia: Lisfranc Injury Core EM: Compartment Syndrome Read More

This week we do a little spaced repetition on adrenal insufficiency and then discuss fluid responsiveness and resuscitation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_75_0_Final_Cut.m4a Download Leave a Comment Tags: Adrenal Insufficiency, Critical Care, Fluid Responsiveness, Fluid Resuscitation, Sepsis, Septic Shock Show Notes Read More Marik PE. Fluid responsiveness and the six guiding principles of fluid resuscitation. Crit Care Med 2016. PMID: 26571187 LITFL: Adrenal Insufficiency EMCrit: Podcast 64 – Assessing Fluid Responsiveness with Dr. Paul Marik Core EM: Adrenal Crisis Core EM: Episode 15.0 – Adrenal Crisis References Cavallaro F et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systemic review and meta-analysis of clinical studies. Intensive Care Med. 2010:36(9):1475-83. PMID: 20502865. Cecconi M et al. Fluid challenges in intensive care: the FENICE study: A global inception cohort study. Intensive Care Med. 2015:41(9):1529-37. PMID: 26162676. Landesberg G et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J. 2012:33(7):895-903. PMID: 21911341. Lee CV et al. Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound. J Crit Care. 2016:31(1):96-100. PMID: 26475100. Marik PE. Noninvasive cardiac output monitors: a state-of the-art review. Cardiothorac Vasc Anesth. 2013:27(1):121-34. PMID: 22609340. Read More

This week we review some pearls in the diagnosis and management of acid reflux. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_74_0_GERD_Final_Cut.m4a Download Leave a Comment Tags: Acid Reflux, Gastrointestinal, GERD, GI Show Notes Take Home Points GERD pain can mimic or co-exist with the more deadly causes of chest pain. Be sure to consider all the serious causes of chest pain, get an EKG and maybe a chest XR while you go about symptom management. Respond to a treatment doesn’t prove a diagnosis. GERD pain may get better with nitro and ACS pain may get better with a GI cocktail. Keep an open mind while seeing these patients. Standard treatment for GERD includes an antacid and H2 blocker and maybe a PPI. Keep in mind that a PPI takes a while to work, so be sure to give something faster acting in the ED And last, for these patients, take those few extra minutes for some counseling on lifestyle modifications. All medications come with side effects, so be sure to address things like diet, smoking and weight loss while you have a captive audience. Read More

This week we dive into the controversies surrounding the PESIT study looking at the prevalence of PE in admitted patients with syncope https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_73_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiovascular, Journal Club, PE, Pulmonary, Pulmonary Embolism, Syncope Show Notes Read More EMLit of Note: The Impending Pulmonary Embolism Apocolypse St. Emlyn’s: JC – Prevelance of PE in Patients with Syncope EM Nerd (EMCrit): The Case of the Incidental Bystander Pulm CCM: PESIT Investigators: The Incidence of PE in Those Hospitalized Following First Syncope References Hutchinson BD et al. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. Am J Rad 2015; 205(2):271-7. PMID: 26204274 Read More