EMplify by EB Medicine

Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. We have a special episode for you this month… We’ve brought Dr. Jeremy Rose, one of the peer reviewers, and a sepsis expert, on with us to talk through the content this month. Jeremy: Dr. Jeremy Rose here. Thanks for having me in on this conversation. I’m always happy to talk about this topic because it’s clearly important. There’s a great deal of confusion around sepsis and I hope that in the next couple minutes we can clarify things in a way that really help your average front line doc trying to get it right. Nachi: So Dr. Rose, before we get started, tell us a bit about your background and your interest in sepsis… Jeremy: I’m the Assistant Medical Director and Sepsis Chair at Mount Sinai Beth Israel in Manhattan. For those listening, my hospital probably looks a little bit like yours. We’re busy, interesting, and just a little rough around the edges. We like it that way. More importantly, though, we mirror the national averages regarding sepsis. Roughly half of in-hospital mortality is associated with septic in some fashion. Pretty incredible when you think about it. Half. Jeff: Sepsis chair... clearly this is an important topic if it warrants it’s own chair at a major hospital in NYC. But getting back to the article this month. This month’s issue was authored by Faheem Guirgis, Laurent Page Black, and Elizabeth DeVos of the University of Florida, Department of Emergency Medicine. Nachi: And it was peer reviewed by Michael Allison, Assistant Director of the Adult ICU at Saint Agnes Hospital, and Jeremy Rose and Eric Steinberg of Mount Sinai Beth Israel. Jeff: So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis? It seems that every month or so we have a new guideline, bundle, definition, or whatever… I think it’s best to start with the basics - At its core, sepsis is a dysregulated response to infection that can be life-threatening. Nachi: Right and it’s the combined inflammatory with immunosuppressive features of sepsis that lead to the devastating organ dysfunction and even death. Optimal management of septic patients has been a source of intense research, stemming from the landmark study by Rivers in 2001. Jeremy, can you give us a little historical context there? Jeremy: Rivers was a real pioneer. He found a 16% mortality reduction with randomization to an early aggressive care bundle. Amazing work. That being said, many components of that bundle have since been disregarded. For example, Manny Rivers would measure CVP in all of his patients, something we rarely do. Nachi: Not to cut you off and steal your thunder there, but we’ll get to the most recent updates in management shortly. Let’s first talk definitions and terminology, and specifically, diagnosis, which is definitely a big elephant in the room. As Jeff mentioned a few minutes ago, diagnostic criteria have undergone so so so many changes. Jeff: Yes it has! 1991 marked the first standardized definition. Then in 2001, sepsis-2 was introduced. In 2014, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine started a task force, and by 2016, updated definitions were out again! Sepsis-3!! A lot of this came after the realization that SIRS was just too broad and was overly sensitive and non-specific. Jeremy, why don’t you take us through Sepsis 3. Jeremy: So just to back up a little and frame this: Here’s the fundamental problem: As we likes to say, “there’s no troponin for sepsis.” And if you look at our patients, we tend not to miss the hypotensive, tachycardic, febrile patient. We know they’re septic. But how do we find the ones who don’t look as sick. Frequently elderly, possibly with normal-ish vitals and no fever. Those can be a lot harder to spot, but they may indeed be septic. Also, for research purposes we have to have a common definition, so Sepsis 3 came up with something called the SOFA score. The problem with the SOFA score is that its difficult to perform in the ED. It has parameters like bilirubin that often aren’t available when we want to screen out very sick patients. Fortunately there is the abridged version qSOFA, which identifies non-icu patients who are at high risk of inpatient mortality. So here it is, and if you get one thing from this episode, this is it: There are ONLY 3 criteria to the qSOFA. 3 Criteria. RR > 22; AMS; SBP <= 100. That’s it. If you have two of these criteria, you are up to 14 times more likely to die of sepsis during a hospital admission. That’s pretty profound; these patients are very sick. This is meant to replace SIRS. It also captures a much sicker population than the patients inclu

Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the September 2018 issue of Emergency Medicine Practice - Emergency Department Management of North American Snake envenomations. Nachi: Although this isn’t something we encountered too frequently – it does seem like I’ve been hearing more about snake bites in the recent months. Jeff: I actually flew someone just the other day because the local ED ran out of CroFab after an envenomation in Western PA. Nachi: Yeah, this is definitely more than “just a boards topic,” and it’s really important to know about in those rare circumstances. In terms of incidence, there are actually about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species. Jeff: That’s a good teaser, so let’s start by recognizing this month’s team – the two authors, Dr. Sheikh, a medical toxicologist, and Patrick Leffers, a pharmD, and emergency medicine and clinical toxicology fellow. Both are at the University of Florida Jacksonville, and they reviewed a total of 120 articles from 2006-2017, in addition to reviews from both Cochrane and Dare. Nachi: And don’t forget our peer reviewers this month, Dr. Daniel Sessions, a medical toxicologist working at the South Texas Poison Center, and our very own editor-in-chief, Dr. Andy Jagoda, who is also Chair of the Department of Emergency Medicine at Mount Sinai in New York City. Jeff: What a team! But, let’s get back to the snakes. As some background, from 2006-2015 there were almost 66,000 reported snake exposures and 31 deaths from snake envenomation in the US. Of course, this number likely underestimates the true total. Nachi: And there are two key subfamilies of venomous snakes to be aware of – the Crotalinae – or pit vipers – which includes rattlesnakes, copperheads, and water moccasins; and the Elapidae – of which you really only need to know about the coral snake. Jeff: And while those are the only two NATIVE snake subfamilies to be acutely aware of, don’t forget that exotic snakes, which are shockingly popular pets -- they can also cause significant morbidity and mortality. Nachi: Oh, and one other quick note before we get into the epidemiology – most of the recommendations this month come from expert opinion, as high quality RCTs are obviously difficult. In addition, many of the studies were based in other countries, where the snakes, the anti-venoms and their availability, and the general healthcare systems are different from those that most of us work in. Jeff: Unless we have listeners abroad? Do we have listeners in other countries? Nachi: Oh we definitely do... but we are going to be a bit biased towards US envenomation today. In any case, venomous snake bites occur most frequently in men aged 18 to 49 during warmer months with provoked bites occurring more frequently in the upper extremities and unprovoked bites in the lower extremities. Jeff: In one study of poison center data from the last decade, nearly half of all victims of snake bites were victims of unknown type snakes. However, of those that were known, copperheads were the most common, while rattlesnakes caused the most fatalities – 19 of 31 in this dataset. Nachi: In a separate study of snake bites in the early 2000s, 32% of exposures were from venomous snakes and 59% of those resulted in admission. That’s remarkably high. Jeff: Snake bite severity depends on several key factors: the amount of venom, the composition of the venom, the body size of the bite victim, the victim's clothing, the size of the bite, comorbid conditions, and the timing and quality of medical care the victim receives. Nachi: To be a bit more specific - First, the amount of venom will depend on the species of snake, with variations even occurring within the same species. Secondly, while there is a correlation between rattlesnake size and bite severity, there is much more at play. Some snakes can even vary the amount of venom based on threat risk – with defensive bites having different profiles than bites to strike prey. Jeff: I found it pretty interesting that an estimated 10-25% of pit viper bites are considered dry bites, that is, ones in which no venom is released. Nachi: Right, this is just one reason why all victims shouldn’t immediately get anti-venom, but we’ll get there. Jeff: We definitely will. As we already stated – venom composition varies greatly. Pit vipers produce a predominantly hemotoxic venom. Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis. Neurotoxicity is rare and is usually due to inter-breeding between species. Nachi: While rattlesnake bites are associated with higher morbidity and mortality, the more common copperhead bites typically only cause local tissue effects. More serious systemic findings such as coagulopathy and respiratory failure have been

Show Notes Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice. Nachi: This month’s topic is one that Jeff has significant personal experience with from his college days. We’re reviewing Cannabinoids -- and emerging evidence in their use and abuse. Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes? Nachi: Sometimes… Jeff: This month’s issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. Nachi: We’re going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready. Jeff: As you’re listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you’re not driving while listening, be sure to jot down these answers and get your CME credit when we’re going through this issue.. Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available. Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure. Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance. Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses. Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising. Jeff: Let’s get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described. Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found in the greatest quantities. The neuropsychiatric and addictive properties of cannabis are due primarily to the delta-9-THC. Jeff: THC and other cannabis derivatives work through the endocannabinoid system and other neuroregulators. The endogenous cannabinoid system has 4 components: (1) endogenous endocannabinoids, (2) receptors, (3) degradation enzymes, and (4) transport mechanisms. Nachi: There are two endogenous endocannabinoids to know about: anandamide (AEA) and 2-arachidonoyl-glycerol. Jeff: Cannabinoid receptors are broadly dispersed through the central nervous system, and to a lesser degree, also to other organ systems. Nachi: Because CB receptors are concentrated within the central nervous system, they exert the majority of their effects on the neuropsychiatric systems. And -- yes that’s a double ding -- the cannabinoid 1 (or CB1) receptor is most responsible for cannabis-induced neuropsychiatric effects. Jeff: Interestingly, the anti-emetic effects and possible palliative properties of cannabis

Join Jeff, a former firefighter, and Nachi, a former mathematician, as they take you through the July 2018 issue of Emergency Medicine Practice: Emergency department management of dyspnea in the dying patient Most Important References 17. Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest. 1986;89(2):234-236. (Prospective; 1754 patients)34. Lunney JR, Lynn J, Foley DJ, et al. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387-2392. (Prospective cohort; 4190 patients)40. Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476-2482. (Cross-sectional survey; 1122 patients/families/providers)41. Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want “everything.” Ann Intern Med. 2009;151(5):345-349. (Review)63. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer. 2009;17(4):367-377. (Nonrandomized trial; 46 patients)66. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. 2010;376(9743):784-793. (Double-blind randomized controlled trial; 239 patients)68. Galbraith S, Fagan P, Perkins P, et al. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage. 2010;39(5):831-838. (Randomized controlled crossover trial; 50 patients)

Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the June 2018 issue of Emergency Medicine Practice: Managing Shoulder Injuries in the Emergency Department Fracture, Dislocation, and Overuse. This month, Richard Pescatore, director of clinical research at Crozer-Keystone Health System and clinical assistant professor at the Rowan University School of Osteopathic Medicine, along with Andrew Nyce, vice chairman and associate professor at cooper medical school of Rowan University reviewed just over 100 articles to come up with their evidence-based recommendations. Their recommendations were then edited by John Munyak of Maimonides and Mark Silverberg of SUNY Downstate and Kings County Hospital. Most Important References * Ponce BA, Kundukulam JA, Pflugner R, et al. Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg. 2013;22(7):993-999. (Prospective cohort; 49 patients) * Slaven EJ, Mathers J. Differential diagnosis of shoulder and cervical pain: a case report. J Man Manip Ther. 2010;18(4):191-196. (Case report) * Helfen T, Ockert B, Pozder P, et al. Management of prehospital shoulder dislocation: feasibility and need of reduction. Eur J Trauma Emerg Surg. 2016;42(3):357-362. (Retrospective review; 70 patients) * Lenza M, Belloti JC, Andriolo RB, et al. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. 2014(5):CD007121. (Systematic review; 3 trials, 354 patients) * Neer CS, 2nd. Displaced proximal humeral fractures: part I. Classification and evaluation. 1970. Clin Orthop Relat Res. 2006;442:77-82. (Review article) * Sholsberg J, Jackson R. Best evidence topic report. Intra-articular corticosteroid injections in acute rheumatoid monoarthritides. Emerg Med J. 2004;21(2):204. (Systematic review; 1 study, 137 patients)

Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the May 2018 issue of Emergency Medicine Practice: Recognizing and Managing Emerging Infectious Diseases in the Emergency Department. This month’s issue was authored by Drs. Millan, Thomas-Paulose, and Egan from Mount Sinai St Luke’s and Mount Sinai West in New York city.

Jaundice is a manifestation of elevated serum bilirubin, and can have many causes, some of which can be life-threatening. Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the April 2018 issue of Emergency Medicine Practice: Jaundice in the Emergency Department: Meeting the Challenges of Diagnosis and Treatment. This month’s issue was authored by Dr. Taylor and Dr. Wheatley both of the Emory School of Medicine. It was peer reviewed by Dr. Chung of the Icahn School of Medicine at Mount Sinai, and Dr. Horan of Our Lady of Lourdes Medical Center.

When treating patients who have suffered injury in a fire, managing their airway is as critical as treating their burns. Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the March 2018 issue of Emergency Medicine Practice: Emergency Department Management of Smoke Inhalation Injuries in Adults. This month’s issue was authored by Dr. Otterness and Dr. Ahn of the Stony Brook School of Medicine. It was also reviewed by a toxicology duo of Dr. Manini of The Icahn School of Medicine at Mount Sinai and Dr. Nelson of Rutgers New Jersey Medical School.

Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. We’ll be taking you through the February 2018 issue of Emergency Medicine Practice: Emergency Department Management of Patients with Thermal Burns.

As the prevalence of cancer continues to increase in the general population and improvements in cancer treatment prolong survival, the incidence of patients presenting to the emergency department with oncologic complications will, similarly, continue to rise. This episode reviews 3 of the more common presentations of oncology patients to the emergency department: metastatic spinal cord compression, tumor lysis syndrome, and febrile neutropenia. Signs and symptoms of these conditions can be varied and nonspecific, and may be related to the malignancy itself or to an adverse effect of the cancer treatment. Timely evidence-based decisions in the emergency department regarding diagnostic testing, medications, and arrangement of disposition and oncology follow-up can significantly improve a cancer patient's quality of life. This episode of EB Medicine's EMplify podcast is hosted by Nachi Gupta, MD, PhD, and Jeff Nusbaum, MD. This month's corresponding full-length journal issue of Emergency Medicine Practice was authored by David Wacker, MD, and Michael McCurdy, MD. It was peer reviewed by Kevin Chase, MD, and Natalie Kreitzer, MD. Link to article: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=564

Lower-extremity dislocations are less common in the emergency department (ED) than shoulder and elbow dislocations, and emergency clinicians’ experience with evaluation and reduction techniques is often limited. Nonetheless, these dislocations can be serious because of their association with vascular injury. This episode discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle. This episode of EB Medicine's EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month's corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Caylyne Arnold, Dr. Zane Fayos, Dr. David Bruner, and Dr. Dylan Arnold. It was peer reviewed by Dr. Melissa Leber and Dr. Christopher Tainter. Link to article: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559

Because of the chronic relapsing nature of inflammatory bowel disease (IBD), emergency clinicians frequently manage patients with acute flares and complications. IBD patients present with an often-broad range of nonspecific signs and symptoms, and it is essential to differentiate a mild flare from a life-threatening intra-abdominal process. Recognizing extraintestinal manifestations and the presence of infection are critical. This episode reviews the literature on management of IBD flares in the emergency department, including laboratory testing, imaging, and identification of surgical emergencies, emphasizing the importance of coordination of care with specialists on treatment plans and offering patients resources for ongoing support This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Michael Burg and Dr. Steven Riccoboni. It was peer reviewed by Dr. Andrew Lee and Dr. Chad Roline. Links and Resouces: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559 - Management of Inflammatory Bowel Disease Flares in the Emergency

COPD has huge economic and human burdens in the US. In fact, in 2010, two studies estimated that COPD exacted a direct and indirect cost of somewhere between $36 and $50 billion dollars in the US. With respect to the ED – in 2011, there were more than 1.7 million ED visits for COPD-related problems, with nearly 1/5th requiring hospitalization. This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by a strong team from the University of Maryland: Drs. Van Holden, Donald Slack, Michael McCurdy, and Nirav Shah. It was peer reviewed by Dr. Gabriel Wardi of the University of California San Diego and Dr. Geralda Xavier of Kings County Hospital in New York City. Links and Resouces: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=557 - Diagnosis and Management of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Primary and secondary adrenal insufficiency are underrecognized conditions among emergency department patients, affecting an estimated 10% to 20% of critically ill patients. The signs and symptoms of cortisol deficit can be nonspecific and wide-ranging, and identification and swift treatment with stress-dosing of hydrocortisone is vital to avoid life-threatening adrenal crisis. This episode offers a review of the literature regarding adrenal disorders, from diagnosis to management to disposition. This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Drs. Cutright, Ducey, and Barthold of the University of Nebraska Medical Center, and it was edited by Dr. Knight of the University of Cincinnati and Dr. Zammit of the University of Rochester. Thank you, team, for your efforts putting this together. Links and resources: EB Medicine - www.ebmedicine.net Recognizing and Managing Adrenal Disorders in the Emergency Department - http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=550

For trauma patients in the ED, life- and limb-threatening injuries take priority, but renal and genitourinary injury can have long-term consequences for patients, including chronic kidney disease, erectile dysfunction, incontinence, and other serious problems. This episode offers a review of the literature regarding treatment of renal and GU injuries, from diagnosis to management to disposition. This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Drs. Bryant and Shewakramani of the University of Cincinnati College of medicine and it was edited by Dr. Bryce of Vanderbilt University Medical Center and Dr. Shaukat of Coney Island Hospital. Thank you, team, for your efforts putting this together. Links and resources: EB Medicine - www.ebmedicine.net Emergency Management of Renal and Genitourinary Trauma: Best Practices Update - http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=547

Though a minority of patients presenting to the emergency department with chest pain have acute coronary syndromes, identifying the patients who may be safely discharged and determining whether further testing is needed remains challenging. This topic is of massive importance to emergency physicians and there is a wealth of literature exploring it. Every year, in the US, there are roughly 8 million ED visits for chest pain, and of those, only 13-25% lead to the diagnosis of acute coronary syndromes or ACS. This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Dr. David Markel, of Tacoma Emergency Care Physicians and was reviewed by Dr. Keith Marill from Mass General and Dr. Andrew Schmidt of the University of Florida College of Medicine. Links and resources: EB Medicine - www.ebmedicine.net Identifying Emergency Department Patients With Chest Pain who are at Low Risk for Acute Coronary Syndromes - https://tinyurl.com/y848wacl MDCalc - www.mdcalc.com

This month's episode of EMplify, a podcast corollary to the Emergency Medicine Practice journal, focuses on management strategies that improve dental emergency outcomes. Hosts Jeff Nusbaum, MD, and Nachi Gupta, MD, cover all aspects of the diagnosis and management of this condition, from initial diagnosis and treatment in the emergency department to controversies and cutting-edge strategies. This podcast is based on the full-length review published in the June 2017 issue of Emergency Medicine Practice. In it, author Ryan Pedigo, MD, Director of Undergraduate Medical Education at Harbor-UCLA Medical Center and Assistant Professor of Emergency Medicine at the David Geffen School of Medicine, cover evidence published in more than 700 articles and reviewed recommendations from the International Association for Dental Traumatology and the Cochrane Database. Topics covered in this episode of EMplify include: Case Presentations Dental Anatomy Pathophysiology Traumatic Dental Emergencies Concussion Subluxation Luxation Avulsion Fracture Ellis classification system Atraumatic dental emergencies Dental Infections Dental Disease Prehospital Care Imaging Nerve blocks Antibiotics Management of tooth trauma Treatment for dental fractures Summary of key points Links and resources: Tables referenced in this podcast episode - http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=543&seg_id=9020 Dental Emergencies: Management Strategies That Improve Outcomes - https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=532 Clinical Decision Making in Emergency Medicine - http://www.clinicaldecisionmaking.com/