Emergency Medicine Cases

Salim Rezaie on single syringe adenosine for SVT, Sarah Reid on pertussis pearls, Elisha Targonsky on management of hyperemesis gravidarum , Joe Nemeth on the utility of hypertension as a risk factor in EM, Justin Morgenstern on tramadol myths, Reuben Strayer on ketamine only breathing intubation (KOBI)...

Dr. Arun Sayal and Dr. Dale Dantzer answer questions such as: How do we know we have adequate shoulder x-ray views? How can we best remember the differential diagnosis of an orthopedic extremity emergency with a normal x-ray? What is the quickest and best way to test neurologic status of patients with shoulder injuries? Why is axillary view of the shoulder so valuable? What is the biggest myth when it comes to the mechanism of injury for posterior glenohumeral shoulder dislocations? What physical exam maneuvers increase suspicion for posterior glenohumeral dislocation? What are the subtle findings on x-ray we should look for in patients with suspected posterior glenohumeral dislocation? What is the preferred first line reduction technique for posterior shoulder dislocation? What are the most common and consequential pitfalls in the management of anterior shoulder dislocations? and many more...

The current outbreak of the novel respiratory pathogen Coronavirus is an opportunity to remind ourselves of how to properly and adequately prepare for an emergency outbreak in our EDs. Although the mortality rate in patients with Coronavirus in this outbreak is less than 1% (which pales in comparison to Ebola or SARS), historically these types of outbreaks have occured every 5-6 years (SARS 2003, HINI 2009, Ebola 2014, Coronavirus 2020), so they are somewhat predictable and we should know how to prepare for them in our EDs. In this special edition EM Cases podcast Dr. Megan Landes, a Global Health expert, researcher and EM educator runs us through how to best practically prepare our EDs for an outbreak like Coronavirus...

Does heparin - LMWH or unfractionated heparin - benefit the patient with a pretty good story for angina with a bump in their troponin and some ST depression in the lateral leads? We’re expected to routinely give heparin for all these NSTEMI and unstable angina patients with any ischemic changes seen on the ECG, right? And for STEMI too. But should we?....

In this EM Quick Hits podcast we have Paul Dorion on immediate cardioversion vs rate control/delayed cardioversion for atrial fibrillation, Justin Morgenstern & Justin Hensley on emergency management of snake bites, Brit Long on reliability of clinical features in the diagnosis of ovarian torsion, Michelle Klaiman on emergency management of crystal methamphetamine use disorder, Hans Rosenberg & Rob Ohle on workup of suspected aortic dissection, and Anand Swaminathan on epinephrine and magnesium sulphate in severe asthma...

The question is: how do we best mentally and physically prepare for an ED shift? Dr. Rob Orman, master educator and fellow podcaster joins Anton to discuss a few options...

Among the presentations seen in the ED, few command the same respect as status epilepticus. It is, in itself, both a diagnostic dilemma and, at times, a therapeutic nightmare. There’s a reason it’s the very first domino to fall in the dreaded sequence “seizure, coma, death”. Status epilepticus can be nuanced to manage. Sure, most seizures self-abort or love an IV dose of lorazepam, but ask anyone who’s been down the propofol route, and they’re not likely to have forgotten the time they stared down a patient who just...would...not....stop...

In this EM Quick Hits podcast we have Emily Austin on physostigmine for anticholinergic toxidrome, Walter Himmel on understanding nystagmus to differentiate central vs peripheral causes of vertigo, Rob Devins on the role of transesophageal echocardiogram in cardiac arrest, Jesse MacLaren on nuances in inferior MI ECG changes and aVL, Andrew Petrosoniak on a practical approach to blunt cerebrovascular injury and Reuben Strayer on choicebo...

What is the essential list of immediate life threats with specific antidotes that we must know for the ED patient with a seizure? What are the key elements for distinguishing a true seizure from syncope? From Psychogenic Non-Epileptic Seizure (PNES)? From TIA? From migraine? How do you distinguish Todd's Paralysis from TIA or stroke? What are indications for lactate and troponins in patients who present with a seizure? Do all patients with first time unprovoked seizures require anti-seizure medication in the ED? What is the preferred anti-seizure medication and route for ED loading for the patient with a first time seizure? Which patients who present with seizure require a CT head in the ED? What are indications and ideal timing for EEG for patient who present to the ED with seizure? and many more...

Sarah Reid on pediatric appendicitis risk calculator, Sheldon Cheskes & Mark Ramzy on double defibrillation for refractory ventricular fibrillation, Hans Rosenberg & Krishan Yadav on cellulitis clinical pearls, Anand Swaminathan on serratus anterior block, Brit Long on recognition of toxic shock syndrome, Justin Morgenstern on tranexamic acid in head injury and CRASH-3...

Rob Simard of POCUS Cases fame and Scott Weingart go beyond ACLS and guide you through the complex world of PEA. We discuss that the palpation technique is poor at determining whether or not a patient has a pulse, that the POCUS pulse is more accurate and as rapid compared to the palpation technique at determining whether or not a patient has a pulse, the difference between true PEA arrest, PseudoPEA and PREM, why epinephrine may be harmful in PEA, Weingart's chain of survival approach from PEA arrest to ROSC, four tools to help differentiate true PEA arrest from PseudoPEA, how to prevent long pauses in chest compressions using POCUS, EM Cases PEA arrest and PseudoPEA suggested dynamic algorithm, vasopressor choices in PseudoPEA, whether the "QRS wide vs narrow width" approach to PEA arrest underlying cause is useful or not and much more...

Justin Morgenstern on the lack of evidence for burn debridement, Jesse MacLaren on ECG Cases - missed ischemia and pitfalls of "normal" computer ECG interpretations, Arun Sayal on clinical diagnosis pitfalls of compartment syndrome, Sarah Reid on pediatric asthma pitfalls and myths, Andrew Petrosoniak on T-spine and L-spine fracture work-up, Michelle Klaiman & Taryn Lloyd on motivational interviewing part 2...

While community acquired pneumonia (CAP) is 'bread and butter' emergency medicine, and the diagnosis is often a 'slam dunk', it turns out that up one third of the time, we are wrong about the diagnosis; that x-rays are not perfect; that blood work is seldom helpful; that not all antibiotics are created equal and that deciding who can go home and who needs to go to the ICU isn’t always so clear cut. With this in mind we are taking a deep dive into CAP, from diagnosis to disposition so that we can better achieve our EM goals of stabilizing sick patients, getting the right diagnosis, initiating the best treatment with the information at hand, prognosticating/appropriately deciding on disposition of patients, and being healthcare and antimicrobial stewards...

Anand Swaminathan on Lemierre's syndrome, Emily Austin on clonidine toxicity, Brit Long on myths of routine coagulation panel testing, Hans Rosenberg and Michael Ho on reversal of anticoagulation, Sheldon Cheskes on mechanical CPR...

Howard Ovens, Grant Innes, Sam Campbell and Anton discuss the root causes, challenges and some of the solutions of one of the defining characteristics of emergency medicine in the 21st century - overcrowding. It is absolutely in the interest of every single ED provider to understand how this problem came to be, and what we can do about it. As citizens of the medical community, becoming aware of the issues that drive ED overcrowding will be a powerful asset in the drive for change. We hope to equip you with the knowledge and actionable moves to effect change on your next shift at the individual level, at the ED level, and even at the hospital and government levels…

Anand Swaminathan on a simple approach to status epilepticus, David Juurlink on codeine and tramadol interactions: nasty drugs with nastier drug interactions, Brit Long on DOACS in patients with malignancy: which patient's with cancer can be safely prescribed DOACs? Ian Stiell on atrial fibrillation rate vs rhythm control controversy, Justin Morgenstern on peripheral vasopressors: safe or unsafe? Michelle Klaiman, Taryn Lloyd on motivational interviewing that makes a difference to patient's lives...

In this EM Cases Best Case Ever podcast Rajiv interviews Dr. Eric Russell, Assistant Professor of Pediatrics at the Baylor College of Medicine, Pediatric Emergency Medicine attending physician at the Texas Children's Hospital, and editor at the Human Diagnosis Project. They discuss a challenging case of a pediatric patient who presents with what at first appears to be bronchiolitis...

In the age of high sensitivity troponins and the HEART pathway, which patients are safe to discharge home from the ED? What are the most useful historical factors to increase and decrease your pretest probability for ACS? Which cardiac risk factors have predictive value for ACS? Why should the words "troponitis" and "troponemia" be banned? How should high sensitivity troponin be interpreted differently than conventional troponin? Which is better for delta troponin interpretation - an absolute change in troponin or a percentage change? Which delta troponin is best - 1hr, 2hr or 3hr? What are the limitations of the HEART pathway? and many more....

In this EM Quick Hits episode: Andrew Petrosoniak on diagnosis and risk stratification of blunt cardiac trauma, Clare Atzema on latest guidelines for anticoagulation in atrial fibrillation, Maria Ivankovic on hydromorphone vs morphine for acute pain, Brit Long on clinical pearls in the diagnosis of myasthenia gravis, Anand Swaminathan on venous access tips and tricks, and bonus material from EM Cases Course June 2018 with Walter Himmel and Barbara Tatham on Physician Compassion and tools to prevent burnout...

In this Episode 127 Drugs that Work and Drugs that Don't Part 2 - Antiemetics, Angioedema and Oxygen, with Justin Morgenstern and Joel Lexchin we discuss the evidence for various antiemetics like metoclopramide, prochlorperazine, promethazine, droperidol, ondansetron, inhaled isopropyl alcohol and haloperidol as well as why should not use an antiemetic routinely with morphine in the ED. We then discuss the evidence for various drugs options for a potpourri of true emergencies like angioedema and hyperkalemia, and wrap it up with a discussion on oxygen therapy...

In this podcast we discuss the key concepts in assessing drug efficacy trials, and provide you with a bottom line recommendation for the use of gabapentinoids, NSAIDs and acetaminophen for low back pain and radicular symptoms, topical NSAIDs and cyclobenzaprine for sprains and strains, caffeine as an adjunct analgesic, why we should never prescribe tramadol, dexamethasone for pharyngitis, calcium channel blockers for hemorrhoids and anal fissures, buscopan for abdominal pain and renal colic and why morphine might be a better analgesic choice than hydromorphone...

Electrical injuries are rare, representing less than 1% of burn center admissions. So there is a paucity of robust evidence for the management of these patients. Nonetheless, in this podcast we’ll give you the tools to help risk stratify electrical injuries, give some guidance on fluid resuscitation, describe immediate management of acute complications and make you aware of the potential delayed complications that must be anticipated...

In this EM Quick Hits Podcast: Ludwig's Angina Emergency Management - Approach, Airway, Imaging, Transient Monocular Vision Loss (TMVL), D-dimer in the Work-up of Pulmonary Embolism in Pregnancy, Management of Pediatric Nasal Foreign Bodies: Tips and Tricks, Sulfamethoxazole-Trimethoprim Drug Interactions and Airway Options in Cardiac Arrest - LMA for all?...

It turns out that for all burn patients—from minor to severe—there is a lot of room for improvement in ED management, counselling and disposition. Things like inaccurate estimation of burn size, unnecessary endotracheal intubation, over- and under-estimation of fluid resuscitation volumes, inadequate analgesia and inappropriate wound dressings are just some of the issues where a small change to ED practice patterns could have a huge impact on patient care. In this EM Cases main episode podcast we have the director of the Burn Unit at Hospital for Sick Children, Dr. Joel Fish and EM educator Dr. Maria Ivankovic discuss dozens of pearls and pitfalls in the management of both pediatric and adult burn and inhalation injuries management with a special appearance by airway master George Kovacs to talk about awake intubation in the burn and inhalation injuries patient...

In this Quick Hits Podcast: David Juurlink on acetaminophen and warfarin drug interaction, Hans Rosenberg on management of dental infections, Emily Austin on dialysis in massive acetaminophen overdose, Andrew Petrosoniak on MTP decisions and the RABT score in trauma , Joel Yaphe on statins for STEMI from Whistler's Update in EM Conference, and George Kovacs on how to maximize success of a cricothyrotomy from EM Cases Course 2019...

On the one hand, UTI is one of the most common bacterial infections in children younger than 2 years of age and could lead to sepsis acutely and theoretically renal failure in the long run. On the other hand, it is important not to over-diagnose UTIs because we know that overuse of antibiotics increases costs, side effects and leads to antibiotic resistance. The first principles questions very much apply here: who to screen, how to screen, and what to do with the screen results. There are risks associated with not having a standardized approach to diagnosing pediatric UTIs. In this EM Cases main episode podcast with Dr. Olivia Ostrow and Dr. Michelle Science we discuss an approach to diagnosing pediatric UTIs whilst revealing some common pediatric UTI myths and misperceptions...

In this Journal Jam podcast we do a deep dive into the hugely complex literature of cardiac stress testing and see whether or not stress testing portends any benefit for patients who we assess in the ED for chest pain. The problem is - if stress testing doesn’t benefit our patients and isn’t a good screening test for preventing MIs, then what do we do with our low risk chest pain patients we see in the ED?

In anticipation of EM Cases Episode 123 Pediatric UTI Myths and Misconceptions, Dr. Olivia Ostrow, Pediatric Emergency Physician at Hospital for Sick Children, Assistant professor at the University of Toronto and a Medical Safety Leader with an academic focus in quality improvement, discusses a case that exemplifies how indiscriminate work up of pediatric UTI can lead to over-testing, over-treating and even worse outcomes...

In this podcast Dr. Sara Gray, intensivist and emergency physician, co-author of The CAEP Sepsis Guidelines, answers questions such as: How does one best recognize occult septic shock? How does SIRS, qSOFA and NEWS compare in predicting poor outcomes in septic patients? Which fluid and how much fluid is best for resuscitation of the septic shock patients? What are the indications for norepinephrine, and when in the resuscitation should it be given, in light of the CENSER trial? What are the goals of resuscitation in the patient with sepsis or septic shock? When should antibiotics administered, given that the latest Surviving Sepsis Campaign Guidelines recommend that antibiotics be administered within one hour of arrival for all patients suspected of sepsis or septic shock? What are the indications for a second vasopressor after norepinephrine? Given the conflicting evidence for steroids in sepsis, what are the indications for steroids? Should we be considering steroids with Vitamin C and thiamine for patients in septic shock? What are the pitfalls of lactate interpretation, and how do serial lactates compare to capillary refill in predicting poor outcomes in light of the ANDROMEDA trial? Is procalcitonin a valuable prognostic indicator in septic patients? and many more...

On this EM Quick Hits podcast we have Natalie May on Kawasaki disease clues to diagnosis, Justin Morgenstern on suturing dog bites: the evidence, Anand Swaminathan on BVM prior to laryngoscopy, Michelle Klaiman on anticraving medications for alcohol use disorder and special guest Howard Ovens on managing ED violence with compassionate care...

In this main episode podcast we discuss the pitfalls in the diagnosis and management of elbow injuries and answer questions such as: What is an easy way to remember the surgical indications for radial head fractures? What is the significance of a coronoid process fracture and how does it change management when seen with a radial head fracture? What is the best way to assess for pronation and supination of the forearm? Why is it so important to assess for the extensor mechanism on physical exam for patients with olecranon fractures? What is a quick easy way to test the peripheral nerves of the upper extremities? Which often missed soft tissue injuries of the elbow require urgent operative management? and many more...

On this EM Quick Hits podcast we have Emily Austin on organophosphate poisoning, Arun Sayal on malrotation of metacarpal fractures, Andrew Petrosoniak on pitfalls in abdominal stab wound management, Anand Swaminathan on tranexamic acid for non-massive hemoptysis, and Natalie May on pediatric IV cannulation tips and tricks...

In this EM Cases main episode podcast, a follow up to our episode on TIA released in November 2018 with Walter Himmel and David Dushenski, we’ll try to simplify the confusing time-based and brain tissue-based options for stroke management. We’ll answer the questions that have been plaguing us for a while now: Which patients are eligible for endovascular therapies? Which patients are the ones who’ll benefit from these therapies and how do we make that happen in our different practice environments? Which patients should be considered for lytic therapy? Which patients should be considered for both lytic and endovascular therapy? and many more...

EM Quick Hits is a brand new EM Cases podcast that contains 5 minute segments chosen from 10 specific topics by 10 different experts and educators. These topics are ones that either are not taught very well in training and/or that physicians tend to be not completely comfortable with. They include toxicology, trauma, ophthalmology, orthopaedics, resuscitation, human factors, addiction and pediatric emergencies. The EM Quick Hits Team is: Emily Austin, Peter Brindley, Chris Hicks, Michelle Klaiman, Anna MacDonald, Natalie May, Justin Morgenstern, Andrew Petrosoniak, Hans Rosenberg, Arun Sayal and Anand Swaminathan...

What should your resuscitation targets be in the first 15 minutes for trauma patients with hemorrhagic shock, neurogenic shock, severe head injury? When is a pelvic binder indicated? Is a bedsheet good enough? What are the most common pitfalls in binding the pelvis? What are the best ways to maintain team situational awareness during a trauma resuscitation? Should we rethink patient positioning for the trauma patient? What are the indications for transport to a trauma center? What is the minimal data set required before transfer? Which patients require a pelvic x-ray prior to transfer to a trauma center? What are the key elements of a transport checklist? What does the future hold for trauma care and many more...

In this part 1 of Trauma - The First and Last 15 Minutes, we answer questions such as: how should we best prepare our team, our gear and ourselves for the trauma patient? How does resequencing the initial trauma resuscitation save lives? How can we most readily identify occult shock, the silent killer in trauma? What are 7 actions to consider in the first 15 minutes of resuscitation? How can the concepts of "controlled resuscitation" and "resuscitation intensity" help us decide resuscitation targets and when to activate a massive transfusion protocol? and many more...

In anticipation of EM Cases Episode 118 Trauma: The First and Last 15 minutes with Andrew Petrosoniak, Kylie Bosman and Chris Hicks we have Joe Nemeth, Trauma Fellowship Director at Montreal General and Associate Professor at both McGill University and University of Toronto discussing his Best Case Ever of a teenager who was "stabbed in the box". Rajiv and Joe discuss preparation for trauma, the role of POCUS in predicting survival in traumatic cardiac arrest, the HOTT mnemonic for reversible causes of trauma arrest and more...

Much has changed in recent years when it comes to TIA risk stratification, workup and antiplatelet therapy. In this podcast we use the overarching theme of timing to elucidate how to distinguish true TIA from the common TIA mimics, the importance of timing in the workup of TIA, why the duration of therapy with dual antiplatelet therapy and timing of starting anticoagulation in patient with atrial fibrillation, contributes to the difference between preventing catastrophic strokes and causing intracranial hemorrhage...

Does epinephrine improve the chances of return of spontaneous circulation at the expense of the brain? In other words, while we know that epinephrine doubles rates of ROSC in all comers in cardiac arrest, there’s never been robust evidence for long term improvements in neurologic functional outcomes. So, are we saving lives, or are we prolonging death? Find out the answer in this Journal Jam podcast with Justin Morgenstern and Rory Spiegel...

This Best Case Ever elucidates the practical challenges of working up pregnant patients in the ED with a suspicion of pulmonary embolism. Since this recording, the first ever multi-center prospective outcome study looking at the pulmonary embolism workup in pregnancy was published in the Annals of Internal Medicine. A suggested algorithm and analysis of the study by Lauren Westafer are provided in these show notes....

In this episode Dr. Kathryn Dong, Dr. Michelle Klaiman and Dr. Aaron Orkin discuss the latest in naloxone in opioid overdose cardiac arrest and altered LOA, a 5-step approach to ED opioid withdrawal management and how we can improve mortality and morbidity in patients with opioid use disorder in the era of the opioid epidemic...

In anticipation of EM Cases Episode 116 on Opioid Misuse, Overdose and Withdrawal, Dr. Michelle Klaiman, Addictions and Emergency Medicine specialist, tells her Best Case Ever exemplifying how we can positively impact the lives of ED patients for years to come - even when they present with simple, run-of-the-mill diagnoses - by thinking outside the box and doing brief screening and interventions for patients with opioid use disorder. She discusses alternative pain control options as well as the use of suboxone to treat opioid withdrawal and opioid addiction.Best Case Ever exemplifying how we can positively impact the lives of ED patients for years to come, even when they present with simple, run-of-the-mill diagnoses, by thinking outside the box and doing brief screening and interventions for patients with opioid use disorder.

Managing acutely agitated patients can cause anxiety in even the most seasoned emergency doctor. These are high risk patients and they are high risk to you and your ED staff. It’s important to understand that agitation or agitated delirium is a cardinal presentation – not a diagnosis. There is pathology lurking beneath - psychiatric, medical, traumatic and toxicological diagnoses driving these patients and we just won’t know which until we can safely calm them down...

In anticipation of Episode 115 Management of the Agitated Patient, Dr. Reuben Strayer tells the story of the case that got him interested in developing an expertise around management of the agitated patient that includes an important simple pitfall and pearl about physical restraint. It that could prevent a death in your ED...

In this EM Cases Journal Jam podcast with Anton Helman, Justin Morgenstern, Rory Spiegel, and special guest Jacques Lee we explore the evidence for femoral nerve blocks and fascia iliaca blocks as well as discuss the practical implementation of them in your ED. We answer questions such as: Do regional nerve blocks for hip fractures effectively reduce pain? Do they decrease opioid use? Are they safe compared to standard pain management? Should the block be done prior to x-ray confirmation? and many more...

In Part 1 of Pulmonary Embolism Challenges in Diagnosis Drs. Helman, Lang and DeWit discussed a workup algorithm using PERC and Wells score, the bleeding risk of treated pulmonary embolism, pearls in decision making on whether or not to work up a patient for pulmonary embolism, how risk factors contribute to pretest probability, the YEARS criteria and age-adjusted D-dimer. In this Part 2 we answer questions such as: what are the important test characteristics of CTPA we need to understand? Which patients with subsegmental pulmonary embolism should we treat? When should we consider VQ SPECT? What is the best algorithm for the work up of pulmonary embolism in pregnant patients? How best should we implement pulmonary embolism diagnostic decision tools in your ED? and many more…

Dr. Kerstin DeWit and Dr. Eddy Lang answer the questions that plague us on almost every shift: Which patients require any work-up at all for PE? What’s the utility of PERC and Well’s scores? Should the newer YEARS decision tool supplant Well’s? When should we order a D-dimer? What’s the diagnostic role of CXR, ECG, POCUS, CTA and VQ? How should we work up pregnant patients for PE? How can we use shared decision making strategies for PE to help us do what’s best for our patients, and many more...

In anticipation of EM Cases Episode 113 Diagnosis an Workup of Pulmonary Embolism with Dr. Kerstin DeWit and Dr. Eddy Lang, we have Dr. Peter Reardon telling us his Best Case Ever (Coding in the Scanner) of a young woman who presents with a seizure followed by hemodynamic instability, who codes while in the CT scanner...

In this EM Cases main Episode 112 Tachydysrhythmias with Amal Mattu and Paul Dorion we discuss a potpurri of clinical goodies for the recognition and management of both wide and narrow complex tachydysrhythmias and answer questions such as: Which patients with stable Ventricular Tachycardia (VT) require immediate electrical cardioversion, chemical cardioversion or no cardioversion at all? Are there any algorithms that can reliably distinguish VT from SVT with aberrancy? What is the "verapamil death test"? While procainamide may be the first line medication for stable VT based on the PROCAMIO study, what are the indications for IV amiodarone for VT? How should we best manage patients with VT who have an ICD? How can the Bix Rule help distinguish Atrial Flutter from SVT? What is the preferred medication for conversion of SVT to sinus rhythm, Adenosine or Calcium Channel Blockers (CCBs)? Why is amiodarone contraindicated in patients with WPW associated with atrial fibrillation? What are the important differences in the approach and treatment of atrial fibrillation vs. atrial flutter? How can we safely curb the high bounce-back rate of patients with atrial fibrillation who present to the ED? and many more...

In anticipation of EM Cases Episode 112 on Tachydysrhthmias with Amal Mattu and Paul Dorion, Melanie Baimel tells her Best Case Ever of a previously healthy young man who presents in refractory ventricular fibrillation after receiving multiple single shocks, ongoing chest compressions, several rounds of epinephrine, amiodarone and dual sequence defibrillation without ROSC...