Core EM - Emergency Medicine Podcast

This week we discuss upper GI bleeding pearls from a workshop we did in our weekly conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_72_0-UGIB_Final_Cut.m4a Download Leave a Comment Tags: Aortoenteric Fistula, Gastric Ulcer, Gastrointestinal, GI, UGIB, Variceal Bleeding Show Notes Take Home Points Respect the UGIB. These patients can bleed a lot. Even if they’re not actively hemorrhagic in front of you, realize that they can open up at any time and decompensate Get your consultants on board early. A skilled endoscopist is your friend as they can get control of bleeding. Don’t forget IR for TIPS in variceal bleeds and general surgery in bleeding ulcers. Activate your massive transfusion protocol if the patient is unstable and give the patient PRBCs, FFP and platelets as indicated. Reverse any anticoagulants as well. Give all patients with confirmed or suspected variceal bleeding antibiotics – typically, ceftriaxone. This intervention saves lives and decreases morbidity. Read More LITFL: EBM Upper GI Haemorrhage EMCrit: Episode 5: Upper GI Bleed Guidelines EMCrit: Intubating the Critical GI Bleeder The NNT: Prophylactic Antibiotics for Cirrhotics with Upper GI Bleed The NNT: Somatostatin Analogues (Octreotide) for Acute Variceal Bleeding EMRAP HD: Placement of a Blakemore Tube for Bleeding Varices Read More

This week we feature a lecture from Anand Swaminathan at our weekly conference on the ED management of acute pulmonary edema https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_71_0_Final_Cut.m4a Download 9 Comments Tags: Acute Decompensated Heart Failure, Acute Pulmonary Edema, ADHF, APE, Cardiovascular Show Notes Read More Core EM: Acute Pulmonary Edema EMCrit: Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema REBEL EM: Morphine Kills in Acute Decompensated Heart Failure emDocs: Furosemide in the Treatment of Acute Pulmonary Edema Read More

This week we discuss the rare, but life-threatening baclofen withdrawal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_70_0_Final_Cut.m4a Download Leave a Comment Tags: Baclofen, Critical Care, Toxicology, Withdrawal Syndromes Show Notes Take Home Points Baclofen withdrawal is a rare complication of intrathecal baclofen pumps. It’s presentation mimics sepsis and alcohol withdrawal and is characterized by hemodynamic instability, hyperthermia, increased spasticity, confusion, altered mental status and seizures. Patients can develop rhabdo from the spasticity and, eventually, can develop multi system organ dysfunction. Treating baclofen withdrawal with oral baclofen is unlikely to work even at large oral doses because only a tiny amount gets into the CSF where it needs to act for withdrawal to be treated Baclofen withdrawal can be emergently treated with increasing benzodiazepine doses, propofol infusions and baclofen administered via a lumbar puncture. Ultimately, these patients all need consultation with either neurosurgery or interventional pain management to interrogate the device and surgically correct the issue. Read more EM: RAP November 2015: Lin Sessions Intrathecal Pumps REBEL EM: Baclofen Withdrawal Chidester S, Smith S. Baclofen pump complications. The NYS Poison Centers Toxicology Letter 2011; 16(4): 1-12. Link Ross J et al. Acute Intrathecal Baclofen Withdrawal: A Brief Review of Treatment Options. Neurocrit Care. 2011;14(1):103-108. PMID: 20717751 Stetkarova I et al. Procedure- and device-related complications of intrathecal baclofen administration for management of adult muscle hypertonia: a review. Neurorehabil Neural Repair. 2010;24(7):609-619. PMID: 20233964 Shirley KW et al. Intrathecal baclofen overdose and withdrawal. Pediatr Emerg Care. 2006;22(4):258-261. PMID: 16651918 Read More

This week we discuss why we use antibiotics in COPD exacerbations and whether we should continue to do so. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_69_0_Final_Cut.m4a Download Leave a Comment Tags: Antibiotics, COPD, COPD Exacerbation, Pulmonary Show Notes Take Home Points Most COPD exacerbations are caused by infectious etiologies. While these can be viral, there’s also a decent chance it was caused by an overgrowth of bacteria that chronically colonize these patients. Strong evidence from systematic reviews demonstrates that antibiotic use reduces in-hospital mortality and decreases treatment failure The GOLD group recommends antibiotics be given to patients who have increased dyspnea, increased sputum volume and increased sputum purulence or require non-invasive or invasive ventilation for their exacerbation. Finally, a short course of antibiotics – either ampicillin, doxycycline or azithromycin is adequate for management. Read More GOLD Reports: Diagnosis, Management and Prevention 2016 Berg RMG, Plovsing RR. The hardships of being a Sith Lord: implications of the biopsychosocial model in a space opera. Adv Physiol Educ 2016; 40: 234-6. PMID: 27105743 Johannes M et al. Antibiotics in Addition to Systemic Corticosteroids for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Resp Crit Care Med 2010; 181(2): 150-7. PMID: 19875685 Quon BS et al. Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis. Chest 2008; 133:756-66. PMID: 18321904 Ram FS et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006:CD004403 PMID: 16625602 Rothberg MB et al. Antibiotic Therapy and Treatment Failure in Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. JAMA 2010; 303(20): 2035-2042 PMID: 20501925 Vollenweider DJ et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012: CD010257 PMID: 23235687 The Podcasting Course Read More

This week we discuss the workup and management of hiccups in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_68_0_Final_Cut.mp3 Download One Comment Tags: Hiccups, Singultus Show Notes Take Home Points Hiccups, or singultus, are caused by a reflex arc involving the vagus nerve, CNS and phrenic nerve. If you remember the path of these nerves, you can remember that possible bad pathologies that could cause a patient to present with prolonged hiccups. Physical maneuvers are the first line for solving the hiccups. Try things that will interrupt respiration or stimulate the vagus nerve. We like the modified valsalva in which the patient blows on a syringe, because it’s pretty easy to get the patient to do. Last, medication options for hiccups include antipsychotics, anticonvulsants, muscle relaxers and dopamine agonist. Generally, we start with chlorpromazine 25-50 mg PO or IM. Read More Steger M et al. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther 2015; 42(9):1037-50. PMID 26307025 Read More

This week we review pearls from our Grand Rounds from George Willis, MD talking about feedback. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_67_0_Final_Cut.m4a Download Leave a Comment Tags: Resident Education Show Notes Read More St. Emlyn’s: #TTCNYC Resources for Feedback Talk Read More

This week, we discuss Boerhaave syndrome focusing on making the diagnosis and managing the patient. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_66_0_Final_Cut.m4a Download One Comment Tags: Chest Pain, Pulmonary Show Notes Take Home Points Keep esophageal rupture on your differential for deadly causes of chest, epigastric or back pain. We don’t see it often, but it’s a real thing. Boerhaave Syndrome is the spontaneous rupture of the esophagus that is caused by a sudden increase in intraesophageal pressure, as seen in forceful vomiting. So, if the patient presents with the right symptoms and any vomiting in their history, keep this diagnosis in mind. Other causes you might see, though less common, are childbirth, seizure, prolonged coughing or laughing, or weightlifting. ED management is essentially ABCs and broad spectrum antibiotics, and maybe even antifungals. As soon as you make this diagnosis, get you CT surgeon on board as the length of time to definitive treatment is directly related to mortality. Read More Radiopaedia: Boerhaave Syndrome LITFL: Roast Duck and Juniper Beer Read More

This week we discuss the diagnosis and management of pericarditis with a focus on not missing the hidden STEMI. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_65_0_Final_Cut.m4a Download Leave a Comment Tags: ACS, Cardiology, Cardiovascular, Colchicine, Pericarditis, STEMI Show Notes Read More ECG Case of the Week (Amal Mattu): Acute STEMI vs. Pericarditis Part 1 + Part 2 REBEL EM: Colchicine for Treatment of Pericarditis SOCMOB: Pericarditis: Treatment and Diagnosis Pocket Card FOAMcast: Episode 54 – The Pericardium Core EM: Pericarditis Pericarditis PV Card (Chris Bond (socmob.org) References Brady W et al. Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment. Acad Emerg Med 2001;8:961–7. PMID: 11581081 Bischof JE et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med 2015 PMID: 26542793 Read More

This week we discuss an age-old debate: Calcium Channel Blockers or Beta Blockers for rate control in atrial fibrillation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_64_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation, Beta Blocker, Calcium Channel Blocker, Cardiology, Rate Control Show Notes CoreEM: Recent Onset Atrial Fibrillation ALiEM: Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers? ALiEM: Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED Fromm C, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015 Apr 22. PMID 25913166 Read More

This week we discuss a recent article looking at the relevance of d/c glucose levels to patient revisits and subsequent hospitalization https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_63_0_Final_Cut.m4a Download Leave a Comment Show Notes Driver BE et al. Discharge glucose is not associated with short-term adverse outcomes in emergency department patients with moderate to severe hyperglycemia. Ann Emerg Med 2016. PMID: 27353284 Read More

This week we discuss the ED management of cardiac arrest with VFib and pulseless VTach. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_62_0_Final_Cut.m4a Download One Comment Tags: Cardiac Arrest, Dual Defibrillation, OHCA, Ventricular Dysrhythmias, Ventricular Fibrillation, Ventricular Tachycardia Show Notes Take Home Points In cardiac arrest, the most important interventions are to deliver electricity quickly when it’s indicated and to administer good high-quality compressions with minimal interruptions to maximize your compression fraction. Medications like epinephrine and amiodarone have never been shown to improve good neurologic outcomes in the ACLS recommended doses. Don’t focus on them. Consider pre-charging your defibrillator to minimize pauses in CPR and maximize your chance for ROSC Finally, remember that as Emergency Physicians, we are specialists in the resuscitation of cardiac arrests. ACLS is just a starting point. Push your understanding of taking care of these patients so you can deliver the best care possible Additional Reading Core EM: Ventricular Tachycardia Core EM: A Simplified Approach to Tachydysrhythmias Core EM: Amiodarone, Lidocaine or Placebo in OHCA emDocs.net: Epinephrine in Cardiac Arrest REBEL EM: Beyond ACLS: Pre-Charging the Defibrillator ACLS VFib and VTach Algorithm References Driver BE et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation 2014; 85(10): 1337-41. PMID: 25033747 Kudenchuk PJ et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. NEJM. 2016; PMID: 27043165 Laina A et al. Amiodarone and Cardiac Arrest: Systematic Review and Meta-Analysis. Int J Cardiol 2016; 221: 780-8. PMID: 27434349 Read More

This week we discuss the presentation and treatment of hypokalemia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_61_0_Final_Cut.m4a Download Leave a Comment Show Notes Take Home Points Hypokalemia has a wide variety of presentations ranging from generalized weakness, to paralysis, to cardiac arrhythmia or cardiac arrest. When you discover hypokalemia, be sure to check and EKG. Think about underlying causes of hypokalemia, because it is rarely a solo event. Treat with oral potassium supplementation of 40-60 orally every 4-6 hours for mild hypokalemia and 10-20 mEq/hour IV for severe or symptomatic hypokalemia. Additional Reading LITFL: Hypokalemia LITFL: Hypokalemic Periodic Paralysis Core EM: Hypokalemia Read More

This week we discuss how to aggressively resuscitate patients with DKA as well as dispelling some dogmatic teachings on the topic. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_60_0_Final_Cut.m4a Download Leave a Comment Tags: Cerebral Edema, DKA, Hypokalemia, Insulin, Resuscitation Show Notes Take Home Points DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis. Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5 The insulin bolus isn’t necessary and appears to cause more episodes of hypokalemia. Just start insulin as an infusion at 0.14 units/kg Be vigilant about cerebral edema. Any change or deterioration in mental status should prompt treatment and evaluation. Mannitol in the euvolemic, normotensive patient and 3% hypertonic saline in the hypotensive/hypovolemic patient Finally, don’t forge to always hunt down the underlying cause of the DKA. Infection and non-compliance is the most common so liberally administer broad spectrum antibiotics if you’ve got even a hint of infection brewing https://www.youtube.com/watch?v=P9sKk4JZmso Additional Reading LITFL: EBM Diabetic Ketoacidosis Core EM: DKA Core EM: Episode 13.0 – Diabetic Ketoacidosis: A Case emDocs: Myths in DKA Management REBEL EM: Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis? References Aurora S et al. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med 2012; 30: 481-4. PMID: 21316179 Boyd JC et al. Relationship of potassium and magnesium concentrations in serum to cardiac arrhythmias. Clin Chem 1984; 30(5): 754-7. PMID: 6713638 Duhon B et al. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother 2013; 47: 970-5. PMID: 23737516 Fagan MJ et al. Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry arethey? Clin Ped 2008; 47(9): 851-6. PMID: Goyal N et al. Utility of Initial Bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med 2010; 38(4): 422-7. PMID: 18514472 Green SM et al. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emergency Medicine 1998; 31: 41-48. PMID: 9437340 Kitabchi AE et al. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Diabetes Care. 2008;31(11):2081. PMID: 18694978 Lebovitz HE: Diabetic ketoacidosis. Lancet 1995; 345: 767-772. PMID: 7891491 Morris LR et al. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med 1986;105(6):836. PMID: 3096181 Muir AB et al. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care 2004; 27(7):1541-6. PMID: 15220225 Okuda Y et al. Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clinical Endocrinology Metabolism 1996; 81: 314-320. PMID: 8550770 Savage MW et al. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med. 2011 May;28(5):508-15. PMID: 21255074 Villon A et al. Does bicarbonate therapy improve management of severe diabetic ketoacidosis? Crit Care Med 1999; 27: 2690-2693. PMID: 10628611 Read More

This week we discuss the recognition, diagnosis and treatment of severe decompensated hyperthyroidism or thyroid storm. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_59_0_Final_Cut.m4a Download Leave a Comment Tags: Thyroid Diseases, Thyroid Storm Show Notes Take Home Points Decompensated hyperthyroidism is a rare, life-threatening condition. It can develop in patients with long-standing untreated hyperthyroidism and is often precipitated by another event such as an infection, surgery, or trauma. Patients present with tachycardia, fever, altered mental status and GI symptoms. Keep thyroid storm in mind if a patient has a history of hyperthyroidism or if things just aren’t making sense with your patient, you can’t find a fever source, they have fever and new afib, things like that. You’re going to use a clinical scoring tool like the Burch-Wartofsky scoring system to make the diagnosis. Treatment is three-fold. First treat the peripheral effects with propranolol. Then prevent further synthesis of thyroid hormone with PTU and corticosteroids. And last prevent the further release of thyroid hormone with iodine. Be sure to hold off on giving the iodine until at least 1 hour after the patient receives PTU to avoid worsening the hyperthyroid. Burch Wartofsky Scale (maryland.ccproject.com) Additional Reading ALiEM: Diagnosing hyperthyroidism: Answers to 7 common questions ALiEM: Thyroid Storm – Treatment Strategies LITFL: Thyroid Storm WikeEM: Burch and Wartofsky Diagnostic Criteria for Thyroid Storm Akamizu T et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012; 22(7): 661-79. PMC: 3387770 Read More

This week we discuss severe hyponatremia - presentation and treatment. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_58_0_Final_Cut.m4a Download Leave a Comment Tags: Electrolytes, Hypertonic Saline, Hyponatremia Show Notes EM Cases: Podcast 60: Emergency Management of Hyponatremia References Adrogue HJ, Maidas NE. Hyponatremia. NEJM 2000; 342(21): 1581-9. PMID: 10824078 Moritz ML, Ayus JC. 100 cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metab Brain Dis 2010; 25: 91-6. PMID: 20221678 Read More

This week we discuss the role of phenobarbital in the management of severe alcohol withdrawal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_57_0_Final_Cut.m4a Download One Comment Tags: Alcohol Withdrawal, Phenobarbital, Toxicology Show Notes References Riggan MA et al. Regarding “Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study.” J Emerg Med 2016; 50 (6): 895-8. PMID: 27221017 Rosenson J et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study. J Emerg Med 2013; 44(3): 592-8. PMID: 2299978 Read More

This week we discuss pearls from a talk from Reuben Strayer on sedation of the agitated patient focusing on patient and staff safety. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_56_0_Final_Cut.m4a Download 3 Comments Tags: Agitation, Droperidol, Excited Delirium, Haloperidol, Lorazepam, Midazolam Show Notes EM Updates: The Ketamine Brain Continuum LITFL: Behavioral Emergencies Core EM: Parenteral Benzodiazepines References Calver L et al. The safety and effectiveness of droperidol for sedation of acute behavioral disturbance in the Emergency Department. Ann Emerg Med 2015; 66(3): 230-8. PMID: 25890395 Read More

This week we dive into the PATCH trial investigating the role of platelet transfusions in patients with spontaneous ICH on antiplatelet meds https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_55_0_Final_Cut.m4a Download Leave a Comment Tags: Intracerebral Hemorrhage, PATCH Trial, Platelets Show Notes Read More REBEL EM: The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage? St. Emlyn’s: JC – Platelets for Intracranial Haemorrhage EM Lit of Note: Put the Platelets Away in ICH References Baharoglu MI et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral hemorrhage associated with anti platelet therapy (PAtCH): a randomized, open-label, phase 3 trial. Lancet 2016. ePub Read More

This week we discuss some of the critical issues in preparation, preoxygenation and positioning in RSI. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_54_0_Final_Cut.m4a Download Leave a Comment Tags: 7 Ps, High-flow Nasal Cannula, Intubation, Preoxygenation, RSI Show Notes Read More EM Updates: Intubation Checklist Core EM: Episode 4.0 – Perimortem C-section, Procedural Sedation and Airway Pearls Core EM: Episode 6.0 – Airway Workshops Sales JC et al. The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med 2013; 20(1): 71-8. PMID: 23574475 LEMON Mnemonic Device MOANS Mnemonic Device Read More

This week we discuss a recent study published in the NEJM on low-dose tPA vs standard-dose in acute ischemic stroke. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_53_0_Final_Cut.m4a Download Leave a Comment Tags: Alteplast, CVA, Ischemic Stroke, The ENCHANTED Trial, tPA Show Notes Read More Anderson CS et al. Low-dose versus standard-dose intravenous alteplase in acute ischemic stroke. NEJM 2016. PMID: 27161018 EMNerd: The Case of the Non-Inferior Inferiority Continues REBEL EM: The ENCHANTED Trial: Is Low-Dose the Right Dose for Intravenous tPA in Acute Ischemic Stroke? EMCrit: Podcast 116 – the tPA for Ischemic Stroke Debate EMNerd: A Secondary Examination of the Adventure of the Cardboard Box SMART EM: Thrombolytics for Acute Stroke Read More

This week we review anaphylaxis, the importance of epinephrine/adrenaline and how to use it properly. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_52_0_Final_Cut.m4a Download One Comment Tags: Allergic Reactions, Allergy, Anaphylaxis, Epinephrine Show Notes Anaphylaxis Definition Read More Tran TP, Muelleman RL: Allergy, Hypersensitivity, Angioedema, and Anaphylaxis, 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) 119: p 1543-1560. YouTube: Epinephrine Auto-Injector Use The SGEM: #57: Should I Stay or Should I Go (Biphasic Anaphylactic Response) Core EM: Biphasic reactions in emergency department patients with allergic reactions or anaphylaxis   References Grunau BE et al. Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis. Ann Emerg Med 2014; 63(6): 736-44. PMID: 24239340 Grunau BE et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis is Not Associated with Decreased Relapses. Ann Emerge Med 2015; 66(4): 381-9. PMID: 25820033 Read More

This week we dive into a recent article on pain control in renal colic and how it affects our management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_51_0_Final_Cut.m4a Download Leave a Comment Tags: Analgesia, Kidney Stones, Renal Colic, Urology Show Notes Read More Core EM: Optimal First Line Analgesia in Ureteric Colic ALiEM: Top 10 reasons NOT to order a CT scan for suspected renal colic REBEL EM: Does Use of Tamsulosin in Renal Colic Facilitate Stone Passage Core EM: Medical Expulsive Therapy (MET) in Renal Colic Wang RC. Managing Urolithiasis. Ann Emerg Med 2015 PMID: 26616536 References Pathan SA et al. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multi group, randomized controlled trial. Lancet 2016. PMID: 26993881 Read More

This week we look at the rarely used, but potentially life-saving, procedure of gastric lavage. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_50_0_Final_Cut.m4a Download Leave a Comment Tags: Gastric Emptying, Gastric Lavage, Toxicology Show Notes Gastric Lavage Indications (Goldfrank’s Toxicologic Emergencies Ch 7) Gastric Lavage Risk Assessment (Goldfrank’s Toxicologic Emergencies Ch 7) Gastric Lavage Placement (Goldfrank’s Toxicologic Emergencies Ch 7) References Adams BK et al. Prolonged gastric emptying half-time and gastric hypo motility after drug overdose. Am J Emerg Med 2004; 22: 548-554. PMID: 15666259 Benson BE et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Tox 2013; 51: 140-6. PMID: 23418938 Gude AB, Hoegberg LCG. Chapter 7. Techniques Used to Prevent Gastrointestinal Absorption. 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. Hoffman RS. Does consensus equal correctness? Clin Tox 2000; 38(7): 689-90. PMID: 11192453 Kulig K et al. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985; 14(6): 562-9. PMID: 2859819 Merigian KS et al. Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med 1990; 8: 479-83. PMID: 1977400 Pond SM et al. Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aus 1995; 163: 34-9. PMID: 7565257 Read More

This week we take a look at alcohol withdrawal with a focus on recognition and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_49_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Withdrawal, Ativan, Benzodiazipines, Delirium Tremens, Ethanol, Thaimine, Valium Show Notes Yip L. Chapter 77. Ethanol. 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. EmCrit Podcast: Delirium Tremens Life in the Fast Lane: Alcohol Withdrawal The Poison Review: CPC: alcohol withdrawal with delirium tremens and a significant missed diagnosis EM Updates: Avoid Alcohol Withdrawal Admissions MDCalc: CIWA Read More

This week we delve into the anticholinergic toxidrome with a focus on management and the use of physostigmine. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_48_0_Final_Cut.m4a Download Leave a Comment Tags: Anticholinergic, Diphenhydramine, Physostigmine, TCA, Toxicology Show Notes Howland M. Antidotes in Depth (A12): Physostigmine Salicylate. 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. Velez LI, Feng SY: Anticholinergics, 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) 150: p 1970-5. Anticholinergic Infographic (BrianandKloss.com) Drugs Exhibiting Anticholinergic Toxicity (Rosen’s) Read More

This week we review mandible dislocations and reduction approahces focusing on the new "syringe" technique. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_47_0_Final_Cut.m4a Download Leave a Comment Tags: Mandible Dislocation, Oral Surgery, Syringe Technique Show Notes Read More ALiEM: Tick of the Trade: Extra-oral reduction technique of anterior mandible dislocation Gorchynski J et al. The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibulardislocations in the emergency department. J Emerg Med. 2014; 47(6):676-81. PMID 25278137   Syringe Technique Step 1 Syringe Technique Step 2 Syringe Technique Step 3 Read More

This week, the podcast features a full length talk from our Grand Rounds series. This talk was given by Ilene Claudius on pediatric SOB https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_46_0_Final_Cut.m4a Download Leave a Comment Tags: Asthma, Atropine, Bronchiolitis, Croup, Magnesium, RSI Show Notes Irazuzta JE et al. High-dose magnesium sulfate infusion for severe asthma in the emergency department: efficacy study. Crit Care Med 2016; 17: e29-e33. PMID: 26649938 Read More

This week we review a number of controversial topics in SSTI management with a focus on the role of antibiotics in abscess management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_45_0_Final_Cut.m4a Download Leave a Comment Tags: Abscess, Cellulitis, Controversy, I+D, Irrigation, TMP-SMX Show Notes Core EM: Predictors of failed outpatient cellulitis treatment EM Nerd: The Case of the Pragmatic Wound REBEL EM: Trimethoprim-sulfamethoxazole for uncomplicated skin abscesses EM Lyceum: Abscess, “Answers” References Peterson D et al. Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients with Uncomplicated Cellulitis. Acad Emerg Med 2014; 21: 526-31. PMID: 24842503 Talan DA et al. Trimethoprim-Sulfamethoxazole versus placebo for uncomplicated skin abscesses. NEJM 2016; 374(9): 823-32. PMID: 26962903 Chinnock B, Hendey GW. Irrigation of cutaneous abscesses does not improve treatment success. Ann Emerg Med 2016; 67(3): 379-83. PMID: 26416494 Read More

This week we touch on some pearls and pitfalls on diagnosis and management of tick borne illnesses. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_44_0_Final_Cut.m4a Download One Comment Tags: Babesiosis, Ehrlichiosis, Lyme Disease, RMSF, Rocky Mountain Spotted Fever, Tick Show Notes CDC: Ticks CDC: Tick Borne Illnesses of the United States Read More

This week we review delayed ICH in patients with head trauma on blood thinners and discuss the role of repeat imaging and admission. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_43_0_Final_Cut.m4a Download 2 Comments Tags: Clopidogrel, Delayed Intracranial Hemorrhage, Head Trauma, Plavix, Warfarin Show Notes Nishijima DK et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and perjury warfarin or clopidogrel use. Ann Emerge Med 2012; 59(6): 460-8. PMID: 22626015 Menditto VG et al. Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 2012; 59(6): 451-5. PMID: 22244878 Miller J et al. Delayed intracranial hemorrhage in the anticoagulated patient: a systematic review. J Trauma Acute Care Surg 2015; 79: 310-3. PMID: 26218702 Read More

This week we review how to ventilate the intubated asthmatic patient. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_42_0_Final_Cut.m4a Download One Comment Tags: Asthma, Crashing Asthmatic, Permissive Hypercapnea, Ventilation Show Notes REBEL EM: The Crashing Asthmatic EMCrit: Podcast 15 – The Severe Asthmatic EMCrit: Dominating the Vent: Part I + Part II Read More

This week we look at herpetic infections of the eye and skin focusing on diagnosis and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_41_0_Final_Cut.m4a Download One Comment Tags: Herpes, Herpetic Keratitis, Shingles, Zoster Show Notes Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev 2010. PMID: 21154352 American Academy of Ophthalmology: Herpes Simplex Virus Keratitis Treatment Guideline Read More

This week we delve into dental emergencies from infections to trauma as well as discussing dental anesthesia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_40_0_Final_Cut.m4a Download Leave a Comment Tags: Dental Caries, Dental Emergencies, Dental Trauma, Dentoalveolar Abscess Show Notes Taming the SRU: Regional Anesthesia of the Face & Mouth ALiEM: Paucis Verbis: Dental trauma ALiEM Paucis Verbis: Dental infections ALiEM Tricks of the Trade: Dental Avulsion and Subluxation EB Medicine: Fixing Faces Pain Painlessly: Facial Anesthesia in Emergency Medicine Core EM: Tongue Blade Test The Dental Box Instructional Videos Read More

This podcast reviews highlights from a grand rounds talk given by Michael Bond on Killer back pain. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_39_0_Final_Cut.m4a Download Leave a Comment Tags: AAA, Back Pain, Epidural Abscess, Vertebral Osteomyelitis Show Notes Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med 2015; 66: 148-53. PMID: 25578887 Read More

This week we discuss everyone's favorite infectious diseases: Gonorrhea and Chlamydia https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_38_0_Final_Cut.m4a Download Leave a Comment Tags: Chlamydia, Gonorrhea, PID, STD, STI Show Notes The SGEM: SGEM #104: Let’s Talk About Sex Baby, Let’s Talk About STDs ALiEM: Is the Pelvic Exam in the Emergency Department Useful? HQMedEd: Blind Swab vs Speculum-Assisted Endocervical Swab EM Lyceum: PID Answers Exposed: Why is Gonorrhea Called the Clap? CDC: Expedited Partner Therapy CDC: Sexually Transmitted Diseases Chart Read More

This week we discuss ovarian pathology focusing on ovarian torsion and tubo-ovarian abscess. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_37_0_Final_Cut.m4a Download Leave a Comment Tags: gynecology, Ovarian Torsion, TOA, tubo-ovarian abscess Show Notes Pediatric EM Morsels: Ovarian Torsion EM Lyceum: Ovarian Torsion Beigi, R.H. (2015). Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Beigi, R.H. (2015). Management and complications of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Hart, D, Lipsky, A. Acute Pelvic Pain in Women. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 266-272. Lee D, Swaminathan A. Sensitivity of Ultrasound for the Diagnosis of Tubo-Ovarian Abscess: A Case Report and Literature Review. J Emerg Med. 2011 vol 40 (2): 170-5. PMID: 20466506 Tibbles, CD. Selected Gynecologic Disorders. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 1355-1362. Read More

This week's podcast delves into cervical spine injuries and the findings found on CT imaging of the cervical spine. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_36_0_Final_Cut.m4a Download Leave a Comment Tags: Cervical Spine, Fracture, Trauma Show Notes Core EM: C-Spine Injuries + CT Interpretation Schwartz DT. Section 5. Cervical Spine. In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008. http://accessemergencymedicine.mhmedical.com/ (via NYU Health Sciences Library) Read More

This week we discuss an article on door to balloon time and focus on the EPs role in patients who present with ST elevations on their EKG. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_35_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiology, Door to Balloon Time, Resuscitation, STEMI Show Notes Fanari Z et al. Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential risks and role of quality improvement. Mayo Clin Proc 2015. PMID: 26549506 REBEL EM: December 2015: All Cardiology REBELCast Read More

This week, we cover the physiologic changes in pregnancy and how they affect trauma management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_34_0_Final_Cut.m4a Download Leave a Comment Tags: Perimortem C-section, Pregnancy, Trauma Show Notes EMCrit: Peri-Mortem C-Section emDocs.net: Resuscitation of the Pregnant Trauma Patient – Pearls and Pitfalls Core EM: Peri-Mortem C-Secton Core EM: Podcast 4.0 Medications in Pregnancy Read More

This week, we review the management of post-partum hemorrhage focusing on identifying the cause, resuscitation and directed medical therapy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_33_0_Final_Cut.m4a Download Leave a Comment Tags: Post-partum hemorrhage, Pregnancy Show Notes Core EM: Shoulder Dystocia Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82. PMID: 24360351 Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82. Drugs for the Management of Uterine Atony – Roberts + Hedges Read More

This is part I of a 2 part series on C-spine CT scans. In part 1, we discuss the basic ins and outs of reading the C-spine CT. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_32_0_Final_Cut.m4a Download Leave a Comment Tags: Cervical Spine, CT Scan Show Notes Core EM: The ABCs of Reading C-Spine CTs Read More

This podcast is a recorded lecture from our conference on why Rocuronium should be the go to drug for RSI in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_31_0_Final_Cut.m4a Download 2 Comments Tags: Airway, Rocuronium, RSI, Succinycholine Show Notes Sydney HEMS Sux Contraindications Read More: Strayer RJ. Rocuronium versus succinylcholine: Cochrane synopsis reconsidered. Ann Emerg Med 2011; 58(2): 217-8 Strayer RJ. Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 345-6. Mallon WK et al. Response to Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 346-7. Strayer RJ. (2010, January 14). Screencast: Rocuronium vs. Succinylcholine in 8 minutes. Retrieved from http://emupdates.com/2010/01/14/rocuronium-vs-succinylcholine/ References Sluga M, Ummenhofer W, Studer W, Siegemund M, Marsch SC. Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: a prospective, randomized trial in emergent cases. Anesth Analg 2005; 101:1356 – 61. McCourt KC, Salmela L, Mirakhur RK, et al. Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia. Anaesthesia 1998;53:867–71. Laurin EG, Sakles JC, Panacek EA, Rantapaa AA, Redd J. A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients. Acad Emerg Med 2000;7:1362–9. Herbstritt A. BET 3: Is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation. Emerg Med J 2012; 29(3): 256-9. Taha SK et al. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia 2010; 65: 358-61. Tang L et al. Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand 2011; 55: 203-8. Read More

This episode delves into pediatric c-spine injuries focusing on the question of who needs imaging? https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_30_0_Final_Cut.m4a Download Tags: Cervical Spine, NEXUS C-spine, Pediatrics Show Notes Leonard JC et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med 2011; 58(2): 145-55. PMID: 21035905 ERCast: Pediatric C-spine Clearnace PECARN Decision Rule PECARN Paramater Definitions PECARN ORs Read More

This week we discuss the work up for dementia and delirium as well as a bit on ischemic CVA management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_29_0_Final_Cut.m4a Download Leave a Comment Tags: CVA, Delirium, Dementia, Stroke, tPA Show Notes SAEM Geriatric Guidelines (includes screening tools for delirium): GEMCast: Diagnosing and Managing Delirium in Older Adults Gioia, LC et al. Blood pressure management in acute intracerebral hemorrhage: current evidence and ongoing controversies. Curr Opin Crit Care. 2015; 21(2):99-106. PMID: 25689125 Miller J et al. Management of hypertension in stroke. Ann Emerg Med. 2014; 64(3): 248-55. PMID: 24731431 EM Nerd: A Truncated Summation of the Adventure of the Cardboard Box Ed in the ED WDYS: Talking about tPA – Expert and Community Commentary   Read More

This week we review some of the different aspects used in assessment of the suicidal patient who presents to the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_28_0_Final_Cut.m4a Download Leave a Comment Tags: Depression, Suicide Assessment Show Notes ERCast: Suicide Risk ERCast: Is My Patient Suicidal Columbia Suicide Severity Rating Scale Read More

Are you ready for endovascular therapy in ischemic CVA? We discuss some of the ins and outs focusing on the MR CLEAN trial. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_27_0_Final_Cut.m4a Download Leave a Comment Tags: CVA, Ischemic Stroke, MR CLEAN Show Notes Montori VM et al. Randomized trials stopped early for benefit: a systematic review. JAMA 2005; 294(17): 2203-9. PMID: 16264162 EMCrit: Podcast 116 – the tPA for Ischemic Stroke Debate EM Nerd: A Truncated Summation of the Adventure of the Cardboard Box (Reviews the major endovascular treatment studies) Read More

This week's podcast is a full length recording of Ashley Shreves' Grand Rounds talk at Bellevue Hospital on dying in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_26_0_Final_Cut.m4a Download Leave a Comment Tags: Palliative Care Show Notes All NYC EM Podcast: Ashley Shreves – Pathway to a Peaceful Death Read More

Emergent placement of a temporary TV pacer is a life-saving procedure. We review the procedure along with some pearls along the way. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_25_0_TV_Pacemakers_Final_Cut.m4a Download Leave a Comment Tags: Transvenous Pacemaker Show Notes Bessman ES: Emergency Cardiac Pacing, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 15:p 277-300. Read More: EM Updates: Electromechanical Dissociation LITFL: Temporary Transvenous Cardiac Pacing Robert’s + Hedges – TV Pacemaker Equipment Read More

This podcast is a brief discussion on hepatic encephalopathy: How it presents, the utility of ammonia levels and what else to look out for. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_24_0_Final_Cut.m4a Download Leave a Comment Tags: Ammonia, AMS, Hepatic Encephalopathy Read More

This week we review small bowel obstruction presentation, diagnosis and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_19_0_Final_Cut.m4a Download Leave a Comment Tags: Large Bowel Obstruction, SBO Show Notes 5 Minute Sono: Small Bowel Obstruction EM Lyceum: GI Imaging FOAMCast: Episode 23 – SBO and Mesenteric Ischemia Read More