EMplify by EB Medicine

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the September 2023 Emergency Medicine Practice article, Emergency Department Management of Patients With Rectal BleedingEtiology/pathophysiologyRisk factorsDifferential diagnosisPrehospital careED history and physical examDiagnostic studiesLaboratory testingImaging studiesTreatmentTransfusionCoagulation reversalEmbolizationSpecial PopulationsPediatricsPregnant patientsElderly patientsScoring systemsDispositionCheck out the clinical pathway at https://clinicalpathways.ebmedicine.net

In this episode, Sam Ashoo, MD, and TR Eckler, MD, interview Al Sacchetti, MD, about the August 2023 Emergency Medicine Practice article, Evidence-Based Management of Pulmonary Embolism in the Emergency DepartmentEtiology/pathophysiologyRisk factorsDifferential diagnosisPrehospital careED history and physical examDiagnostic scoring systemsPregnant patients Diagnostic studiesECGD-DimerTroponin & BNPChest x-rayCT V/Q scansMRIUSTreatmentIV fluidsAnticoagulationVasopressorsThrombolyticsThrombectomyECMODispositionCheck out the clinical pathway at https://clinicalpathways.ebmedicine.net

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2023 Emergency Medicine Practice article, Diagnosing and Treating Pericarditis and Myocarditis in the Emergency DepartmentEpidemiologyNomenclatureEtiologyDifferential diagnosisPrehospital careED history and physicalDiagnosticsECGLabsImaging (X-ray, CT, US, MRI)Treatment Special populationsCOVID-19AthletesMIS-C

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the June 2023 Emergency Medicine Practice article, Hypertensive Emergencies: Guidelines and Best Practice RecommendationsEpidemiologyEtiologyDifferential diagnosisPrehospital careHistory and physical DiagnosticsTreatmentAcute decompensated heart failureAcute ischemic strokeAcute coronary syndromeIntracerebral hemorrhageSubarachnoid hemorrhageAortic dissectionHypertensive encephalopathySevere pre-eclampsia and eclampsiaControversiesArterial line placementBeta blockers and cocaineRisk management caveatsSummary

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the May 2023 Emergency Medicine Practice article on Emergency Department Management of Gastrointestinal Foreign Body IngestionEpidemiologyEtiology - types of ingestionsAnatomy - common locations by ageFood impactionSharp objectsButton batteriesMagnetsColorectal foreign bodiesPrehospital careHistory and PhysicalImagingExpectant managementEndoscopic removalNon-endoscopic techniquesBody PackingGlucagonGastric button batteriesSummary

In this episode, Sam Ashoo, MD, talks with Rob Orman, MD, founder of Orman Physician Coaching, about longevity in emergency medicine. Personal foundation Regular check-insBecoming an expert in… Job stressLiving beneath your meansRecharging and shift workBad outcomesPhysician loungeLearning to say noSet a reminderMore at Orman Physician Coaching

Announcements: The interactive Clinical Pathways have launched and they are available for free! In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the March 2023 Emergency Medicine Practice article on Emergency Department Management of Infective Endocarditis-Associated StrokeEpidemiologyPathophysiologyPopulations at RiskComplicationsIntracranial hemorrhageAneurysmsHeart blockPrehospital CareED History and ExaminationImagingAntibiotic TherapySurgical TreatmentSpecial PopulationsSummary

Announcements: The interactive Clinical Pathways have launched and they are available for free! — In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the February 2023 Pediatric Emergency Medicine Practice article on Pediatric Electrolyte Emergencies: Recognition and Management in the Emergency Department — History Point-of-care testing I/O lines Presentation, differential, and treatment of:HyponatremiaHypernatremiaHypokalemiaHyperkalemiaHypocalcemiaHypercalcemiaHypomagnesemiaHypophosphatemia

Announcements: The interactive Clinical Pathways have launched and they are available for free! ___In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2023 Pediatric Emergency Medicine Practice article on the Responsible and Safe Use of Opioids in Children and Adolescents in the Emergency DepartmentDEA-X Waiver Repeal:The Mainstreaming Addiction ActThe Medication Access and Training Expansion Act (MATE)FOAMed postOpioids in Children and Adolescents: IntroductionEpidemiology and Statistics Medication safety at homeEscalation of pain meds at homeNaloxone prescriptionsMedications in childrenCodeineTramadolNSAIDsLocal anesthetics and nerve blocksIntranasal meds: Ketamine and fentanylOpioids and sedationRegional anesthesiaChronic pain

Announcements: The interactive Clinical Pathways have launched and they are available for free! — In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2022 Emergency Medicine Practice article on the Management of Allergic Reactions and Anaphylaxis in the Emergency Department. IntroThe number of ED visits and hospitalizationsStudies show up to 57% of anaphylactic reactions are not recognized, and epinephrine is not administered in up to 80% of cases. Criteria2006 Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN)WAO revised the criteria in 2020 Delphi group and Brown et alPathophysiology EpidemiologyMost common causes in children and adultsMore than half of deaths from anaphylaxis occur within the first hour of symptom onsetPrehospital CareGive epi, H1 blockersMainstay = recognitionED CareAirwayEpinephrineDecontaminationH1 and H2 blockersCorticosteroidsBiphasic reactionsGlucagonSpecial CasesAlpha-galScombroidKounis syndrome

Announcements: 1) The interactive Clinical Pathways have launched and they are available for free! 2) 2023 E/M coding guidelines are in effect. See the summary here. ___ In this episode, Sam Ashoo, MD, interviews Ara Festekjian, MD, one of the authors of the November 2022 Pediatric Emergency Medicine Practice article on Pediatric Septic Shock in the Emergency Department Introduction: How common is sepsis in kids and what is the mortality rate in the US? DefinitionsSeptic shockSepsis associated organ dysfunctionSepsis-3Compensated vs uncompensated shock EtiologyNeonateCentral line and VP shuntsAspleniaImmunocompromised children Differential Diagnosis Prehospital Care ED EvaluationHistoryExaminationSeptic shock + cardiogenic shockWarm vs cold shockEvolution of physical exam findingsDiagnosticsLabsImagingTreatmentIV/IO placementFluid bolusesAntibiotics Pressors Airway management Special PopulationsFebrile neutropeniaNewborns with septic shockControversiesFluid volumeFluid typeAntibiotic timingCorticosteroids

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2022 Evidence-Based Urgent Care article on Influenza in Urgent Care.EpidemiologyHistorical dataSince COVID, tracking "influenza-like illness" has been complicatedInfluenza deaths and ageAnnual mortality OutbreaksTransmissionClassificationInfluenza A, B, and CHemagglutinin and neuraminidase subgroupsAntigenic drift and shiftPathophysiologyTransmissionIncubation Secondary infectionH3N2VaccinesEgg-based, cell-based, and recombinant influenza vaccinesCDC recommendationsPatients aged >65 yearsDifferential DiagnosisComplications TestingWhen is it indicated? What types of tests are available? Testing in periods of low and high prevalence TreatmentHigh-risk conditions that suggest treatment Antiviral medications Oseltamivir: NNT and NNHResistance patternsBilling and Coding

In this episode, Sam Ashoo, MD, interviews Prayag Mehta, MD, and Nikola Milanko, MD, two of the authors of the October 2022 Emergency Medicine Practice article on Angioedema in the Emergency Department Pathophysiology: Non-pitting edema of respiratory or GI tractHistamine meditated, bradykinin mediated, or idiopathicAcquired, inherited, or idiopathicDo they present differently? (Urticaria, speed of onset)Histamine MediatedMost common form: 40%-70%Can be triggered by NSAIDsCan be induced by physical mechanism like cold, vibrationIs rash a reliable method of distinguishing the types?Bradykinin MediatedMay progress slowlyCan be inherited or acquiredCommon triggers include ACE inhibitors and TPATable 1 Differential Diagnosis Prehospital CareProtect airwayEpi, steroids, antihistaminesAvoid CPAPED HistoryFigure 2: Distinguishing characteristics of histamine vs bradykinin mediatedED ExamImportance of repetitive examsAirway examinationLaryngoscopy?DiagnosticsFigure 6: Flow diagram of ED workupLabsImagingTreatmentAirway: IntubationMedicationSpecial PopulationsPediatricPregnant/lactating patientsControversiesTXADisposition

In this episode, Sam Ashoo, MD, interviews Ami Shah, MD, MPH, and Don Walker, MD, about eye injuries in the pediatric population. Why ocular injuries? Why did you pick this topic? What kind of injuries are included and at what age are they most common? Injury zones and terminology Differential DiagnosisWhat should we keep in mind when we are confronted with an ocular injury? (Table 3)Prehospital CareWhat do our EMS colleagues need to keep in mind when transporting a child with an ocular injury?How can they help us in the ED?ED EvaluationHistory: What's important to know?Physical: Visual acuity and eye examDiagnostics: Slit lamp, ocular pressure, US, CT, MRITreatmentLid lacerations: Who repairs and when?Orbital fractures: What should we be looking for? Why is it different in children? When does repair typically occur?Corneal abrasionsCorneal foreign bodyChemical injuries: Irrigate with what and for how long?Traumatic hyphema: Treatment, dispositionTraumatic iritis: Treatment, outcomeOpen globe injuriesRetrobulbar hematoma - First 10 EMSpecial PopulationsHemophilia, Von Willebrand diseaseSickle cell and traitNeonates and infantsContact lensesControversies and Cutting EdgeKetamineTetanusNSAIDs, topical?Topical anestheticsVisual acuity apps

In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Rob Orman, MD, founder of Orman Physician Coaching, about career disillusionment.Career Disillusionment: What is it? How do we combat it? Should we combat it? A frog in boiling water... BurnoutTwo questions to ask yourselfHow coaching can helpThe advice trapA framework to explore your career and life goalsMore at Orman Physician Coaching.

In this episode, Sam Ashoo, MD interviews Rawad Rayes, MD and Eva Tovar Hirashima, MD, MPH – two of the authors of the August 2022 PEMP article on Pediatric Firearm Injuries to the Extremity: Management in the Emergency Department.Episode Outline:How common are pediatric firearm injuries? What is the most common location of these injuries? Is there much literature published on this topic? Epidemiology What’s been the trend in pediatric firearm injuries over the past 10 years? Do we have any idea how/why these are occurring (ie, accidental, intentional, etc)Terminology: For those unfamiliar with firearms (table 1)Ballistics: Mechanisms of damage. Pre-hospital careTrauma center transportPrehospital hemorrhage control -- Combat application tourniquet, anything else? ED EvaluationSIPA -- What is it and why use it? Primary survey -- Tachycardia -> delayed cap refill -> hypotension in children? Secondary SurveyDiagnostic Studies: Damage Control ResuscitationWound Care -- Do we remove projectiles? Can they stay in? Antibiotics Joint InvolvementCompartment Syndrome -- 3 As vs 6 PsRhabdomyolysisControversiesCTA for all injuries? Hemostatic devices -- Any role for these in the ED?

In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Andrew Phillips, MD, MEd, founder of EM Coach, about artificial intelligence and emergency medicine education.EM/Critical care practice - what’s that like? EM Coach - what is it? Artificial Intelligence -What is it and how does EM Coach use it? The algorithmHow did you create it? What does it do? The evidence behind itHow and where to access EM Coach

In this episode, Sam Ashoo, MD interviews Lela Bachrach, MD, MS, Larissa Truschel, MD, MPH, and Makini Chisolm-Straker, MD, MPH - the authors of the July 2022 PEMP article on Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to human trafficking. Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department EMplify - Sept 2022Episode Outline:Differential DiagnosisWhat is the differential diagnosis for this scenario in the ED?Are these diagnoses mutually exclusive ?EMS/Prehospital CareWhat role do EMS providers play in the recognition of trafficking?ED EvaluationWhat are common presentations/complaints that may represent trafficking?Examination: Privacy, use of a separate room, how do we accomplish this with minors?Ground rules: What does this mean? How do you state this in your practice? Do you find this dissuades patients form reporting?Technology: What if they are on the phone?History - HEADS-EDPhysical examination - Findings that lead to suspicion, documentation best practices.Diagnostic StudiesImaging: Any role for this?Lab testing: STI, anything else?Screening tools: Trauma-informed care, PEARR toolLocal laws differ by state. How do we handle this with patients? Does it dissuade reporting?"Rescuing mentality" and what that means in the EDTreatment MedicalBeyond medicines: Local services, national hotlineSpecial PopulationsDiagnosis: What to chart? National Human Trafficking Hotline 1-888-373-7888https://humantraffickinghotline.org/

In this episode of EMplify: Conversation – Sam Ashoo, MD, and TR Eckler, MD, speak with John Roberts, MD, MPH, about his work with the International Medical Corps and his efforts in Ukraine.Topics include:What is the International Medical Corps (IMC) and what does it do?What has IMC been doing in the U.S.?What is involved in disaster response?What has IMC been doing in Ukraine?What are the conditions like in Ukraine now?How does bombing of civilian areas affect Ukraine and the IMC projects?How can we support IMC efforts?How can we volunteer with the IMC?How does IMC balance long-term efforts and short-term relief to prevent harm to communities?How has the war in Ukraine effected surrounding areas?What has been most frustrating and most rewarding for you in your work with IMC?How did you start your career in disaster medicine and how would someone interested in it follow your footsteps?LinksIMC WebsiteIMC JobsRoster PositionsRoster position - MDRoster position - Nurse Roster position - Nurse Practitioner Roster position - Midwife Disaster MedicineThe Nuts & Bolts of Global EM, free e-book

In this episode, Sam Ashoo, MD interviews Adam Sigal, MD and Stephanie Costa, MD - the authors of the August 2022 EMP article on Managing Acute Cardiac Valvular Emergencies in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to valvular emergencies. Managing Acute Cardiac Valvular Emergencies in the Emergency DepartmentEMplify - August 2022Episode Outline:Why Valvular disease? How common is it? How often do we see it in the ED? Which valves are we talking about? Aortic Valve DiseaseTypes and causesMitral Valve DiseaseTypes and causesTricuspid and Pulmonic DiseaseDifferential Diagnosisacute coronary syndromes (ACS)pulmonary embolismtamponadechronic obstructive pulmonary disease (COPD)pneumoniapneumothoraxPrehospital CareEvaluation of chest painHistoryShock ED EvaluationHistoryAortic StenosisAortic RegurgitationMitral StenosisMitral RegurgitationPhysical exam findings Diagnostic Testing LabsECGCXRBedside USFormal ECHOTreatmentSpecial PopulationsProsthetic valvesPregnant patientsSee Episode Page

In this episode of EMplify, Sam Ashoo, MD reviews recent updates on the following topics: COVID-19Public health emergency extendedCases increasingMedications and Vaccinations availablePharmacists prescribing COVID medicationsCDC COVID Therapeutics websiteHHS COVID Therapeutics LocatorMonkeypoxCases increasingVaccinationTestingFOAMED post on Diagnosis and Treatment PPEScience Direct article on Monkeypox 3I ToolMedication ShortagesBenzodiazepinesFOAMED post on benzodiazepine equivalenceAmerican Society of Health System Pharmacists (ASHP)988 Crisis LineBaby Formula Shortage

In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss meningococcal meningitis and the recent outbreak in Florida.Topics discussed include:Which vaccines are currently approved by the FDA and recommended by the CDC.The difference between the MEN ACWY vaccine and the meningococcal B vaccine.What the current recommendations are for those exposed.Challenges for healthcare providers treating patients who have been exposed or have symptoms.Further reading:Hogan AN, Brockman II CR, Santa Maria A. Emergency department management of adults with infectious meningitis and encephalitis. Emerg Med Pract. 2022 Apr;24(4):1-24. Epub 2022 Apr 2. PMID: 35315604.CDC Meningococcal Disease and Vaccination. As always, we value your feedback. Please take our listener survey.See the episode page for more details.

In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss high sensitivity troponin testing and clinical pathways.Topics discussed include: Which troponin assay are you currently using and what are its limits of detection? Do delta troponin results only count if they increase? If the test result is indeterminate, then what? repeat in 1 hr (European standard), repeat in 3 hours (depending on chest pain onset), or just admit if the HEAR(T) score is high? What does one negative troponin on presentation mean? No death in 30 days to 1 year but still missed MI?And more... ReferencesAnand A, et al; HiSTORIC Investigators†. High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial. Circulation. 2021 Jun 8;143(23):2214-2224. doi: 10.1161/CIRCULATIONAHA.120.052380. Epub 2021 Mar 23. PMID: 33752439; PMCID: PMC8177493.Chapman AR, et al. Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary Syndrome. JAMA. 2017 Nov 21;318(19):1913-1924. doi: 10.1001/jama.2017.17488. Erratum in: JAMA. 2018 Mar 20;319(11):1168. Soerensen NA [corrected to Sorensen NA]. PMID: 29127948; PMCID: PMC5710293.Chenevier-Gobeaux C, et al. Multi-centre evaluation of recent troponin assays for the diagnosis of NSTEMI. Pract Lab Med. 2018 Feb 26;11:23-32. doi: 10.1016/j.plabm.2018.02.003. PMID: 30014015; PMCID: PMC6045566.Chiang CH, Chiang CH, Lee GH, Qian F, Chen SC, Lee CC. Time to Implement the European Society of Cardiology 0/1-Hour Algorithm. Ann Emerg Med. 2020 Nov;76(5):690-692. doi: 10.1016/j.annemergmed.2020.05.038. PMID: 33097132; PMCID: PMC7575504.McCarthy CP, Januzzi JL Jr. Increasingly Sensitive Troponin Assays: Is Perfect the Enemy of Good? J Am Heart Assoc. 2020 Dec;9(23):e019678. doi: 10.1161/JAHA.120.019678. Epub 2020 Nov 26. PMID: 33238785; PMCID: PMC7763764.Neumann JT, et al. Application of High-Sensitivity Troponin in Suspected Myocardial Infarction. N Engl J Med. 2019 Jun 27;380(26):2529-2540. doi: 10.1056/NEJMoa1803377. PMID: 31242362.Miller J, Cook B, Singh-Kucukarslan G, Tang A, Danagoulian S, Heath G, Khalifa Z, Levy P, Mahler SA, Mills N, McCord J. RACE-IT - Rapid Acute Coronary Syndrome Exclusion using the Beckman Coulter Access high-sensitivity cardiac troponin I: A stepped-wedge cluster randomized trial. Contemp Clin Trials Commun. 2021 Apr 23;22:100773. doi: 10.1016/j.conctc.2021.100773. PMID: 34013092; PMCID: PMC8114080.

In this episode of EMplify: Conversation, Sam Ashoo, MD and Rob Orman, MD discuss cognitive reframing.What is cognitive reframing you ask? It is a tool for dealing with a particularly difficult event. In our case, we discuss the “near miss” medical case and how it impacted a physician. Then we discuss how the use of cognitive reframing can help improve our perception of these “near miss” events in medicine. We also discuss what this tool can do for our longevity in medicine, regardless of our career choices. So take a listen. You may be surprised how this tool can be used in all aspects of your life.Rob Orman refers to a videos he created for a client for the post-shift power-down. You can find it and other helpful videos on his YouTube channel.Also, if you would like to learn more about Dr Rob Orman’s coaching services, visit his home page .As always, we value your feedback. Please take our listener survey.See the episode page for more details.

In this episode, Sam Ashoo, MD interviews Prayag Mehta, MD and Joshua Kern, MD – two of the authors of the June, 2022 EMP article on Procedural Sedation and Analgesia in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to sedation in adults and pediatrics !Procedural Sedation and Analgesia in the Emergency DepartmentEMplify – June 2022Episode Outline:1.Procedural sedation and analgesia (PSA): terminology2.Levels of sedationMinimalModerateDeepGeneral anesthesia3.Prehospital care4.ED care: patient assessmentASA class systemComplicationsEquipment needed (Table 1)Larson maneuver (Figure 2)5.Procedural techniqueCurrent ACEP and AAP recommendationsData for 1- or 2-physician sedation6.Preprocedural fastingDo we even need to consider this in PSA?7.Capnography8.Oxygen supplementation9.Preprocedural opioids10.Preprocedural sedatives11.Anticholinergics12.Antiemetics13.Treatment (Table 2)FentanylRemifentanilMidazolamNitrous oxidePropofolKetamineKetofolEtomidate14.Reversal agentsNaloxoneFlumazenil15.Special populationsPediatricsPregnancyGeriatrics16.Cutting edgeDexmedetomidine

The war in Ukraine has now been ongoing for 100 days. In today’s episode of EMplify: Conversations we hear from Dr. J.P. McBryde about his experience as an emergency physician volunteering in Ukraine.You can read more about Med Global and their efforts in Ukraine, on their home page:https://medglobal.org/ukraine/We would love to have your feedback. Please take the listener survey:https://www.surveymonkey.com/r/ZQRWQFWThanks for being a listener.

EpidemiologyCaused by double stranded DNA virus, genus orthopoxvirus, closely related to smallpox and cowpox.Discovered in 1958 in monkeys with first human case recorded in 1970 in the Democratic Republic of Congo. (CDC) It is a zoonotic disease , meaning it is transmitted from animal to humans, with primary reservoir in squirrels, Gambian poached rats, dormice, different species of monkeys and others. First reported in the U.S. in 2003. Cases were related to pet prairie dogs that had been housed with monkeypox virus infected African rodents, imported from Ghana (WHO)There are 2 clades (having evolved from same ancestral line) of the disease. The current outbreak is from the West African lineage. (WHO)West African – milder disease, 1-3% fatalityCongo Basin – severe disease, 10% fatality Due to the similarity in the viruses, immunization against smallpox has been found to prevent infection with monkeypox. The WHO believes that increasing frequency of worldwide infection may be related to waning immunity against smallpox, since that disease was eradicated in 1980 and the vaccine is no longer popularly used. TransmissionAnimal to human – contact with sick or dead animals, ingesting poorly cooked meat of infected animals.Human to human -” Human-to-human transmission is thought to occur primarily through large respiratory droplets. Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required. Other human-to-human methods of transmission include direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens.” (CDC)SymptomsInitial 1-3 days – fever, lymphadenopathy, back pain, headache, myalgias, fatigue2-4 weeks of rash progression: macules -> papules -> vesicles -> pustules -> scabsThe pox rash starts on the face and spreads to the rest of the body.TestingDetection is by PCR testing, ideally of body fluid contained in the pox blisters.Test kits are available through local U.S. Health Departments and the CDC. All suspected cases should be reported to local authorities.TreatmentTreatment includes vaccinating anyone who has been exposed with the smallpox vaccine (ring vaccination). The general population is no longer routinely vaccinated due to side-effects of the smallpox vaccine.No current recommendation exists for antiviral therapy or smallpox immunoglobulin therapy. See CDC recommendations PreventionThe JYNNEOS vaccine was FDA approved in 2019 for adults > 18 against both smallpox and monkeypox. It is a 2 dose non-replicating attenuated virus that does not produce a lesion, and therefore can not cause transmission to others. The CDC Advisory Committee on Immunization Practices is currently evaluating vaccine data with a formal recommendation pending. Media reports note the U.S. government has ordered millions of doses. The original smallpox vaccine (DRYVAX) is no longer in production. However, a second generation clone, ACAM2000, is produced by Synofi and approved by the FDA. The WHO notes that smallpox vaccine is 85% effective in preventing monkeypox.Vaccination is recommended for lab workers and anyone exposed to monkeypox. The CDC recommends vaccination within 4 days of exposure to prevent disease, with ACAM2000. However, vaccination between days 4-14 is also recommended to reduce disease severity. Vaccination does carry risks. The CDC estimates “Based on past experience, it is estimated that between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening complications from the vaccine” (ACAM2000) but notes that disease fatally is 1-10% outweighing the risk of vaccination. Further ReadingCurrent WHO Outbreak TrackerCDC Monkeypox ReferenceJohns Hopkins Monkeypox Reference

This is the second episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.This episode is a conversation between Dr. T.R. Eckler and Dr. Sam Ashoo about airway management and how it has changed in their practice over the last decade. This podcast makes reference to the EB Medicine course – Current Topics in Airway Management: Mechanical Ventilation, Supraglottic Airway Devices, and Intubating Patients With COVID-19, which can be found here:https://www.ebmedicine.net/airway-trainingWe would love to have your feedback. Please take the listener survey:https://www.surveymonkey.com/r/ZQRWQFWThanks for being a listener.

In this episode, Sam Ashoo, MD interviews Kyle Howarth, MD and Joby Thoppil, MD, PhD – two of the authors of the May, 2022 EMP article on Cellulitis and Skin and Soft Tissue Infections. Listen to the discussion to hear more about the emergency department management of cellulitis and necrotizing skin infections.Episode 69 – Emergency Department Management of Cellulitis and Other Skin and Soft-Tissue Infections (https://www.ebmedicine.net/topics/infectious-disease/emergency-medicine-skin)EMplify – May 2022Episode Outline:1. Why cellulitis/skin infections?2. TerminologyErysipelas vs cellulitis vs fasciitisPurulent cellulitis3. Most common pathogens4. Special situations5. Necrotizing infection classification system – is this helpful in the ED, and if so, why?6. Differential – unilateral vs bilateral presentation7. Prehospital care8. ED evaluationHistory – what should we be asking?Examination: SSTI vs NSTI9. DiagnosticsPOCUS: “cobblestoning” and fluid collectionXray: subcutaneous gasCT: when is this helpful?10. LabsBlood cultures – if given the option, are they helpful? Wound cultures – any role for these? Routine labs (CBC, BMP, etc) – are they helpful? LRINEC score – what is it and should we be using it? 11. Treatment NSTI antibiotics Abscesses 12. Special populations IV drug users Diabetic patients Immunocompromised patients 13. Wound irrigation and loop drainage 14. Disposition

The first episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.Take the listener survey:https://www.surveymonkey.com/r/ZQRWQFWMore on the Dr Lorna Green Legislation here:https://www.ebmedicine.net/ebmblog/general-emergency-medicine/news-updates/dr-lorna-breen-health-care-provider-protection-act/

Episode 68 -- Emergency Department Management of Adults With Infectious Meningitis and Encephalitis – An Interview with Dr. Andrew HoganEMplify -- April 2022Interview with the Author: Andrew N. Hogan, MD1.Meningitis vs encephalitisWhy this topic?What do the words mean? What's the difference?2.Bacterial meningitisHow common is it in the US? Is it more common in third world countries?Mortality rate in the USCauses – if Neisseria and H influenzae improved post vaccination, why not S pneumoniae disease ? (Table 1)3.Viral meningitisHow common is it in the US?What are the common causes? (Table 2)4.Viral encephalitisSame prognosis as viral meningitis?Same organisms as viral meningitis? (Table 2)Does COVID-19 cause this illness?5.Fungal infectionsWho gets these?60% die? 1 million cases a year, 600K deaths?6.Prehospital care:What does EMS need to know?How do they protect themselves from being exposed?How can they help us make the diagnosis?EMS is giving antibiotics in some areas?PEP7.ED evaluation: History8.ED evaluation: Physical exam9.Diagnostics: CSFWhat's large volume? Is it safe?Cell counts on tubes 1+4, all the time or only if traumatic and obviously bloody?Is opening pressure helpful?CSF lactate level – can this be run in a normal lactic acid analyzer?PCR/NAAT testing10.Serum labsWhat is helpful?Serum PCRSerum cryptococcal antigen11.Imaging Is CT imaging before LP still necessary? Can we be selective?Is MRI helpful in the ED, or is there a role in encephalitis?12.TreatmentAntibioticsSteroids: Who gets them? When? Are there downsides of giving them?13.Special populationsAutoimmune diseaseLacking childhood vaccinesHealthcare associated infections14.Cutting edge15.Disposition

Episode 67 – Managing Postpartum Complications in the Emergency Department – An Interview with Dr. Nicole Yuzuk, Dr. Joseph Bove, and Dr. Riddhi DesaiEMplify – March 2022Interview with the Authors: Nicole Yuzuk, DO, Joseph Bove, DO, and Riddhi Desai, DOEpisode Outline:1.Why is this an important topic in EM? 2.Hemorrhage etiologies and definition3.Headache etiologies, both common and the more dangerous (ICH)4.Fever and infectionMastitisEndometritis5.Preeclampsia/eclampsia Definition, diagnosis, risk factors (Table 1)6.HELLP syndromeDefinition, diagnosis (Table 2)7.Peripartum cardiomyopathyTime of onset, how to make the diagnosis, risks (Table 3)8.Prehospital careIV fluidsTXAAMS evaluationChest painFever/hypotension 9.ED evaluation History (what kind of things should we remember to ask?) Physical exam (what should we be paying attention to?) 10.Diagnostic studiesHemorrhage (exam, vitals, labs, US)Headache (labs, imaging – what type?)Fever and infection (labs, imaging – US or CT, antibiotics)Cardiopulmonary complaints (labs, imaging, ECG)11.TreatmentHemorrhage Headache (CVT)Infection (mastitis, endometritis, wound Infection)Preeclampsia, eclampsia, HELLP, seizuresCardiomyopathy12.What about breastfeeding mothers? 13.Controversies and cutting edgeEndovascular therapyThromboelastography

Episode 66 – Acute Asthma Exacerbations – An Interview with Dr. Steven Hochman and Dr. Brandon SomwaruEMplify – February 2022Emergency Department Management of Acute Asthma ExacerbationsInterview with the authors: Steven M. Hochman, MD, and Brandon Somwaru, DO Episode Outline:EpidemiologyRisk factors for death from asthma (Table 1)Triggers for asthma attacksVariants of asthma (Table 2)Differential diagnosis (Table 3)Can PE be a trigger for an acute asthma attack? Prehospital careED care: history (what should we ask?)ED care: physical exam (what are we looking for?)Classifying mild/moderate/severe asthma Lab studiesPOCUS (Table 5 and Figure 3)Peak expiratory flowETCO2 capnography and capnometryChest x-rayTreatment (Table 6)MedicationsOxygenSABA vs LABAWhat about MDIs?Continuous nebs?AnticholinergicsSteroids (IV, oral, inhaled; prednisone vs dexamethasone)Magnesium sulfateEpinephrineTerbutalineKetamineNIPPVIntubation pearls and pitfalls (Table 8)Special populationsPediatrics PregnancyCOVID-19 Controversies and cutting edgeBiologicsFractional exhaled nitric oxideHeliox High flow nasal cannulaDelayed sequence intubationECMODisposition

Interview with author: Rachel Sullivan, MDWhy joint pain ?Differential Diagnosis Mono vs Poly Articular Presentation? Figure 1Infectious, degenerative, autoimmune, crystal deposition, reactive, traumaticSeptic Arthritis-Bimodal incidence RisksSeptic arthritis is polyarticular in 15% to 20% of cases, and in these cases, the mortality is highGonococcal Highest riskCommonly affected jointsSymptomatic or asymptomatic infection Lyme ArthritisViral – Zika, chikungunya, human parvovirus B19, hepatitisDegenerative osteoarthritis AutoimmuneGoutCPPDPrehospital ED History – table 2, table 4ED exam Labs – do we need them? ImagingArthrocentesis – Table 5TreatmentSpecial PopulationsProstheses Immunocompromised HIVClinical Pathway

EMplify – December 2021Announcements:The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,This month get a $50 Amazon Gift Card with all orders over $300 at https://www.ebmedicine.netCheck out the newly redesigned FOAMed blog at https://www.ebmedicine.net/ebmblog/Thoracic Aortic Syndromes in The Emergency Department: Recognition and ManagementInterview with author: Anthony Hackett, MDThoracic Aortic SyndromesDissection, Intramural Hematoma, and Penetrating Aortic UlcersPathophysiologyIntima, media, and adventitiaEpidemiology and classification Debakey vs Stanford classification- do we still use Debakey ? Risk FactorsPrehospital Care – what should EMS be looking for? ED CareHistory HTN, Pulse defecits, Chest Pain, Syncope?Table 3ADD-RS scoreExamDiagnosticsLabsEKG – STEMI? ImagingCXREcho CTMRIAortogramTreatmentBP managementHeart RateShockSurgery – Who goes and when? Special populationsPregnancyControversiesD-Dimer

EMplify – November 2021Announcements:The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,Also, this month use code ACEP21! and get 20% of all orders at https://www.ebmedicine.netEmergency Department Management of Rib FracturesAuthor: Patrick Maher, MDEpisode Outline:Why rib fractures?AnatomyFig 1Pre-hospitalED evaluationHistory Physical ExamImagingNexus Chest Decision Instrument in Blunt TraumaACR criteria for imagingCT vs xrayUltrasound TreatmentMedsBindersKinesiotaping – Fig 4Respiratory supportOperative fixationSpecial PopulationsElderlyCancer patientsPediatricsDispositionBattle ScoreRib ScoreFVC

EMplify - October 2021Announcements: The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,Also, this month use code SB25 and get a $25 Starbucks gift card when you subscribe at ebmedicine.net Emergency Dept. Management of Cervical Spine Injuries Authors: Geoffrey Jara-Alamonte, MDChandni Pawar, MDEpidemiologyAnatomy (Figure 2 +3)Spinal Cord Injury Injury (Table1)PrimarySecondaryDifferential DiagnosisPrehospital Care - selective immobilizationED evaluationsHistoryPhysical Exam (Table 6)ImagingVascular Injury - Modified Denver Criteria (table 9)TreatmentSpecial PopulationsPediatrics

EMplify - September 2021Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !! Also, this month use code SB25 and get a $25 Starbucks gift card when you subscribe at ebmedicine.net !Abnormal Uterine Bleeding in the Emergency DepartmentAuthors:Tazeen Abbas, MDAbbas Husain, MD, FACEPPhysiology reviewTerminologyDifferentiating Causes: PALM-COEINStructural: Polyp, Adenomyosis, Leiomyoma, Malignancy/HyperplasiaNon-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise specifiedOther causes: thyroid disease, hyperprolactinemia, stress, weight loss and anorexia, heavy exerciseAge Based Differential12-18Immaturity of the hypothalamic-pituitary- ovarian axisSexually transmitted infectionsCoagulopathies, and bleeding disorders (von Willibrand disease)19-39polypsfibroidsmalignancyPCOSAge 40 and olderendometrial atrophymalignancyHistoryPhysical ExamDiagnostic StudiesTreatmentUnstableStableSpecial CasesDOACsPrepubescent girlsgenital injuries

EMplify – August 2021Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !!August 2021 Pediatric Emergency Medicine PracticeLess Lethal Law Enforcement WeaponsAuthors: Jessica Osterman, MD , Cara Buchanan, MDWhat kinds of less-lethal weapons are law enforcement using?Pepper sprayConducted Electrical Weapons (CEWs)K-9sBeanbag gunsRubber bulletsStingballsDifferential DiagnosisPrehospital CareTrauma Informed CareConductive Electrical Weapons – TaserChemical Irritants- Pepper Spray, Tear GasK9 InjuriesKinetic Impact Projectiles- Rubber Bullets, Beanbags, Sting Balls/GrenadesSounds:Police Siren https://freesound.org/people/MultiMax2121/sounds/156869/Ambulance https://freesound.org/people/sofialomba/sounds/469413/Angry Man https://freesound.org/people/ebcrosby/sounds/334439/Taser https://freesound.org/people/The_Chemical_Workshop/sounds/403252/Taser https://freesound.org/people/Greub/sounds/402636Coughs https://freesound.org/people/freesound/sounds/25301/Dog Bark https://freesound.org/people/ivolipa/sounds/337101/Grenade https://freesound.org/people/superfreq/sounds/268101/Last Updated on April 29, 2022

EMplify – July 2021Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !!HIV- An Interview With Dr. Daniel EganSee the EB Medicine Article @ https://www.ebmedicine.net/topics/infectious-disease/HIVWhy HIV? 2018 , 1,2 million people living with HIV, almost 40k new infectionsPeople living with HIV visit the ED 3 x per year on averageHIV infected patients accounted for 6 in 1000 ED visits in 2017New Transmission of HIV, Figure 1What does acute infection look like ?What about chronic infection ?The chronic phase can last 10 years or more and be asymptomatic.Are people with HIV more likely to develop: CAD, COPD, DVT and why?What if they are on medication for HIV?Screening in the ED, everyone? Do they have to have symptoms or risks?What does universal screening mean?What does risk based screening mean?What are the risk factors? What if I see someone on PrEP who is in the ED for an unrelated complaint?HistoryAsk about cd4 and viral load and last testAsk about he of opportunistic infectionsAsk about medication side effectsWhat else?ExamLabs – rapid testing, 4th gen, viral load and cd4, etcImagingTreatmentTable 1Highly effective and reduces transmissionMedication side effects (we don’t have to dwell on each Med and side effect and just reference the charts)hep B virus deactivationSystem Based DiseaseHeart Failure and CADPCP (role of LDH)TBCOPDRenal Disease – stones , radiolucentNeurologic- CVA, cryptococcal meningitis, toxo, progressive multi focal leukoencephalopathy, HANDGI – diarrhea causes, c diff, hep CHeme- cytopeniaEndocrine – metabolic syndromeMusculoskeletalPsychiatric table 3DermSpecial CircumstancesPEPPrEP

EMplify - June 2021 Announcements: The Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this summer !! Syncope- An Interview With Dr. James Morris See the EB Medicine Article @ https://www.ebmedicine.net/topics/cardiovascular/syncope Why syncope? Prevalence, hospitalizations, etc. Etiology: figure 1 is fantastic. Physiologic basis of syncope Neurally mediated Orthostatic - are we still doing orthostatic vitals in the ED? Cardiac Differentiating syncope from seizure Features that point to seizure Urinary incontinence Number of jerks Age? Prehospital care is all about details What did bystanders see? What do paramedics see? Any trauma? Any neuro deficits ? Glucose ECG ED History - table 4 History of similar Prodrome Associated symptoms (chest pain, neuro symptoms, etc) Falls Pre-syncope ? ED exam Vitals, vitals, vitals Orthostatic vitals ? Carotid sinus massage, why this? Do we do in the ED? ECG Brugada, blocks, VT, ST changes, etc Labs BNP, delta bnp ? Trop Lactic acid Pregnancy test CBC lutes Bun/Cr Echo - any role in the ED? CT Head PE- get this on everyone ? Is it high prevalence? Risk stratification tools- the bad and the worse Table 7, amazing Controversies Admitting the elderly Orthostatic vitals (we discussed already) Disposition

EMplify - May 2021 Announcements: The Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this summer !! Atrial Fibrillation : An Approach To Diagnosis And Management In The Emergency Department - An Interview with Dr Brian Millman Epidemiology Causes Prehospital treatment - careful with causes of the A Fib. ED Evaluation History - beware the causes Physical ECG Labs Imaging Echocardiography Treatment Rate control Calcium channel blockers Beta blockers Esmolol Magnesium Rhythm control Amiodarone Procainamide Cardioversion Watch and Wait Anticoagulation Disoposition

EMplify - April 2021AnnouncementsTraumatic Hemorrhage in the ED- with Dr Scott Weingart - April 13th, 8pm EST Free ! Register now: https://www.crowdcast.io/e/traumatic-hemorrhagic/registerPandemic Preparedness publication is coming soon.Mt Sinai COVID-19 Treatment Protocols have been updated and are available for free here: https://www.ebmedicine.net/topics/COVID-19/ProtocolsThe Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com Management of Suspected Rabies Exposure in the Emergency Department - An Interview with Dr. Bess StorchEpidemiology:Fatality rate of over 99%Half of cases occur in children95% of cases are in resource limited countries, 35% in India99% caused by infected dogs (worldwide)In the US, cases are predominantly bat variantWhy this topic?"In a recent survey of licensed physicians, less than half could identify rabies transmission routes, the correct PEP schedule, and the correct anatomic administration sites."Pathophysiology:What causes it? The RNA virus LyssavirusHow is it transmitted?How does it reach the brain?ED Evaluation:What does it look like clinically?5 stages- incubation, prodrome, acute neurologic phase, coma deathWhy doesn’t everyone just get vaccinated?What patient medical history is important ? Steroids, chloroquineWhat animals are high risk?What about pets and quarantine?What about rodents ?Is there any role for labs or imaging ?What is the treatment regimen for those who are unvaccinated? And vaccinated?What about people who are immunosuppressed?Children?Pregnant?Recently traveled?

EMplify - March 2021Management of Acute Urinary Retention in the Emergency Department An algorithmic approach to urinary retention.Relieve the obstruction FoleyCudet catherSilicone catheterSuprapubic catheterDetermine the cause - StructuralMedications / ToxicologicNeurologicInfectiousAlpha blockersAntibioticsSlow vs rapid bladder decompressionAdmit or dischargePhimosis and ParaphimosisAnnouncements: New Airway Course Available: Current Topics in Airway Management: Mechanical Ventilation, Supraglottic Airway Devices, and Intubating Patients With COVID-19Upcoming Live Course: Dr. Scott Weingart - Traumatic Hemorrhage - April 13th., 8-9pm, ESTLook for the "Key Points And Pearls From 2020" coming to your inbox or mailbox next month !

EMplify - February 2021Community Acquired Pneumonia - An Interview with Dr. Matthew DeLaney, FACEP1. Pneumonia and nomenclature : healthcare associated vs hospital associated2. COVID-19 and antibiotics3. Bacteriology - Strep is only 10-15% of hospitalized pneumonia, Viral pneumonia is about 20% (pre covid)4. Conditions that predispose to pneumoniachronic lung disease (chronic obstructive pulmonary disease, bronchiectasis)smokingolder ageimmuno-compromiseproton-pump inhibitors, H2 blockers, and antipsychotic agents5. Is there a historical or exam item most likely to be indicative of pneumonia?6. How good is a CXR?7. When should I consider a CT if the CXR is normal?8. Procalcitonin9. Blood cultures, sputum cultures, urine antigens- are these helpful?10. CURB-65 vs PSI11. Antibiotics- table 3 major and minor, history of prior infection, and doxy for everyone !12. Duration - 5 days works13. A walk through the pathway

EMplify January 2021Evaluation and Management of ST-Segment Elevation Myocardial Infarction in the Emergency DepartmentAuthorsMarshall Frank, DO, MPH, FACEPCarson Sanders, BS, NRP, CCEMT-PBryan P. Berry, MD, BCEM, FACEP TopicsEpidemiologyPathophysiologyPrehospital careEmergency Dept EvaluationHistoryPhysicalImagingLabsElectrocardiogramaVRPosterior LeadsLBBBSerial ECGsReciprocal ChangesPericarditis vs STEMITreatmentOxygenOpioidsAntiplatelet AgentsNitroglycerinBeta BlockersReperfusionPCIThrombolyticsDysrhythmiasAnticoagulantsTransfersSpecial CircumstancesGenderAgeCocaineHave questions or comments on the podcast? Write us at [email protected] .

EMplify December 2020Rhabdomyolysis: Evidence- Based Management in the Emergency Department Authors: Gi Xiang Lee, MDDavid Duong MD, MS, FACEPTopics: Evidence ReviewBiology & PathophysiologyDifferential DiagnosisPre-hospital careEmergency Department EvaluationHistoryPhysical ExaminationLabsTreatmentSpecial PopulationsDisposition Have questions or comments on the podcast? Write us at [email protected] .Don’t forget about the $50 Amazon card with any order over $300 through 12/31/20. Use code AMAZON20

EMplify November 2020An Evidence-Based Approach to Nonoperative Management of Traumatic Hemorrhagic Shock in the Emergency Department Authors: Christopher Pitotti, MD, FACEPJason David, MD Topics:The Lethal Triad Prehospital Care Tourniquets - Placement and PitfallsStop The BleedHemostatic DressingsTXATemperature ManagementED AssessmentShock RecognitionPredictors of Massive TransfusionImagingUltrasound - eFASTCTLabsViscoelastic Clot TestingTreatmentREBOA- Resuscitative Endovascular Balloon Occlusion of the AortaCPRResuscitative ThoracotomyAirway - IntubationBreathingCirculationMassive TransfusionCrystalloidBlood ProductsSpecial Populaations Have questions or comments on the podcast? Write us at [email protected] .

EMplify October 2020 Management of Deep Vein Thrombosis in the Emergency Department Authors: Shane R. Sergent, DO, FAAEM, FACOEP, FAWM, RDMS Michael Galuska, MD, FACEP, FAAEM John Ashurst, DO, MSc, FACEP, FACOEP Topics: Epidemiology Causes: • Unprovoked • Provoked Risk Factors Testing • D-dimer • Ultrasound Anticoagulation • Heparins • DOACs • Warfarin • Other Special Populations • Malignancy • Pregnancy • Elderly • Distal Calf DVT Have questions or comments on the podcast? Write us at [email protected] .

Emergency Care for Transgender and Gender-Diverse Children and Adolescents - An Interview With Dr. Hannah Janeway and Dr. Clinton Coil This issue of Pediatric Emergency Medicine Practice is available at no cost here: https://www.ebmedicine.net/topics/ethics/trasnsgender-gender-diverse-children Topics: What is the difference between gender and sexual orientation? What are some of the terms we may encounter (current or retired)? How does a lack of knowledge / competency regarding care for transgender and gender diverse (TGD) youth create barriers to effective care? Or negatively affect the quality of care these patients receive? What is the best way to approach a transgender patient in the ER? There are a number of ways transgender patient may alter their appearance. Why are these methods relevant (complications) and how do I ask about them? Tucking Packing Binding What medical gender-affirming therapies are currently available? And what complications can they cause? Pubertal suppression Feminizing or masculinizing hormones Contraception Is gender-affirming surgery used in this population ? What types (chest, genital) ? STI’s and Pregnancy are still considerations, correct? What are some of the problems that transgender youth have an increased risk of? Substance abuse Suicide Self harm Anxiety Depression Eating disorders Physicians and sexual violence Family rejection Homelessness Food insecurity Poverty What are some helpful resources if I want to learn more? UCSF Center for Excellence for Transgender Health (https://prevention.ucsf.edu/transhealth) PFLAG (https://pflag.org/) Learn more about EBMedicine and subscribe to Emergency Medicine Practice or Pediatric Emergency Medicine Practice here: https://www.ebmedicine.net/