Episodes

Dec 1

We review BRUEs (Brief Resolved Unexplained Events). Hosts: Ellen Duncan, MD, PhD Noumi Chowdhury, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/BRUE.mp3 Download Leave a Comment Tags: Pediatrics Show Notes What is a BRUE? BRUE stands for Brief Resolved Unexplained Event. It typically affects infants <1 year of age and is characterized by a sudden, brief, and now resolved episode of one or more of the following: Cyanosis or pallor Irregular, absent, or decreased breathing Marked change in tone (hypertonia or hypotonia) Altered level of responsiveness Crucial Caveat: BRUE is a diagnosis of exclusion . If the history and physical exam reveal a specific cause (e.g., reflux, seizure, infection), it is not a BRUE. Risk Stratification: Low Risk vs. High Risk Risk stratification is the most important step in management. While only 6-15% of cases meet strict “Low Risk” criteria, identifying these patients allows us to avoid unnecessary invasive testing. Low Risk Criteria To be considered Low Risk, the infant must meet ALL of the following: Age: > 60 days old Gestational Age: GA > 32 weeks (and Post-Conceptional Age > 45 weeks) Frequency: This is the first episode Duration: Lasted < 1 minute Intervention: No CPR performed by a trained professional Clinical Picture: Reassuring history and physical exam Management for Low Risk: Generally do not require extensive testing or admission. Prioritize safety education/anticipatory guidance. Ensure strict return precautions and close outpatient follow-up (within 24 hours). High Risk Criteria Any infant not meeting the low-risk criteria is automatically High Risk. Additional red flags include: Suspicion of child abuse History of toxin exposure Family history of sudden cardiac death Abnormal physical exam findings (trauma, neuro deficits) Management for High Risk: Requires a more thorough evaluation. Often requires hospital admission. Note: Serious underlying conditions are identified in approx. 4% of high-risk infants. Differential Diagnosis: “THE MISFITS” Mnemonic T – Trauma (Accidental or Non-accidental/Abuse) H – Heart (Congenital heart disease, dysrhythmias) E – Endocrine M – Metabolic (Inborn errors of metabolism) I – Infection (Sepsis, meningitis, pertussis, RSV) S – Seizures F – Formula (Reflux, allergy, aspiration) I – Intestinal Catastrophes (Volvulus, intussusception) T – Toxins (Medications, home exposures) S – Sepsis (Systemic infection) Workup & Diagnostics Step 1: Stabilization ABCs (Airway, Breathing, Circulation) Point-of-care Glucose Cardiorespiratory monitoring Step 2: Diagnostic Testing (For High Risk/Symptomatic Patients) Labs: VBG, CBC, Electrolytes. Imaging: CXR: Evaluate for infection and cardiothymic silhouette. EKG: Evaluate for QT prolongation or dysrhythmias. Neuro: Consider Head CT/MRI and EEG if there are concerns for trauma or seizures. Clinical Pearl: Only ~6% of diagnostic tests contribute meaningfully to the diagnosis. Be judicious—avoid “shotgunning” tests in low-risk patients. Prognosis & Outcomes Recurrence: Approximately 10% (lower than historical ALTE rates of 10-25%). Mortality: < 1%. Nearly always linked to an identifiable cause (abuse, metabolic disorder, severe infection). BRUE vs. SIDS: These are not the same. BRUE: Peaks < 2 months; occurs mostly during the day. SIDS: Peaks 2–4 months; occurs mostly midnight to 6:00 AM. Take-Home Points Diagnosis of Exclusion: You cannot call it a BRUE until you have ruled out obvious causes via history and physical. Strict Criteria: Stick strictly to the Low Risk criteria guidelines. If they miss even one (e.g., age < 60 days), they are High Risk. Education: For low-risk families, the most valuable intervention is reassurance, education, and arranging close follow-up. Systematic Approach: For high-risk infants, use a structured approach (like THE MISFITS) to ensure you don’t miss rare but reversible causes. Read More

Nov 1

Lessons from Rwanda’s Marburg Virus Outbreak and Building Resilient Systems in Global EM. Hosts: Tsion Firew, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Marburg_Virus.mp3 Download Leave a Comment Tags: Global Health , Infectious Diseases Show Notes Context and the Rwanda Marburg Experience The Threat: Marburg Virus Disease is from the same family as Ebola and has historically had a reported fatality rate as high as 90%. The Outbreak (Sept. 2024): Rwanda declared an MVD outbreak. The initial cases involved a miner, his pregnant wife (who fell ill and died after having a baby), and the baby (who also died). Healthcare Worker Impact: The wife was treated at an epicenter hospital. Eight HCWs were exposed to a nurse who was coding in the ICU; all eight developed symptoms, tested positive within a week, and four of them died. The Turning Point: The outbreak happened in city referral hospitals where advanced medical interventions (dialysis, mechanical ventilation) were available. Rapid Therapeutics Access: Within 10 days of identifying Marburg, novel therapies ( experimental drugs and monoclonal antibodies) and an experimental vaccine were made available through diplomacy with the US government/CDC and agencies like WHO, Africa CDC, CEPI and more. The Outcome: This coordinated effort—combining therapeutics, widespread testing, and years of investment in a resilient healthcare system—helped curb the fatality rate down to 23% . Barriers and Enablers in Outbreak Preparedness Fragmented Systems: Emergency and surveillance functions often operate in silos , leading to delayed or missed outbreak identification (e.g., inconsistent travel screening at JFK during early COVID-19 vs. African countries). Solution: Empowering Emergency Departments and the community as the sentinel site can bridge this gap. Limited Frontline Capacity and Protection: Clinicians are often undertrained and underprotected and are frequently not part of the decision-making for surveillance. Weak Governance and Accountability: Unclear command structures and lack of feedback discourage early reporting . Enabler: Strong governance and accountability in Rwanda helped contain the virus. Dependence on External Programs: Many low-income countries rely on outside sources for vaccines and therapeutics, slowing response. Solution: Invest in local production (e.g., Rwanda’s pre-outbreak investment in developing its own mRNA vaccines). Lack of Resource-Smart Innovation: Gaps exist in things like integrating digital triage tools and surveillance systems. Four Pillars of a Responsive and Equitable Emergency System Workforce: Invest in pre-service and in-service training , mentorship, and fair compensation to ensure a skilled, protected, and motivated team. Integration into the Health System: Emergency care (including pre-hospital services) must not operate in silos; it needs to be embedded in national health strategies and linked to surveillance, referral, and financing systems. Equity in Design and Policy: The system must address the needs and protection of vulnerable groups and work closely with policymakers. Data: Utilize real-time data and dashboards to provide a feedback loop between clinicians and policymakers, enabling tailored and innovative interventions. Advice for Clinicians in Global Health Work Start Small and Build Trust: Meaningful work requires humility and relationship over scale or visibility. Focus on local priorities and sustainable change through long-term partnership , not just presence. Avoid the “savior mindset” . Be T-Shaped: Be deep in one specialty (e.g., EM) but fluent across other critical areas like policy, finance, and data, as these drive decision-making. Focus on Knowledge Transfer: True impact means making yourself less essential over time. Prioritize mentorship, co-creation, and sharing leadership opportunities. Looking Ahead: Global Threats Shaping the Next Decade The future of EM will be shaped by the convergence of several complex challenges: Climate and Environmental Crisis: Extreme heat, floods, and vector-borne illnesses will strain emergency systems. Preparation: Invest in climate-resilient infrastructure for both EDs and the community. Outbreaks and Biosecurity: Future outbreaks will emerge faster than current systems can handle, coupled with challenges from anti-microbial resistance. Conflict, Displacement, and Urbanization: Mass migration and overcrowded cities will require new models of emergency care that are mobile, scalable, and inclusive. Preparation: Building resilient healthcare systems ready for crisis mental health and cross-border coordination. Digital Tools and AI: These can augment solutions, but investment is needed in data governance and ethical AI that preserves local control and adapts to local capacity. Read More

Oct 2

We review the diagnosis, risk stratification, & management of acute pulmonary embolism in the ED. Hosts: Vivian Chiu, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Pulmonary_Embolism.mp3 Download One Comment Tags: Pulmonary Show Notes Core Concepts and Initial Approach Definition: Obstruction of pulmonary arteries, usually from a DVT in the proximal lower extremity veins (iliac/femoral), but may be tumor, air, or fat emboli. Incidence & Mortality: 300,000–370,000 cases/year in the USA, with 60,000–100,000 deaths annually. Mantra: “Don’t anchor on the obvious. Always risk stratify and resuscitate with precision .” Risk Factors: Broad, including older age, inherited thrombophilias, malignancy, recent surgery/trauma, travel, smoking, hormonal use, and pregnancy. Clinical Presentation and Risk Stratification Presentation: Highly variable, showing up as anything from subtle shortness of breath to collapse. Acute/Subacute: Dyspnea (most common), pleuritic chest pain, cough, hemoptysis, and syncope. Patients are likely tachycardic, tachypneic, hypoxemic on room air, and may have a low-grade fever. Chronic: Can mimic acute symptoms or be totally asymptomatic. Pulmonary Infarction Signs: Pleuritic pain, hemoptysis, and an effusion. High-Risk Red Flags: Signs of hypotension (systolic blood pressure < 90 mmHg for over 15 minutes), requirement of vasopressors, or signs of shock → activate PERT team immediately. Crucial Mimics: Think broadly; consider pneumonia, ACS, pneumothorax, heart failure exacerbation, and aortic dissection. Workup & Diagnostics History/Scoring: Ask about prior clots, recent surgeries, hospitalizations, travel. Use Wells/PERC criteria to assess pretest probability. Labs: D-dimer: A good test to rule out PE in a patient with low probability . If suspicion is high, proceed directly to imaging. Troponin/BNP: Act as RV stress gauges . Elevated levels are associated with increased risk of a complicated clinical course (25-40%). Lactate: Helpful in identifying patients in possible cardiogenic shock. EKG: Most common finding is sinus tachycardia . Classic RV strain patterns (S 1 Q 3 T 3 , T-wave changes/inversions) are nonspecific. Imaging: CXR: Usually normal, but quick and essential to rule out other causes. CTPA: The usual standard and gold standard for stable patients . High sensitivity (> 95%) and can detect RV enlargement/strain. V/Q Scan: Option for patients with contraindications to contrast (e.g., severe contrast allergies). POCUS (Point-of-Care Ultrasound): Useful adjunct for unstable patients. Bedside Echo: Can show signs of RV strain (enlarged RV, McConnell sign). Lower Extremity Ultrasound: Can identify a DVT in proximal leg veins. Treatment & Management Resuscitation (Reviving the RV): Oxygenation: Give supplementally as needed (nasal cannula, non-rebreather, high flow). Intubation: Avoid if possible ; positive pressure ventilation can worsen RV dysfunction. Fluids: Be judicious ; even the smallest amount can worsen RV overload. Vasopressors: Norepinephrine is preferred as first-line for hypotension/shock. Anticoagulation (Start Immediately): Initial choice is UFH or LMWH (Lovenox) . Lovenox is preferred for quicker time to therapeutic range, but is contraindicated in renal dysfunction, older age, or need for emergent procedures. DOACs can be considered for stable, low-risk patients as an outpatient. Escalation for High-Risk PE Systemic Thrombolytics: Consider for very sick patients with shock/cardiac arrest (e.g., Alteplase 100 mg over two hours or a bolus in cardiac arrest). High risk of intracranial hemorrhage; weigh risks versus benefits. PERT Activation: Engage multidisciplinary teams (usually including ICU, CT surgery, and interventional radiology). Interventions: Consult specialists for catheter-directed thrombolysis or suction embolectomy . Surgical embolectomy can also be considered. Bridge to Care: Activate the ECMO team early for unstable patients to buy valuable time. Prognosis & Disposition Mortality: Low risk < 1%; intermediate 3-15%; high risk 25-65%. Complications: 3-4% of patients develop Chronic Thromboembolic Pulmonary Hypertension (CTEPH) . Others may have long-term RV dysfunction and chronic shortness of breath. Recurrence: ∼ 30% chance in the next few weeks to months, if not treated correctly. Disposition: ICU: All high-risk and some intermediate-high risk patients. Regular Floor: Intermediate-low risk patients. Outpatient Discharge: Low-risk patients can be sent home on anticoagulation. Use PSI or HESTIA scores to risk stratify suitability, typically starting a DOAC. Shared Decision-Making: Critical to ensure care is safe and consistent with the patient’s wishes. Read More

Sep 1

We break down pneumothorax: risks, diagnosis, and management pearls. Hosts: Christopher Pham, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumothorax.mp3 Download Leave a Comment Tags: Chest Trauma , Pulmonary , Trauma Show Notes Risk Factors for Pneumothorax Secondary pneumothorax Trauma: rib fractures, blunt chest trauma (as in the case). Iatrogenic: central line placement, thoracentesis, pleural procedures. Primary spontaneous pneumothorax Young, tall, thin males (10–30 years). Connective tissue disorders: Marfan, Ehlers-Danlos. Underlying lung disease: COPD with bullae, interstitial lung disease, CF, TB, malignancy. Technically, anyone is at risk. Symptoms & Differential Diagnosis Typical PTX presentation: Dyspnea, chest pain, pleuritic discomfort. Exam clues: unilateral decreased breath sounds, focal tenderness/crepitus. Red flags (suggest tension PTX): JVD Tracheal deviation Hypotension, shock physiology Severe tachycardia, hypoxia Differential diagnoses: Pulmonary: asthma, COPD, pneumonia, pulmonary edema (SCAPE), ILD, infections. Cardiac: ACS, CHF, pericarditis. PE and other acute causes of dyspnea. Diagnostics Bloodwork: limited role, except type & screen if intervention likely. EKG: reasonable given chest pain/shortness of breath. Imaging: POCUS (bedside ultrasound) High sensitivity (86–96%) & specificity (97–100%). Signs: Seashore sign: normal lung sliding. Barcode sign: absent lung sliding. Lung point: most specific for PTX. CXR Sensitivity ~70–90% for small PTX. May show pleural line, hyperlucency. CT chest (gold standard) Defines size/severity. Rules out mimics (bullae, pleural effusion, hemothorax). Guides intervention choice. Management First step for all: Oxygen supplementation (non-rebreather if possible). Accelerates resorption of pleural air. Stable vs. unstable decision point: Unstable/tension PTX Immediate needle thoracostomy (14-g angiocath, 2nd ICS midclavicular). Temporizing until chest tube/pigtail placed. Stable, small PTX (<2 cm on O₂) Observation, supplemental O₂, conservative management. Stable, larger PTX or symptomatic Chest tube or pigtail catheter insertion. Pigtail catheters: less invasive, more comfortable, similar efficacy for simple PTX. Large bore tubes: indicated if associated with blood, pus, large collections. Disposition Admit all patients with chest tubes; cannot be discharged with tube in place. Service responsible varies by hospital: trauma, CT surgery, MICU, etc. Level of care (ICU vs. floor) depends on stability: ICU if unstable course, intubated, shock physiology. Stepdown/floor if stable and straightforward. Take Home Points Always broaden differential in dyspnea/chest pain → don’t anchor on asthma/COPD. Exam findings + history (trauma, risk factors) crucial to raising suspicion. Ultrasound is more sensitive than CXR and highly specific when lung point found. Oxygen is first-line; intervention determined by size + stability. Pigtail catheters increasingly favored for simple, stable PTX. All patients with intervention require admission; service varies by institution. Read More

Aug 2

Angioedema – Recognition and Management in the ED Hosts: Maria Mulligan-Buckmiller, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Angioedema.mp3 Download Leave a Comment Tags: Airway Show Notes Definition & Pathophysiology Angioedema = localized swelling of mucous membranes and subcutaneous tissues due to increased vascular permeability. Triggers increased vascular permeability → fluid shifts into tissues. Etiologies Histamine-mediated (anaphylaxis) Associated with urticaria/hives, pruritus, and redness. Triggered by allergens (foods, insect stings, medications). Rapid onset (minutes to hours). Bradykinin-mediated Hereditary angioedema (HAE): C1 esterase inhibitor deficiency (autosomal dominant). Acquired angioedema: Associated with B-cell lymphoma, autoimmune disease, MGUS. Medication-induced: Most commonly ACE inhibitors; rarely ARBs. Typically lacks urticaria and itching. Gradual onset, can last days if untreated. Idiopathic angioedema Unknown cause; diagnosis of exclusion. Clinical Presentations Swelling Asymmetric, non-pitting, usually non-painful. May involve lips, tongue, face, extremities, GI tract. Respiratory compromise Upper airway swelling → stridor, dyspnea, sensation of throat closure. Airway obstruction is the most feared complication. Abdominal manifestations Bowel wall angioedema can mimic acute abdomen: Nausea, vomiting, diarrhea, severe pain, increased intra-abdominal pressure, possible ischemia. Key Differentiating Features Histamine-mediated: rapid onset, hives/itching, resolves quickly with epinephrine, antihistamines, and steroids. Bradykinin-mediated: slower onset, lacks urticaria, prolonged duration, less responsive to standard anaphylaxis medications. Diagnostic Approach in the ED Focus on airway (ABCs) and clinical assessment. Labs (e.g., C4 level ) useful for downstream diagnosis (esp. HAE) but not for acute management. Imaging: only if symptoms suggest abdominal involvement or to rule out other causes. Treatment Strategies Airway protection is always priority: Early consideration of intubation if worsening obstruction or inability to manage secretions. Histamine-mediated (anaphylaxis): Epinephrine (IM), antihistamines, corticosteroids. Bradykinin-mediated: Epinephrine may be tried if unclear etiology (no significant harm, lifesaving if histamine-mediated). Targeted therapies: Icatibant: bradykinin receptor antagonist. Ecallantide: kallikrein inhibitor (less available). C1 esterase inhibitor concentrate: replenishes deficient protein. Fresh frozen plasma (FFP): contains C1 esterase inhibitor. Tranexamic acid (TXA): off-label, less evidence, considered if no other options. Complications to Watch For Airway compromise: rapid deterioration possible. Abdominal compartment syndrome from bowel edema (rare, surgical emergency). Take-Home Points Secure the airway if in doubt. Differentiate histamine-mediated vs bradykinin-mediated by presence/absence of hives/itching and speed of onset. Use epinephrine promptly if suspecting histamine-mediated angioedema or if uncertain. Consider bradykinin-targeted therapies for confirmed hereditary, acquired, or ACE-inhibitor–related angioedema. Recognize ACE inhibitors as the most frequent medication trigger; ARBs rarely cause it. Labs and imaging generally don’t change initial ED management but aid diagnosis for follow-up care. Read More

Jul 1

Granulomatosis with Polyangiitis (GPA) – Recognition and Management in the ED Hosts: Phoebe Draper, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/GPA.mp3 Download One Comment Tags: Rheumatology Show Notes Background A vasculitis affecting small blood vessels causing inflammation and necrosis Affects upper respiratory tract (sinusitis, otitis media, saddle nose deformity), lungs (nodules, alveolar hemorrhage), and kidneys (rapidly progressive glomerulonephritis) Can lead to multi-organ failure, pulmonary hemorrhage, renal failure Red Flag Symptoms: Chronic sinus symptoms Hemoptysis (especially bright red blood) New pulmonary complaints Renal dysfunction Constitutional symptoms (fatigue, weight loss, fever) Workup in the ED: CBC, CMP for anemia and AKI Urinalysis with microscopy (hematuria, RBC casts) Chest imaging (CXR or CT for nodules, cavitary lesions) ANCA testing (not immediately available but important diagnostically) Management: Stable patients: Outpatient workup, urgent rheumatology consult, prednisone 1 mg/kg/day Unstable patients: High-dose IV steroids (methylprednisolone 1 g daily x3 days), consider plasma exchange, cyclophosphamide or rituximab initiation, ICU admission Conditions that Mimic GPA: Goodpasture syndrome (anti-GBM antibodies) TB, fungal infections Lung malignancy Other vasculitides (EGPA, MPA, lupus) ANCA Testing Utility: C-ANCA/PR3-ANCA positive in 80-90% of GPA cases P-ANCA/MPO-ANCA more common in MPA Don’t delay treatment while awaiting results if suspicion is high Outcomes: Without treatment: Fatal within a year (renal failure, respiratory complications) With treatment: 5-year survival ~75-90%, but ~50% relapse rate Long-term rheumatology follow-up is essential Take-Home Points: Always include vasculitis in the differential for unexplained respiratory, renal, or systemic symptoms. Recognize pulmonary-renal syndromes early. Initiate high-dose steroids immediately for unstable patients without waiting for ANCA results. GPA is rare but life-threatening – early recognition saves lives. Read More

Jun 2

We discuss capacity assessment, patient autonomy, safety, and documentation. Hosts: Anne Levine, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Capacity_Assessment.mp3 Download One Comment Show Notes The Importance of Capacity Assessment Arises frequently in the ED, even when not formally recognized Carries both legal implications and ethical weight Failure to appropriately assess capacity can result in: Forced treatment without justification Missed opportunities to respect autonomy Increased risk of litigation and poor patient outcomes Defining Capacity Capacity is: Decision-specific: varies based on the medical choice at hand Time-specific: can fluctuate due to medical conditions, intoxication, delirium Distinct from competency, which is a legal determination Relies on a patient’s ability to: Understand relevant information Appreciate the consequences Reason through options Communicate a clear choice Real-World ED Examples Intoxicated patient with head trauma refusing CT Unreliable neuro exam Potentially time-sensitive intracranial injury Elderly patient with sepsis refusing admission due to caregiving responsibilities Balancing autonomy vs. beneficence Patient with gangrenous diabetic foot refusing surgery Demonstrates logic and consistency despite high-risk decision The 4 Pillars of Capacity Assessment Understanding Can the patient explain: Their condition Recommended treatments Risks and benefits Alternatives and outcomes? Sample prompts: “What are the options for your situation?” “What might happen if we do nothing?” Appreciation Does the patient grasp the personal relevance of the information? Sample prompts: “Why do you think we’re recommending this?” “How do you think this condition could affect you?” Reasoning Can the patient logically explain their choice? Must demonstrate a rational process, even if the outcome seems unwise Sample prompts: “What factors are you considering in making this decision?” “What led you to this conclusion?” Choice Is the patient able to clearly communicate a decision? Any modality acceptable: verbal, written, gestural Sample prompts: “We’ve discussed several options. What do you want to do?” “Have you decided what option is best for you?” Common ED Challenges & Solutions Time Pressure Capacity assessments can be time-consuming Yet, patients leaving AMA without proper evaluation are at higher risk: ↑ 30-day mortality ↑ 30-day readmission Communication Barriers Language differences → use certified interpreters Cognitive impairment or psych illness → clarify baseline status Noisy ED environment → relocate to quiet space Use simple language, avoid jargon Ethical Dilemmas Providers may disagree with patient choices Ensure decision-making process—not the choice itself—is being judged Use tools like the Aid to Capacity Evaluation (ACE) When uncertain, consult Psychiatry or Risk Management Best Practices in Documentation Clearly document: The patient’s understanding, appreciation, reasoning, and choice Information delivered: Condition Treatment recommendations Alternatives and risks Patient’s responses and logic Witnesses to the conversation Any discharge instructions, including: Follow-up plans Prescriptions provided Return precautions Also document: If patient refused treatment, document: That risks and benefits were clearly explained That refusal was voluntary If treatment was administered despite objection: Document rationale for presumed lack of capacity Legal/ethical justification for action Involvement of other services (e.g., Psychiatry, Risk) Read More

May 1

We dive into the recognition and management of blast crisis. Hosts: Sadakat Chowdhury, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blast_Crisis.mp3 Download 2 Comments Tags: Hematology , Oncology Show Notes Topic Overview Blast crisis is an oncologic emergency, most commonly seen in chronic myeloid leukemia (CML). Defined by: >20% blasts in peripheral blood or bone marrow. May include extramedullary blast proliferation. Without treatment, median survival is only 3–6 months. Pathophysiology & Associated Conditions Usually occurs in CML, but also in: Myeloproliferative neoplasms (MPNs) Myelodysplastic syndromes (MDS) Transition from chronic to blast phase often reflects disease progression or treatment resistance. Risk Factors 10% of CML patients progress to blast crisis. Risk increased in: Patients refractory to tyrosine kinase inhibitors (e.g., imatinib). Those with Philadelphia chromosome abnormalities. WBC >100,000, which increases risk for leukostasis. Clinical Presentation Symptoms often stem from pancytopenia and leukostasis: Anemia: fatigue, malaise. Functional neutropenia: high WBC count, but increased infection/sepsis risk. Thrombocytopenia: bleeding, bruising. Leukostasis/hyperviscosity effects by system: Neurologic: confusion, visual changes, stroke-like symptoms. Cardiopulmonary: ARDS, myocardial injury. Others: priapism, limb ischemia, bowel infarction. Rapid deterioration is common — early recognition is critical. Diagnostic Workup CBC with differential: assess blast % and cytopenias. Peripheral smear and manual diff: confirm immature blasts. CMP: screen for tumor lysis syndrome: Elevated potassium, phosphate, uric acid. Low calcium. LDH & uric acid: markers of high cell turnover. Coagulation studies (PT, PTT): assess for DIC. Definitive tests (done inpatient): bone marrow biopsy, flow cytometry. Emergency Department Management Resuscitation & ABCs: oxygen, IV fluids, vitals monitoring. Avoid aggressive transfusions: Risk of hyperviscosity with PRBCs and platelets. Initiate broad-spectrum antibiotics early: High suspicion for sepsis in functionally neutropenic patients. Consider antifungals for prolonged febrile neutropenia. Cytoreduction strategies: Hydroxyurea to lower WBCs quickly. Tyrosine kinase inhibitors (TKIs). High-dose chemotherapy. Early consultation with hematology/oncology is essential. Mutation testing may guide targeted therapy. Prognosis Without treatment: median survival ~3 months. With treatment: Potential survival >1 year. Best outcomes in patients who enter a second chronic phase and undergo allogeneic stem cell transplant. Ethical & Logistical Considerations Treatment may involve aggressive interventions with serious side effects. Important to assess: Patient goals of care. Capacity for informed consent. Resource limitations: Not all hospitals have oncology services. Patients may require transfer over long distances. Emphasize early, transparent discussions with patients and families. Top 3 Take-Home Points Recognize early: Look for cytopenias, leukostasis, and rapid clinical decline. Resuscitate appropriately: Start antibiotics; be cautious with transfusions. Call for help: Early hematology/oncology involvement is essential for definitive care. Read More

Apr 15

We explore the expanding field of Geriatric Emergency Medicine. Hosts: Ula Hwang, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Geriatric_Emergency_Medicine.mp3 Download One Comment Tags: Geriatric Show Notes Key Topics Discussed Importance and impact of geriatric emergency departments. Optimizing care strategies for geriatric patients in ED settings. Practical approaches for non-geriatric-specific EDs. Challenges in Geriatric Emergency Care Geriatric patients often present with: Multiple chronic conditions Polypharmacy Functional decline (mobility issues, cognitive impairments, social isolation) Adapting Clinical Approach Core objective remains acute issue diagnosis and treatment. Additional considerations for geriatric patients: Review and caution with medications to prevent adverse reactions. Address functional limitations and cognitive impairments. Emphasize safe discharge and care transitions to prevent unnecessary hospitalization. Identifying High-Risk Geriatric Patients Screening tools: Identification of Seniors at Risk (ISAR) Frailty screens Alignment with the “Age-Friendly Health Systems” initiative focusing on: Mentation Mobility Medications Patient preferences (what matters most) Mistreatment (elder abuse awareness) Minimizing Hospital-Related Harms Involvement of multidisciplinary teams: Social workers and care managers for care transitions Geriatric-certified pharmacists for medication review Coordination with outpatient services post-discharge Implementing Geriatric Care in All EDs Basic geriatric care achievable even in resource-limited or rural EDs. Level 3 Geriatric ED Accreditation can be achieved through: Improved care transitions Staff education enhancements Age-friendly environments (comfort, nutrition, hydration) Future of Geriatric Emergency Medicine Vision: Universal integration of geriatric-focused care. Goals: Enhanced patient experience Improved care transitions Alignment of treatments with patient goals Broader enhancement of emergency care quality for all patient populations Read More

Apr 2

We discuss the injuries sustained from smoke inhalation. Hosts: Sarah Fetterolf, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Smoke_Inhalation.mp3 Download Leave a Comment Tags: Environmental , Toxicology Show Notes Table of Contents 00:37 – Overview of Smoke Inhalation Injury 00:55 – Three Key Pathophysiologic Processes 01:41 – Physical Exam Findings to Watch For 02:12 – Airway Management and Early Intervention 03:23 – Carbon Monoxide Toxicity 04:24 – Workup and Initial Treatment of CO Poisoning 06:14 – Cyanide Toxicity 07:19 – Treatment Options for Cyanide Poisoning 09:12 – Take-Home Points and Clinical Pearls Physiological Effects of Smoke Inhalation: Thermal Injury: Direct upper airway damage from heated air or steam. Leads to swelling, inflammation, and possible airway obstruction. Chemical Irritation: Causes bronchospasm, mucus plugging, and inflammation in the lower airways. Increases capillary permeability, potentially causing pulmonary edema. Systemic Toxicity: Primarily involves carbon monoxide and cyanide poisoning. Clinical Signs and Symptoms: Physical Exam: Facial burns, singed nasal hairs Hoarseness, stridor (upper airway swelling) Carbonaceous sputum (lower airway edema) Systemic Symptoms: Headache, dizziness, nausea Syncope, seizures, altered mental status Airway Management Considerations: Not every patient requires immediate intubation. Intubation should be performed early if airway compromise is suspected, as swelling can rapidly progress. Close airway monitoring recommended for all patients. Carbon Monoxide Poisoning: Common cause of death post-smoke inhalation (50–75% of fire-related injuries). Hemoglobin affinity 250 times greater for CO than oxygen, impairing tissue oxygenation. Diagnosis: Carboxyhemoglobin level via VBG (ensure proper lab ordering). Pulse oximetry unreliable; falsely high readings. Treatment: Immediate high-flow oxygen administration. Consider hyperbaric oxygen therapy for severe cases to reduce delayed neurocognitive sequelae. Cyanide Poisoning: Blocks cytochrome oxidase in electron transport chain, halting aerobic ATP production. Patients present critically ill; notable features include: Elevated lactate levels (>8–10 mmol/L) Arterialization of venous blood Treatment: First-line therapy: hydroxocobalamin (Cyanokit) binds cyanide forming vitamin B12 for renal excretion. Alternative: Cyanide antidote kit (amyl nitrite, sodium nitrite, sodium thiosulfate); induces methemoglobinemia and requires monitoring. Important note: hydroxocobalamin turns blood and urine bright red; draw labs beforehand. Key Takeaways: Assess for airway compromise and signs of inhalation injury early. Maintain a high index of suspicion for CO and cyanide poisoning in smoke inhalation victims. Immediate, aggressive oxygen therapy and early antidote administration can significantly impact outcomes. Read More

Mar 3

We discuss the evaluation of and treatment options for acute back pain. Hosts: Benjamin Friedman, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Back_Pain.mp3 Download Leave a Comment Tags: Musculoskeletal , Orthopaedics Show Notes **Please fill out this quick survey to help us develop additional resources for our listeners: Core EM Survey ** Clinical Evaluation: Primary Goal: Distinguish benign musculoskeletal pain from serious pathology. Red Flags: Look for indicators of spinal infection, spinal bleed, or space-occupying lesions (e.g., tumors, large herniated discs). Assessment: A thorough history and neurological exam (strength testing, gait) is essential. Additional Tools: Use bedside ultrasound for post-void residual assessment in suspected cauda equina syndrome Imaging Guidelines: Routine Imaging: Generally not indicated for young, healthy patients without red flags. ACEP Recommendations: Avoid lumbar X-rays in patients under 50 without risk factors, as they do not change management and may increase costs and ED time. Advanced Imaging: Reserve MRI for patients with red flags, neurological deficits, or suspected cauda equina syndrome; CRP may be a part of your calculus when evaluating for infectious causes of back pain Treatment Options: Evidence-Based First-Line: NSAIDs offer modest benefit. Skeletal muscle relaxants can be used but require caution due to side effects. Ineffective Therapies: Acetaminophen shows no benefit for back pain. Steroids are not recommended for non-radicular pain, with only limited benefit in sciatica. Topical treatments, lidocaine patches, and opioids are not supported by evidence and may pose additional risks. Alternative and Experimental Interventions: Nerve Blocks: Current evidence is limited; more research is needed on trigger point injections and erector spinae plane blocks. Severe Pain Management: A single opioid dose (preferably codeine or oral morphine) may be considered to facilitate discharge when necessary. Use diazepam sparingly for immediate mobilization. Onsite physical therapy in the ED can be beneficial when available. Preventing Chronic Pain: Research Focus: Ongoing studies are evaluating whether duloxetine (Cymbalta) can prevent the transition from acute to chronic back pain. Non-Pharmacologic Measures: Consider spinal mobilization, physical therapy, acupuncture, and cognitive behavioral therapy (CBT) as adjuncts in management. Take-Home Points: Most acute back pain is benign, but watch for red flags like IV drug use, anticoagulation, or neurological symptoms (e.g., weakness, bladder dysfunction) that may indicate serious conditions like spinal infections, bleeds, or cord compression. Avoid unnecessary lumbar X-rays in young, healthy patients without red flags—MRI is preferred only for those with risk factors, neurological deficits, or suspected cauda equina syndrome. Use NSAIDs and skeletal muscle relaxants for acute musculoskeletal back pain, as they offer modest benefits. Avoid opioids, acetaminophen, and steroids for non-radicular pain, as they lack evidence. For severe, uncontrolled pain, consider a single opioid dose (e.g., codeine) or diazepam sparingly Encourage patients to engage in non-pharmacologic therapies like yoga, massage, or cognitive behavioral therapy to aid recovery and prevent chronic pain. Read More

Feb 2

We discuss the impact of family presence during resuscitations. Hosts: Ellen Duncan, MD, PhD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Family_Presence_During_Resuscitation.mp3 Download Leave a Comment Tags: Critical Care , Pediatrics Show Notes Overview Historical Context: The conversation around allowing family members in the room during resuscitation events began gaining attention in 1987. Since then, the practice has been increasingly encouraged. Current Practices in Pediatrics: Family presence during pediatric resuscitations remains inconsistent, with healthcare provider acceptance ranging from 15% to 85%. Many subspecialists and consultants still request that families step out, often due to outdated concerns. Common Concerns & Myths: Interference in resuscitation → Studies show minimal disruption. Legal risks → No increased litigation risk has been demonstrated. Family trauma → Research suggests that presence may help with grieving and reduce PTSD symptoms. Evidence from the Literature New England Journal of Medicine study on Family Presence During Cardiopulmonary Resuscitation (Jabre et al., 2013) : In a randomized controlled trial of 570 relatives, PTSD-related symptoms were significantly higher in family members who were not offered the opportunity to be present during resuscitation. 79% of relatives in the intervention group witnessed CPR compared to 43% in the control group. Family members who did not witness CPR had a higher likelihood of PTSD symptoms (adjusted OR 1.7, p=0.004). Anxiety and depression symptoms were also higher in those who did not witness CPR . Impact on Medical Teams: The study found no evidence that family presence affected resuscitation success rates, medical team stress levels, or led to legal consequences. Health professionals’ concerns over interference were largely unfounded. Guideline Support & Barriers to Implementation Professional recommendations from pediatric societies support family presence during resuscitations. Barriers include: Lack of institutional policies ensuring family inclusion. Lack of formal training for providers on how to support families during these critical moments. Final Takeaways Encouraging institutional policy changes and training providers is key to implementing family presence during codes. Medical teams should challenge outdated practices and prioritize family-centered care in the emergency department. Family-witnessed resuscitation does not increase stress, legal risk, or compromise medical care—but it can significantly improve bereavement outcomes. Read More

Jan 1

We discuss the recognition and treatment of necrotizing fasciitis. Hosts: Aurnee Rahman, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Necrotizing_Fasciitis.mp3 Download Leave a Comment Tags: Critical Care , General Surgery Show Notes Table of Contents 0:00 – Introduction 0:41 – Overview 1:10 – Types of Necrotizing Fasciitis 2:21 – Pathophysiology & Risk Factors 3:16 – Clinical Presentation 4:06 – Diagnosis 5:37 – Treatment 7:09 – Prognosis and Recovery 7:37 – Take Home points Introduction Necrotizing soft tissue infections can be easily missed in routine cases of soft tissue infection. High mortality and morbidity underscore the need for vigilance. Definition A rapidly progressive, life-threatening infection of the deep soft tissues. Involves fascia and subcutaneous fat, causing fulminant tissue destruction. High mortality often due to delayed recognition and treatment. Types of Necrotizing Fasciitis Type I (Polymicrobial) Involves aerobic and anaerobic organisms (e.g., Bacteroides, Clostridium, Peptostreptococcus). Common in immunocompromised patients or those with comorbidities (e.g., diabetes, peripheral vascular disease). Type II (Monomicrobial) Often caused by Group A Streptococcus (Strep pyogenes) or Staphylococcus aureus. Can occur in otherwise healthy individuals. Vibrio vulnificus (associated with water exposure) is another example. Fournier’s Gangrene (Subset) Specific to perineal, genital, and perianal regions. Common in diabetic patients. Higher mortality, especially in females. Pathophysiology Spread Along Fascia Poor blood supply in fascial planes allows infection to advance rapidly. Tissue ischemia worsened by vascular thrombosis → rapid necrosis. High-Risk Patients Diabetes with vascular compromise. Recent surgeries or trauma (introducing bacteria into deep tissue). Immunosuppression (e.g., cirrhosis, malignancy, or immunosuppressive meds). NSAID use may mask symptoms, delaying diagnosis. Clinical Presentation Early Signs & Symptoms Severe Pain out of proportion to exam findings. Erythema (often with indistinct borders). Fever, Malaise (systemic signs of infection). Rapid progression with possible color changes (red → purple). Bullae Formation (fluid-filled blisters) and skin necrosis/gangrene. Crepitus in polymicrobial cases (gas production in tissue). Late-Stage Signs Systemic toxicity: hypotension, multi-organ failure if untreated. Diagnosis Clinical Suspicion Is Key Pain out of proportion, rapid progression, systemic signs. The “finger test” (small incision to explore fascial planes). Surgical Consultation Early surgical exploration is often the definitive diagnostic step. Lab Tests LRINEC Score (CRP, WBC, Hemoglobin, Sodium, Creatinine, Glucose) to stratify risk. Not definitive but can guide suspicion. Imaging CT scan may reveal gas in tissues, fascial edema, or muscle involvement. Must not delay surgical intervention if clinical suspicion is high. Treatment Principles Immediate & Aggressive Surgical Debridement Often multiple surgical procedures are required as necrosis progresses. Debridement back to healthy tissue margins. Empiric Broad-Spectrum Antibiotics Cover gram-positive (including MRSA), gram-negative, and anaerobes. Examples include: Vancomycin or Linezolid (for MRSA). Piperacillin-tazobactam or Carbapenems (for gram-negative & anaerobes). Clindamycin (to inhibit bacterial toxin production). Adjust based on culture results later. Adjunct Therapies Hyperbaric Oxygen Therapy (if available) for resistant cases. Evidence is mixed; not universally accessible. Supportive Care Intensive monitoring, often in an ICU setting. Fluid resuscitation & vasopressors for septic shock. Prognosis & Disposition High Mortality Rate Influenced by infection site, patient’s baseline health, and speed of intervention. Importance of Rapid Intervention Early recognition, aggressive surgery, and antibiotics improve survival. Long-Term Considerations Patients may require extensive rehabilitation. Reconstructive surgery often needed for tissue deficits. Disposition Operative management is mandatory; patients do not go home. Critical care admission is typical for hemodynamic monitoring and support. Five Key Take-Home Points High Suspicion Saves Lives: Recognize severe pain out of proportion as a critical red flag. Know Your NF Types & Risk Factors: Type I polymicrobial vs. Type II monomicrobial, plus subsets (Fournier’s). Clinical Diagnosis Above All: LRINEC and imaging help, but timely surgical exploration is paramount. Combined Surgical & Medical Therapy: Early debridement + broad-spectrum antibiotics (including toxin inhibition) is lifesaving. Extended Recovery & Mortality Risks: High mortality if missed or delayed. Expect prolonged rehab and possible multiple surgeries. Resources & Further Reading LRINEC Score Calculator EMCrit – Necrotizing Fasciitis Read More

Dec 2, 2024

We sit down with one of our toxicologists to discuss acetaminophen toxicity. Hosts: Marlis Gnirke, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acetaminophen_Toxicity.mp3 Download One Comment Tags: Toxicology Show Notes Table of Contents 0:35 – Hidden acetaminophen toxicity in OTC products 3:24 – Pharmacokinetics and toxicokinetics 6:06 – Clinical Course 9:22 – The antidote – NAC 11:02 – The Rumack-Matthew Nomogram 17:36 – Treatment protocols 22:34 – Monitoring and Lab Work 23:23 – Considerations when treating pediatric patients 23:57 – IV APAP overdose, fomepizole 25:42 – Take Home Points Acetaminophen vs. Tylenol: The importance of recognizing that acetaminophen is found in many products beyond Tylenol. Common medications containing acetaminophen, such as Excedrin, Fioricet, Percocet, Dayquil/Nyquil, and others. The risk of unintentional overdose due to combination products. Prevalence of Acetaminophen Toxicity: Widespread availability and under-recognition contribute to its prevalence. The potential for unintentional overdose when taking multiple medications containing acetaminophen. Pharmacokinetics and Metabolism: Normal metabolism pathways of acetaminophen and the role of glutathione. Formation of the toxic metabolite NAPQI during overdose situations. Saturation of safe metabolic pathways leading to hepatotoxicity. Pathophysiology of Liver Injury: How excessive NAPQI leads to hepatocyte death, especially in zone III of the liver. The difference between therapeutic dosing and overdose metabolism. Clinical Stages of Acetaminophen Toxicity: Stage 1: Asymptomatic or nonspecific symptoms (first 24 hours). Stage 2: Onset of hepatic injury (24-72 hours), elevated AST/ALT. Stage 3: Maximum hepatotoxicity (72-96 hours), signs of liver failure. Stage 4: Recovery phase, complete hepatic regeneration if survived. Antidote – N-Acetylcysteine (NAC): Mechanisms of NAC in replenishing glutathione and detoxifying NAPQI. The importance of early administration, ideally within 8 hours post-ingestion. NAC’s role even in late presenters and in fulminant hepatic failure. The Rumack-Matthew Nomogram: How to use the nomogram for acute overdoses to determine the need for NAC. Limitations in chronic overdoses and late presentations. Emphasis on obtaining accurate time of ingestion and acetaminophen levels. Treatment Protocols: Standard 21-hour IV NAC protocol and dosing specifics. Managing anaphylactoid reactions associated with IV NAC. Criteria for extending NAC therapy beyond 21 hours. Monitoring and Laboratory Work: Importance of trending AST/ALT, INR, creatinine, lactate, and phosphate. Use of the King’s College Criteria for potential liver transplant evaluation. Special Considerations: Adjustments in pediatric patients regarding NAC dosing volumes. Awareness of IV acetaminophen overdoses and their management. Emerging discussions on the use of fomepizole in massive overdoses. Take-Home Points: Comprehensive Medication History: Always inquire about all medications taken to assess for potential acetaminophen exposure. Early Recognition and Treatment: Due to often silent initial stages, maintain a high index of suspicion and measure acetaminophen levels promptly. Understanding Metabolism and Toxicity: Recognize how overdose alters metabolism, leading to toxic NAPQI accumulation. N-Acetylcysteine Efficacy: NAC is most effective when administered early but remains beneficial even in advanced stages. Proper Use of the Nomogram: Utilize the Rumack-Matthew Nomogram appropriately for acute ingestions and consult toxicology when in doubt. Monitoring and Continuing Care: Be vigilant in monitoring laboratory values and prepared to extend NAC therapy as needed. Consultation and Resources: Engage with poison control centers and utilize available resources for complex cases. Resources Mentioned Rumack-Matthew Nomogram Rumack-Matthew Nomogram, credit: MDCalc King’s College Criteria King’s College Criteria for Acetaminophen Toxicity Use this tool to assess the need for liver transplant evaluation in cases of acetaminophen-induced hepatic failure. Includes criteria for pH, INR, creatinine, and more. Poison Control Center (available 24/7 for consultation): 1-800-222-1222 References Goldfrank’s Toxicologic Emergencies, 9th Edition was consulted for information on the pharmacokinetics and clinical presentation of acetaminophen toxicity. For more details, see: Nelson, L. S., Howland, M. A., Lewin, N. A., Smith, S. W., Goldfrank, L. R., & Hoffman, R. S. (Eds.). (2011). Goldfrank’s toxicologic emergencies (9th ed.). McGraw-Hill Education. Read More

Nov 1, 2024

We review Sexually Transmitted Infections and pertinent updates in diagnosis and management. Hosts: Avir Mitra, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Sexually_Transmitted_Infections_2_0.mp3 Download Leave a Comment Tags: gynecology , Infectious Diseases , Urology Show Notes Table of Contents (1:49) Chlamydia (3:31) Gonorrhea (4:50) PID (6:14) Syphilis (8:08) Neurosyphilis (9:13) Tertiary Syphilis (10:06) Trichomoniasis (11:13) Herpes (12:49) HIV (14:10) PEP (15:13) Mycoplasma Genitalium (18:00) Take Home Points Chlamydia: Prevalence: Most common STI. High percentage of asymptomatic cases (40% to 96%). Presentation: Urethritis, cervicitis, pelvic inflammatory disease (PID), prostatitis, proctitis, pharyngitis, arthritis. Importance of considering extra-genital sites (oral and rectal infections). Testing: Gold Standard: Nucleic Acid Amplification Test (NAAT) via PCR. Sampling Sites: Endocervical or urethral swabs preferred over urine samples due to higher sensitivity. Triple-site testing (genital, rectal, pharyngeal) recommended for comprehensive detection. Treatment Updates: Previous Regimen: Azithromycin 1 g orally in a single dose. Current First-Line Treatment: Doxycycline 100 mg orally twice daily for 7 days. Alternatives: Azithromycin remains an option for patients unlikely to adhere to a 7-day regimen or for pregnant patients. Note: PID treatment differs and will be discussed separately. Gonorrhea: Presentation: Similar to chlamydia; can be asymptomatic. Symptoms include urethritis, cervicitis, PID, prostatitis, proctitis, pharyngitis. Testing: Gold Standard: NAAT. Sampling Sites: Endocervical swabs are more sensitive than urine samples. Triple-site testing is crucial to avoid missing infections. Treatment Updates: Previous Regimen: Ceftriaxone 250 mg IM plus azithromycin 1 g orally. Current Recommendation: Ceftriaxone 500 mg IM single dose. Adjusted due to rising azithromycin resistance and updated pharmacokinetic data. Co-Infection Considerations: High rates of chlamydia and gonorrhea co-infection (20% to 40%). CDC recommends empiric treatment for chlamydia when treating gonorrhea to prevent complications like PID and infertility. Pelvic Inflammatory Disease (PID): Etiology: Not solely caused by chlamydia and gonorrhea; about 50% of cases involve other pathogens like bacterial vaginosis (BV) organisms and anaerobes. Treatment Changes: Expanded Coverage Regimen: Ceftriaxone 500 mg IM once. Doxycycline 100 mg orally twice daily for 14 days. Metronidazole 500 mg orally twice daily for 14 days. Inclusion of metronidazole addresses anaerobic bacteria contributing to PID. Syphilis: Stages and Presentation: Primary Syphilis: Painless chancre on genitals. Treatment: Penicillin G 2.4 million units IM single dose. Secondary Syphilis: Rash (often diffuse), mucocutaneous lesions, nonspecific joint pain. Treatment: Same as primary syphilis. Latent Syphilis: Asymptomatic phase; divided into early (<1 year) and late (>1 year). Treatment for Late Latent: Penicillin G 2.4 million units IM once weekly for 3 weeks. Recommended when the timing of infection is unclear. Neurosyphilis: Can occur at any stage. Symptoms include visual changes, severe headaches, neurological deficits. Diagnosis: Requires lumbar puncture (LP) for confirmation. Treatment: Admission for intravenous penicillin G. Tertiary Syphilis: Rare, advanced stage with severe manifestations (e.g., gummas, cardiovascular complications, neurological signs). Treatment: Extended penicillin therapy similar to late latent syphilis. Trichomoniasis: Presentation: Often asymptomatic. In women: Vaginal discharge. In men: Urethritis. Testing: Shift from wet mount microscopy to NAAT for improved detection. Swab samples preferred over urine for higher sensitivity. Treatment Updates: Previous Regimen: Metronidazole 2 g orally in a single dose. Current Recommendations: Women: Metronidazole 500 mg orally twice daily for 7 days. Men: Single 2 g dose remains acceptable. Herpes Simplex Virus (HSV): Types and Transmission: HSV-1 and HSV-2: Both can cause oral and genital infections. Increasing crossover between oral and genital sites. Testing: Serum IgG testing not useful for acute diagnosis due to widespread prior exposure. Preferred Method: PCR testing from lesion swabs. Clinical Tip: If the lesion is characteristic, clinicians may start treatment without waiting for test results. Treatment: Preferred Medication: Valacyclovir (Valtrex) for ease of dosing. Dosage: Initial episode: 1 g orally twice daily for 7 to 10 days. Recurrence: 1 g daily for 5 days. Alternative: Acyclovir for cost considerations. Human Immunodeficiency Virus (HIV): Testing Limitations: Window Periods: Fourth-generation tests have a window period of 2 to 4 weeks. Negative results during this period may not rule out recent infection. Acute HIV Infection: Presents with flu-like symptoms: malaise, joint pains, fatigue. Diagnosis Challenges: Standard HIV tests may be negative during the window period. Options: Empiric treatment with follow-up testing. Order an HIV viral load test (more sensitive but expensive and delayed results). Post-Exposure Prophylaxis (PEP): Timing: Initiate ideally within 72 hours of potential exposure. Duration: 28-day regimen. Pre-Treatment Testing: Baseline HIV test to rule out existing infection. Renal and hepatic function tests to monitor for medication side effects. Follow-Up: Reassess renal/hepatic function in 2 weeks. Mycoplasma genitalium: Recognition: Newly recognized STI by the CDC in 2021. Causes cervicitis and urethritis. Possible associations with PID and proctitis, but not definitively established. Testing: When to Test: Only in patients with persistent symptoms after standard STI testing and treatment. Not recommended for initial screening. Method: NAAT. Treatment: Step 1: Doxycycline 100 mg orally twice daily for 7 days. Step 2: Moxifloxacin 400 mg orally once daily for 7 days. Addresses antibiotic resistance concerns and ensures comprehensive treatment. General Management and Patient Counseling: Partner Notification: Encourage patients to inform sexual partners for testing and treatment. Medication Adherence: Emphasize the importance of completing the full course of prescribed medications. Prevention Measures: Discuss the use of barrier protection (e.g., condoms) to prevent transmission and reinfection. Follow-Up Care: Advise patients to return if symptoms persist, indicating possible infections like Mycoplasma genitalium. Key Take-Home Points: Chlamydia Treatment Update: Doxycycline 100 mg orally twice daily for 7 days is now first-line treatment for cervical infections. For epididymitis, extend doxycycline to 10 days. Gonorrhea Treatment Update: Treat with a single 500 mg IM dose of ceftriaxone. PID Management Update: Expanded antimicrobial coverage includes: Ceftriaxone 500 mg IM once. Doxycycline 100 mg orally twice daily for 14 days. Metronidazole 500 mg orally twice daily for 14 days. Mycoplasma genitalium Recognition: Test in patients with persistent symptoms after standard treatment. Treat with doxycycline followed by moxifloxacin. HIV Testing and PEP: Be aware of HIV test window periods; negative results may not rule out recent infection. Consider HIV viral load testing if acute infection is suspected. Initiate PEP within 72 hours for a 28-day course, ensuring clear discharge planning and patient support. Read More

Oct 1, 2024

We discuss migraines with one of the authorities in the field. Hosts: Benjamin Friedman, MD of Montefiore Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Migraines.mp3 Download Leave a Comment Tags: Neurology Show Notes Initial Approach to Diagnosing Migraines: Differentiating between primary headaches (migraine, tension-type, cluster) and secondary causes (e.g., subarachnoid hemorrhage). The importance of patient history and reevaluation after initial treatment. Recognizing the unique presentation of cluster headaches and their management implications. Effective Acute Migraine Treatments: First-line treatments including anti-dopaminergic medications like metoclopramide (Reglan) and prochlorperazine (Compazine) , and parenteral NSAIDs like ketorolac (Toradol) . The limited role of triptans in the ED due to side effects and less efficacy compared to anti-dopaminergics. The use of nerve blocks (greater occipital nerve block and sphenopalatine ganglion block) as effective treatments without systemic side effects. Treatments to Avoid or Use with Caution: Diphenhydramine (Benadryl): Studies show it does not prevent akathisia from anti-dopaminergics nor improve migraine outcomes. IV Fluids: Routine use is not supported unless the patient shows signs of dehydration. Magnesium: Conflicting evidence with some studies showing no benefit or even harm. Managing Refractory Migraines: Second-line treatments including additional doses of metoclopramide combined with NSAIDs or dihydroergotamine (DHE). Considering opioids as a last resort when other treatments fail. The potential use of newer medications like lasmiditan and CGRP antagonists . Preventing Recurrence of Migraines: Administering a single dose of dexamethasone (4 mg IV) to reduce the risk of headache recurrence after discharge. Prescribing NSAIDs or triptans upon discharge for outpatient management. Recognizing and addressing chronic migraine, and initiating preventive therapies like propranolol when appropriate. Key Takeaways Differentiate Primary from Secondary Headaches and Reassess After Treatment: Use patient history and reevaluation post-treatment to distinguish migraines from more serious conditions, reducing unnecessary imaging and procedures. First-Line Treatments Are Effective: Anti-dopaminergic medications and NSAIDs are the mainstay of acute migraine treatment in the ED. Reserve opioids for cases unresponsive to multiple lines of treatment. Avoid Unnecessary Interventions: Diphenhydramine and routine IV fluids do not have proven benefits and can be excluded to streamline care. Utilize Nerve Blocks for Refractory Cases: Greater occipital nerve blocks and sphenopalatine ganglion blocks are effective alternatives for patients not responding to medication. Prevent Recurrence with Dexamethasone and Outpatient Planning: A single IV dose of dexamethasone can help prevent recurrence. Provide prescriptions and consider preventive therapies to reduce future ED visits. Read More

Sep 2, 2024

We discuss a new class of medications, Immune Checkpoint Inhibitors, and their side effects. Hosts: Avir Mitra, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Immune_Checkpoint_Inhibitors.mp3 Download Leave a Comment Tags: Oncology Show Notes Overview of Immune Checkpoint Inhibitors (ICIs) ICIs are a relatively new class of oncologic drugs that have revolutionized cancer treatment. Unlike chemotherapy, ICIs help the immune system develop memory against cancer cells and adapt as the cancer mutates. Since their release in 2011, ICIs have expanded to 83 indications for 17 different cancers, with approximately 230,000 patients using them. Mechanism of Action Cancer cells can evade the immune system by binding to T cell receptors that downregulate the immune response. ICIs work by blocking these receptors or ligands, preventing the downregulation and allowing T cells to proliferate and attack cancer cells. Common ICIs Risks and Toxicities of ICIs ICIs can lead to autoimmune attacks on healthy cells due to immune system upregulation. Immune-related adverse effects (irAEs) include colitis, pneumonitis, dermatitis, hepatitis, and endocrine issues (e.g., hypothyroid, hypocortisolemia, hypophysitis). These toxicities can present as infections, making diagnosis challenging in the emergency room. Management of ICI Toxicities in the ER Diagnosis: Look for signs that mimic infections (e.g., cough and fever in pneumonitis). Diagnostic Imaging in pneumonitis: If CXR is normal but suspicion is high, consider CT scans to differentiate conditions like pneumonitis from other issues such as malignancy-associated pleural effusion or acute pulmonary embolism. Treatment: The primary treatment for irAEs is steroids (e.g., prednisone 1 mg/kg). Start steroids early and hold the ICI to manage symptoms effectively and increase the likelihood of resuming ICI therapy later. Consider using antibiotics in combination with steroids if there is uncertainty about whether symptoms are due to infection or ICI toxicity. Coordinate care with the patient’s oncologist if possible Disposition Decisions Patient disposition (admit vs. discharge) should depend on clinical presentation and severity. Coordination with oncology is crucial; they are often comfortable with starting steroids even if there is a potential infection. Patients can be discharged if symptoms are mild, but sicker patients with more complex presentations may require admission. Take-Home Points ICIs are a new class of cancer drugs that effectively target cancer cells but come with unique immune-related toxicities. Diagnosing irAEs can be challenging due to symptom overlap with infections. The cornerstone of treatment is early administration of steroids and temporarily holding the ICI. Close collaboration with oncology teams is essential for optimal patient management. Read More

Aug 1, 2024

We discuss a case of ataxia in children and how to approach the evaluation of these pts. Hosts: Ellen Duncan, MD, PhD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Ataxia_in_Children.mp3 Download Leave a Comment Tags: Neurology , Pediatrics Show Notes Introduction The episode focuses on ataxia in children, which can range from self-limiting to life-threatening conditions. Pediatric emergency medicine specialist shares insights on the topic. The Case An 18-month-old boy presented with ataxia, unable to keep his head up, sit, or stand, and began vomiting. Previously healthy except for recurrent otitis media and viral-induced wheezing. The decision to take the child to the emergency department (ED) was based on acute symptoms. Differential Diagnosis Common causes include acute cerebellar ataxia, drug ingestion, Guillain-Barre syndrome, and basilar migraine. Less common causes include cerebellitis, encephalitis, brain tumors, and labyrinthitis. Importance of History and Physical Examination A detailed history and physical exam are essential in diagnosing ataxia. Key factors include time course, recent infections, signs of increased intracranial pressure, and toxic exposures. Look for signs such as bradycardia, hypertension, vomiting, and overall appearance. Diagnostic Workup Initial tests include point-of-care glucose and neuroimaging for concerns about trauma or increased intracranial pressure. MRI is preferred for posterior fossa abnormalities, but non-contrast head CT is commonly used due to accessibility. Lumbar puncture may be needed if meningismus is present. Treatment Approach Treatment depends on the underlying cause: Acute cerebellar ataxia is self-limiting and typically resolves with time. Antibiotics are required for meningitis or encephalitis. Steroids may be useful for cerebellitis and acute disseminated encephalomyelitis (ADEM). Specialist consultations are necessary for severe diagnoses like intracranial masses. Outcome of the Case Study The child had a normal fast T2 MRI and improved during the ED stay. Diagnosed with a combination of cerebellar ataxia and labyrinthitis. Received myringotomy tubes and experienced no further neurologic changes or otitis media episodes. Take-Home Points Diverse Etiologies: Ataxia in children can have various causes that range from self-limiting to life-threatening Comprehensive Assessment: History and physical exams guide diagnosis and workup direction, focusing on symptom time course, infections, and toxic exposures. Physical Examination Clues: Vital signs and appearance offer clues; increased ICP may present with bradycardia, hypertension, and vomiting. Diagnostic Imaging: Point-of-care glucose testing and neuroimaging are key; MRI is preferred for posterior fossa abnormalities. Tailored Treatment: Treatment varies by cause; acute cerebellar ataxia typically resolves over time without specific intervention. Read More

Jul 1, 2024

We discuss the approach to diagnosing and managing hypernatremia in the emergency department. Hosts: Abigail Olinde, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hypernatremia.mp3 Download Leave a Comment Tags: Electorlye Show Notes Episode Overview: Introduction to Hypernatremia Definition and basic concepts Clinical presentation and risk factors Diagnosis and management strategies Special considerations and potential complications Definition and Pathophysiology: Hypernatremia is defined as a serum sodium level over 145 mEq/L. It can be acute or chronic, with chronic cases being more common. Symptoms range from nausea and vomiting to altered mental status and coma. Causes of Hypernatremia based on urine studies: Urine Osmolality > 700 mosmol/kg Causes: Extrarenal Water Losses: Dehydration due to sweating, fever, or respiratory losses Unreplaced GI Losses: Vomiting, diarrhea Unreplaced Insensible Losses: Burns, extensive skin diseases Renal Water Losses with Intact AVP Response: Diuretic phase of acute kidney injury Recovery phase of acute tubular necrosis Postobstructive diuresis Urine Osmolality 300-600 mosmol/kg Causes: Osmotic Diuresis: High glucose (diabetes mellitus), mannitol, high urea Partial AVP Deficiency: Incomplete central diabetes insipidus Partial AVP Resistance: Nephrogenic diabetes insipidus Urine Osmolality < 300 mosmol/kg Causes: Complete AVP Deficiency: Central diabetes insipidus Complete AVP Resistance: Nephrogenic diabetes insipidus Urine Sodium < 25 mEq/L Causes: Extrarenal Water Losses with Volume Depletion: Vomiting, diarrhea, burns Unreplaced Insensible Losses: Sweating, fever, respiratory losses Urine Sodium > 100 mEq/L Causes: Sodium Overload: Ingestion of salt tablets, hypertonic saline administration Salt Poisoning: Deliberate or accidental ingestion of large amounts of salt Mixed or Variable Urine Sodium Causes: Diuretic Use: Loop diuretics, thiazides Adrenal Insufficiency: Mineralocorticoid deficiency Osmotic Diuresis with Renal Water Losses: High glucose, mannitol Risk Factors: Patients with impaired thirst response or those unable to access water (e.g., altered or ventilated patients) are at higher risk. Important to consider underlying conditions affecting thirst mechanisms. Diagnosis: Initial assessment includes history, physical examination, and laboratory tests. Key tests: urine osmolality and urine sodium levels. Lab errors should be considered if the clinical picture does not match the lab results. Management Strategies: Calculate the Free Water Deficit (FWD) to guide treatment. Administration routes include oral, NGT, G-tube, or IV with D5W for larger deficits. Safe correction rate is 10-12 mEq/L per day or 0.5 mEq/L per hour to avoid cerebral edema. Address hypovolemia with isotonic fluids before correcting sodium. Monitoring and Follow-Up: Monitor sodium levels every 4-6 hours. Assess urine output and adjust free water administration as needed. Admission to ICU for symptomatic patients or those with severe hypernatremia (sodium >160 mEq/L). Decision to discharge vs admit is a complicated one that factors in symptoms, etiology, degree of hypernatremia, patient preference, access to follow up, etc. Take Home Points: Hypernatremia is a serum sodium level over 145 mEq/L, with symptoms ranging from nausea to coma. It is primarily caused by water loss exceeding intake due to various factors like sweating, vomiting, diarrhea, and renal issues. Correcting hypernatremia too quickly can lead to cerebral edema, so a safe correction rate is essential. Initial treatment involves calculating the Free Water Deficit and selecting the appropriate administration route. Monitor sodium levels frequently and decide on admission or discharge based on symptoms, sodium levels, and patient’s ability to follow up. Read More

Jun 3, 2024

We discuss an approach to the acutely agitated patient and review medications commonly used. Hosts: Jonathan Kobles, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Agitation.mp3 Download Leave a Comment Tags: Agitation , psychiatry , Toxicology Show Notes Background/Epidemiology • Definition and Scope : Agitation encompasses behaviors from restlessness to severe altered mental states. It’s a common emergency department presentation, often linked with acute medical or psychiatric emergencies. • Significance : Patients with agitation are at high risk for morbidity and mortality, necessitating prompt and effective management to prevent harm to themselves and healthcare providers. A Changing Paradigm in Describing Agitation • Terminology Shift : Move away from terms like ‘excited delirium’ due to their politicization and stigmatization. Focus on describing agitation by severity and underlying causes. Agitation as a Multifactorial Process • Complex Nature : Recognize agitation as a result of various factors, including medical, psychiatric, and environmental influences. Recognizing Agitation • Signs and Symptoms : Identify agitation early by monitoring for behaviors such as hostility, pacing, non-compliance, and verbal aggression. Initial Evaluation • Severity Assessment : Determine the severity of agitation and prioritize reversible causes and life-threatening conditions. • Diagnostic Steps : Perform vital signs check, blood glucose levels, ECG, and a targeted medical screening exam. Life Threats • Immediate Concerns : Identify and address immediate life threats such as hypoxia, hypoglycemia, trauma, and acute neurological emergencies. Forming a Differential Prior to Treatment • Prioritization : Severe agitation requires immediate treatment to facilitate further evaluation and reduce risk of harm. Physician/Staff Safety • Safety Measures : Ensure personal and team safety by maintaining a calm environment and preparing for potential violence. Multimodal Approach • Self-check In : Physicians should mentally prepare and approach the situation calmly to ensure effective management. • Verbal De-escalation : Use techniques focused on safety, therapeutic alliance, and patient autonomy to manage agitation non-pharmacologically. Medication Administration • Oral/Sublingual Medications : Consider oral medications for less severe cases to maintain patient autonomy and avoid invasive procedures. • IM or IV Medications : Use intramuscular or intravenous medications for rapid control in severe cases. Specific Medication Regimens • PO Regimens : • Medications : Antipsychotics like Zyprexa (olanzapine) 5-10 mg, benzodiazepines like Ativan (lorazepam) 1-2 mg. • Benefits : Empower patients with a sense of autonomy, avoid injection-related trauma. • Pharmacokinetics : • Olanzapine : Onset in 15-45 minutes, peak effect in 1-2 hours, duration 12-24 hours. • Lorazepam : Onset in 30-60 minutes, peak effect in 2 hours, duration 6-8 hours. • IV/IM Regimens : • Medications : Droperidol, haloperidol, midazolam, ketamine. • ACEP 2023 Guidelines : Recommend droperidol with midazolam or an atypical antipsychotic for severe agitation. • Pharmacokinetics (IM) : • Haloperidol : IM onset in 15, time to sedation ~25 minutes, can last for 2 hours • Droperidol : IM onset in 5-10 minutes, duration 2-4 hours but can last as long as 12 hours • Midazolam : IM onset ~15 minutes, , duration 20 minutes – 2 hours. • Lorazepam : IM onset ~15-30 minutes, , duration up to 3 hours • Ketamine : IM onset in ~5 minutes, duration 5-30 minutes. Special Situations • Elderly/Dementia : Optimize environment, use non-pharmacologic measures, avoid benzodiazepines to reduce delirium risk. • Parkinson’s Disease : Avoid antipsychotics that can precipitate a Parkinsonian crisis. • Autism/Pediatrics : Engage caregivers, create a calming environment, avoid aggressive measures. • Alcohol Withdrawal : Utilize benzodiazepines and phenobarbital. Re-dosing and Physical Restraints • Re-dosing : Use the lowest effective dose, consider continuous monitoring, and reassess frequently. • Physical Restraints : Employ as a last resort, ensuring close monitoring for any adverse effects. Final Points • Clinical Leadership : Physicians should lead with clear communication, planning, and support for the team. • Continuous Learning : Regular debriefing and assessment after each incident to improve future responses. Read More

May 1, 2024

We discuss an approach to the critically ill infant. Hosts: Ellen Duncan, MD, PhD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/The_Critically_Ill_Infant.mp3 Download Leave a Comment Tags: Pediatrics Show Notes The Critically Ill Infant: THE MISFITS Trauma ‘T’ in the mnemonic stands for trauma, which includes both accidental and intentional causes. Considerations for Non-accidental Trauma : Stresses the importance of considering non-accidental trauma, especially given that it may not always present with obvious external signs. Anatomical Vulnerabilities : Highlights specific anatomical considerations for infants who suffer from trauma: Infants have proportionally larger heads, increasing their susceptibility to high cervical spine (c-spine) injuries. Their liver and spleen are less protected, making abdominal injuries potentially more severe. Heart 5 T’s of Cyanotic Congenital Heart Disease : Introduces a mnemonic to help remember key right-sided ductal-dependent lesions: Truncus Arteriosus : Single vessel serving as both pulmonary and systemic outflow tract. Transposition of the Great Arteries : The pulmonary artery and aorta are switched, leading to improper circulation. Tricuspid Atresia : Absence of the tricuspid valve, leading to inadequate development of the right ventricle and pulmonary circulation issues. Tetralogy of Fallot : Comprises four defects—ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. Total Anomalous Pulmonary Venous Connection (TAPVC) : Pulmonary veins do not connect to the left atrium but rather to the right heart or veins, causing oxygen-rich blood to mix with oxygen-poor blood. Other Significant Conditions : Ebstein’s Anomaly : Malformation of the tricuspid valve affecting right-sided heart function. Pulmonary Atresia/Stenosis : Incomplete formation or narrowing of the pulmonary valve obstructs blood flow to the lungs. Left-sided Ductal-Dependent Lesions : Conditions such as aortic arch abnormalities (coarctation or interrupted arch), critical aortic stenosis, and hypoplastic left heart syndrome are highlighted. These generally present with less obvious cyanosis and more pallor. Diagnostic and Management Considerations : Routine prenatal ultrasounds detect most cases, but conditions like coarctation of the aorta and TAPVC might not be apparent until after birth when the ductus arteriosus closes. Emphasizes the importance of a thorough physical exam: checking for murmurs, assessing hepatosplenomegaly, feeling for femoral pulses, measuring pre- and post-ductal saturations, and taking blood pressures in all four limbs. Treatment Recommendations : Early initiation of alprostadil (a prostaglandin) for patients with suspected ductal-dependent lesions to maintain ductal patency. Preparedness for potential complications from alprostadil treatment, such as apnea and hypotension, which may necessitate intubation and hemodynamic support. Endocrine Focuses on acute salt-wasting crisis in undiagnosed Congenital Adrenal Hyperplasia (CAH). Electrolyte imbalances: ↓Na, ↑K, ↓HCO3, ↓Glu. Treatment: hydrocortisone (25mg for babies, 50mg for kids, 100mg for adults). Metabolic Electrolyte abnormalities such as hypoglycemia (values: <60 in infants, <40 in neonates). Broad differential. Rule of 50s for correction: D% x #ml/kg fluid = 50. Inborn Errors of Metabolism Major classes include organic acidurias (profound anion gap metabolic acidosis) and urea cycle defects (hyperammonemia) Recommendation: Draw gas and ammonia level. Sepsis Emphasized as a critical condition in the differential diagnosis for ill infants, though placed later in the mnemonic for easier recall. Presentation and Diagnosis : Sepsis in infants often presents nonspecifically, making early detection challenging. Immediate drawing of blood cultures upon suspicion of sepsis. Initial Treatment : Prompt initiation of antimicrobials and fluids. Use of vancomycin for gram-positive and MRSA coverage, a third-generation cephalosporin or pip-tazo for broad bacterial coverage, and acyclovir for HSV. (tailor based on age and institutional guidelines) Supportive Care : Highlights the necessity of fluid resuscitation to stabilize the patient. Formula Formula-Related Electrolyte Imbalances : Incorrect mixing of infant formula can cause hypo- or hypernatremia. Consequences of Electrolyte Imbalances : Both conditions can lead to severe outcomes including altered mental status, seizures, coma, and potentially death. Management Strategies : Treatment varies based on the sodium levels: Symptomatic hyponatremia is treated with hypertonic saline. Hypernatremia requires fluid resuscitation. Intestinal Catastrophe Specific Conditions : Malrotation with Midgut Volvulus : Twisting of the intestines that can obstruct blood flow. Necrotizing Enterocolitis (NEC) : Can occur in both full-term and preterm infants, involves inflammation and bacterial infection that can destroy bowel tissue. Hirschsprung-associated Enterocolitis : Complication of Hirschsprung’s disease involving blockage and infection. Intussusception : Older infants might only show altered mental status instead of the typical intermittent pain and lethargy. Symptoms : Common symptoms include bilious emesis (green vomit) or hematemesis (vomiting blood). Emergency Response : Urges early mobilization of pediatric surgery and radiology teams upon suspicion of these conditions. Toxins Includes intentional or unintentional ingestion. One pill killers include: calcium channel blockers (CCB), tricyclic antidepressants (TCA), opiates, sulfonylureas, Class 1 antiarrhythmics, antimalarials, camphor, oil of wintergreen. Seizures The second ‘S’ in the mnemonic refers to seizures, which can be triggered by various conditions such as hypoglycemia, sepsis, inborn errors of metabolism, and trauma. First-Line Treatment : Actively seizing patients should initially be treated with benzodiazepines. Second-Line Medications : Includes fosphenytoin, phenobarbital, levetiracetam (Keppra), and valproic acid. Management of Reversible Causes : Urges prompt treatment of any identifiable causes like hypoglycemia or electrolyte imbalances. Special Consideration : Notes the possibility of pyridoxine-dependent epilepsy in neonates, recommending pyridoxine (vitamin B6) for intractable seizures unresponsive to multiple antiepileptic drugs (AEDs). Read More

Apr 1, 2024

We review Acute Respiratory Distress Syndrome Hosts: Sadakat Chowdhury, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/ARDS.mp3 Download Leave a Comment Tags: Critical Care , Pulmonary Show Notes Definition of ARDS: Non-cardiogenic pulmonary edema characterized by acute respiratory failure. Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio <300 mmHg, even with positive end-expiratory pressure (PEEP) >5 cm H2O. Severity based on oxygenation (Berlin criteria): Mild: PaO2/FiO2 200-300 mmHg Moderate: PaO2/FiO2 100-200 mmHg Severe: PaO2/FiO2 <100 mmHg Epidemiology: Occurs in up to 23% of mechanically ventilated patients. Mortality rate of 30-40%, primarily due to multiorgan failure. Differentiation from Cardiogenic Pulmonary Edema: Chest CT shows diffuse edema and pleural effusion in cardiogenic edema; patchy edema, dense consolidation in ARDS. Ultrasound may show diffuse B lines in cardiogenic edema; patchy B lines and normal A lines in ARDS. Pathophysiology: Exudative phase: Immune-mediated alveolar damage, pulmonary edema, cytokine release. Proliferative phase: Reabsorption of edema fluid. Fibrotic phase: Potential for prolonged ventilation. Etiology: Direct lung injury (pneumonia, toxins, aspiration, trauma, drowning) and indirect causes (sepsis, pancreatitis, transfusion reactions, certain drugs). Diagnostics: Comprehensive workup including imaging (chest X-ray, CT), laboratory tests (complete blood count, basic metabolic panel, blood gases), and specialized tests depending on suspected etiology. Management Strategies: Steroids: Beneficial in certain etiologies of ARDS, with specifics on dosing and duration. Fluid Management: Conservative fluid strategy, diuresis guided by patient condition. Ventilation: Non-invasive ventilation (NIV) preferred in specific cases; mechanical ventilation strategies to ensure lung-protective ventilation. Proning: Used in severe ARDS to improve oxygenation. Inhaled Vasodilators: Used for refractory hypoxemia and specific complications like right heart failure. Extracorporeal Membrane Oxygenation (ECMO): Considered for severe ARDS as salvage therapy. Supportive Care: Includes monitoring and management of complications, nutrition, and physical therapy. Ventilation Specifics: Tidal volume and pressure settings aim for lung-protective strategies to prevent ventilator-induced lung injury. Permissive hypercapnia, plateau pressure, PEEP, and ventilation mode adjustments based on patient response. ARDSnet Table: ventilator_protocol_2008-07 Read More

Mar 1, 2024

We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview Hosts: Stefanie Biondi, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Nitrous_Oxide_Toxicity.mp3 Download Leave a Comment Tags: Toxicology Show Notes Patient Case Illustration Hypothetical case: 21-year-old male with no previous medical history, experiencing a month of progressively worsening numbness, tingling, and weakness. Initially starting in his toes and spreading to his hips, and later involving his hands, the symptoms eventually escalated to the point of immobilization. Despite initially denying drug use, the patient admitted to using 40-60 canisters of nitrous oxide (whippets) every weekend for the last three months. Background and Recreational Use of Nitrous Oxide Nitrous oxide, a colorless, odorless gas with anesthetic properties. Synthesized in the 18th century. Its initial medical purpose expanded into recreational use due to its euphoric effects. Resurgence as a recreational drug during the COVID-19 lockdowns. Accessibility and legal status. Public Misconceptions and Health Consequences There are widespread misconceptions about nitrous oxide Particularly the belief in its safety and lack of long-term health risks. Contrary to popular belief, frequent use of nitrous oxide can lead to significant, sometimes irreversible, health issues. Neurological Examination and Diagnosis Key components of the examination include assessing strength, sensation, cranial nerves, and proprioception, with specific abnormalities such as symmetrically decreased strength in a stocking-glove pattern, upgoing Babinski reflex, and positive Romberg sign being indicative of potential toxicity. Physical Exam Findings: Upper vs Lower Motor Neuron Lesions Localize the Lesion- Differential Diagnoses for Extremity Weakness Localize the Lesion- Differential Diagnoses for Extremity Weakness Localize the Lesion- Differential Diagnoses for Extremity Weakness MRI Findings and Subacute Combined Degeneration The MRI displayed symmetric high signal intensity in the dorsal columns, a diagnostic feature identified as the inverted V sign or inverted rabbit ear sign. Significance of the Inverted V Sign : This MRI sign is pathognomonic for subacute combined degeneration, indicating it is a distinct marker for this condition. T2 Weighted Axial Images : The inverted V sign is observed in T2 weighted axial MRI images, which are used to evaluate the presence and extent of demyelination within the spinal cord. Interpretation of Hyperintense Signals : Hyperintense signals on T2 weighted images generally indicate demyelination, where the protective myelin sheath around nerve fibers is damaged or destroyed. Anatomical Location : The dorsal columns, located anatomically dorsal (toward the back) within the spinal cord, will appear toward the bottom of the screen in an axial (cross-sectional) view on the MRI. Demyelination Appearance : Demyelination in the dorsal columns, typically situated in the thoracic spine, manifests as an upside-down V shape on the MRI, correlating with the described inverted V or rabbit ear sign. Pathophysiology of SCD due to Nitrous Oxide Nitrous Oxide’s Effect on Vitamin B12 : Nitrous oxide inactivates vitamin B12 by oxidizing a cobalt component within the molecule, rendering the vitamin functionally ineffective despite adequate consumption and absorption. Impact on Methionine Synthase : The oxidation of vitamin B12 by N2O prevents it from activating methionine synthase, an enzyme critical for important biochemical processes. Folate to Tetrahydrofolate Conversion : Inactive methionine synthase cannot convert folate into tetrahydrofolate, which is necessary for DNA synthesis. This disruption can lead to megaloblastic anemia, a condition associated with N2O-induced subacute combined degeneration. Conversion of Homocysteine to Methionine : Methionine synthase is also responsible for converting homocysteine to methionine. Methionine is essential for the maintenance of myelin integrity, the protective sheath around nerve fibers. Demyelination and Neurological Symptoms : The inability to maintain myelin integrity due to disrupted methionine production leads to the demyelination of dorsal columns and peripheral motor/sensory nerves, characteristic of N2O-SCD. Normal B12 Levels with Functional Deficiency : Blood levels of vitamin B12 can appear normal in individuals affected by N2O exposure, as the issue lies in the vitamin’s inactivation rather than its absence, creating a functional deficiency. Diagnosis of N2O-SCD : To diagnose N2O-induced SCD, healthcare providers need to check for elevated levels of methylmalonic acid and homocysteine. These substances are typically metabolized with the help of vitamin B12, and their elevated levels indicate a functional deficiency of B12 due to N2O exposure. Treatment and Management Lack of Standardized Treatment : There is no universally accepted treatment protocol for N2O induced SCD, but common practices exist based on neurologist recommendations. B12 Injection Protocol : A common approach involves administering vitamin B12 injections daily or every other day until there is noticeable improvement in symptoms. Once symptoms start to improve, the frequency of injections can be reduced to once a week. Importance of Abstinence from N2O : For recovery to be possible, it is crucial that the patient completely abstains from using whippets (recreational N2O canisters). Continuing to use N2O can inactivate the administered vitamin B12, undermining the treatment efforts. Recovery Process : Recovery from N2O induced SCD is typically slow and may not be complete. While remyelination and neurological function can gradually improve, the process is lengthy and may not fully return to baseline. Recovery Statistics : Approximately 80% of individuals with N2O-SCD experience some improvement after a year of consistent B12 treatment. However, only between 10% and 20% of patients fully recover to their pre-condition baseline. Risk Factors and Prevalence : The risk of developing SCD correlates with the frequency and quantity of N2O use. About 3.4% of individuals who use whippets will develop SCD, with the risk increasing to 8.5% among those who use more than 100 canisters per session. The case in point involved a patient using 20-40 canisters per session. Increased Risk with Preexisting Conditions : Individuals who already have a vitamin B12 deficiency are at a greater risk of experiencing SCD symptoms, even with minimal use of whippets. This highlights the importance of understanding individual health conditions and potential vulnerabilities when assessing risk. Conclusion and Preventive Measures Providers should be vigilant in screening for nitrous oxide use among patients presenting with unexplained neurological symptoms. The goal is to enhance early detection and treatment of N2O-induced SCD and to educate patients on the potential long-term health consequences of recreational nitrous oxide use. References Neurology. Mumenthaler M , Mattle H , Taub E , ed. 4th Edition. Stuttgart: Thieme; 2003. doi:10.1055/b-005-148905 Zayia LC, Tadi P. Neuroanatomy, Motor Neuron. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554616/ Khin-Htun S, Tan H, Aung T. “Approach to a Patient With Weakness” 2021 Feb 15. Youtube. https://www.youtube.com/watch?v=3WQvtCuC4Fo&t=922s Bhattacharyya S.Spinal Cord Disorders: Myelopathy, The American Journal of Medicine, Volume 131, Issue 11, 2018, Pages 1293-1297, ISSN 0002-9343,https://doi.org/10.1016/j.amjmed.2018.03.009. ​​Garg RK, Malhotra HS, Kumar N. Approach to a case of myeloneuropathy. Ann Indian Acad Neurol. 2016 Apr-Jun;19(2):183-7. doi: 10.4103/0972-2327.182303. PMID: 27293327; PMCID: PMC4888679. Lim PAC. Transverse Myelitis. Essentials of Physical Medicine and Rehabilitation. 2020:952–9. doi: 10.1016/B978-0-323-54947-9.00162-0. Epub 2019 Apr 17. PMCID: PMC7151963. Jayarangaiah A, Lui F, Theetha Kariyanna P. Lambert-Eaton Myasthenic Syndrome. [Updated 2023 Oct 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507891/ Nguyen TP, Taylor RS. Guillain-Barre Syndrome. [Updated 2023 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532254/ Froese DS, Fowler B, Baumgartner MR. Vitamin B12 , folate, and the methionine remethylation cycle-biochemistry, pathways, and regulation. J Inherit Metab Dis. 2019 Jul;42(4):673-685. doi: 10.1002/jimd.12009. Epub 2019 Jan 28. PMID: 30693532. Guo CJ, S. Kaufman B. Inhalational Anesthetics. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e . McGraw-Hill Education; 2019. Accessed February 27, 2024. https://accessemergencymedicine-mhmedical-com.ezproxy.med.nyu.edu/content.aspx?bookid=2569&sectionid=210274345 Lin JP, Gao SY, Lin CC. The Clinical Presentations of Nitrous Oxide Users in an Emergency Department. Toxics. 2022 Feb 26;10(3):112. doi: 10.3390/toxics10030112. PMID: 35324737; PMCID: PMC8950993. Qudsiya Z, De Jesus O. Subacute Combined Degeneration of the Spinal Cord. [Updated 2023 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559316/ Hemmer B, Glocker FX, Schumacher M , et al Subacute combined degeneration: clinical, electrophysiological, and magnetic resonance imaging findings Journal of Neurology, Neurosurgery & Psychiatry 1998;65:822-827. Shah K, Murphy C. Nitrous Oxide Toxicity: Case Files of the Carolinas Medical Center Medical Toxicology Fellowship. J Med Toxicol. 2019 Oct;15(4):299-303. doi: 10.1007/s13181-019-00726-x. Epub 2019 Aug 6. PMID: 31388940; PMCID: PMC6825085. Kalmoe MC, Janski AM, Zorumski CF, Nagele P, Palanca BJ, Conway CR. Ketamine and nitrous oxide: The evolution of NMDA receptor antagonists as antidepressant agents. J Neurol Sci. 2020 May 15;412:116778. doi: 10.1016/j.jns.2020.116778. Epub 2020 Mar 19. PMID: 32240970. https://www.nytimes.com/2021/01/30/style/nitrous-oxide-whippets-tony-hsieh.html Read More

Feb 1, 2024

We review threatened abortion and the complexities in its care. Hosts: Stacey Frisch, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Threatened_Abortion.mp3 Download One Comment Tags: OBGYN Show Notes Background Defined as vaginal bleeding during early pregnancy (before 20 weeks) with a closed cervical os, no passage of fetal tissue, and IUP on ultrasound Occurs in 20-25% of all pregnancies. Initial Assessment and Management Priority is to assess patient stability, establish good IV access, FAST may be helpful in identifying some ruptured ectopics early Broad differential diagnosis is crucial to avoid mistaking conditions like ectopic pregnancy for other emergencies. Importance of a detailed history and physical examination. Diagnostic Approach Essential tests include HCG level, urinalysis, and possibly CBC + blood type/Rh status. Rhogam’s use is well-supported in second and third trimester bleeding; however, data is less robust for first trimester bleeding in preventing sensitization Importance of interpreting b-HCG with caution and understanding HCG discriminatory zones. Use of ultrasound imaging, both bedside and formal, to assess the pregnancy’s status. Patient Counseling and Management Open and honest communication about the prognosis of threatened abortion. Addressing psychosocial aspects, including dispelling guilt and myths, and screening for intimate partner violence and mental health issues. Recommendations against bedrest and certain activities Lack of evidence supporting restrictions on sexual activity. Standard pregnancy guidelines: avoiding smoking, alcohol, drug use, and starting prenatal vitamins. Follow-up and Precautions Adopting a wait-and-see approach for stable patients, with scheduled follow-ups for ultrasounds and beta-HCG tests. Educating patients on critical warning signs that require immediate medical attention. Emphasizing the importance of returning to the hospital if experiencing significant bleeding or other severe symptoms. Take Home Points Threatened Abortion is defined as Experiencing abdominal pain and/or vaginal bleeding during early pregnancy (before 20 weeks), characterized by a closed cervical os and no expulsion of fetal tissue. In these cases, it is important to assess patient stability promptly. Keep your differential broad in these cases. The evaluation will in most cases involve a combination of labs and ultrasound imaging. Understand that the Rhogam certainly has a role in second and third trimester vaginal bleeding in the Rh-negative patient, and that there is a dearth of good data on its role in the first trimester – it will ultimately be a decision that is made by you, OBGYN, and the patient. Approach the interpretation of HCG levels with caution and remember that ectopic pregnancies might not adhere to conventional HCG levels. Established follow up and discharge instructions are crucial. Manage stable patients with a watchful waiting approach, scheduling subsequent visits for continuous ultrasounds and HCG testing. Clearly outline the importance of immediate medical attention for symptoms such as intense bleeding, significant abdominal pain, fever, or feelings of insecurity at home. Finally, we play an important role wherein we must ensure that the patient is medically stable and psychosocially safe. Here, compassionate communication is crucial when discussing what the diagnosis might entail, alleviate any feelings of blame or shame, and remain vigilant for signs of intimate partner violence or mental health issues. As emergency medicine physicians, it’s crucial for us to approach these cases with a comprehensive mindset. Read More

Jan 3, 2024

We review a general approach to syncope in children. Hosts: Brian Gilberti, MD Ellen Duncan, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Syncope_in_Children.mp3 Download Leave a Comment Tags: Cardiology , Pediatrics Show Notes Initial Evaluation and Management : Similar initial workup for children and adults: checking glucose levels for hypoglycemia and conducting an EKG. The history and physical exam are crucial. Dextrose Administration in Children : Explanation of the ‘rule of 50s’ for determining the appropriate dextrose solution and dosage for children. ECG Analysis : Importance of ECG in diagnosing dysrhythmias like long QT syndrome, Brugada syndrome, catecholamine polymorphic V tach, ARVD, ALCAPA, and Wolff-Parkinson-White syndrome. Younger children’s dependency on heart rate for cardiac output and the risk of arrhythmias in kids with congenital heart disease. Condition Characteristic ECG Findings Congenital/Acquired Long QT Syndrome (LQTS) Prolonged QT interval Congenital/Acquired Wolff-Parkinson-White Syndrome (WPW) Short PR interval, Delta wave Congenital Brugada Syndrome ST elevation in V1-V3, Right bundle branch block Congenital Atrioventricular Block (AV Block) PR interval prolongation (1st degree), Missing QRS complexes (2nd & 3rd degree) Congenital/Acquired Supraventricular Tachycardia (SVT) Narrow QRS complexes, Absence of P waves, Tachycardia Congenital/Acquired Ventricular Tachycardia Wide QRS complexes, Tachycardia Congenital/Acquired Arrhythmogenic Right Ventricular Dysplasia (ARVD/C) Epsilon waves, V1-V3 T wave inversions, Right bundle branch block Congenital Hypertrophic Cardiomyopathy (HCM) Left ventricular hypertrophy, Deep Q waves Congenital Pulmonary Hypertension Right ventricular hypertrophy, Right axis deviation Acquired Athlete’s Heart Sinus bradycardia, Voltage criteria for left ventricular hypertrophy Acquired Catecholaminergic Polymorphic VT (CPVT) Bidirectional or polymorphic VT, typically normal at rest Congenital Anomalous Origin of Left Coronary Artery from Pulmonary Artery (ALCAPA) May be normal, signs of ischemia or infarction in severe cases Congenital History Taking : Key aspects include asking about syncope with exertion, syncope after being startled, and syncope after pain or emotional stress. Prolonged loss of consciousness may indicate seizures, and emotional stress and pain can trigger breath-holding spells. Breath-Holding Spells : Clarification of misconceptions about breath-holding spells, discussing their causes and characteristics, like cyanotic and pallid types. Association with iron deficiency and the fact that most children outgrow these spells by age 8. Physical Examination and History : A cardiac exam is vital, with specific signs to look for, like murmurs in hypertrophic cardiomyopathy. History can help identify the etiology of syncope, such as vasovagal responses or orthostatic hypotension. Vasovagal Syncope : Common in kids, especially teenagers, typically presenting with a prodrome of lightheadedness, diaphoresis, and pallor. Normal glucose and EKG are expected in these cases. Additional Lab Tests : Pregnancy tests in reproductive-age women, and checking for less common causes like pulmonary embolism, subarachnoid hemorrhage, and toxic exposures. Take Home Points: Immediate assessments for syncope in children should include a FS to evaluate for hypoglycemia and an ECG to evaluate any cardiac rhythm or conduction abnormalities. Apply the “Rule of 50s” for hypoglycemic patients to suggest which fluids should be used. Refer to our table for ECG findings to look out for when reviewing ECG tracings for these patients. Pay particular attention to clues in the history that would suggested HCOM or seizures. Breath-holding spells usually resolve by eight HCOM murmurs will increase with Valsalva maneuver Always keep your differential broad when approaching these patients given the heterogeneity of potential pathology that could lead to this chief complaint Read More

Dec 1, 2023

We go over the treatment of rapid atrial fibrillation (afib with RVR). Hosts: Brian Gilberti, MD Jonathan Kobles, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Rapid_Atrial_Fibrillation.mp3 Download One Comment Tags: Cardiology Show Notes Understanding AF with RVR Categories General AF with RVR: Definition and basic understanding. Rapid AF with Pre-excitation: Characteristics and complications. Chronic AF in Critical Illness: Identification and special considerations. Stability Assessment in AF with RVR ACLS Protocols: Distinction between unstable and stable patients. Unstable Patients: Immediate need for synchronized cardioversion, standard dose at 200 J for adults. Stable Patients: Rate vs. rhythm control strategies, consideration of underlying etiology. Limitations in Chronic AF: Challenges in patients with AF secondary to critical illness. ACLS Guidelines and ECG Findings Tachycardia with a Pulse Approach: Initial assessment guidelines. ECG Interpretation: Irregularly Irregular Rhythm: Absence of discernible P waves. Ventricular Rate: Typically over 100 bpm. QRS Complexes: Usually narrow, alterations in the presence of bundle branch block or ventricular rate-related aberrancy. Identifying Pre-Excitation Syndromes: Signs of shortened PR interval and slurred QRS, indication of Wolff-Parkinson-White Syndrome. AF with Pre-Excitation (WPW Syndrome) Risk Assessment: Dangers of using AV nodal blockers (BB/CCB, digoxin, adenosine). Alternative Management: Utilization of procainamide or amiodarone for stable patients, synchronized electrical cardioversion for unstable patients. Treatment Approaches for AF Types General Rapid AF: First Line Agents: Metoprolol vs. Diltiazem. Metoprolol Considerations: Dosing (5 mg every 10-15 minutes, max 15 mg), benefits in CAD and HF, limitations in asthma/COPD patients. Diltiazem Advantages: Faster action, suitability in asthma/COPD, typical dosing (0.25 mg/kg initial, followed by 0.35 mg/kg if needed). Critically Ill Patients: Tailoring treatment to underlying pathology, avoiding typical AF pharmacologic treatments. Systematic Evaluation of Tachycardia Causes (TACHIES Mnemonic) Thyrotoxicosis, Alcohol withdrawal, Cardiac issues, Hemorrhage, Intervals (WPW), Embolus, Sepsis. Application of the mnemonic for a comprehensive approach to differential diagnosis. Ultrasound in Diagnostic Assessment Application in Undiagnosed Tachycardia: Identifying EF, pericardial effusion, valvular pathology, and signs of pulmonary embolism. Fluid Status Evaluation: Use of ultrasound for assessing b-lines in lung scans. Management of Chronic AF with HD Instability Assessment of Hemodynamic Impact: Effects of extreme tachycardia on cardiac output, preload and afterload considerations. Chronic vs. Paroxysmal AF: Differentiation in clinical presentation and treatment response. Approaches in Complex AF Cases Addressing RVR of Unclear Etiology: Targeted therapies based on suspected underlying causes. Medication Strategies: Amiodarone: Bolus and drip approach, slow AV nodal without significant impact on contractility. Esmolol: Titration for heart rate control, short-acting nature allowing for rapid cessation if adverse effects are observed. Comprehensive Patient Disposition Considerations: Hemodynamic stability, underlying cause, comorbidities, outpatient follow-up feasibility. Decision-Making Process: Balancing acute management with long-term treatment strategies. Take Home Points Differentiation in AF with RVR Types : It’s essential to distinguish between primary AF with RVR, chronic AF with RVR related to other health issues, and new-onset AF (NOAF) with RVR in critically ill patients, as each type necessitates a unique approach to treatment. ACLS Guidelines for AF with RVR : The ACLS guidelines provide a treatment framework, particularly recommending immediate synchronized cardioversion for unstable patients. However, these guidelines may have limited effectiveness for chronic AF with RVR patients suffering from underlying critical illnesses. ECG Diagnosis in AF : Identifying AF on an ECG is crucial, with key indicators being an irregular rhythm without clear P waves and a ventricular rate exceeding 100 bpm. Accurate ECG interpretation guides effective treatment planning. Special Cases like WPW Syndrome : WPW syndrome and similar conditions require careful treatment consideration, as standard AF treatments can worsen these conditions. Alternatives like procainamide or amiodarone are often more appropriate. Patient-Centered Management of AF with RVR : Management should account for the patient’s overall health, underlying conditions, the chronicity of AF, and other comorbidities. Drugs like metoprolol and diltiazem offer benefits and risks, demanding personalized treatment plans. Pathophysiology in Critical AF Patients : Understanding the underlying pathophysiology in critically ill patients is vital. Tachycardia in these cases might be compensatory, necessitating an investigation into causes like myocarditis, dehydration, or GI bleeding. Systematic Evaluation with TACHIES Mnemonic : The mnemonic TACHIES (Thyrotoxicosis, Alcohol withdrawal, Cardiac issues, Hemorrhage, Intervals [WPW], Embolus, Sepsis) aids in systematically assessing and addressing emergent tachycardia causes in critically ill patients. Read More

Nov 1, 2023

We discuss Electrical Storm (VT storm) and how to care for the very irritable heart. Hosts: Brian Gilberti, MD Reed Colling, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Electrical_Storm.mp3 Download Leave a Comment Tags: Cardiology Show Notes Background/Overview of VT: Definition: What makes it a storm Three or more sustained episodes of VF, VT, or appropriate ICD shocks in a 24-hour period Pathophysiology: Understanding the origin and mechanism Sympathetic drive/adrenergic surge Underlying pathology: Sodium channelopathies, infiltrative disease like cardiac sarcoidosis, etc. RF’s / trigger / population (reversible cause in ~25% of patients) MI Electrolyte Derangements (emphasis on potassium and magnesium) New/worsening heart failure Catecholamine Surge Drugs (stimulants, cocaine, amphetamines, etc) QT Prolongation Thyrotoxicosis Clinical Presentation: Symptoms of VT: spectrum of symptoms – from palpitations to syncope to cardiac arrest Differentiating VT from other potential ER presentations. Diagnostics in ER: Electrocardiogram (ECG): Recognizing VT patterns. Monomorphic vs polymorphic (Torsades) may change management Wide QRS Fusion best Capture beats Concordance AV-dissociation Lab tests: Potassium, magnesium, troponins, TFTs, etc. Acute Management in the ER: Hemodynamically stable vs. unstable V Unstable = cardioversion Sedation Catecholamine surge should be considered No ideal agent Etomidate or propofol can be considered Ketamine may worsen irritability Pharmacological treatments: Amiodarone Class III antiarrhythmic Most studied in VT storm First line Beta Blockers Propranolol B1 and B2 activity Non-pharmacological approaches: Immediate synchronized cardioversion IABP / ECMO considered for HD unstable patient Cath lab if ischemic etiology suspected Stellate Ganglion Block Take Home Points Definition : VT Storm is commonly defined as three or more sustained episodes of ventricular fibrillation, ventricular tachycardia, or appropriate ICD shocks within a 24-hour period. Varied Presentation : Patients may experience a range of symptoms from palpitations to severe hemodynamic instability. ECG and Diagnosis : Initial ECG may not show VT; continuous cardiac monitoring or device interrogation may be required for diagnosis. VT Identification : Look for wide QRS, rate over 100, fusion beats, capture beats, and AV dissociation to identify VT. Management in Hemodynamic Instability : Cardiovert if the patient shows signs of hemodynamic instability. Sedation Considerations : Be cautious with sedation, especially with ketamine, as it may worsen cardiac irritability in these already adrenergic state patients. Medication Choices : Typically, amiodarone and propranolol are used to manage VT Storm. Cardiology Involvement : Involve cardiology early on, as treatment may extend beyond medications. Read More

Oct 1, 2023

We revisit the topic of Hyperkelamia to update our prior episode from 2015 (pre-Lokelma) Hosts: Brian Gilberti, MD Jonathan Kobles, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hyperkalemia.mp3 Download 2 Comments Tags: Renal Colic Show Notes Introduction Background Physiology : Normal range and the significance of deviations (>5.5 mEq/L) Epidemiology : Prevalence of hyperkalemia in the ER ESRD missed HD → ECG, monitor Causes / Risk Factors Causes Kidney Dysfunction, Medications, Cellular Destruction, Endocrine Causes, Pseudohyperkalemia High-Risk Medications: Antibiotics: Bactrim, antifungals Calcineurin inhibitors Beta-blockers ACE/ARB K+ Sparing diuretics NSAIDs Digoxin SUX – high risks in neuromuscular disease Lab errors, hemolysis in samples VBG vs Chem accuracy When to repeat a hemolyzed sample 2023 study : Of the 145 children with hemolyzed hyperkalemia, 142 (97.9%) had a normal repeat potassium level. Three children (2.1%) had true hyperkalemia: one had known chronic renal failure and was referred to the ED due to concern for electrolyte abnormalities; the other 2 patients had diabetic ketoacidosis (DKA). Clinical Presentation / eval Symptomatic vs. Asymptomatic : “First symptom of hyperkalemia is death” If severe, ascending muscle weakness → paralysis Point at which patients experience symptoms depends on chronicity >7 mEq/L if chronic and can be lower if acute Hyperkalemia can be a cause of non-specific GI symptoms EKG Changes : ECG findings may be the first marker the ER doc gets that something is wrong Typical changes: Peaked T-waves, shortened QT Lengthening of PR interval and QRS duration Bradycardia / Junctional rhythm Hyperkalemia can produce bradycardia without other ECG findings Ones associated with VT/VF/code, death in one study: QRS widening (RR = 4.74), Junctional Rhythm (RR = 7.46), HR <50 (RR = 12.29) while no adverse outcomes with just peaked T waves or PR prolongation ( Durfey, 2017 ) Don’t be fooled by a normal ECG, may be normal, but it’s also on case report level to have K > 9 and a normal ECG Series of 127 patient (K 6-9.3), no serious arrhythmia noted, only 46% had ECG changes, ( Acker, 1998) ECG changes are not linear, there is no exact association between K+ levels and ECG changes ECG changes may be hidden and subtle in patients with underlying inter-ventricular conduction delay (BBBs) Be suspicious of the patient with LBBB > 160 ms or RBBB > 140 ms BRASH Syndrome Synergism between hyperkalemia, renal failure/injury and AV nodal blocking agents -> may produce ECG changes out of proportion to serum potassium levels. Labs Chem, VBG, +/- CK if you think muscle breakdown is at play (Tintinalli talks about looking at urine K, but this is not most people’s practice) Consider evaluation for adrenal insufficiency Waiting for labs may not be an option Renal dysfunction + consistent ECG findings → prompt treatment before chem results Realistically 2 hours to get back chemistry in most settings ≈ eternity Management in the ER Discontinue/hold any nephrotoxins or medications in suspected medication-induced hyperkalemia A. Acute Management Strategies : Cardiac protection with calcium 1g over 5-10 mins Lasts 30-60 mins, may have to redose Dose considerations if on digoxin AEs: Calciphylaxis and hypercalcemia Fast pushes can result in hypotension, arrhythmia Calcium chloride vs calcium gluconate Caution in patients taking Digoxin IVF choice – NS vs LR Caution/Avoid fluid in patients with ESRD/CHF or signs of VOL Shifting potassium: insulin/glucose 5 units vs 10 units 5 similar effect, less hypoglycemic episodes (LaRue 2017) If doing 10 units, start D10W at 50-75 cc/h after amp of d50 but be mindful that anuric patient who missed HD may not have much room for volume Decrease but about 0.5-1.2 mEq/L Effect starts 10-20 mins after administration and can last 4-6 hours Albuterol 10-20 mg over 10 mins (NB: higher dose than for asthma) Peak effect at 90 mins Decreases by 0.5 – 1.0 mEq/L alone With insulin, ~1.2 mEq/L, additive effect Bicarbonate Controversy. Useless in hyperkalemic, nonacidotic patient. Useful as drip but takes hours to work, again, volume in anuric patient an issue May be most useful in patients with renal failure and hyperkalemia 2/2 volume loss Hypertonic Bicarb is ineffective – More potassium is pulled out of cells due to osmotic shift. Removal: Lokelma (Sodium Zirconium cyclosilicate) Luckily residents have never had to use Kayexalate Can start working in 1-2 hours of administration 0.37 mEq/L reduction at 4 hours after 10 g Not a magic bullet in patients who need dialysis Diuretics No studies that demonstrate effectiveness in this ED setting May be effective in patients with normal renal function If patient not anuric, may be worth using, can give 40 mg, but again, should not be the only attempted method of removing K Nephron BOMB Loop Diuretic (160-250 mg IV Lasix or 4-5 mg IV Bymex) Thiazide (500-1000 mg IV chlorothiazide or 5-10 mg metolazone) +/- Acetazolamide +/- Fludrocortisone May help stimulate the kidneys to secrete potassium Primarily helpful in patients with mineralocorticoid deficiencies Dialysis Involve renal early because it takes a while to call in an HD nurse sometimes If no access and emergent HD is required → HD catheter placement Strategies for suspected Brash syndrome Epinephrine/Levo (if hypotensive/bradycardic) Calcium gtt Disposition/wrap up Many factors at play here – patient preference, access, degree of hyperkalmia, identifiable / corrected cause Take Home points Hyperkelamia causes can be put into three categories, pseudohyperkalemia, due to redistribution, and due to total body increase in potassium. Check out the show notes for a more complete list Hyperkalemia can be difficult to pick up on before the labs come back because it can lurk without symptoms or even ECG changes If a patient does have ECG changes, they may not follow that linear pattern that is traditionally taught and ECGs can be poorly sensitive. Now, if you do see changes, the ones that are more commonly associated with adverse events are QRS widening, junctional rhythm, and bradycardia Treatment is a numbers game, calcium for cardiac stabilization can last just 30-60 minutes, insulin will be the fastest way to shift potassium back into cells, but be mindful that 10 units is associated with increased episodes of hypoglycemia whereas 5 units may have the same effect in reducing potassium. And albuterol is at a much higher dose than what is given for asthma Lokelma is now a pillar of treatment for removal of potassium. Diuretics with the goal of kiuresis may have a role in the oliguric patient, and increased doses along with other agents may buy time in patients with severe hyperK when HD is not readily available Involve renal early if you think that the patient will require HD Read More

Sep 1, 2023

We go over the essential and complex topic of vasopressors in the ED. Hosts: Brian Gilberti, MD Catherine Jamin, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vasopressors.mp3 Download Leave a Comment Tags: Critical Care Show Notes Introduction Host: Brian Gilberti, MD Guest: Catherine Jamin, MD Associate professor of Emergency Medicine at NYU Langone Health Vice Chair of Operations Triple-boarded in Emergency Medicine, Internal Medicine, and Critical Care Medicine Topic: Vasopressors: Essential agents for supporting critically ill patients in the ED What Are Vasopressors and When to Use Them Two primary mechanisms to increase blood pressure: Increasing systemic vascular resistance via vasoconstriction Increasing cardiac output via augmenting inotropy and chronotropy Indicators for vasopressor use: MAP <65, systolic BP <90, or significant drop from baseline BP Signs of organ dysfunction like altered mental status, decreased urine output, elevated lactate Fluid resuscitation either ineffective or contraindicated (e.g., in CHF patients) Commonly Used Vasopressors in the ED Norepinephrine Epinephrine Vasopressin Phenylephrine Norepinephrine Mechanism: Stimulates alpha-1 (vasoconstriction) and beta-1 receptors (increases inotropy & chronotropy) Starting Dose: 10 mcg/min, titrate to MAP >65 Max Dose: No strict limit but usually add a 2nd pressor at 15-20 mcg/min Situational Preference: First-line for most cases of shock (septic, undifferentiated, hypovolemic, cardiogenic) Pros: Can be infused peripherally via large bore IV Vasopressin Mechanism: Activates V1a receptors causing vasoconstriction Dose: Fixed, non-titratable dose of 0.04 units/min Situational Preference: Second-line in septic shock Concerns: Potential for peripheral ischemia Phenylephrine Mechanism: Stimulates alpha-1 receptors causing vasoconstriction Starting Dose: 100 mcg/min, titrate to MAP >65 Situational Preference: High cardiac output states, tachyarrhythmias, peri-intubation Concerns: Increases afterload, can worsen low cardiac output states Epinephrine Mechanism: Stimulates alpha-1, beta-1 and beta-2 receptors Starting Dose: 5-10 mcg/min, titrate to MAP >65 Situational Preference: Anaphylactic shock, septic cardiomyopathy Limitations: Can induce tachycardia, may elevate lactate levels Escalation Strategy in Refractory Shock Norepinephrine -> Vasopressin (with stress dose steroids) -> Epinephrine Consider POCUS, lactate, central venous saturation, and acid-base status Peripheral Pressors Can safely be administered peripherally via large bore IVs in proximal upper extremity Sites: Cephalic or basilic veins Adverse Events: Low at 1.8% based on meta-analysis Actions in case of extravasation: Phentolamine injection, nitroglycerin paste Push-Dose Pressors Primarily Phenylephrine (peri-intubation, during procedures) Also Epinephrine for peri-code situations Doses: Epi – 5-20 mcg every 2-5 min Take-Home Points Most used medications are going to be norepinephrine, vasopressin, phenylephrine, and epinephrine. Consider these medications if there are signs of end-organ dysfunction, there is a considerable delta in baseline BP, systolic is less than 90 and/or MAP is less than 65 Norepinephrine is a good pressor for a lot of the situations that we encounter in the emergency department, such as septic shock, undifferentiated shock and hypovolemic shock. Vasopressin is commonly the second we reach for in most of these scenarios Epinephrine will be first for anaphylactic shock and may be the third agent in septic shock Think about phenylephrine in high-output states (patients with tachydysrhythmias), or with AS, though be cautious in patient with low cardiac output The benefits outweigh risks for peripheral pressors in situations where you promptly have to increase blood pressure while you work on central access Push-dose pressures can help you in a peritinbatuion or pericode situation because it is going to be one of the fastest ways we can boost BP while we work on other measures to stabilize the patient Additional References Importance of RUSH (Rapid Ultrasound in SHock) exam for diagnosis and treatment planning: https://emcrit.org/rush-exam/ Read More

Aug 1, 2023

We discuss the diagnosis and management of septic arthritis in the pediatric population. Hosts: Brian Gilberti, MD Ellen Duncan, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Joint_in_Children.mp3 Download 2 Comments Tags: Infectious Diseases , Pediatrics Show Notes General Pain in joint for pediatric patient has a broad differential, including transient synovitis and septic arthritis Transient synovitis, also known as toxic synovitis, is a common condition affecting kids aged 3-10 and often occurs after a viral infection. It is typically self-limiting and not considered a serious condition. Septic arthritis is an infection in the joint space, typically affecting only one joint. It is often difficult to diagnose due to the fact that many patients, particularly under the age of 3, may not be able to localize their pain to a specific joint. Workup Diagnostic work-up for septic arthritis begins with blood work, which includes a complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and blood cultures. Lyme disease studies may also be necessary since Lyme disease can cause joint pain. Patients with transient synovitis typically have mild elevation in inflammatory markers, while those with septic arthritis usually show a significant elevation. Imaging studies, including X-rays, ultrasound to evaluate for a joint effusion, and MRI to assess for associated osteomyelitis, are also part of the diagnostic approach. The Kocher criteria, developed specifically for septic arthritis of the hip, are a useful tool for clinical decision-making. The criteria include fever above 38.5 C, inability to bear weight, ESR above 40, and a white blood cell count above 12,000. 1 criterion met = 3% probability of septic arthritis 2 criteria met = 40% probability of septic arthritis 3 criteria met = 93% probability of septic arthritis 4 criteria met = 99+% probability of septic arthritis If septic arthritis is suspected, orthopedics should be consulted immediately. Joint fluid aspiration is necessary for diagnosis and should not be delayed. The fluid should be sent for cell count, gram stain, glucose, culture, and PCR if available. Septic arthritis is most commonly caused by bacterial infections, with Staph aureus being the most common organism. In school-age children, other bacteria such as Strep pyogenes, Strep pneumoniae, and Haemophilus influenzae should also be considered. In preschool-aged children, K. kingae is also considered. In older children and neonates, the range of potential bacteria varies. Management Empiric antibiotic therapy should target the most likely organisms and should not be delayed. Antibiotics may be narrowed once culture results are obtained. The choice of antibiotics is dependent on the age group, with specific combinations suggested for neonates, children between 1 month and 4 years, and children aged 5 and older. Cultures are only positive in 50-60% of cases. Synovial fluid PCR studies can help narrow antibiotic treatment. Take Home Points Limp in the pediatric population can commonly be transient synovitis but we should always consider septic arthritis Some clues in the history and physical that would point you towards septic arthritis include fever, refusal to bear weight, and limited range of motion on exam We are going to have to get labs, including CBC, inflammatory markers, and preoperative labs, along with an XR and possibly an ultrasound Kocher criteria is one tool that can help us determine if this is a patient that requires a joint tap. Arthrocentesis is the gold standard for diagnosis, but antibiotics should be started promptly if the diagnosis is suspected. The choice of antibiotics is dependent upon age group. Neonates get vanc/cefepime, kids 1-4 yo get vanc / ceftriaxone Older than 5 yo get vancomycin Add ceftriaxone to them if patient has sickle cell disease, are immunocompromised, or Lyme or STI are suspected Always cross check with institutional preferences / guidelines when choosing antibiotics Read More

Apr 29, 2022

A quick primer on hypocalcemia in the ED. Hosts: Joseph Offenbacher, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/hypocalcemia.mp3 Download 4 Comments Tags: calcium , Critical Care , Endocrine Show Notes Swami’s CoreEM Post Hypocalcemia Repletion: IV calcium supplementation with 100-300 mg Ca2+ raises serum Ca2+ by 0.5 – 1.5 mEq For acute but mild symptomatic hypocalcemia: 200-1000mg calcium chloride IV or 1-2g IV calcium gluconate over 2 hours For severe hypocalcemia: 1g calcium chloride IV or 1-2g IV calcium gluconate IV over 10 minutes repeated q 60 min until symptoms resolve References: Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008; 336:1298. ​​Desai TK, Carlson RW, Geheb MA. Prevalence and clinical implications of hypocalcemia in acutely ill patients in a medical intensive care setting. Am J Med 1988; 84:209. Goltzman, D. Diagnostic approach to hypocalcemia. UpToDate. UpToDate; Jul 17, 2020. Accessed April 29, 2022. https://www.uptodate.com/contents/plantar-fasciitis Kelly A, Levine MA. Hypocalcemia in the critically ill patient. J Intensive Care Med 2013; 28:166. Pfenning CL, Slovis CM: Electrolyte Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 125: p 1636-53. Swaminathan, A. (2016, January 27). Hypocalcemia . CoreEM. Retrieved April 29, 2022, from https://coreem.net/core/hypocalcemia/ Vantour L, Goltzman D. Regulation of calcium homeostasis. In: rimer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, 9th ed, Bilezikian JP (Ed), Wiley-Blackwell, Hoboken, NJ 2018. p.163. Read More

Feb 11, 2022

How and when to reverse anticoagulation in the bleeding EM patient. Hosts: Joe Offenbacher, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/AC_reversal.mp3 Download 3 Comments Tags: Anticoagulation , Critical Care , Resuscitation Show Notes Coagulation Cascade: Algorithm for Anticoagulated Bleeding Patient in the ED: Indications for Anticoagulation Reversal: References: Baugh CW, Levine M, Cornutt D, et al. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Ann Emerg Med . 2020;76(4):470-485. doi:10.1016/j.annemergmed.2019.09.001 Eikelboom JW, Quinlan DJ, van Ryn J, Weitz JI. Idarucizumab: The Antidote for Reversal of Dabigatran. Circulation. 2015 Dec 22;132(25):2412-22. doi: 10.1161/CIRCULATIONAHA.115.019628. PMID: 26700008. Fariborz Farsad B, Golpira R, Najafi H, et al. Comparison between Prothrombin Complex Concentrate (PCC) and Fresh Frozen Plasma (FFP) for the Urgent Reversal of Warfarin in Patients with Mechanical Heart Valves in a Tertiary Care Cardiac Center. Iran J Pharm Res . 2015;14(3):877-885. Fariborz Farsad B, Golpira R, Najafi H, et al. Comparison between Prothrombin Complex Concentrate (PCC) and Fresh Frozen Plasma (FFP) for the Urgent Reversal of Warfarin in Patients with Mechanical Heart Valves in a Tertiary Care Cardiac Center. Iran J Pharm Res . 2015;14(3):877-885. Palta S, Saroa R, Palta A. Overview of the coagulation system. Indian J Anaesth . 2014;58(5):515-523. doi:10.4103/0019-5049.144643 Siegal DM, Curnutte JT, Connolly SJ, Lu G, Conley PB, Wiens BL, Mathur VS, Castillo J, Bronson MD, Leeds JM, Mar FA, Gold A, Crowther MA. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015 Dec 17;373(25):2413-24. doi: 10.1056/NEJMoa1510991. Epub 2015 Nov 11. PMID: 26559317. Read More

Dec 9, 2021

A primer on this airway/ ID/ ENT emergency. Hosts: Joe Offenbacher MD, A Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/ludwigs_2.mp3 Download 2 Comments Tags: Airway , ENT , Infectious Diseases Show Notes References: Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig’s Angina. Ann Maxillofac Surg 2015; 5:168. Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis 2009; 13:327. Brook I. Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin North Am. 2007 Jun;21(2):355-91, vi. doi: 10.1016/j.idc.2007.03.014. PMID: 17561074. Chong W, Hijazi M, Abdalrazig M, Patil N. Respect the Floor of the Mouth. J Emerg Med. 2020 Jul;59(1):e27-e29. doi: 10.1016/j.jemermed.2020.04.015. Epub 2020 May 19. PMID: 32439254. http://www.emdocs.net/ludwigs-angina-2/ Mohamad I, Narayanan MS. “Double Tongue” Appearance in Ludwig’s Angina. N Engl J Med 2019; 381:163. Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J. 2004 Mar;21(2):242-3. doi: 10.1136/emj.2003.012336. PMID: 14988363; PMCID: PMC1726306. Wolfe MM, Davis JW, Parks SN. Is surgical airway necessary for airway management in deep neck infections and Ludwig angina? J Crit Care. 2011 Feb;26(1):11-4. doi: 10.1016/j.jcrc.2010.02.016. PMID: 20537506. Read More

Oct 29, 2021

A quick overview of pneumothorax for the EM physician: the what, why, diagnosis, and treatment. Hosts: Joe Offenbacher, MD Audrey Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumothorax_CoreEM_podcast.mp3 Download One Comment Tags: #pneumothorax #FOAMed Show Notes Shownotes: CoreEM Pulmonary Ultrasound Post References: Bense L, Lewander R, Eklund G, et al. Nonsmoking, non-alpha 1-antitrypsin deficiency-induced emphysema in nonsmokers with healed spontaneous pneumothorax, identified by computed tomography of the lungs. Chest 1993; 103:433. Bense L, Wiman LG, Hedenstierna G. Onset of symptoms in spontaneous pneumothorax: correlations to physical activity. Eur J Respir Dis 1987; 71:181. Brown SGA, Ball EL, Perrin K, Asha SE, Braithwaite I, Egerton-Warburton D, Jones PG, Keijzers G, Kinnear FB, Kwan BCH, Lam KV, Lee YCG, Nowitz M, Read CA, Simpson G, Smith JA, Summers QA, Weatherall M, Beasley R; PSP Investigators. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020 Jan 30;382(5):405-415. doi: 10.1056/NEJMoa1910775. PMID: 31995686. Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol 2013; 16:351. Chan KK, Joo DA, McRae AD, et al. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev 2020; 7:CD013031. Ebrahimi A, Yousefifard M, Mohammad Kazemi H, et al. Diagnostic Accuracy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffos 2014; 13:29. Gobbel Jr WG, Rhea Jr WG, Nelson IA, Daniel RA. Spontaneous pneumothorax. J Thorac Cardiovasc Surg 1963; 46:331. Lesur O, Delorme N, Fromaget JM, et al. Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax. Chest 1990; 98:341. Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005; 33:1231. Melton LJ 3rd, Hepper NG, Offord KP. Influence of height on the risk of spontaneous pneumothorax. Mayo Clin Proc 1981; 56:678. Ohata M, Suzuki H. Pathogenesis of spontaneous pneumothorax. With special reference to the ultrastructure of emphysematous bullae. Chest 1980; 77:771. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000; 342:868. Read More

Sep 1, 2021

An interesting back story on this must-not-miss EKG finding in the ED! Hosts: Joseph Offenbacher, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/CoreEM_Wellens.mp3 Download One Comment Tags: #FOAMed , #wellens , Cardiology , EKG , STEMI Show Notes Hosts: Joe Offenbacher MD, Audrey Bree Tse MD EKG Findings in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481. Table 1 in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481. REFERENCES: de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481. Lee, M., & Chen, C. (2015). Myocardial Bridging: An Up-to-Date Review. Journal of Invasive Cardiology, 27(11), 521–528. https://lifeinthefastlane.com/ecg-library/wellens-syndrome/ Lin AN, Lin S, Gokhroo R, Misra D. Cocaine-induced pseudo-Wellens’ syndrome: a Wellens’ phenocopy. BMJ Case Rep. 2017 Dec 14;2017:bcr2017222835. doi: 10.1136/bcr-2017-222835. PMID: 29246935; PMCID: PMC5753703. Rhinehardt, J., Brady, W. J., Perron, A. D., & Mattu, A. (2002). Electrocardiographic manifestations of Wellens’ syndrome. The American Journal of Emergency Medicine, 20(7), 638–643. https://doi.org/10.1053/ajem.2002.34800 Tandy, TK; Bottomy DP; Lewis JG (March 1999). “Wellens’ syndrome”. Annals of Emergency Medicine. 33 (3): 347–351. PMID 10036351 . doi : 10.1016/S0196-0644(99)70373-2 . (via Wikipedia) Read More

Mar 4, 2021

We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage. Hosts: Mark Iscoe, MD Brian Gilberti, MD Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/SAH.mp3 Download One Comment Tags: Critical Care , Neurology , Subarachnoid Hemorrhage Show Notes Non-contrast head CT showing SAH ( Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 22770) Hunt-Hess grade and mortality (from Lantigua et al. 2015.) Hunt-Hess grade Mortality (%) 1. Mild Headache 3.5 2. Severe headache or cranial nerve deficit 3.2 3. Confusion, lethargy, or lateralized weakness 9.4 4. Stupor 23.6 5. Coma 70.5 Ottawa Subarachnoid Hemorrhage Rule, and appropriate population for rule application (from Perry et al. 2017) Apply to patients who are: Alert ≥ 15 years old Have new, severe, atraumatic headache that reached maximum intensity within 1 hour of osnet Do not apply to patients who have: New neurologic deficits Previous diagnosis of intracranial aneurysm, SAH, or brain tumor History of similar headaches (≥ 3 episodes over ≥ 6 months) SAH cannot be ruled out if the patient meets any of the following criteria: Age ≥ 40 Symptom of neck pain or stiffness Witnessed loss of consciousness Onset during exertion “Thunderclap headache” (defined as instantly peaking pain) Limited neck flexion on examination (defined as inability to touch chin to chest or raise head 3 cm off the bed if supine) ___________________________ Special Thanks To: Dr. Mark Iscoe, MD ( Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue) ___________________________ References: Bellolio MF, Hess EP, Gilani WI, et al. External validation of the Ottawa subarachnoid hemorrhage clinical decision rule in patients with acute headache. Am J Emerg Med. 2015;33(2):244-9. Carstairs SD, Tanen DA, Duncan TD, et al. Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage. Acad Emerg Med. 2006;13(5):486-492. Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711-1737. Czuczman AD, Thomas LE, Boulanger AB, et al. Interpreting red blood cells in lumbar puncture: distinguishing true subarachnoid hemorrhage from traumatic tap. Acad Emerg Med. 2013;20(3):247-256. Dugas C, Jamal Z, Bollu PC. Xanthochromia. [Updated 2020 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526048/ Goldstein JN, Camargo CA, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. 2006;26(6):684-90. Kumar A, Niknam K, Lumba-brown A, et al. Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians. Neurocrit Care. 2019. Lantigua H, Ortega-Gutierrez S, Schmidt JM, et al. Subarachnoid hemorrhage: who dies, and why? Crit Care. 2015;19:309. Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage. Lancet. 2017;389(10069):655-666. Mayer PL, Awad IA, Todor R, et al. Misdiagnosis of symptomatic cerebral aneurysm. Prevalence and correlation with outcome at four institutions. Stroke. 1996;27(9):1558-63. Meurer WJ, Walsh B, Vilke GM, Coyne CJ. Clinical guidelines for the emergency department evaluation of subarachnoid hemorrhage. J Emerg Med. 2016;50(4):696-701. Perry JJ, Spacek A, Forbes M, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage? Ann Emerg Med. 2008;51(6):707-713 Perry JJ, Stiell IG, Sivilotti MLA, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010;341:c5204. Perry JJ, Stiell IG, Sivilotti MLA, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;343(jul18 1):d4277-d4277. Perry JJ, Stiell IG, Sivilotti ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013;310(12):1248-55. Perry JJ, Sivilotti MLA, Sutherland J, et al. Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. CMAJ. 2017;189(45):E1379-E1385. Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke. 2007;38(4):1216-21. Read More

Jan 12, 2021

We discuss the (F)utility(?) of ED Utox screens with our very own Dr. Phil DiSalvo. Hosts: Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Urine_Drug_Screen_final.mp3 Download Leave a Comment Tags: Toxicology Show Notes Special Thanks To: Dr. Philip DiSalvo, MD Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue New York City Poison Control Center References: Christian MR, et al. Do rapid comprehensive urine drug screens change clinical management in children? Clin Toxicol (Phila). 2017;57:977-980. Grunbaum AM, Rainey PM (2019). Chapter 7: Laboratory Principles. In Goldfrank’s toxicologic emergencies. New York, NY: McGraw-Hill Education. Moeller K, Kissack J, Atayee R, Lee K. Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens. Mayo Clinic Proceedings Review. Volume 92, Issue 5, p774-796, May 1, 2017. https://www.mayoclinicproceedings.org/article/S0025-6196(16)30825-4/fulltext Table 2: Approximate Drug Detection Time in the Urine Table 4: Summary of Agents Contributing to Results by Immunoassay Read More

Jul 26, 2020

EM management of the rare but potentially complicated precipitous vaginal breech delivery. Hosts: Audrey Bree Tse, MD Masashi Rotte, MD MPH https://media.blubrry.com/coreem/content.blubrry.com/coreem/Breesashi_Breech_CoreEM.mp3 Download One Comment Tags: Obstetrics , Precipitous Deliveries , Pregnancy Show Notes Frank Breech Presentation: Complete Breech Presentation: Incomplete Breech (“Footling”) Presentation: Pinard Maneuver: Mauriceau Maneuver: References: Cunningham FG et al. Breech Presentation and Delivery. Williams Obstetrics, 22nd ed. 2005. Desai S, Henderson SO. Labor and Delivery and Their Complications. Rosen’s Emergency Medicine , 8e. 2014. Chapter 181. Gabbe SG et al. Obstetrics: Normal and Problem Pregnancies, 2nd e. 1991. p.479. Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet Gynecol Clin North Am. 2005; 32: 165. VanRooyen MJ, Scott J. Emergency Delivery. Tintanelli’s Emergency Medicine, 7th e. 2011. Chapter 105. http://www.emdocs.net/the-complicated-delivery-what-do-you-do/#:~:text=Deliveries%20that%20occur%20in%20the,in%20denial%20of%20their%20pregnancies. https://ranzcog.edu.au/womens-health/patient-information-resources/breech-presentation-at-the-end-of-your-pregnancy https://wikem.org/wiki/Breech_delivery Read More

Jun 30, 2020

The speech given by Dr. Goldfrank at the 2020 NYU / Bellevue Emergency Medicine Graduation Ceremony https://media.blubrry.com/coreem/content.blubrry.com/coreem/Goldfrank_Graduation_Speech_2020.mp3 Download Leave a Comment Tags: Graduation. Goldfrank Show Notes Graduation 2020 Lewis R. Goldfrank, MD June 17, 2020 WELCOME TO THE GRADUATES Congratulations to a wonderful group of physicians. It is a pleasure to recognize your great accomplishments in the presence of your friends, families, loved ones and the residents and faculty who have learned so much from and with you. I would first like to recognize those of you who are members of the Gold Humanism Honor Society. There are a remarkable number of awardees in our graduating class of 2020. CLASS OF 2020 Joe Bennett (R) Max Berger (R) Ashley Miller (R) Leigh Nesheiwat (S) Kristen Ng (R) Emily Unks (S) AND Arie Francis (R) Nisha Narayanan (S) FUTURE PGY-4 Elena Dimiceli (S) Kamini Doobay (S) Mark Iscoe (R) FUTURE PGY-3 Stasha O’Callaghan (S) Nicholus Warstadt (S) FUTURE PGY-1 Aaron Bola (S) Alison (Ali) Graebner (S) Aron Siegelson (S) Melissa Socarras (S) Sarah Spiegel (S) Thomas Sullivan (S) Christy Williams (S) GOLD HUMANISM CORE VALUES Integrity, Excellence, Compassion, Altruism, Respect, Empathy, Service These are the values you want as a doctor for yourself or a loved one, to have outstanding listening skills with patients to be at your side during a medical emergency, to have exceptional interest in service to the community, to have the highest standards of professionalism to integrate a humanistic approach in patient care. These values are what brought all of you to NYU-Bellevue and that you have honed throughout your training. The remainder of this talk shows how all of you have been successful and demonstrated these values some of you were elected to the Gold Humanism—all of you have achieved humanistic success. Your personal efforts in the face of uncertainty of the evolution of the pandemic, the inadequate supplies, the hospital and governmental problematic decisions are remarkable. In our country, the President did not mourn the loss of more than a 100,000 human beings and the needs of society. Nor did he provide the leadership and moral support that the country desperately needed to optimally handle this unprecedented crisis. You, in contrast, demonstrate unflappable commitment to address and overcome obstacles to care for your patients, assist your peers, educate and care for your families and friends, while also caring for yourselves. This is a tribute to your humanism. You created essential ways to help patients who were isolated from families and friends during the critical phases of COVID-19. You utilized new tools to communicate your sorrow, your compassion and love, to maintain essential humanistic traditions of medicine while you could not talk, touch or utilize other essential skills to the fullest extent of a physician. When you recognized that all your knowledge of the social determinants of medicine was playing out as COVID-19 assaulted the poorest in our country, the people of color, the people with essential jobs without personal protective equipment, the people crowded in apartments and subways and buses, you spoke up and acted with appreciation and understanding of these disparities. You recognized that our system of using medicine to correct the societal social institutionally entrenched disparities was inadequate. George Floyd’s death, and that of Breonna Taylor and innumerable others document the racism in America that destroys a part of us each and every day and by extension reinforces and normalizes white privilege. The ever increasing body of video evidence of the horrors of systemic racism is indisputable. You recognized that the American system of criminalization of social determinants is unacceptable. You spoke up and demonstrated that you saw our blind spots on policing and race. You protested to demand change in America. Change for equity and justice must occur throughout our society. “Black Lives Matter” will only be realized when the social determinants are truly addressed through changes that impact every vulnerable person. We must recognize that person, institutional and societal failures will not be corrected by medicalizing or criminalizing of socially determined inequities. Racism is systemic. Today you are seeking to create essential changes in medicine that will only occur when all the workplaces and governmental sites across the country, are enriched to allow a full representation of all the voices of all the people. You are leaders in the response to COVID-19 and the fight against racism. You will not only be remembered for having been present, but particularly for how you have responded. Thank you for your courage, creativity, resiliency and ability to transition and advance under duress. It was a privilege to watch you demonstrate the importance of your core values and the impact that your training here at NYU/Bellevue has had on your ability to integrate them into your practice. You are truly individuals of immense potential, ideal for advancing our world. How you keep these values and grow them in the next developmental stage of your careers will be critical. Each of you will contribute according to your talent, resources and priorities whether in clinical practice, academics, advocacy or public health. Always in every encounter with patients and their families “Be the change that you wish to see in the world” Mahatma Ghandi. THANK YOU AND CONGRATULATIONS! Read More

Feb 17, 2020

An overview and management tips of hemoptysis in the ED. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hemoptysis.mp3 Download One Comment Tags: Critical Care , Pulmonary Show Notes OVERVIEW: Definition: expectoration/ coughing of blood originating from tracheobronchial tree Sources: Bronchial arteries (90%): under systemic circulatory pressure to supply supporting structures of the lung → heavier bleeding Pulmonary arteries (5%): under low pressure to supply alveoli → milder bleeding Nonbronchial arteries (5%): intercostal arteries, coronary arteries, thoracic/ upper/ inferior phrenic arteries Quantification: Mild: <20mL/ 24h Massive defined anywhere from >300mL-1L/ 24hr Mortality: 38% for massive (>500mL/ 24hr) vs 4.5% for nonmassive Etiology (in adults): Infectious (most common): Bronchitis PNA (necrotizing, lung abscess) TB Viral Fungal Parasitic Malignancy: Primary lung cancer vs metastatic disease Pulmonary: Bronchiectasis COPD PE/ infarction Bronchopleural fistula Sarcoidosis Cardiac: Mitral stenosis Tricuspid endocarditis CHF Rheumatological: Goodpasture Syndrome SLE Vasculitis (Wegener’s, HSP, Behcet) Amyloidosis Hematological: Coagulopathy/ thrombocytopenia/ platelet dysfunction DIC Vascular: Pulmonary HTN AA Pulmonary artery aneurysm Aortobronchial fistula Pulmonary angiodysplasia Toxins: Anticoagulation/ aspirin/ antiplatelets Penicillamine, amiodarone Crack lung Organic solvents Trauma: Tracheobronchial rupture Pulmonary contusion Other: bronchoscopy/ lung biopsy Pulmonary artery or central venous catheterization Foreign body aspiration Pulmonary endometriosis (catamenial hemoptysis) Idiopathic (up to 25% of cases) Pseudohemoptysis: Sinusitis Epistaxis Rhinorrhea Pharyngitis URI Aspiration GIB WORKUP: HPI: CP, SOB B symptoms: fever, weight loss, chills, night sweats Lymphadenopathy Timeframe: acute vs chronic Prior lung/ renal/ cardiac disease Recreational drug/ cigarette/ chemical exposures travel/ infectious exposure Medications Any other sites of bleeding Precipitating factors Description of blood clots Patients are unable to accurately estimate degree of bleeding PE: Petechiae, edema, ecchymosis, ulcers, clubbing (chronic lung disease) Cardiopulmonary Sputum samples Labs: CBC w/ diff, BMP, LFTs, coags, T&S ABG UA Infectious workup if suspected: cultures, grain stains Imaging: CXR: 20% will be normal. May see tumour, cavity, effusion, infiltrate, PTX. Early pulmonary hemorrhage may present as infiltrate CT: only for stable patients! May see bronchiectasis, cavitary lesions, acinar nodules, tumours CTA: bronchial arteries, aneurysms, PE ECHO: identify valvular abnormalities, signs of PE, aortic aneurysm Bronchoscopy: Not often performed in ED, but therapeutic & diagnostic Allows direct visualization of tumours, foreign bodies, granulomas, infiltration, as well as local therapy (vasoconstrictive agents, stent/ balloon tamponade, electrocautery, procoagulants) MANAGEMENT: Goals: Control airway Protect healthy lung Identify and treat underlying cause Stabilize hemodynamics with volume resuscitation Provider precautions (respiratory & contact) ABCs, close monitoring Early airway management: massive hemoptysis, respiratory compromise, hypoxia, risk factors (elderly, AMS, coagulopathic) 2 x suction, preoxygenation, patient positioned upright, >8Fr ETT to facilitate suctioning/ bronch If bleeding side can be identified, consider “selective intubation” into nonbleeding lung to minimize further aspiration of blood and to provide ventilation Life threat = asphyxiation, not exsanguination. ~Only 150cc anatomic dead space in major airways 2 x large bore IVs MTP prn vs volume resuscitation “Bad lung down” in lateral position: theoretical belief to minimize reflux of blood into normal lung Correct coagulopathy Consider nebulized TXA for nonmassive hemoptysis (500mg w/ NS per neb) Double-blind, randomized controlled trial in 2018 Nebulized TXA (500mg TID) vs placebo (normal saline) in hemodynamically stable adult patients admitted with mild hemoptysis (<200 mL/ 24hr) and no respiratory instability Additional exclusion criteria included those with renal failure, hepatic failure, or coagulopathy Assessed mortality and hemoptysis recurrence rate at 30 days and 1 year 25 patients randomized to receive TXA nebs, 22 randomized to receive normal saline nebs Results: Resolution of hemoptysis within 5 days of admission was significantly higher in TXA-treated patients than placebo patients (96% vs 50%; P < 0.0005) Mean hospital length of stay was shorter for TXA group (5.7 +- 2.5 days vs 7.8 +- 4.6 days; P = 0.046) Fewer patients in TXA group required invasive procedures to control bleeding vs placebo group (0% vs 18.2%; P = 0.041) No side effects were noticed in either group Antibiotics if infectious Bronchoscopy: local therapy (vasoconstrictive agents, stent/ balloon tamponade, electrocautery, procoagulants) Rigid bronch for unstable patients to evacuate clots vs fiberoptic bronch for stable patients Bronchial artery embolization (call IR early!) May require lobectomy or pneumonectomy (consult thoracic surgery) DISPOSITION: Low threshold for higher level of care: only mild, hemodynamically stable hemoptysis on floor Discharge: only if certain regarding etiology in healthy, hemodynamically stable patients with scant, resolved hemoptysis, no coagulopathy, and reassuring workup Ensure patients have reliable follow up and avoid smoking. Strict return precautions! REFERENCES: Kiraly A, Pang P, Cheema N. Hemoptysis . In: Schaider J, Barkin R, Hayden S, Wolfe R, Barkin A, Shayne P, Rosen P. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 5th Edition. Philadelphia, PA: Wolters Kluwer; 2015; 504-505. Nickson, C. Haemoptysis. Life in the Fastlane. [litfl.com/haemoptysis/]. Updated April 9, 2019. Retrieved February 10, 2020. Wand O, Guber E, Guber A, Schochet GE, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. December 2018; 154(6): 1379-1384. Young WF. Hemoptysis. In: Cline, David,eds. Tintinalli’s Emergency Medicine Manual. 7th Edition. New York : McGraw-Hill Medical; 2011; 473-476. Read More

Jan 27, 2020

We go over the recent updates in the workup and management of pneumonia. Hosts: Brian Gilberti, MD Audrey Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumonia_Updates.mp3 Download Leave a Comment Tags: Infectious Diseases , Pulmonary Show Notes 2007 Infectious Diseases Society of America/American Thoracic Society Criteria for Defining Severe Community-acquired Pneumonia Validated definition includes either one major criterion or three or more minor criteria Minor criteria Respiratory rate > 30 breaths/min PaO2/FIO2 ratio<250 Multilobar infiltrates Confusion/disorientation Uremia (blood urea nitrogen level > 20 mg/dl) Leukopenia* (white blood cell count , 4,000 cells/ml) Thrombocytopenia (platelet count , 100,000/ml) Hypothermia (core temperature , 368 C) Hypotension requiring aggressive fluid resuscitation Major criteria Septic shock with need for vasopressors Respiratory failure requiring mechanical ventilation A special thanks to our Infectious Diseases Editor: Angelica Cifuentes Kottkamp, MD Infectious Diseases & Immunology NYU School of Medicine Read More

Jan 13, 2020

Diagnosing and managing one of our critical diagnoses - posterior stroke. Hosts: Mukul Ramakrishnan, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/final_posterior_stroke_podcast_post_edit.mp3 Download 2 Comments Tags: Neurology , Posterior Stroke Show Notes See Dr. Newman-Toker demonstrate the HINTS exam here Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10 Read More

Dec 16, 2019

We discuss one of the most complex problems we face – Homelessness Hosts: Kelly Doran, MD Audrey Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Homelessness.mp3 Download One Comment Tags: Social Emergency Medicine Show Notes Special Thanks To: Dr. Kelly Doran, MD MHS Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue ___________________________ References: Doran, K.M. Commentary: How Can Emergency Departments Help End Homelessness? A Challenge to Social Emergency Medicine. Ann Emerg Med. 2019;74:S41-S44. Doran, K.M., Raven, M.C. Homelessness and Emergency Medicine: Where Do We Go From Here? Acad Emerg Med. 2018;25:598-600. Salhi, B.A., et al. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med. 2018;25:577-93. U.S. Department of Housing and Urban Development, Annual Homeless Assessment Report to Congress. Available at: https://www.hudexchange.info/resource/5783/2018-ahar-part-1-pit-estimates-of-homelessness-in-the-us/ U.S. Interagency Council on Homelessness. Home, Together Federal Strategic Plan to Prevent and End Homelessness. https://www.usich.gov/resources/uploads/asset_library/Home-Together-Federal-Strategic-Plan-to-Prevent-and-End-Homelessness.pdf Read More

Nov 25, 2019

We go into one of the more complex injuries – blunt neck trauma. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blunt_Neck_Injuries.mp3 Download One Comment Tags: Trauma Show Notes Overview Blunt neck trauma comprises 5% of all neck trauma Mortality due to loss of airway more so than hemorrhage Mechanism MVCs with cervical hyperextension, flexion, rotation during rapid deceleration, direct impact Strangulation: hanging, choking, clothesline injury (see section on strangulation in this chapter) Direct blows: assault, sports, falls Initial Management/Primary Survey Airway Evaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromise Early aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema Assume a difficult airway Breathing Supplemental oxygen Assess for bilateral breath sounds Can use bedside US to evaluate for pneumothorax or hemothorax Circulation Assess for open wounds, bleeding, hemorrhage IV access Disability Maintain C-spine immobilization Calculate GCS Look for seatbelt sign Secondary Survey Evaluate for specific signs of vascular, laryngotracheal, pharyngoesophageal, and cervical spinal injuries with inspection, palpation, and auscultation Perform extremely thorough exam to evaluate for any concomitant injuries (e.g. stab wounds, gunshot wounds, intoxications/ ingestions, etc.) Types of Injuries Vascular injury Overview Carotid arteries (internal, external, common carotid) and vertebral arteries injured Mortality rate ~60% for symptomatic blunt cerebral vascular injury Mechanism Hyperextension and lateral rotation of the neck, direct blunt force, strangulation, seat belt injuries, and chiropractic manipulation Morbidity due to intimal dissections, thromboses, pseudoaneurysms, fistulas, and transections Clinical Features Most patients are asymptomatic and do not develop focal neurological deficits for days if Horner’s syndrome, suspect disruption of thoracic sympathetic chain (wraps around carotid artery) specific screening criteria are used to detect blunt cerebrovascular injury in asymptomatic patients (see below) Tintinalli 2016 Diagnostic Testing Gold standard for blunt cerebral vascular injury = MDCTA (multidetector four-vessel CT angiography) <80% sensitive but 97% specific Also images aerodigestive tracts and C-spine (unlike angiography) Followed by Digital Subtraction Angiography (DSA) for positive results or high suspicion Angiography is invasive, expensive, resource-intensive, and carries a high contrast load Management Antithrombotics vs. interventional repair based on BCVI grading system Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology All patients with blunt cerebral vascular injury will require admission Tintinalli 2018 Pharyngoesophageal injury Overview Rare in blunt neck trauma Includes hematomas and perforations of both pharynx and esophagus Mechanism Sudden acceleration or deceleration with hyperextension of the neck Esophagus is thus forced against the spine Clinical Features Dysphagia, odynophagia, hematemesis, spitting up blood Tenderness to palpation SC emphysema Neurological deficits (delayed presentation) Infectious symptoms (delayed presentation) Diagnostic Testing Esophagography with water-soluble contrast (e.g. Gastrograffin) If negative contrast esophagography, obtain flexible endoscopy (most sensitive) Combination of contrast esophagography + esophagoscopy has sensitivity close to 100% Swallow studies with water-soluble agent MDCTA Plain films of neck and chest Findings such as pneumomediastinum, hydrothorax, or retropharyngeal air may suggest perforation but are not sensitive Management All pharyngoesophageal injuries receive IV antibiotics with anaerobic coverage Parenteral/ enteral nutrition NGT should only be placed under endoscopic guidance to avoid further injury Medical management vs. surgical repair depending on extent of injury Surgical repair for esophageal perforations or pharyngeal perforations >2cm Involve consultants early: trauma surgery, vascular surgery, otolaryngology, gastroenterology All patients with blunt cerebral vascular injury will require admission Laryngotracheal injury Overview Occurs in >0.5% of blunt neck trauma Includes hyoid fractures, thyroid/ cricoid cartilage damage, cricotracheal separation, vocal cord disruption, tracheal hematoma or transection Mechanism Assault, clothesline injuries, direct blunt force from MVCs compressing the larynx between a fixed object and the spine Clinical Features Patients are often asymptomatic at first and then develop airway edema and/or hematoma resulting in airway obstruction Children are at higher risk for airway compromise due to less cartilage calcifications Diagnostic Testing Flexible fiberoptic laryngoscopy (FFL) to assess airway patency and extent of intraluminal injury MDCTA Obtain 1-mm cuts of larynx and perform multiplanar reconstructions Consider POCUS to detect laryngotracheal separation Plain films of neck and chest Poor sensitivity for penetrating neck trauma injuries Can show extraluminal air, fracture or disruption of cartilaginous (e.g. larynx) structures Management When securing airway, use an ETT that is one size smaller due to likelihood of airway edema Conservative management (IV antibiotics, steroids, observation) vs. surgical repair Grades III, IV, and V laryngotracheal injuries as defined by Schaefer and Brown’s classification system require OR Tintinalli 2018 Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology, otolaryngology Cervical spine/ spinal cord injury See chapter for spinal trauma Disposition Admit symptomatic patients to monitored setting Given delayed symptoms, consider monitoring patients who are asymptomatic on arrival Serial exams for worsening dyspnea, dysphonia, stridor, drooling, bruits, focal neuro deficits Only discharge after ruling out airway threat, neurological deficit, vascular injury, or suicidal/ homicidal ideation Monitor asymptomatic patients on home anticoagulation in ED for at least 6 hours from trauma to rule out delayed neck hematoma Social work and/or psychiatry for patients in whom you suspect suicide risk or domestric violence, look for other signs of self harm Take Home Points Aggressive early airway management for unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology, otolaryngology Victims of blunt cerebral vascular injury may present completely asymptomatic but develop delayed neurological symptoms; close observation and monitoring is recommended especially for patients on home anticoagulation Remember to evaluate for concomitant injuries Psychiatric evaluation for all attempted suicides References Bromberg, William. et al. Blunt Cerebrovascular Injury Practice Management Guidelines: The Eastern Association for the Surgery of Trauma. J Trauma. 68 (2): 471-7, Feb 2010. Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139:540–545; discussion 545–546. Joshua AA. Neck Trauma, Blunt, Anterior . In: Schaider J, Barkin R, Hayden S, Wolfe R, Barkin A, Shayne P, Rosen P. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 5th Edition. Philadelphia, PA: Wolters Kluwer; 2015; 738-739. Tintinalli, J., Stapczynski, J. Stephan, editor, Ma, O. John, editor, Yealy, Donald M., editor, Meckler, Garth D., editor, & Cline, David, editor. (2018). Tintinalli’s emergency medicine : A comprehensive study guide (9th ed.). Walls, R., Hockberger, Robert S., editor, & Gausche-Hill, Marianne, editor. (2018). Rosen’s emergency medicine : Concepts and clinical practice (Ninth ed.). Advanced trauma life support. (2018). 10th ed. Chicago, IL: American College of Surgeons. Special thanks to Sana Maheshwari, MD NYU Bellevue Emergency Medicine Residency PGY3 Read More

Nov 4, 2019

We dissect one of the most common injuries we see in the ER -- ankle sprains Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Ankle_Sprains.mp3 Download 3 Comments Tags: Orthopedics Show Notes Background Among most common injuries evaluated in ED A sprain is an injury to 1 or more ligaments about the ankle joint Highest rate among teenagers and young adults Higher incidence among women than men Almost a half are sustained during sports Greatest risk factor is a history of prior ankle sprain Anatomy Bone: Distal tibia and fibula over the talus → constitutes the ankle mortise Aside from malleoli, ligament complexes hold joint together Medial deltoid ligament Lateral ligament complex Anterior talofibular ligament Most commonly injured Weakest 85% of all ankle sprains Posterior talofibular ligament Calcaneofibular ligament Syndesmosis Mechanism of Injury Lateral ankle sprains Most common among athletes ATFL most commonly injured Combined with CFL in 20% of injuries 2/2 inversion injuries Medial ankle sprains Less common than lateral because ligaments stronger and mechanism less frequent More likely to suffer avulsion fracture of medial malleolus than injure medial ligament 2/2 eversion +/- forced external rotation Typically landing on pronated foot -> external rotation High Ankle sprains Syndesmotic injury More common in collision sports (football, soccer, etc) Grade I Mild Stretch without “macroscopic” tearing Minimal swelling / tenderness No instability No disability associated with injury Grade II Moderate Partial tear of ligament Moderate swelling / tenderness Some instability and loss of ROM Difficulty ambulating / bearing weight Grade III Severe Complete rupture of ligaments Extensive swelling / ecchymosis / tenderness Mechanical instability on exam Inability to bear weight Examination Beyond visual inspection for swelling, ecchymoses, abrasions, or lacerations Palpation Pain when palpating ligament is poorly specific but may indicate injury to structure Check sites for Ottawa ankle rules to evaluate if there may be an associated fracture with injury Posterior edge or tip of lateral malleolus (6 cm) Posterior edger or tip of medial malleolus (6 cm) Base of fifth metatarsal Navicular bone Acute ATFL rupture / Grade III Sprain 90% chance of this injury if hematoma and localized tenderness with palpation present on exam over this ligament Anterior drawer test Assess for anterior subluxation of talus from the tibia Ankle in relaxed position, distal extremity is stabilized with one hand while the other cups the heel to apply anterior force Compare to contralateral side Difficult to determine if there is an acute rupture at this point and may be more easily diagnosed in subacute phase (4-5 days after injury) Ability to perform exam adequately limited by pain, swelling and potential muscle spasm Talar tilt test If applying inversion force to ankle and there is excessive mobility → calcaneofibular ligament Thompson test Can be performed if there is concern for concomitant Achilles tendon injury Do not miss a Maisonneuve fracture by palpating proximally about the fibular ahead as forces may be transmitted through the syndesmosis Squeeze test – pressure just proximal to ankle If elicits pain → concern for syndesmotic injury Diagnostics X-rays indicated if unable to rule out using Ottawa Ankle Rules Sn (Up to 99.6) (one of the best validated tools we use in the ER) May have trouble applying rule if there is question of patients ability to sense pain (diabetic neuropathy), in which case obtain radiographs Treatments RICE Crutch train so they can be weight bearing a tolerated Ideally initiate within first 24 hours of injury Ice 15-20 minutes q2-3h over the first 48 hours or until swelling improves NSAIDs Topical and PO are better than placebo We do not know if PO is superior to topical NSAIDs Early mobilization / Functional Rehab (sample patient instructions here ) Work to restore range of motion, strength, proprioception For Grade I and II, can begin as soon as the patient can tolerate and ideally within 1 week of the injury Patients return to work sooner, decreased chronic instability, less recurrent injuries Dorsiflexion, plantarflexion, and perform foot circles as well as toe curls, inversion and eversion as tolerated Proprioception Balancing on wobble board Continue exercises until patient is able to return to activities at full capacity, without pain Immobilization High re-injury rates and important to protect against this Grade I No immobilization required +/- Ace wrap Grade II Aircast brace Ensure patient understands that they should still partake in rehabilitation exercises Grade III Data conflicts RCT, multicenter study comparing aircast brace, compression bandage, Bledsoe immobilization boot and below-knee cast for 10 days Ankle function at 3 months Cast group had most improvement No difference at 9 months in function or complications May be institution-dependent and a cast can be offered initially Prognosis Acute inflammation → reduction in swelling → development of new tissue → strengthening of tissue Return of basic function, though limited, occurs over 4-6 weeks depending on severity of sprain Try to limit strain put on joint (no heavy lifting, walking on uneven surfaces, try to limit standing while at work) Follow up: If pain or instability does not improve over 4-6 weeks Grade III sprains Medial ankle sprains (may have underlying fracture that was undetected in ED on XR) Syndesmosis injuries (protracted recovery course) Injuries associated with fractures or dislocation / subluxation Read More

Oct 21, 2019

An overview of Vaping Associated Lung Injury (VALI) Hosts: Audrey Bree Tse, MD Larissa Laskowski, DO Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vaping_Associated_Lung_Injury.mp3 Download 2 Comments Tags: Pulmonary , Toxicology Show Notes Why this matters As of Oct 15, vaping has been associated with acute lung injury in over 1400 people 33 deaths have been confirmed in 24 states 70+% of those with VALI are young men A large number of patients are requiring ICU/ intubation/ ECMO 4 main ingredients in solvent +/- Flavor additives +/- Nicotine or THC (Tetrahydrocannabinol) Propylene Glycol (PG) Vegetable Glycerin (VG) CDC definition of VALI (Vaping Associated Lung Injury) Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset AND Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT AND Absence of pulmonary infection on initial work-up. No evidence in the medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process). *Dabbing allows the user to ingest a high concentration of THC. Butane Hash Oil (BHO), an oil or wax-like substance extracted from the marijuana plant, is placed on a “nail” attached to a specialized glass bong called a “rig.” A blow torch is used to heat the wax, which produces a vapor that can then be inhaled to supposedly produce an instantaneous effect. Pathophysiology At present, no single compound or ingredient has emerged as the cause, and there may be more than one cause The only common thread among the cases is that ALL patients reported using e-cig or vaping products Leading potential toxins: Vaping products containing THC concentrates: most cases are linked to THC concentrates that were either purchased on the street or from other informal sources (meaning not from a dispensary) Vitamin E acetate: nutritional supplement safe when ingested or applied to the skin (but likely not when inhaled) has been found in nearly all product samples of NY state cases of suspected VALI vitamin E acetate is NOT an approved additive at least by NYS Medical Marijuana program Other potential toxins: IT CANNOT BE UNDERSTATED that a small percentage of persons w/ VALI have reported exclusive use of nicotine-containing vape products, such as JUUL; as such, we must consider the potential toxicity of standard e-liquid or vape juice Flavor additives, that exists as chemical aldehydes: irritating and potentially damaging to lung tissue PG/VG: shown not only to break down to formaldehyde which is a known carcinogen, but also to produce lipoid pneumonia in rat lungs Some devices are easily manipulated to increase the capacity to produce vapor; increasing these settings may impact heating temperature, metabolic breakdown, and release of microscopic metal particles Lungs are multifunctional, including serving as an immune organ: lungs cleave proteins of all of the bacteria, viruses and other pathogens we are exposed to and inhale daily human studies on those that are chronic e-cig users or vapers have revealed that these products are shifting the balance of proteases and antiproteases in our lungs such that the proteases are destroying native lung tissue similar to how traditional cigarettes cause COPD Many potential reactions: NEJM article in references: details four radiographic phenotypes essentially reflecting different pathologic changes Long-term Effects Long term effects are unknown (some pts have required home oxygen on discharge) Risk for recurrence or relapse, especially if repeat exposure Presentation 95% of pts have had pulmonary sxs (cough, cp, dyspnea) 77% of pts have had GI sxs (abd pain, n/v/d) 85% of pts w/ constitutional sxs (f/c, weight loss) 57% w/ hypoxia (O2 < 95%) Unfortunately auscultation has been unreliable and poorly sensitive Workup There is no specific test or marker for dx, so VALI is still considered a dx of exclusion Labs: CBC ESR/CRP (93% w/ elevated ESR) LFTs (50% w/ transaminitis) ABG: hypoxia Imaging: CXR: typically shows bilateral infiltrates, although not always and there have even been some cases w/ unremarkable chest XR (so high degree of clinical suspicion in any person p/w hypoxia) CT: ground glass opacities, typically bilaterally Management Dispo: 96% of cases required hospitalization Any pt w/ hypoxia, respiratory distress, or comorbidities Outpatient only if: no hypoxia or respiratory distress, reliable followup within 48h and good social support (keep in mind that some patients w/ mild symptoms of first presentation deteriorated rapidly within 48h) Empiric treatments for pneumonia inc abx, antivirals Steroids (methylpred 60mg q6h, based on how index cases in Illinois were managed) Case reports have documented improvement Mechanism: blunting of inflammatory response Aggressive supportive care Special Thanks To: Dr. Larissa Laskowski, DO Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue New York City Poison Control Center References: Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html Carlos WG, Crotty Alexander LE, Gross JE, Dela Cruz CS, Keller JM, Pasnick SP, Jamil S. Vaping-associated Pulmonary Illness (VAPI). Public Health Information Series. Am J Respir Crit Care Med Vol. 200, 13-15, 2019. www.atsjournals.org/doi/pdf/10.1164/rccm.2007P13 Henry TS, Kanne JP, Kilgerman SJ. Images of Vaping-Associated Lung Disease — Correspondence. N Engl J Med. 2019 Oct 10; 381;15. Layden JE, Ghana I, Pray I, Kimball A, Layer M, Tenforde M, Navon L, Hoots B, Salvatore PP, Elderbrook M, Haupt T, Kanne J, Patel MT, Saathaff-Huber L, King BA, Schier JG, Mikosz CA, Meiman J. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print]. https://www.ncbi.nlm.nih.gov/pubmed/31491072?dopt=AbstractPlus Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019. MMWR Morb Mortal Wkly Rep 2019;68:919–927. DOI: http://dx.doi.org/10.15585/mmwr.mm6841e3external icon . https://www.health.ny.gov/press/releases/2019/2019-09-05_vaping.htm Read More

Sep 23, 2019

An overview of septic arthritis. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Arthritis.mp3 Download One Comment Tags: Infectious Diseases , Orthopedics Show Notes Episode Produced by Audrey Bree Tse, MD Background Bacteria enters the joint by hematogenous spread due to absence of basement membrane in synovial space from invasive procedures, contiguous infection (e.g. osteomyelitis, cellulitis), or direct inoculation (e.g. plant thorns, nails) WBCs migrate into joint → acute inflammatory process → synovial hyperplasia, prevents new cartilage from forming, pressure necrosis on surrounding joint, purulent effusion Why do we care? irreversible loss of function in up to 10% & mortality rate as high as 11% Cartilage destruction can occur in a matter of hours Complications include bacteremia, sepsis, and endocarditis Etiology Risk factors: extremes of age, RA, DJD, IVDA, endocarditis, GC, immunosuppression, trauma, or prosthesis Organisms: Staph: staph aureus (most common), MRSA, Staph epidermis N gonorrhea: young healthy sexually active adults Strep: group A & B GNRs: IVDA, diabetics, elderly Salmonella: sickle cell disease Cutibacterium acnes: prosthetic shoulder infection Consider mycobacterial & fungal in more indolent courses Presentation Typically a single, warm, erythematous, tender joint (#1: knee (50% of cases) → hip, shoulder, ankle) *Any joint can be involved! IVDA can involve sacroiliac, costochondral, & sternoclavicular joints Classic teaching: very painful with ROM, but this is not always present! Joint usually held in position of maximum joint volume Prosthetic joints may have less pain than expected for a septic joint given changed anatomy and disrupted nerve endings In 10-20% of cases, can see polyarticular involvement GC typically monoarticular but commonly polyarticular Often have fever & separate infection as well (only see fever in ~60% of cases) Diagnostics Arthrocentesis: Gold standard Tap joint even if acceptable ROM: septic joints can have normal motion so it does not exclude the diagnosis! Use ultrasound if possible Relative contraindications: overlying cellulitis (risk of seeding joint) or severe coagulopathies (weigh risk of creation or worsening of iatrogenic hemarthrosis) Keep in mind that a “dry tap” may occur due to incorrect needle placement, absent/ minimal joint effusion, ort mechanical obstruction Note: talk to ortho colleagues if prosthesis present prior to performing arthrocentesis Ortho team may want to perform the arthrocentesis themselves because scar tissue formation and altered anatomic relationships make the procedure more challenging Usually want to perform washout in OR plus/ minus antibiotic spacer Send fluid for protein, glucose, cell count with differential, gram stain, culture, and crystals Often see decreased glucose and elevated protein The presence of crystals does not rule out septic arthritis No clear number of synovial WBCs to define septic arthritis, but in general: >30 to 50K/ mm3 synovial WBCs with PMN predominance (>75%) seen in septic arthritis A 2011 meta-analysis suggests +LRs of 4.7 (95% CI = 2.5 to 8.5) and +LR of 13.2 (95% CI = 3.6 to 51.1) for a sWBC count of >50L × 109 or >100K, respectively Use the synovial WBC count plus the whole clinical picture to rule in or out the diagnosis of septic arthritis (do not use the synovial WBC in isolation) Different threshold for prosthetic joints: WBC > 1100 or >64% PMNs = septic arthritis Gram stains only identify causative organisms 1/3 of the time Culture negative arthrocentesis can be seen in cases where abx have been given prior to arthrocentesis, or in TB/ brucella/ nocardia/ other indolent organisms like fungi Labs: No studies have demonstrated an acceptable sensitivity or overall diagnostic accuracy of peripheral WBC count for SA, but usually see leukocytosis with left shift ESR and CRP are reasonably sensitive but there is no cutoff that significantly increases or decreases the pretest probability UA, urine cultures, blood cultures: send even if no fever Blood cultures are positive in 50-70% of nonGC SA If GC suspected, do GC NAAT from throat/ rectal/ urethral/ cervical discharge Imaging: XRs: effusion, baseline status of joint, contiguous osteomyelitis, fractures, foreign body US: effusion CT, MRI: not really used in ED Differential Viral arthritis RA gout/ pseudogout HIV associated arthritis Reactive arthritis Lyme Osteo Septic bursitis Trauma Treatment Septic arthritis is an orthopedic emergency! Needs IV abx + often washout of the joint Hold abx as much as possible prior to tap unless pt is unstable or tap cannot be performed easily Initiate empiric IV antibiotic therapy prior to definitive cultures based Transition to organism-specific antibiotic therapy once culture sensitivities result Start empiric abx based on gram stain if available (in non-=GC SA, grain stain is positive in 50% of cases), age group, & risk factors Empiric abx: Vancomycin 15mg/kg q12h (to cover MRSA) + cefepime 2gr IV q8h (to cover gram-negatives) If gram stain with GPC = Vancomycin 15mg/kg q12h If gram stain with GN diplococci = ceftriaxone 1gr IV q24h + Azithromycin 1gr q24h If gram stain with GN rods = cefepime 2gr IV q8h If penicillin allergy: ciprofloxacin 500mg q12h or aztreonam 2gr q8h No need to cover anaerobes unless human/dog/cat bite (then use Unasyn to cover eikenella, pastereulla, capnocytophaga, anaerobes, etc.) They usually need antibiotics for 2-6 weeks: 2 weeks for strep, up to 6 weeks if S aureus Pain control: consider moderately flexed splinting Admit all patients with suspected septic arthritis until SA is ruled out, abx, monitoring, likely operative intervention Take-Home Points Patients may present with either a single affected joint or polyarticular; they may or may not have a fever Have a high index of suspicion for SA, and a low threshold to tap: pts do not necessarily present w/ “classic” findings and it is difficult to distinguish SA from crystal arthropathy ESR, CRP, serum WBC are not definitive diagnostic tools for septic arthritis There is no exact cutoff for synovial WBCs for diagnosis: use whole clinical picture & keep 50K in mind for native joints, and >1100 for prostheses Treat with empiric abx after tap then narrow accordingly, & admit all patients with septic arthritis Involve your ortho colleagues early especially for prosthesis References Carpenter CR, Schuur JD, Everett WW, et al. Evidence-based diagnostics: Adult septic arthritis. Acad Emerg Med. 2011;18:781-796. Jones D, Clements C. Physical exam and bloodwork do not adequately differentiate infectious from inflammatory arthritis. In: Mattu A, Chanmugam A, Swadron S, Woolridge D, Winters M. Avoiding Common Errors in the Emergency Department. 2nd Edition. Philadelphia, PA: Wolters Kluwer; 2017; 412-414. Kazzi A, Zaghrini E. Septic Arthritis . In: Schaider J, Barkin R, Hayden S, Wolfe R, Barkin A, Shayne P, Rosen P. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 5th Edition. Philadelphia, PA: Wolters Kluwer; 2015; 102-103. Osmon D, Berbari E, Berendt A, Lew D, Zimmerli W, Steckelberg J, Rao N, Hanssen A, Wilson W. Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of America, Clinical Infectious Diseases , Volume 56, Issue 1, 1 January 2013, Pages e1–e25, https://doi.org/10.1093/cid/cis803 Mlynarek C, Sullivan A. Arthrocentesis Tips. In: Mattu A, Chanmugam A, Swadron S, Woolridge D, Winters M. Avoiding Common Errors in the Emergency Department. 2nd Edition. Philadelphia, PA: Wolters Kluwer; 2017; 684-686. Purcell D, Terry B, Sharp B. Joint Arthrocentesis. In: Purcell D, Chinai S, Allen B, Davenport M. Emergency Orthopedics Handbook. 1st Edition. Cham, Switzerland: Springer; 2019; 87-104. Sheth U, Moore D. Septic Arthritis — Adult . OrthoBullets. [ https://www.orthobullets.com/trauma/1058/septic-arthritis–adult ]. Updated 1/9/19. Accessed 8/2/19. A special thanks to our Infectious Diseases Editor: Angelica Cifuentes Kottkamp, MD Infectious Diseases & Immunology NYU School of Medicine A special thanks to our Orthopedics Editor: Daniel Purcell, MD Emergency Medicine NYU Langone Brooklyn Read More

Aug 26, 2019

A look at the most common type of seizures in the young pediatric population. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Febrile_Seizures.mp3 Download Leave a Comment Tags: Pediatrics Show Notes Background The most common type of seizure in children under 5 years of age Occur in 2-5% of children In children with a fever, aged 6 months to 5 years of age, and without a CNS infection Risk Factors 4 times more likely to have a febrile seizure if parent had one Also increase in risk if siblings or nieces / nephews had one Common associated infections Human Herpesvirus 6 Human Herpesvirus 7 Influenza A & B Simple Febrile Seizure Generalized tonic-clonic activity lasting less than 15 minutes in a child 6 months to 5 years of age Complex Febrile Seizure Lasts longer than 15 minutes, occurs in a child outside of this age range, are focal, or that recur within a 24-hour period. Diagnostics / Workup Gather thorough history and perform thorough physical exam Most cases will not require labs, imaging or EEG If e/o meningitis, perform LP AAP suggests considering LP in: Children 6-12 months who are not immunized for H flu type B or strep pneumo Children who had been on antibiotics For complex seizures, clinician may have a lower threshold for obtaining labs Hyponatremia is more common in this group than in the general population. LPs are more commonly done by providers, but these are low yield with one study showing bacterial meningitis being diagnosed in just 0.9% (Kimia 2010), all of whom did not have a normal exam or negative cultures. Neuroimaging is also exceedingly low yield if the patient returns to baseline (Teng 2006) One study that showed that the duration of complex febrile seizure, being greater than 30 minutes, was associated with a higher incidence of bacterial meningitis. (Chin 2005) Of they have history and exam concerning for meningitis, they should get an LP If they look dehydrated or edematous, you would have more of a reason to get a chemistry Treatment Benzodiazepine if seizure lasted for >5 minutes, either IV or IN Supportive care Tylenol or motrin if febrile Fluids if signs of dehydration Antipyretics “around the clock” A majority of data show no benefit in preventing recurrence of seizure One study (Murata 2018) found that giving tylenol q6h at 10 mg/kg for the first 24 hours following the initial seizure decreased the rate of recurrence when compared to children who did not receive antipyretics. NNT here was 7 Questionable whether we can generalize these findings from a single ED in Japan. No role for antiepileptics Prognosis High rate of recurrence (~1/3) within 1 year of initial seizure Risk increases for Younger age at which they had initial seizure Lower temperature at which they had seizure If initial febrile seizure was prolonged, more likely that the next will be prolonged 1-2% develop epilepsy for simple febrile seizure, slightly above risk of general population 5-10% develop epilepsy for complex febrile seizure Follow up with PMD Generally, peds neuro follow up is not necessary References Chin RF, Neville BG, Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child. 2005;90(1):66-9. Kimia A, Ben-Joseph EP, Rudloe T, Capraro A, Sarco D, Hummel D, et al. Yield of lumbar puncture among children who present with their first complex febrile seizure. Pediatrics. 2010;126(1):62-9. Murata S, Okasora K, Tanabe T, Ogino M, Yamazaki S, Oba C, et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. 2018;142(5). Patel N, Ram D, Swiderska N, Mewasingh LD, Newton RW, Offringa M. Febrile seizures. BMJ. 2015;351:h4240. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013;54(12):2101-7. Stapczynski, J. S., & Tintinalli, J. E. (2016). Tintinalli’s emergency medicine: A comprehensive study guide, 8th Edition. New York: McGraw-Hill Education. Subcommittee on Febrile S, American Academy of P. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-94. Teng D, Dayan P, Tyler S, Hauser WA, Chan S, Leary L, et al. Risk of intracranial pathologic conditions requiring emergency intervention after a first complex febrile seizure episode among children. Pediatrics. 2006;117(2):304-8. Warden CR, Zibulewsky J, Mace S, Gold C, Gausche-Hill M. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003;41(2):215-22. A special thanks to our editors: Michael A. Mojica, MD Director, Pediatric Emergency Medicine Fellowship Bellevue Hospital Center Christie M. Gutierrez, MD Pediatric Emergency Medicine Fellow Columbia University Medical Center Morgan Stanley Children’s Hospital New York Presbyterian Read More

Jul 30, 2019

A review for the emergency physician of this common tick-borne illness. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Lyme_Disease.mp3 Download Leave a Comment Tags: Infectious Diseases Show Notes Episode Produced by Audrey Bree Tse, MD Background Most common tick-born illness in North America Endemic in Northeast, Upper Midwest, northwest California 80% to 90% in summer months Pathophysiology Ixodes tick (deer tick) has a 3-stage life cycle (larvae, nymph, adult) & takes 1 blood meal per stage Deer tick feeds on an infected wild animal (infected with spirochete Borrelia burgodrferi) then bites humans On humans, they typically move until they encounter resistance (e.g. hairline, waistband, elastic, skin fold). It takes 24-48 hrs for B. Burgdorferi to move from the tick to the host Pathogenesis: organism induced local inflammation, cytokine release, autoimmunity No person to person transmission Clinical Presentation Stage 1: Early Symptom onset few days to a month after tick bite Erythema migrans rash: bulls eye rash seen in more than 90% of patients with Lyme disease (Irregular expanding annular lesion(s)) Regional adenopathy, intermittent fevers, headache, myalgias, arthralgia, fatigue, malaise Stage 2: disseminated/ secondary Days to weeks after tick bite Intermittent fluctuating sx that eventually resolve Triad of aseptic meningitis, cranial neuritis, and radiculoneuritis: bell palsy most common Cardiac symptoms: tachycardia, bradycardia, AV block, myopericarditis Stage 3: tertiary/ late Symptoms occur >1 year after tick bite Acrodermatitis chronic atrophicans: Atrophic lesions on extensor surfaces of extremities (resembles scleroderma) Monoarthritis, oligoarthritis (knee > shoulder > elbow) GI: Hepatitis, RUQ pain Ocular: keratitis, uveitis, iritis, optic neuritis Neurological: Chronic axonal polyneuropathy or encephalopathy Chronic Lyme disease (versus well-accepted Lyme disease sequelae): Continuation of symptoms after antibiotics Current recommendation for management is supportive care only Pediatric considerations: More likely to be febrile than adults Facial palsy accompanied by aseptic meningitis in 1/3 Untreated kids can develop keratitis Excellent prognosis if appropriately treated History Travel, camping, woods, playing under leaves or in wood piles Living in endemic area (Northeastern area: Maine to Virginia; upper Midwestern: Wisconsin, Minnesota; Northwest California) Endemic in Northern Europe and Eastern Asia as well History of tick bite (- 30-50% of patients recall tick bite) Flu like illness in summer Rash: https://www.cdc.gov/lyme/signs_symptoms/rashes.html Joint complaints Cardiac complaints Neurologic complaints Careful search for tick Diagnosis Labs CBC (leukocytosis, anemia, thrombocytopenia) ESR: most common lab abnormality (>30 mm/hr) Chem 7 LFTs: commonly elevated especially GGT Cultures not typically indicated LP when meningeal signs (CSF: pleocytosis, elevated protein, CSF spirochete ABs). LP function is more to rule out other etiologies of meningitis rather than diagnose Lyme meningitis given that lyme PCR and lyme Ab index are not very accurate. Serological Testing Serological testing is not always warranted because of the very high incidence of false positive results Serologies are not useful in acute phase (<30 days of infection) because they are negative; it takes several weeks to develop enough antibodies for either test below (ELISA or Western Blot) Acute Lyme is a clinical diagnosis and does not need laboratory testing, especially in endemic areas such as NY If pretest probability is high (symptoms consistent with Lyme + epidemiological background), say patients with CN palsy, meningitis, carditis, or migratory large joint arthritis, then serologies can be very helpful Do not test if patients in endemic areas with potential tick exposure present with EM — just treat with antibiotics Do not test if patients in endemic areas present with no history of tick exposure or only nonspecific symptoms Test if you have high suspicion of lyme without EM PCR is highly specific and sensitive but not available for routine use. There are two tests you need to use together: 1) ELISA: this detects antibodies to lyme bacteria (borrelia burgdorferi) in your blood, BUT it can’t distinguish between borrelia and similar bacteria (even sometimes normal flora that lives in you). In addition, IgM response takes 1-2 weeks while IgG response takes 2-4 weeks. If ELISA is positive or equivocal, then you move onto the: 2) Western blot test: this looks for antibodies not to the whole organism, but to the basic building blocks of the lyme bacteria — the individual proteins, BUT many types of bacteria use the same building blocks. So the CDC says that the Western Blot test must detect IgG antibodies to 5 out of the 10 proteins. See figure 2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918152/ Two-tiered testing has sensitivity between 70-100% and specificity ~95% in late stages Interpretation of Lyme serologies should be done by an ID specialist because they can be confusing and can lead to wrong conclusions if unfamiliar with them NYC is an endemic region where 5% of the population can have a positive without symptoms! If somebody who HAD Lyme disease but successfully treated it with doxycycline tested themselves years later, they could still have the antibodies and therefore it would look like they still had Lyme disease (despite being cured) Positive serology or previous Lyme disease not ensure protective immunity Other tests: Arthrocentesis for acute arthritis: elevated cryoglobulin XRs: may show soft tissue, cartilaginous, osseous changes ECG Differential Diagnosis Tick-borne diseases: Rocky Mountain Spotted fever, tularemia, relapsing fever, Colorado tick fever, tick-bite paralysis, babesiosis, anaplasmosis, powassan virus Remember that doxycycline covers anaplasmosis and lyme but not babesiosis, which requires Atovaquone Rheumatic fever (usually presents with erythema marginatum rash, valvular involvement rather than heart block, TM joint arthritis) Viral meningitis Septic arthritis Syphilis Parvovirus B19 Infectious endocarditis Juvenile rheumatoid arthritis Reiter syndrome Brown recluse spider bite Fibromyalgia Chronic fatigue syndrome Treatment Remove tick: disinfect site then with blunt instrument, grasp tick proximal to skin and pull upward with gentle constant traction. Mouthparts will release after about a minute. If residual mouthparts are left in skin, leave them alone to avoid infection (they will extrude from skin naturally over time). Since ticks that have not attached or are moving on the skin cannot transmit Lyme, they can just be brushed off. NS IVF bolus, supportive care Cardiac monitoring, temporary pacemaker for heart block Beware Jarisch Herxheimer reaction: worsening of sx a few hours after treatment initiated Aspirin for cardiac involvement, NSAIDs for arthralgias/ arthritis Prophylaxis: Per the IDSA, give a single dose of 200 mg PO doxycycline to patients who meet all of the following criteria: Deer tick has been attached for 36 hours or more (the rationale for time of attachment relates to the fact that the spirochetes live in the tick’s gut so they need a long time to multiply and travel to the salivary glands (event that’s triggered by a blood meal) and later overcome the salivary gland (which only a few do) and finally reach the patient’ skin Prophylaxis can be provided within 72 hours of tick removal Local rate of B. Burgdorferi infection in ticks exceeds 20% (in the northeast USA, the prevalence of infected ticks is between 15-20%) Doxycycline can be used (children >8 years old, non-pregnant females) A 2001 study examined doxycycline vs placebo prophylaxis. A single dose of 200 mg of oral doxycycline or placebo was given to persons presenting within 72 hours of removal of an I scapularis tick. One of 235 persons in the doxycycline group developed erythema migrans (EM) versus 8 of 247 in the placebo group, for treatment efficacy of 87% ( 95% CI, 25%–98%; P <0.04 ) (9). Reasonable alternative strategy: monitor for EM or other signs of infection then initiate treatment if they develop Lyme disease (excellent outcomes in patients treated during early EM stage of disease) Antibiotics: Antibiotics can speed resolution of arthritis and cardiac conduction delays, but not necessarily facial palsy Doxycycline has the best bioavailability and CNS penetration Always check with your ID colleagues to determine appropriate duration of treatment in more serious cases of Lyme disease Stage 1: Amoxicillin (500 mg PO TID) or cefuroxime (500 mg PO BID) or doxycycline (100 mg PO BID; > 8 years old & not pregnant) x 21 days; azithromycin (500 mg PO qday x 14-21 days) IV therapy in pregnant patients Stage 2: PO antibiotics for isolated Bell palsy and mild involvement Amoxicillin with probenecid (500 mg PO TID) x 30 days or doxycycline (100 mg PO BID; > 8 years old & not pregnant) x 10-21 days IV ceftriaxone (2 g IV qday) x 14-21 days, or penicillin G (20-24 million units IV q4-6h x 14-28 days) for meningitis, carditis, severe arthritis Stage 3: Penicillin G (20-24 million units IV q4-6h) x 14-21 days or ceftriaxone (2 g IV qday x 14-28 days) Dispotition Admit unstable or sick patients, those with meningoencephalitis, & carditis (telemetry/ ICU admission) DC patients treated with PO therapy Future prevention strategies: wear long pants & shirts, light-colored clothing (easier to spot crawling ticks), tuck pants into socks, DEET spray, clothing impregnated with permethrin References Baker C et al, Lyme Disease Review Panel of the Infectious Diseases Society of America (IDSA). Final report of the lyme disease review panel of the infectious diseases society of America (IDSA). 2006. https://www.idsociety.org/globalassets/idsa/topics-of-interest/lyme/idsalymediseasefinalreport.pdf (22 July 2019, date last accessed) Centers for Disease Control and Prevention. CDC — Lyme. 2019. https://www.cdc.gov/lyme/index.html (22 July 2019, date last accessed) Hilton E, DeVoti J,, Benach JL, Halluska ML, White DJ, Paxton H, Dumler JS. Seroprevalence and seroconversion for tick-borne diseases in a high-risk population in the northeast United States. Am J Med. 1999 Apr;106(4):404-9. Hu LT. Lyme Disease . Ann Intern Med. 2016;164:ITC65-ITC80. Doi: 10.7326/AITC201605030 Lee, M. Lyme Disease . Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 2015; 664-665. Nadelman RB, Nowakowski J, Fish D et al., Tick Bite Study Group. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. 2001;345:79-84. Sanders, L. (2009). Every patient tells a story: Medical mysteries and the art of diagnosis. A special thanks to our Infectious Diseases Editor: Angelica Cifuentes Kottkamp, MD Infectious Diseases & Immunology NYU School of Medicine Read More

Jul 15, 2019

An in depth review of this notorious parasite. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Malaria.mp3 Download Leave a Comment Tags: Infectious Diseases Show Notes Background In 2017, there were 219 million cases and 435,000 people deaths from malaria Five species: Falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. Falciparum , Vivax and Knowlesi can be fatal History of recent travel to Africa (69% of cases in US), particularly to west-Africa should raise suspicion for malaria Clinical Manifestations Average incubation period for Falciparum is 12 days 95% will develop symptoms within 1 month Clinical findings with high likelihood ratios include periodic fevers, jaundice, splenomegaly, pallor. Can also have vomiting, headache, chills, abdominal pain, cough, and diarrhea Severe malaria has a mortality of 5% to 30%, even with therapy Diagnostic criteria for severe malaria: Ashley 2018 Most common manifestations of severe malaria affect the brain, lungs, and kidneys Patients with cerebral malaria can present encephalopathic or comatose, some severe enough to exhibit extensor posturing, or seizures Can have acute lung injury with a quarter of these patients progressing to ARDS Can have AKI from ATN and resultant acidosis Labs may be unremarkable but watch for anemia and thrombocytopenia Hgb <5 has an OR = 4.9 for death Severe thrombocytopenia has an OR = 2.8 Anemia + Thrombocytopenia has an OR = 13.8 (Lampah 2015, PMID 25170106 ) Watch for hypoglycemia Be mindful of co-infection with salmonella and HIV Obtain BCx, cover with ceftriaxone Diagnosis Blood smear Thick smear to increase sensitivity for detecting parasites Thin smear for quantifying parasitemia and species The first smear is positive in over 90% of cases, but if suspicion is high, it has to be repeated BID for 2-3 days for proper exclusion of malaria ( CDC 2019 ) Management For uncomplicated, non-severe cases, most patients with falciparum should be admitted, especially those with no prior exposure to malaria parasites Malarone is one of the first line options Check out other suggested regimens from the CDC Important to note that when they take this, ensure they take with milk or food containing fat to enhance absorption Severe Malaria Resuscitative efforts directed at affected organ Can deteriorate rapidly Initiate IV Artesunate if high level of suspicion Requires call to CDC: CDC Malaria Hotline: (770) 488-7788 or (855) 856-4713 (toll-free) Monday–Friday 9am–5pm EST – (770) 488-7100 after hours, weekends, and holidays Benzodiazepines for seizures Be judicious with fluids as this can precipitate pulmonary edema and cerebral edema a/w increased mortality in children at 48 hour (Maitland 2011, PMID: 21615299 ; Hanson 2013, PMID: 23324951 ) Take Home Points This is going to be a diagnosis that is mainly made through a thorough history, and pay particular attention to those with recent travel to West-Africa The incubation period for falciparum is 12 days, but there is a range of weeks and we should consider Malaria when consistent symptoms develop within 1 month of travel to an endemic area Typical signs and symptoms for uncomplicated malaria are periodic fevers, jaundice, pallor Be mindful of end organ involvement, such as cerebral edema, ATN, and pulmonary edema; these cases are considered to be severe and treated differently than uncomplicated malaria Uncomplicated cases should get Malarone or Coartem Severe cases require IV Artesunate Be judicious with your fluid resuscitation as this can harm our patients References Centers for Disease Control and Prevention. CDC Parasites – Malaria. 2019 https://www.cdc.gov/parasites/malaria/index.html (7 July 2019, date last accessed) Ashley EA, Pyae Phyo A, Woodrow CJ. Malaria. Lancet. 2018;391(10130):1608-21. Hanson JP, Lam SW, Mohanty S, Alam S, Pattnaik R, Mahanta KC, et al. Fluid resuscitation of adults with severe falciparum malaria: effects on Acid-base status, renal function, and extravascular lung water. Crit Care Med. 2013;41(4):972-81. Lampah DA, Yeo TW, Malloy M, Kenangalem E, Douglas NM, Ronaldo D, et al. Severe malarial thrombocytopenia: a risk factor for mortality in Papua, Indonesia. J Infect Dis. 2015;211(4):623-34. Lokken KL, Stull-Lane AR, Poels K, Tsolis RM. Malaria Parasite-Mediated Alteration of Macrophage Function and Increased Iron Availability Predispose to Disseminated Nontyphoidal Salmonella Infection. Infect Immun. 2018;86(9). Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-95. Park SE, Pak GD, Aaby P, Adu-Sarkodie Y, Ali M, Aseffa A, et al. The Relationship Between Invasive Nontyphoidal Salmonella Disease, Other Bacterial Bloodstream Infections, and Malaria in Sub-Saharan Africa. Clin Infect Dis. 2016;62 Suppl 1:S23-31. Tintanelli, Judith E., et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Eighth edition. New York: McGraw-Hill Education, 2016: p.1070-1077 World Health Organization. Guidelines for the treatment of malaria. Third edition April 2015. WHO. 2015 https://www.who.int/malaria/publications/atoz/9789241549127/en/ (7 July 2019, date last accessed) A special thanks to our editor: Angelica Cifuentes Kottkamp, MD Infectious Diseases & Immunology NYU School of Medicine Read More

Jul 1, 2019

A look at this common and controversial topic. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Otitis_Media.mp3 Download Leave a Comment Tags: Pediatrics Show Notes Background: The most common infection seen in pediatrics and the most common reason these kids receive antibiotics The release of the PCV (pneumococcal conjugate vaccine), or Prevnar vaccine, has made a big difference since its release in 2000 (Marom 2014) This, along with more stringent criteria for what we are calling AOM, has led to a significant decrease in the number of cases seen since then 29% reduction in AOM caused by all pneumococcal serotypes among children who received PCV7 before 24 months of age The peak incidence is between 6 and 18 months of age Risk factors: winter season, genetic predisposition, day care, low socioeconomic status, males, reduced duration of or no breast feeding, and exposure to tobacco smoke. The predominant organisms: Streptococcus pneumoniae , non-typable Haemophilus influenzae (NTHi) , and Moraxella catarrhalis . Prevalence rates of infections due to Streptococcus pneumoniae are declining due to widespread use of the Prevnar vaccine while the proportion of Moraxella and NTHi infection increases with NTHi now the most common causative bacterium Strep pneumo is associated with more severe illness, like worse fevers, otalgia and also increased incidence of complications like mastoiditis. Diagnosis The diagnosis of acute otitis media is a clinical one without a gold standard in the ED (tympanocentesis) Ear pain (+LR 3.0-7.3), or in the preverbal child, ear-tugging or rubbing is going to be the most common symptom but far from universally present in children. Parents may also report fevers, excessive crying, decreased activity, and difficulty sleeping. Challenging especially in the younger patient, whose symptoms may be non-specific and exam is difficult Important to keep in mind that otitis media with effusion, which does not require antibiotics, can masquerade as AOM AAP: Diagnosis of Acute Otitis Media (2013)* In 2013, the AAP came out with a paper to help guide the diagnosis of AOM Moderate-Severe bulging of the tympanic membrane or new-onset otorrhea not due to acute otitis externa (grade B) The presence of bulging is a specific sign and will help us distinguish between AOM and OME, the latter has opacification of the tympanic membrane or air-fluid level without bulging (Shaikh 2012, with algorithm) Bulging of the TM is the most important feature and one systematic review found that its presence had an adjusted LR of 51 (Rothman 2003) Classic triad is bulging along with impaired mobility and redness or cloudiness of TM Mild bulging of the tympanic membrane AND (grade C) Recent onset (48hrs) Ear pain (verbal child) Holding, tugging, rubbing of the ear (non-verbal child) OR Intense erythema of the tympanic membrane * The diagnosis should not be made in the absence of a middle ear effusion (grade B) Treatment Options A strategy of “watchful waiting” in which children with acute otitis media are not immediately treated with antibiotic therapy, has been endorsed by the American Academy of Pediatrics. Who gets antibiotics? Depends on age, temperature, duration of otalgia, laterality / otorrhea, and access to follow up Get’s antibiotics: <6 months: Treat 6 months to 2 years: Treat Exception, AAP permits initial observation: unilateral AOM with mild symptoms (mild ear pain, <48h, T <102.2) But know that there is a high rate of treatment failure (Hoberman 2013) >2: Treat Unless they have mild symptoms and it’s unilateral, you can observe for 48-72 hours Why do we give antibiotics? Demonstrated reduction in pain, TM perforations, contralateral episodes of AOM They are no walk in the park, with increased adverse events (vomiting, diarrhea, rash) Two well-designed clinical trials (2011) randomized approximately 600 children meeting strict diagnostic criteria for acute otitis media to receive Augmentin or placebo. These studies demonstrated a significant reduction in symptom burden and clinical failures in those who received antibiotics. The authors conclude that those patients with a clear diagnosis of acute otitis media would benefit from antibiotic therapy AAP AOM Treatment Algorithm Antibiotic Selection High-dose amoxicillin in most (for now) Amoxicillin should not be used if the patient has received Amoxicillin in the past 30 days, has concomitant purulent conjunctivitis (likely H flu) or is allergic to penicillin. beta lactamase resistant antibiotic should be used. Amoxicillin clavulanate or 2 nd or 3 rd generation cephalosporins (including intramuscular ceftriaxone). Patients with a history of type 1 hypersensitivity reactions to penicillin should be treated macrolides. Studies on duration of therapy have shown better results with 10-day duration in children younger than 2 years and suggest improved efficacy in those 2-5 years. For patients older than 5 years, shorter course therapy (5-7 days) can be utilized. Pain Control Motrin and APAP may have benefit with otalgia reduction Other Decongestants and antihistamines have been shown to not benefit patients in terms of duration of symptoms or complication rate. Not surprisingly, these agents increase the side-effects experienced by patients. Follow up If you chose to observe, let the parents know to return to ED or f/u with their provider in 48-72 hours if they symptoms do not improve. Providing a prescription to parents with clear instructions on when to fill it is also an acceptable option. Strict return precautions should be given if patient develops meningismus or facial nerve palsy. If antibiotics were initiated, and there isn’t improvement in 2-3 days, the diagnosis of AOM should be revisited and, if still suspected, we have to consider that the causative bug is resistant to the prescribed antibiotic. These patients should RTED or f/u with their pediatrician for escalation of care Amoxicillin → Augmentin Augmentin → Ceftriaxone IM Macrolide → no clear antimicrobial agent, consult pediatric ENT If antibiotics are initiated with resolution of symptoms, the patient should f/u in 2-3 months to ensure resolution of the middle ear effusion and ensure that there is no associated conductive hearing loss References : Coker TR, Chan LS, Newberry SJ, Limbos MA, Suttorp MJ, Shekelle PG, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA. 2010;304(19):2161-9. Hoberman A, Ruohola A, Shaikh N, Tahtinen PA, Paradise JL. Acute otitis media in children younger than 2 years. JAMA Pediatr. 2013;167(12):1171-2. Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-99. Marom T, Tan A, Wilkinson GS, Pierson KS, Freeman JL, Chonmaitree T. Trends in otitis media-related health care use in the United States, 2001-2011. JAMA Pediatr. 2014;168(1):68-75. Rothman R, Owens T, Simel DL. Does this child have acute otitis media? JAMA. 2003;290(12):1633-40. Shaikh N, Hoberman A, Rockette HE, Kurs-Lasky M. Development of an algorithm for the diagnosis of otitis media. Acad Pediatr. 2012;12(3):214-8. Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2013(1):CD000219. See our core article on the topic by Dr. Deborah Levine and Dr. Michael Mojica here A special thanks to our editors: Michael A. Mojica, MD Director, Pediatric Emergency Medicine Fellowship Bellevue Hospital Center Christie M. Gutierrez, MD Pediatric Emergency Medicine Fellow Columbia University Medical Center Morgan Stanley Children’s Hospital New York Presbyterian Read More

Jun 17, 2019

A look at foot fractures – which can be splinted and which may need the OR. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Foot_Fractures.mp3 Download Leave a Comment Tags: Orthopedics Show Notes Episode Produced by Audrey Bree Tse, MD Background: Why do we care about Jones fractures? Propensity for poor healing due to watershed area of blood supply Fifth metatarsal fractures account for 68% of metatarsal fractures in adults Proximal 5th metatarsal fractures are divided into 3 zones (93% zone 1, 4% zone 2, 3% zone 3) Zone 1 (pseudo-Jones): Tuberosity avulsion fracture Typically avulsion type injuries due to acute episode of forefoot supination with plantar flexion Typical fracture pattern is transverse to slightly oblique Zone 2 (Jones fracture): Fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal Typically acute episode of large adduction force applied to forefoot with the ankle plantar flexed Zone 3: Proximal diaphyseal stress fracture Typically results from a fatigue or stress mechanism Clinical Presentation: History of acute or repetitive trauma to forefoot Fracture type / pattern closely related to injury location Foot often swollen, ecchymotic, very tender to fifth metatarsal +/- crepitus, inability to hear weight Diagnosis: Clinical exam: Evaluate skin integrity Check neurovascular status Evaluate toes/ feet/ ankles/ tib fib/ knees/ hips, involved tendon function, associated adjacent structures (Achilles, ankle ROM/ function, etc) 3 XR views: lateral, anteroposterior, 45* oblique Acute stress fractures are typically not detected on the standard 3 views; therefore, repeat XRs 10-14d after onset of sx (may see radiolucent reabsorption gap around fracture) For more complex mid foot trauma, consider CT to r/o Lisfranc Treatment: Consider classification of fracture, patient demographics & activity level when deciding on treatment Tertiary care centers that have access to Orthopedics/Podiatry services Consider consultation for “true” Jones fractures, as some cases may be operatively managed acutely and/or for expedited follow-up to be arranged If working in community/rural locations: other than patients that present with “open” injuries, concerns for compartment syndrome (almost never), and “high-end”/professional athletes, there are generally no other circumstances that would require expedited transfer to a tertiary care center for immediate further evaluation. Less favorable outcomes associated with certain patient factors: female gender, DM, obesity Surgical: Different modalities of surgery: Intramedullary screw Bone graft Closed reduction and fixation with K-wire ORIF (all +/- need for bone graft) Surgery likely recommended for displacement >10 degrees of plantar angulation or 3-4 mm of translation in any plane Indications for OR: Neck and shaft fractures with >10 degrees plantar angulation or 3mm of displacement in any plane with insufficient closed reduction Avulsion fractures (zone one) with >3 mm of displacement or comminuted Zone two fractures: displaced zone two fractures require operative management. For acute non displaced Jones fractures, consider early intramedullary screw fixation in athletes (studies have shown return to sport ~ 8 weeks, weight bearing within 1-2 weeks) Zone three fractures (diaphyseal stress fractures) in athletes Nonoperative: All non displaced fifth metatarsal fractures can be treated non operatively Non displaced zone 1 fractures: protected weight bearing/ symptomatic care in short leg walking cast, air-boot, posterior splint, or compression wrap/ rigid shoe until discomfort subsides Zone 2 and 3 fractures are more complex because they often result in prolonged healing time and potential for delayed/ nonunion Acute zone 2 fractures: nonweightbearing in short leg cast for 6-8 weeks Acute zone 3 fractures: nonweightbearing in short leg cast for up to 20 weeks With respect to athletes: repeat fracture after surgical treatment of Jones fracture can occur after healing and screw removal; thus it is recommended that the screw be left in until the end of the athlete’s career References: Bowes J, Buckley R. Fifth metatarsal fractures and current treatment. World J Orthop . 2016;7(12):793–800. Published 2016 Dec 18. doi:10.5312/wjo.v7.i12.793 Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006 Mar; 27(3): 172-4. Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 2004;35 Suppl 2:SB77–SB86. Tham W, Sng S, Lum YM, Chee YH. A Look Back in Time: Sir Robert Jones, ‘Father of Modern Orthopaedics’. Malays Orthop J . 2014;8(3):37–41. doi:10.5704/MOJ.1411.009 Thomas JL, Davis BC. Three-wire fixation technique for displaced fifth metatarsal base fractures. J Foot Ankle Surg. 2011;50:776–779. ______________________ LISFRANC SHOW NOTES: Intro: Can’t miss diagnoses: needs stat ortho 20% miss rate Can be dislocation, fracture, fracture dislocation, or ligamentous injury Jacques Lisfranc in Napoleonic Wars: performed transmetatarsal amputation for midfoot gangrene Anatomy: Lisfranc ligament: 3 ligaments that run from the base of the second metatarsal to the medial cuneiform bone. Helps attach the forefoot to the midfoot bones If ligament complex gets disrupted, can end up with chronic deformity and disability Injury definitions: Dislocation: widening between base of 1st and 2nd metatarsal, or between cuneiforms Fracture dislocation: associated fracture, most commonly at the base of the proximal second metatarsal Physical Exam: Pain and swelling in midfoot Pain elicited with passive abduction and pronation of the midfoot while holding heel steady Plantar ecchymosis r/o compartment syndrome Feel for DP pulse! Diagnosis: XRs: AP, lateral, oblique, stress views with weight bearing Watch out for “fleck sign” Consider CT if pt cannot bear weight, or even if XR negative and high suspicion Treatment: Ortho consult! ______________________ THANKS TO DANNY PURCELL, MD and MAY LI, MD Read More

Jun 3, 2019

A discussion with Drs. McNamara and Leifer on the essentials and beyond of debriefing Hosts: Brian Gilberti, MD Audrey Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Debriefing.mp3 Download One Comment Tags: Resuscitation , Simulation Show Notes TAKE HOME POINTS Debriefing after a clinical case in the ED is a way to have an interprofessional, reflective conversation with a focus on improving for the next patient. We can debrief routine cases, challenging cases, or even cases that go well. Follow a structure when leading a debrief. The prebrief sets ground rules and informs the team that the debrief is optional and will only take 3-5 minutes. Introduce names and roles Then give a one-liner about what happened in the case, followed by a plus/ delta: address what went well and why, then how to improve Finally, wrap up with take home points Pitfalls to watch out for in clinical debriefing include: Avoid siloing or alienating any learners. Learn from all your colleagues on your team- it’s less about medicine and more about interprofessional and systems issues Don’t pick on individual performance. It’s not about shaming- it’s about improving patient care Avoid “guess what I’m thinking” questions; ask real questions Proceed with caution in order to dampen or avoid psychological trauma and second victim syndrome. The learner may ask “was this my fault?”; we never want a learner to feel this way. Ask, what systems supported or did not support you today? Talk about what happened. Avoid shame and blame. Have the right values and do it for the right reasons. ADDITIONAL TOOLS PEARLS Debriefing Tool INFO Model: GUESTS Dr. Shannon McNamara completed residency in Emergency Medicine at Temple University hospital and fellowship in Medical Simulation at Mount Sinai St. Lukes-Roosevelt. She now is the Director of the Simulation Division in the NYU Department of Emergency Medicine. She’s thrilled to have somehow made a career out of teaching people to talk about their feelings using big computers shaped like people. Dr. Jessica Leifer attended NYU for medical school and completed her residency training in emergency medicine at Mount Sinai St. Luke’s-Roosevelt. She completed a fellowship in medical simulation at the Mount Sinai Hospital. She is now simulation faculty in the NYU department of Emergency Medicine. Her academic interests include using simulation for patient safety, operations, and improving teamwork. Read More

May 20, 2019

A look at one of the most common and potentially concerning upper respiratory infections in children. Host: Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Croup.mp3 Download One Comment Tags: Airway , Infectious Diseases , Pediatrics Show Notes Background Croup is a viral infection starts in the nasal and pharyngeal mucosa but spreads to the larynx and trachea Subglottic narrowing from inflammation Dynamic obstruction Barking cough Inspiratory stridor Causes: Parainfluenza virus (most common) Rhinovirus Enterovirus RSV Rarely: Influenza, Measles Age range: 6 months to 36 months Seasonal component with high prevalence in fall and early winter Differential Bacterial tracheitis Acute epiglottitis Inhaled FB Retropharyngeal abscess Anaphylaxis Presentation & Diagnosis Classically a prodrome of nonspecific symptoms for 1-3 days with low grade fevers, congestion, runny nose. Symptoms reach peak severity on the 4 th day “Steeple sign” on Xray (subglottic narrowing) present in only 50% of patients with croup Assess air entry, skin color, level of consciousness, for tachypnea, if there are retractions / nasal flaring (if present at rest or with agitation) & coughing “Westley Croup Score” ( https://www.mdcalc.com/westley-croup-score ) Chest wall retractions Stridor Cyanosis Level of consciousness Air entry Management Mild Croup Occasional barking cough, but no stridor at rest and mild to no retractions Tx: Single dose of dex Has been shown to improve severity and duration of symptoms Route is not particularly important, whether it’s PO, IV or IM Chosen route should aim to minimize agitation in the patient that might worsen their condition May be managed at with supportive care Humidifiers (NB: there isn’t good evidence supporting the use of humidifiers) Antipyretics PO fluids Moderate Group May have stridor at rest, mild-moderate retractions but no AMS and will not be in distress. Tx: Dex + Racemic Epinephrine Racemic epinpehrine will start to work in about 10 minutes Effects last for more than an hour Severe group Receives the same initial therapy as the moderate group with dex and race epi Pts with worrisome signs: stridor at rest, marked retraction, cyanosis and/or lethargy Heliox (a combinations of 70-80% helium + 20-30% oxygen) may be attempted There is limited evidence to support the role of heliox in croup, NB: Pt may require higher levels of oxygen than the 20-30% mixture may provide Intubation Anticipate edema narrowing the airway Consider starting with a tube that is 0.5 to 1 mm smaller than size typically used Disposition: Patients without stridor at rest or respiratory distress can be generally discharged from the ED If epinephrine is given, patients should be monitored for 2-4 hours for reemergence of symptoms as the medication wears off Take Home Points Croup usually affects children within the age range of 6 months to 36 months with the most common cause being parainfluenza virus Given the symptom overlap, we must consider more concerning diagnoses, including bacterial tracheitis, in these patients, especially if they are ill appearing or traditional therapies are ineffective All patients benefit from a one-time dose of dexamethasone and, if racemic epinephrine is given, the patient should be observed for at least 3 hours If intubation is required, anticipate a narrowed airway Parent Article: https://coreem.net/core/croup/ by Dr. Pankow Read More

May 6, 2019

A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/SJS.mp3 Download Leave a Comment Tags: Critical Care , Dermatology Show Notes Episode Produced by Audrey Bree Tse, MD Rash with dysuria should raise concern for SJS with associated urethritis Dysuria present in a majority of cases SJS is a mucocutaneous reaction caused by Type IV hypersensitivity Cytotoxic t-lymphocytes apoptose keratinocytes → blistering, bullae formation, and sloughing of the detached skin Disease spectrum SJS = <10% TBSA TEN = >30% TBSA SJS/ TEN Overlap = 10-30% TBSA Incidence is estimated at around 9 per 1 million people in the US Mortality is 10% for SJS and 30-50% for TEN Mainly 2/2 sepsis and end organ dysfunction. SJS can occur even without a precipitating medication Infection can set it off especially in patients with risk factors including HIV, lupus, underlying malignancy, and genetic factors SATAN for the most common drugs Sulfa, Allopurinol, Tetracyclines, Anticonvulsants, and NSAIDS Anti-epileptics include carbamazepine, lamictal, phenobarb, and phenytoin Can have a curious course Hypersensitivity reaction can develop while taking medication, or even one to four weeks after exposure In pediatric population, mycoplasma pneumonia and herpes simplex have been identified as precipitating infections Patients often have a prodrome 1-3 days prior to the skin lesions appearing May complain of fever, myalgias, headaches, URI symptoms, and malaise Rash may be the sole complaint Starts as dark purple or erythematous lesions with purpuric centers that progress to bullae Skin surrounding the lesions detaches from the dermis with just light pressure (Nikolsky Sign) Up to 95% of patients will have mucous membrane lesions ~85% will have conjunctival lesions Symptoms: Burning or itching eyes, a cough or sore throat, pain with eating, pain with urinating or defecating Source: JAMA Dermatol. 2017 Differential Diagnosis: SSSS, autoimmune bullous diseases, bullous fixed drug eruption, erythema multiforme, thermal burns, phototoxic reactions, and TSS SJS is a clinical diagnosis Basic workup: CBC, chemistry panel, LFTs, and a UA Treatment Supportive care IV fluid repletion guided by TBSA affected, as well as electrolyte, protein, and energy supplementation Consider protecting airway if significant oral mucosal involvement Stop the offending agent (if there is one) Advanced wound care and pain control Consults: Derm to do a biopsy, +/- ophthalmology, gyn / urology to prevent strictures or contractures Consider transferring to a burn center Dispo: Low threshold for ICU admission SCORTEN ( max of 7 points) 1 point each for Age over 40 Current cancer >30% body surface area affected HR >120 BUN >28 Glucose >240 Bicarb <20 Score of 2 points or higher should -> ICU Take Home Points SJS may begin like the flu, with lesions appearing 1-3 days after the prodrome starts Have to have a high suspicion for SJS because it is deadly. It’s a clinical diagnosis — derm biopsy is supportive A thorough history and physical exam are key. Remember the characteristic rash and bullae, and always look in the mouth and eyes. Ask about dysuria, sore throat, and eye irritation, as well as preceding medications or infections. Think SATAN! Prompt supportive care focused on ABCs and IVF repletion are critical. These patients can get sick really fast, so consider an ICU or burn unit. References: Barrett W. Quick Consult: Symptoms: Rash, Dysuria, and Mouth Sores. Emergency Medicine News. 41(4): 15-16, April 2019. Bivins H, Comes J. Stevens-Johnson Syndrome. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 2015; 1076-1077. Ergen EN, Hughey LC. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. JAMA Dermatol. 2017;153(12):1344. doi:10.1001/jamadermatol.2017.3957 Gerull R, Nelle M, Schaible T. Toxic epidermal necrolysis and Stevens-Johnson syndrome: A review. Crit Care Med. 2011; 39:1521-1532. Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Current Perspectives on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Clin Rev Allergy Immunol. 2018;54(1):147-76. McNeil, D. (2019). Measles Cases Surpass 700 as Outbreak Continues Unabated . [online] Nytimes.com. Available at: https://www.nytimes.com/2019/04/29/health/measles-outbreak-cdc.html [Accessed 6 May 2019]. Mustafa SS, Ostrov D, Yerly D. Severe Cutaneous Adverse Drug Reactions: Presentation, Risk Factors, and Management. Curr Allergy Asthma Rep. 2018;18(4):26. Read More

Apr 22, 2019

A look at the opioid epidemic and what ED providers can do to combat this formidable foe. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Opioid_Epidemic.mp3 Download Leave a Comment Tags: Opioid Dependence , Opioid Free ED Show Notes Consider alternatives to opiates for acute pain NSAIDs Subdissociative ketamine Nerve blocks Curb misuse and diversion through prescribing a short supply and perform I-STOP checks Narcan is not just for acute overdose treatment by EMS or within the ED anymore We can equip patients, family members and friends with Narcan kits prior to discharge In New York state, can prescribe Narcan to patients with near fatal overdoses or who screen positive for an opioid use disorder Intranasal formulation is cheaper and more commonly prescribed than IM Buprenorphine induction can be done in the ED for patients in active withdrawal, as calculated by the COWS score. MDcalc calculator: https://www.mdcalc.com/cows-score-opiate-withdrawal Providers do not need an X-waiver to give a dose of Buprenorphine in the ED for 3 days Home induction can be considered for patients not actively withdrawing but would like to enter medication assisted treatment Some considerations: Contraindicated in patients with severe liver dysfunction and with hypersensitivity reaction to drug Oversedation can occur with concurrent use of benzodiazepines and alcohol Will precipitate withdrawal if concurrently using full opioid agonists Longitudinal care has to be established for patients started on Buprenorphine SAMHSA’s Buprenorphine practitioner locator site: https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator Buprenorphine Induction Pamphlet Read More

Apr 8, 2019

In this episode, we discuss the recent measles outbreak and how ED providers can best prepare to treat this almost vanquished foe. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Measles_Final_Cut.mp3 Download One Comment Tags: Infectious Diseases , Pediatrics Show Notes Episode Produced by Audrey Bree Tse, MD References: CDC Measles for Health Care Providers. https://www.cdc.gov/measles/hcp/index.html#lab. Gladwin M, Trattler B. Orthomyxo and Paramyxoviridae. In: Clinical Microbiology Made Ridiculously Simple. 4th ed. Miami, FL: MedMaster, Inc; 2009: 240-243. Hussey G, Klein M. A Randomized, Controlled Trial of Vitamin A in Children with Severe Measles. N Engl J Med. 1990; 323: 160-164.doi: 10.1056/NEJM199007193230304. Nir, Sarah Mailin and Gold, Michael. “An Outbreak Spreads Fear: Of Measles, of Ultra-Orthodox Jews, of Anti-Semitism.” New York Times [New York City] 03/29/2019. https://www.nytimes.com/2019/03/29/nyregion/measles-jewish-community.html A massive thanks to: Shweta Iyer, MD: NYU Langone 3rd year Pediatric Emergency Medicine Fellow. Jennifer Lighter, MD: Assistant Professor of Pediatric Infectious Diseases, NYU School of Medicine. Michael Mojica, MD: Associate Professor of Pediatric Emergency Medicine, NYU Langone Medical Center. Michael Phillips, MD: Chief Hospital Epidemiologist, NYU Langone Medical Center. Read More

Mar 22, 2019

In this episode, we discuss acute decompensated heart failure and how to best manage these dyspneic patients in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_ADHF.mp3 Download Leave a Comment Tags: Cardiology , Respiratory Show Notes Features that increase the probability of heart failure. ( Wang 2005 ) B-lines seen in pulmonary edema. Positioning of ultrasound probe in BLUE protocol. ( Lichtenstein 2008 ) Read More

Mar 8, 2019

In this episode, we discuss Boxer's fractures and how to best manage them in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Boxer_s_Fracture_eq.m4a Download One Comment Tags: Orthopedics , Trauma Podcast Video https://youtu.be/UreET5eLHas Show Notes Background: 40% of all hand fractures A metacarpal fracture can occur at any point along the bone (head, neck, shaft, or base) “Boxer’s” fractures classically at neck Most common mechanism: direct axial load with a clenched fist Most common metacarpal injured is the 5 th A majority of these injuries are isolated injuries, closed and stable Examination: Ensure that this is an isolated injury May note a loss of knuckle contour or shortening A thorough evaluation of the skin is important Patients may also have fight bites and require irrigation and antibiotics Tender along the dorsum of the affected metacarpal Evaluate the range of motion as the commonly seen shortening results in extension lag For every 2 mm of shortening there is going to be a 7 degree decrease in ability to extend the joint Check rotational alignment of digits with the MCP and PIP at 50% flexion. Partially clench their fist and ensure that the axis of each digit converges near the scaphoid pole / mid wrist Deformity is often seen due to the imbalance of volar and dorsal forces Dorsal angulation AP, lateral and oblique views should be obtained on XR The degree of angulation is estimated with the lateral view NB: Normal angle between the metacarpal head and neck is 15 degrees Management: Most may be splinted with an ulnar gutter splint Must be closed, not significantly angulated, and not malrotated When splinting, place the wrist in slight extension, MCP (knuckles) at 90 degrees and the DIP and PIP in a relaxed, slightly flexed position A closed reduction is indicated if there is significant angulation “20, 30, 40” rule If angulation is more than: 20 in the middle finger metacarpal 30 in the ring finger metacarpal 40 in the pinky finger metacarpal Analgesia with a hematoma block or ulnar nerve block Reduction technique: https://www.aliem.com/2013/01/trick-of-trade-reducing-metacarpal/ Referral: May have mild deformity or decreased functionality and strength in hand grip after this injury Emergent evaluation if: Open fracture Neurovascular compromise Follow up: Refer to hand specialist Within 1 week if fractures of 4 th and 5 th metacarpals with angulation 3 to 5 days if the 2 nd and 3 rd metacarpalsare affected Immobilized for three to four weeks in splint Healing may take up to six weeks Take Home Points: This is one of the most common fractures we will see as emergency physicians When evaluating these patients, ensure that this are no other more severe, life-threatening injuries, and pay particular attention to the skin exam so that you do not miss a fight-bite Reductions may be required if there is significant angulation, which is guided by the 20, 30, 40 rule Finally, emergent specialist evaluation is indicated if there is an open fracture or evidence of neurovascular compromise Read More

Aug 13, 2018

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_157_0_Final_Cut.m4a Download 5 Comments Read More

Jul 30, 2018

This week we dive into a recent article highlighting a major update in the treatment of community acquired pneumonia (CAP) https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_156_0_Final_Cut.m4a Download Leave a Comment Tags: CAP , Macrolides , Pulmonary Show Notes Read More REBEL EM: Update in Community Acquired Pneumonia (CAP) Treatment – Macrolide Resistance Moran GJ, Talan, DA; Pneumonia, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 76: p 978-89. Haran JP et al. Macrolide resistance in cases of community-acquired bacterial pneumonia in the emergency department. J Emerg Med 2018. PMID: 29789175 Mandell LA et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27–72. PMID: 17278083 Arnold FW et al. A worldwide perspective of atypical pathogens in community-acquired pneumonia. AmJ Respir Crit Care Med 2007;175:1086–93. PMID: 17332485 Read More

Jul 23, 2018

This week we discuss three recent articles looking at esmolol in refractory VF, c-spine clearance and antibiotics after abscess drainage https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_155_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiac Arrest , Cervical Spine , Esmolol , I+D , Infectious Diseases , Journal Club , MRSA , Refractory VF , Trauma Show Notes Read More REBEL EM: Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses Bryan Hayes at ALiEM: Sulfamethoxazole-Trimethoprim for Skin and Soft Tissue Infections: 1 or 2 Tablets BID? The SGEM: SGEM#164: Cuts Like a Knife Core EM: Antibiotics in the Treatment of Smaller Abscesses EM Nerd: The Case of the Pragmatic Wound REBEL EM: Refractory ventricular fibrillation Resus.ME: Esmolol for Refractory VF Read More

Jul 16, 2018

This week we review femoral shaft fractures with a focus on assessment and analgesia https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_154_0_Final_Cut.m4a Download Leave a Comment Tags: Femoral Nerve Blocks , Orthopedics Show Notes Read More Orthobullets Femoral Shaft Fracture Rosen’s Emergency Medicine Concepts and Clinical Practice( link ) Tintinalli’s Emergency Medicine( link ) Femoral Nerve Block video ( link ) Read More

Jul 9, 2018

More amazing pearls from our Bellevue morning report series. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_153_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Intoxication , Discitis , ESRD , Necrotizing Fasciitis Show Notes Read More Core EM: Spinal Epidural Abscess REBEL EM: Cauda Equina Syndrome Radiopaedia: Discitis LITFL: Necrotizing Fasciitis REBEL Cast: Episode 50 – Intoxicated Patients Can Equal Badness Read More

Jul 2, 2018

This week, we discuss penetrating neck trauma and some pearls and pitfalls in management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_152_0_Final_Cut.m4a Download One Comment Tags: Neck Trauma , Trauma Show Notes REBEL EM: Penetrating Neck Injuries Zone 1 Zone 2 Zone 3 Anatomic Landmarks Clavicle/Sternum to Cricoid Cartilage Cricoid Cartilage to the Angle of the Mandible Superior to the Angle of the Mandible Anatomic Structures in Zone Proximal Common Carotid Artery Carotid Artery Vertebral Artery Subclavian Artery Vertebral Artery Distal Carotid Artery Vertebral Artery Jugular Vein Distal Jugular Vein Lung Apices Pharynx Salivary and Parotid Glands Trachea Trachea Cranial Nerves IX – XII Thyroid Esophagus Spinal Cord Esophagus Larynx Thoracic Duct Vagus Nerve Spinal Cord Recurrent Laryngeal Nerve Spinal Cord Hard + Soft Signs of Major Aerodigestive or Neurovascular Injury Hard Signs Soft Signs Airway Compromise Hemoptysis Expanding or Pulsatile Hematoma Oropharyngeal Blood Active, Brisk Bleeding Dyspnea Hemorrhagic Shock Dysphagia Hematemesis Dysphonia Neurologic Deficit Nonexpanding Hematoma Massive Subcutaneous Emphysema Chest Tube Air Leak Air Bubbling Through Wound Subcutaneous or Mediastinal Air Vascular Bruit or Thrill Crepitus WTA Management Algorithm for Penetrating Neck Injury (Sperry 2013) Read More

Jun 25, 2018

This week we discuss the difficult to diagnose and high morbidity cauda equina syndrome. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_151_0_Final_Cut.m4a Download Leave a Comment Tags: Back Pain , Cauda Equina Show Notes Take Home Points Cauda equina syndrome is a rare emergency with devastating consequences Early recognition is paramount as the presence of bladder dysfunction portends bad functional outcomes The presence of bilateral lower extremity weakness or sensory changes should alert clinicians to the diagnosis. Saddle anesthesia (or change in sensation) and any bladder/bowel changes in function should also raise suspicion for the disorder MRI is the diagnostic modality of choice though CT myelogram can be performed if necessary Prompt surgical consultation is mandatory for all patients with cauda equina syndrome regardless of symptoms at presentation Read More EM Cases: Best Case Ever 11: Cauda Equina Syndrome OrthoBullets: Cauda Equina Syndrome Radiopaedia: Cauda Equina Syndrome Perron AD, Huff JS: Spinal Cord Disorders, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 106: p 1419-30. References Lavy C et al. Cauda Equina Syndrome. BMJ 2009; 338: PMID: 19336488 Todd NV. Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurg 2005;19:301-6 PMID: 16455534 Read More

Jun 18, 2018

This week we review some recent publications on steroids in pharyngitis and the VAN assessment in stroke. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_150_0_Final_Cut.m4a Download Leave a Comment Tags: Pharyngitis , Steroids , VAN Assessment Show Notes Read More The SGEM: SGEM #203: Let Me Clear My Sore Throat with a Corticosteroid Core EM: Corticosteroids in Pharyngitis – Systematic Review + Meta-Analysis REBEL EM: Does it Take a VAN to Identify Emergency Large Vessel Occlusion (EVLO) in Ischemic Stroke? REBEL EM: Stroke Workflow in 2018 Stroke Workflow 2017 (REBEL EM) References Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials BMJ 2017; 358 :j3887. PMID: 28931508 Teleb MS et al. Stroke vision, aphasia, neglect (VAN) assessment – a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. J Neurointervent Surg 2017; 9(2): 122-6. PMID: 26891627 Read More

Jun 11, 2018

This week the podcast features a lecture from Dr. Frosso Admakos - Assistant Residency Director at Metropolitan Hospital in NYC https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_149_0_Final_Cut.m4a Download One Comment Tags: All NYC EM , Pediatrics , Trauma Show Notes Take Home Points While peds traumas and severe traumas are uncommon, stay cool and collected – you’ve run many resuscitations in the past and resuscitating a kid is no different. You’ve got this When it comes to access, think 1, 2 IO. 2 shots at a peripheral line and if you don’t get it, go to IO Tachycardia should be assumed to be compensated shock until proven otherwise. Don’t write tachycardia off as anxiety Failed airway approach – place an 18 gauge catheter into the neck – hopefully through the cricothyroid membrane and bag through that. If you still have difficult getting an airway from above, consider a retrograde intubation over a wire Read More University of Maryland EM: Retrograde Intubation Read More

Jun 4, 2018

This episode reviews the highlights from the recent ACEP clinical policy on acute VTE management in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_148_0_Final_Cut.m4a Download Leave a Comment Tags: Deep Venous Thrombosis , DVT , PE , Pulmonary Embolism , VTE Show Notes Take Home Points The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing. Age-adjusted D-dimers are ready for use and it doesn’t matter if your assay uses FEU (cutoff 500) or DDU (cutoff 250). For FEU use an upper limit of 10 X age and for DDU use an upper limit of 5 X age. For now, subsegmental PEs should continue to routinely be anticoagulated even in the absence of a DVT. Keep an eye out for more research on this area. Although outpatient management of select PE patients (using sPESI or Hestia criteria) may be standard practice, the evidence wasn’t strong enough for ACEP to give it’s support Patients with DVT can be started on a NOAC and discharged from the ED sPESI Tool (MDCalc.com) PERC Decision Tool (MDCalc.com) Read More REBEL EM: ACEP Clinical Policy on Acute VTE 2018 Core EM: PE Rule-Out Criteria RCT Core EM: Age-Adjusted D-dimer (Using D-dimer Units) Core EM: Age Adjusted D-dimer in PE – The ADJUST-PE Trial REBEL EM: Is It PROER to PERC It Up References ACEP Clinical Policies Subcommittee. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71(5): e59-109. PMID: 29681319 Jaconelli T, Eragat M, Crane S. Can an age-adjusted D-dimer level be adopted in managing venous thromboembolism in the emergency department? A retrospective cohort study. European journal of emergency medicine : official journal of the Eur Soc Emerg Med. 2017. PMID: 28079562 Freund Y et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA 2018; 319(6): 559-66. PMID: 29450523 Read More

May 28, 2018

This episode reviews the identification and management of patients with salicylate toxicity. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_147_0_Final_Cut.m4a Download 4 Comments Tags: Aspirin , Salicylate , Toxicology Show Notes Take Home Points Always consider salicylate toxicity: In patients with tachypnea, hyperpnea, AMS and clear lungs In the presence of an anion gap metabolic acidosis with a respiratory alkalosis Treat salicylate toxicity by alkalinizing the blood and urine to increase excretion Avoid intubation until absolutely necessary. If you do have to intubate, minimize apneic time and consider awake intubation and nake sure your ventilator settings match the patient’s necessary high minute ventilation Think about chronic salicylate toxicity in unexplained altered mental status, tachypnea or metabolic acidosis in elderly Know indications for hemodialysis in salicylate toxic patients Read More REBEL EM: Salicylate Toxicity LITFL: Salicylates Wiki EM: Salicylate Toxicity Rebel EM: Acute Salicylate Toxicity, Mechanical Ventilation, and Hemodialysis Mosier JM et al. The Physiologically Difficult Airway. The western journal of emergency medicine. 16(7):1109-17. 2015. PMID: 26759664 Read More

May 21, 2018

More pearls from our fantastic morning report series at Bellevue. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_146_0_Final_Cut.m4a Download Leave a Comment Tags: Endocarditis , Ludwig's Angina , Penetrating Neck Trauma Show Notes Take Home Points In patients with neck pain, consider Ludwig’s angina particularly if they have any swelling, fever, truisms or respiratory difficulty. Consider early airway management and get your consultants involved early for operative management Endocarditis is a tricky diagnosis and will often be subtle. Any patient with a prosthetic valve and a fever has endocarditis until proven otherwise. Suspect it in any patient with fever and a murmur, get lots of cultures and remember that TEE is the gold standard but, TTE is highly specific Finally, penetrating neck trauma. Patients with hard signs – airway compromise, ongoing brisk bleeding, an expanding/pulsatile hematoma, neurologic compromise, shock or hematemesis should go directly to the OR and don’t probe the wounds! Hard Signs in Penetrating Neck Injury (Sperry 2013) Management Algorithm for Penetrating Neck Injury (Sperry 2013) Read More LITFL: Ludwig’s Angina Core EM: Infective Endocarditis EM Cases: Endocarditis and Blood Culture Interpretation Sperry JL et al. Western Trauma Association Critical Decisions in Trauma: Penetrating Neck Trauma. J Trauma Acute Care Surg 2013; 75(6): 936-41. PMID: 24256663 [ OPEN ACCESS ] Read More

May 14, 2018

This week we discuss some pearls from the 14th All NYC EM Conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_145_0_Final_Cut.m4a Download Leave a Comment Tags: Documentation , Major Trauma , Massive Transfusion Protocol Show Notes All NYC EM Conference Read More Core EM: Episode 77.0 – Give TXA Now! Read More

May 7, 2018

This week we dive into rhinosinusitis exploring the recommendations of who needs antibiotics and who doesn't. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_144_0_Final_Cut.m4a Download Leave a Comment Tags: Acute Bacterial Sinusitis , ENT , Sinusitis Show Notes Take Home Points Acute rhinosinusitis is a clinical diagnosis The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement. Read More Core EM: Acute Rhinosinusitis The NNT.com : Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults The NNT.com : Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Read More

Apr 30, 2018

This week we review the presentation, examination and diagnosis of testicular torsion. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_143_0_Final_Cut.m4a Download Leave a Comment Tags: Acute Scrotal Pain , Torsion , Urology Show Notes Take Home Points Consider the diagnosis of testicular torsion in all patients with acute testicular pain Testicular torsion is a surgical emergency that requires immediate urologic consultation to increase the rate of tissue salvage. History, physical examination and ultrasound are all flawed in making the diagnosis. The gold standard is surgical exploration Consider manual detorsion in patients where consultation will be delayed Show Notes Core EM: Testicular Torsion Ben-Israel T et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28:786-789. Sidler D et al. A 25-year review of the acute scrotum in children. S Afr Med J. 1997;87(12) 1696-8. PMID: Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID: Ban KM, Easter JS: Selected Urologic Problems; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 99: p 1326-1356 . Read More

Apr 23, 2018

This week we discuss more pearls from our morning report conference on APE, SAH and caustic ingestions. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_142_0_Final_Cut.m4a Download Leave a Comment Tags: APE , Cardiology , Caustic Ingestions , CHF , SAH , SCAPE , Subarachnoid Hemorrhage , Toxicology Show Notes Take Home Points In patients with APE, give high-dose nitro to decrease after load and preload quickly. 400-500 mcg/min for the first 4-5 minutes is my standard approach Consider DSI to facilitate pre-oxygenation. Ketamine is your go to drug here A NCHCT performed within 6 hours of symptom onset is extremely sensitive for ruling out SAH but, nothing is 100%. If you’ve got a high-risk patient, you should still consider LP Patients with caustic ingestions can have rapidly deteriorating airways. Prepare early and be ready to take over the airway at a moments notice Read More Core EM: Acute Pulmonary Edema EMCrit: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) EMCrit: Delayed Sequence Intubation Core EM: Setting Up Non-Invasive Ventilation The SGEM: Thunderstruck (Subarachnoid Hemorrhage) Friedman BW. Managing Migraine. Ann Emerg Med 2017; 69(2): 202-7. PMID: 27510942 Read More

Apr 16, 2018

This week we discuss some recent publications relevant to EM: ADRENAL, Idarucizumab and Time to Furosemide. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_141_0_Final_Cut.m4a Download Leave a Comment Tags: ADRENAL , CHF , Corticosteroids , Furosemide , Idarucizumab , Journal Club , Journal Update , Sepsis Show Notes Read More Core EM: Idarucizumab for Reversal of Dabigitran Core EM: Idarucizumab for Reversal of Dabigitran II First10EM: Idarucizumab: Plenty of Optimism, Not Enough Science EM Lit of Note: The Door-to-Lasix Quality Measure EMS MED: When It’s More Complicated Than A Tweet: Door-To-Furosemide And EMS REBEL EM: Door to Furosemide (D2F) in Acute CHF . . . Really? emDocs.net : Furosemide in the Treatment of Acute Pulmonary Edema Core EM: Door-to-Furosemide Time References Pollack et al. Idarucizumab for dabigitran reversal – full cohort analysis. NEJM 2017; 377(5): 431-41. PMID: 28693366 Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized with Acute Heart Failure J Am Coll Cardiol 2017; 69(25): 3042-51. PMID: 28641794 Read More

Apr 9, 2018

This week we discuss the disutility of orthostatic vital signs as a diagnostic tool in patients with suspected volume loss. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_140_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiology , Orthostatic Hypotension Show Notes Summary: Based on the limited available evidence, it’s unlikely orthostatic vital sign measurement can be used to determine which patients have volume loss and which do not. The baseline prevalence of orthostatic vital signs is common and patients will not always develop orthostatic vital signs in response to volume loss. Therefore, there will both be patients who are orthostatic by numbers without volume loss and there will be patients with volume loss who are not orthostatic by numbers. Symptoms, with the exception of inability to stand to have orthostatics performed, are not useful either. Bottom Line: Based on the low overall sensitivity of orthostatic vital sign measurements, they should not be used to influence clinical decision making. Read More REBEL EM: Orthostatic Hypotension in Volume Depletion References: Skinner JE et al. Orthostatic heart rate and blood pressure in adolescents: reference ranges. J Child Neuro 2010; 25(10): 1210-5. PMID: 20197269 Stewart JM. Transient orthostatic hypotension is common in adolescents. J Pediatr 2002; 140: 418-24. PMID: 12006955 Ooi WL et al. Patterns of orthostatic blood pressure change and the clinical correlates in a frail, elderly population. JAMA 1997; 277: 1299-1304. PMID: 9109468 Aronow WS et al. Prevalence of postural hypotension in elderly patients in a long-term health care facility. Am J Cardiology 1988; 62(4): 336-7. PMID: 3135742 Witting MD et al. Defining the positive tilt test: a study of healthy adults with moderate acute blood loss. Ann Emerg Med 1994; 23(6): 1320-3. PMID: 8198307 McGee S et al. The rational clinical examination. Is this patient hypovolemic. JAMA 1999; 281(11): 1022-9. PMID: 10086438 Johnson DR et al. Dehydration and orthostatic vital signs in women with hyper emesis gravidarum. Acad Emerg Med 1995; 2(8): 692-7. PMID: 7584747 Read More

Apr 2, 2018

This week we welcome back Andy Little from Doctors Hospital in Columbus, Ohio to chat about ear foreign body removal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_139_0_Final_Cut.m4a Download Leave a Comment Tags: ENT , Foreign Body Show Notes Read More DiMuzio J, Deschler, DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol. 2002; 23(4):473-5. PMID: 12170148 Leffler S et al. Chemical immobilization and killing of intra-aural roaches: an in-vitro comparative study. Ann Emerg Med. 1993; 22(12):1795-8. PMID: 8239097 ALiEM: Trick of the Trade: Ear Foreign Body Removal with Modified Suction Setup Read More

Mar 26, 2018

This week we review pearls from the EEMCrit conference back in January 2018. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_138_0_Final_Cut.m4a Download Leave a Comment Tags: BRASH , Hyperkalemia , TTP , Ventricular Tachycardia , VTach Show Notes Show Notes Core EM: Procainamide vs Amiodarone in Stable Wide QRS Tachydysrhythmias (PROCAMIO) PulmCrit: Myth-Buesting: Lactated Ringers is Safe in Hyperkalemia, and Is Superior to NS PulmCrit: BRASH Syndrome Read More

Mar 19, 2018

This podcast discusses an 8 step process for building better presentations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_137_0_Final_Cut.m4a Download One Comment Show Notes Resources: P Cubed Presentations Presentation Zen Presentation Zen: Simple Ideas on Presentation Design and Delivery Keynotable Read More

Mar 12, 2018

This week we discuss some pearls and pitfalls when caring for HIV+ patients in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_136_0_Final_Cut.m4a Download One Comment Tags: AIDS , HIV , Infectious Diseases , PCP , TB , Tuberculosis Show Notes HIV Associated Infections Based on CD4 Count (cooperhealth.org) Total Lymphocyte Count = (% lymphocytes x WBC count)/100 TLC 1200 cells/mm 3 correlated with CD4 count of < 200 cells/mm 3 with a maximal sensitivity of 72.2%, and specificity of 100% TLC1500 cells/mm 3 correlated with CD4 count of 200 – 499 cells/mm 3 with a maximal sensitivity of 96.7% and specificity of 100% TLC 1900 cells/mm 3 correlated with CD4 count of ≥ 500 cells/mm 3 with a maximal sensitivity of 98.5% and specificity of 100% Show Notes REBEL EM: REBEL Cast Episode 1 – Total Lymphocyte Count as a Surrogate Marker for CD4 Count LITFL: HIV and AIDS References Obirikorang C et al. Total Lymphocyte Count as a Surrogate Marker for CD4 Count in Resource-Limited. BMC Infectious Diseases Journal 2012; 12 (128): 1 – 5. PMID: 22676809 Read More

Mar 5, 2018

This podcast reviews how clinicians should think about patients who's shock isn't responding to our typical management options. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_135_0_Final_Cut.m4a Download One Comment Tags: Critical Care , Resuscitation , Shock , Vasopressors Show Notes Read More Core EM: Occult Causes of Non-Response to Vasopressors Emergency Medicine Updates: Hypotension: Differential Diagnosis EMCrit: Steroids in Septic Shock – PRE-ADRENAL The Bottom Line: Steroids in Sepsis EMCrit: RUSH Exam Read More

Feb 26, 2018

More pearls from our fantastic morning report series. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_134_0_Final_Cut.m4a Download 2 Comments Tags: ALL , Altered Mental Status , Hyperleukocytosis , Hyponatremia , Leukostasis Show Notes Take Home Points 1. When seeing patients with AMS, think of the 5 broad categories of pathologies – VS abnormalities, toxic-metabolic, infectious causes, CNS abnormalities and, lastly as a diagnosis of exclusion – psychiatric issues 2. In kids with AMS, think of zebra diagnoses and toxic ingestions and remember that primary psychosis is rare 3. Patients with ALL are susceptible to developing hyperleukocytosis. If the WBC is > 100K, think about getting hematology on the line to initiate chemo induction and leukopheresis 4. Always think about electrolyte disorders, particularly hypoNa in patients with global AMS. Remember to treat severe hypoNa w/ hypertonic saline and, to correct slowly as to avoid ODS Read More LITFL: HSV Encephalitis EM Cases: Episode 60 – Emergency Management of Hyponatremia Core EM: Severe Hyponatremia Core EM: Episode 58: Hyponatremia Read More

Feb 19, 2018

This week we dive in to the initial trauma assessment. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_133_0_Final_Cut.m4a Download Leave a Comment Tags: ABCDEs , Trauma Show Notes Take Home Points Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team Complete the primary survey (ABCDEs) and address immediate life threats Round out your assessment with a good medical history and remember to complete a comprehensive head-to-toe exam Read More Shlamovitz GZ, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007;50(1):25-33, 33.e1. PMID: 17391807 ER Cast: Gunshot to the Groin with Kenji Inaba EM:RAP: Do We Still Need The C-Collar ? YouTube: Death of the Dinosaur: Debunking Trauma Myths by Dr. S.V. Mahadevan REBEL EM: Is ATLS wrong about palpable blood pressure estimates? Life in the Fast Lane: Digital rectal exam (DRE) in trauma Read More

Feb 12, 2018

This week we dive into the rare but potentially fatal, and difficult to diagnose, air embolism. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_132_0_Final_Cut.m4a Download 2 Comments Tags: Air Embolism , Central Lines , Hyperbaric Oxygen Show Notes Take Home Points Air embolism is a rare but potentially fatal complication of central line placement and some surgical procedures and of course of as the result of barotrauma. Recognizing the signs and symptoms of air embolism can be tricky because it will look like any other ischemic process. Consider air embolism if you have a patient that rapidly decompensates after placement of a central line, the most likely culprit for those of us in the ED. Treatment should focus on supportive cares. Give supplemental O2, IV fluids and hemodynamic support and consider hyperbarics and cardiopulmonary bypass for the super sick patient. Show Notes Core EM: Air Embolism Blanc et al. Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation. Intensive Care Med. 2002; 28(5): 559-63. PMID 12029402 Read More

Feb 5, 2018

This week we explore the presentation, diagnosis and management of SBP. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_131_0_Final_Cut.m4a Download Leave a Comment Tags: Gastroenterology , Infectious Diseases , SBP Show Notes Take Home Points SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis An ascites PMN count > 250 cells/mm 3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL) Read More Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205. REBEL EM: Spontaneous Bacterial Peritonitis EMRAP: C3 Live Paracentesis Video LITFL: Spontaneous Bacterial Peritonitis SinaiEM: SBP Pearls REBEL EM: Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)? Core EM: Episode 123.0 – Paracentesis Journal Update Read More

Jan 29, 2018

Another set of high-yield pearls coming out of our morning report conferences. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_130_0_Final_Cut.m4a Download Leave a Comment Tags: Babesiosis , Carbon Monoxide , Doxycycline , Myasthenia Gravis , Tick-Borne Illnesses Show Notes Take Home Points Non-specific viral syndromes are usually just that, a viral syndrome but, be cautious as a number of more serious ailments can present similarly. This includes tick borne illnesses, acute HIV and carbon monoxide Doxycycline is safe in kids. The dental staining seen with tetracycline is specific to that drug, not the class. If doxy is the best drug for the disease, use it. Lots of meds can lead to a myasthenia gravis exacerbation. Carefully review meds before prescribing for interactions Read More CDC: Research on Doxycycline and Tooth Staining Core EM: Episode 96.0 – Carbon Monoxide Poisoning Sinai EM: Succinycholine in Myasthenia Gravis Read More

Jan 22, 2018

We welcome Meghan Spyres back to the podcast to discuss toxic alcohol ingestion diagnosis and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_129_0_Final_Cut.m4a Download Leave a Comment Tags: Ethylene Glycol , Fomepizole , Methanol , Toxic Alcohols , Toxicology Show Notes Take Home Points Suspect a toxic alcohol in any patient with a large osmol gap or a large anion gap metabolic acidosis and consider treating these patients empirically. Fomepizole is the critical antidote for toxic alcohol ingestions but, patients are likely going to require dialysis as well. Call your local poison control center if you suspect a toxic alcohol ingestion to help guide management. Read More LITFL: Toxic Alcohol Ingestion ER Cast: Mind the Gap: Anion Gap Acidosis FOAMCast: Episode 43 – Alcohols Read More

Jan 15, 2018

This week, we sit down with Billy Goldberg - senior faculty at NYU/Bellevue, to discuss some nuances of hip dislocation management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_128_0_Final_Cut.m4a Download Leave a Comment Tags: Orthopedics , Trauma Show Notes Read More Core EM: Hip Dislocation OrthoBullets: Hip Dislocation EMin5: Hip Dislocation Read More

Jan 8, 2018

This week we talk about the subacute headache and the dangerous, can't miss diagnoses of cerebral venous thrombosis and IIH https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_127_0_Final_Cut.m4a Download Leave a Comment Tags: Cerebral Venous Sinus Thrombosis , Headache , Neurology Show Notes Take Home Points Keep IIH and CVST on the differential for patient’s coming in with a subacute headache, particularly if they have visual or neuro symptoms. Consider an ocular ultrasound! It’s quick, shockingly easy to do, and can help point you toward a diagnosis you may have otherwise overlooked. I have made it my practice now to include a quick look in the physical exam of my patients with a concerning sounding headache or a headache with neurologic symptoms. Consider IIH particularly in an overweight female of child bearing age with a subacute headache, but remember patients outside that demographic can have IIH as well. Consider CVST in a patient with a thrombophilic process like cancer, pregnancy or the use of OCPs or androgens or in a patient with a recent facial infection like sinusitis or cellulitis. Read More WikEM: Idiopathic Intracranial Hypertension WikEM: Ocular Ultrasound Sinai EM Ultrasound – Pseutotumor Cerebri Read More

Dec 18, 2017

This week we discuss the uncommon but must make diagnosis of flexor tenosynovitis https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_126_0_Final_Cut.m4a Download Leave a Comment Tags: Hand , Kanavel Signs , Orthopedics , Soft Tissue Infections Show Notes Take Home Points Think about flexor tenosynovitis in a patient with atraumatic finger pain. They may have any combination of these signs: Tenderness along the course of the flexor tendon Symmetrical swelling of the finger – often called the sausage digit Pain on passive extension of the finger and Patient holds the finger in a flex position at rest for increased comfort Give antibiotics to cover staph, strep and possibly gram negatives. Get your surgeon to see the patient, while we can get the antibiotics started, these patients need admission and may require surgical intervention. Infographic by Dr. Y. Jay Lin Read More Mailhot T, Lyn ET: Hand; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 50: p 534-571 OrthoBullets: Pyogenic Flexor Tenosynovitis Ped EMMorsels: Flexor Tenosynovitis Read More

Dec 11, 2017

This week we discuss some critical pearls and teaching points from our morning report conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_125_0_Final_Cut.m4a Download One Comment Tags: Fluoroquinolones , Pneumonia , Spleen Show Notes FOAMCast: Episode 17 – The Spleen! Read More

Dec 4, 2017

This week we discuss a quick case leading into the management of MALA. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_124_0_Final_Cut.m4a Download 2 Comments Tags: Metformin , Toxicology Show Notes Take Home Points In patients with shortness of breath and clear lungs, consider metabolic acidosis with respiratory alkalis as a potential cause Suspect MALA in any patient on metformin who presents with abdominal pain, nausea and vomiting and/or AMS Patients with MALA will have a low pH, a high-anion gap metabolic acidosis and high lactate levels Call your tox consultant to assist with management which will focus on fluid resuscitation with isotonic bicarbonate and dialysis Read More Bosse GM. Antidiabetics and Hypoglycemics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Accessed October 31, 2017 LITFL: Metformin-Associated Lactic Acidosis LITFL: Metformin The Poison Review: 6 Pearls About Metformin and Lactic Acidosis Read More

Nov 27, 2017

This week we dive into a recent journal article questioning whether we should tap all ascites. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_123_0_Final_Cut.m4a Download Leave a Comment Tags: Albumin , Cirrhosis , Paracentesis , SBP , Spontaneous Bacterial Peritonitis Show Notes Take Home Points SBP is a difficult diagnosis to make clinically. While patients may have the triad of fever, abdominal pain and increasing ascites, they are far more likely to only have 1 or 2 of these symptoms In patients admitted to the hospital with ascites, consider performing a diagnostic paracentesis on all patients as limited literature shows an association with decreased mortality and, the procedure is simple and low risk Once you get the fluid, focus on the cell count: WBC > 500 or PMN > 250 should prompt treatment with a 3rd generation cephalosporin and albumin infusion Gaetano et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. Journal of Gastroenterology and Hepatology 2016. PMID: 26642977 Read More EMRAP: C3 Live Paracentesis Video LITFL: Spontaneous Bacterial Peritonitis SinaiEM: SBP Pearls REBEL EM: Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)? Approach to the Diagnosis and Treatment of SBP (University of Washington) Read More

Nov 20, 2017

This week we discuss the tibio-femoral knee dislocation focusing on identification of the dangerous complications. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_122_0_Final_Cut.m4a Download Leave a Comment Tags: Knee Dislocation , Orthopedics , Popliteal Artery Show Notes Take Home Points Up to 50% of true knee dislocations will spontaneously reduce prior to arrival. Be suspicious of a dislocation in any patient who describes the joint moving out of place or if they have significant swelling, joint effusion or ecchymosis despite normal X-rays In all patients with suspected dislocation, perform a neurovascular exam immediately as popliteal artery injury is common. If they’ve got an absent DP or PT pulse, reduce immediately and get a CT angiogram as quickly as possible to assess for popliteal injuries If distal pulses are intact, you can either do ABIs and if normal, observe and repeat them or get a CTA. If the ABI is abnormal or the patient had an absent or decreased pulse at any point, get the CTA Read More OrthoBullets: Knee Dislocation Radiopaedia: Knee Dislocation EM: RAP: Obese Patient and Knee Dislocations Core EM: True Knee and Patellar Dislocations Read More

Nov 13, 2017

This week we dive into the diagnosis and management of pancreatitis in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_121_0_Final_Cut.m4a Download Leave a Comment Tags: Gastroenterology , GI , Pancreatitis Show Notes Ranson’s Criteria for Pancreatitis-Associated Mortality (Rosen’s) Take Home Points Pancreatitis is diagnosed by a combination of clinical features (epigastric pain with radiation to back, nausea/vomiting etc) and diagnostic tests (lipsae 3x normal, CT scan) A RUQ US should be performed looking for gallstones as this finding significantly alters management The focus of management is on supportive care. IV fluids, while central to therapy, should be given judiciously and titrated to end organ perfusion Patients will mild pancreatitis who are tolerating oral intake and can reliably follow up, can be discharged home Read More Hemphill RR, Santen SA: Disorders of the Pancreas; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 91: p 1205-1226 PulmCrit: The Myth of Large-Volume Resuscitation in Acute Pancreatitis PulmCrit: Hypertriglyceridemic Pancreatitis: Can We Defuse the Bomb? Read More

Nov 6, 2017

This week we discuss common bites, stings and envenomations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_120_0_Final_Cut.m4a Download Leave a Comment Tags: Bee Sting , Black Widow , Brown Recluse Spider , Hymenoptera Show Notes Take Home Points The most common bites and stings you will see are by bees and ants. These can present as a local reaction, toxic reaction, anaphylaxis or delayed reaction. For all of these, treat with local wound care and epinephrine for any systemic symptoms. The brown recluse spider is found in the Midwest and presents as local pain and swelling but carries the risk of a necrotic ulcer The black widow spider is found all around the US and presents with either localized or generalized muscle cramping, localized sweating and potentially tachycardia and hypertension. Treatment is symptom management with analgesics and benzos. The bark scorpion usually presents with localized pain and swelling, but particularly in children, may present with a serious systemic presentation including jerking muscle movements, cranial nerve dysfunction, hypersalivation, ataxia and opsoclonus, which is the rapid, involuntary movement of the eyes in all directions. Treatment is supportive cares, but remember to call your poison center to ask about antivenin. Read More WikEM: Brown Recluse Spider Bite WikEM: Black Widdow Spider Bite WikEM: Hymenoptera Stings Read More

Oct 30, 2017

This week we review 4 articles discussed in our conference in the last month. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_119_0_Final_Cut.m4a Download Leave a Comment Tags: ACS , AMI , Cardiac Arrest , Cardiology , Oxygen , Pediatrics , POCUS , Syncope Show Notes Take Home Points Tachycardia in peds patients at discharge was associated with more revisits but not with more critical interventions. If your workup is reassuring, isolated tachycardia in and of itself shouldn’t change your disposition. Supplemental O2 is not necessary in the management of AMI patients with an O2 sat > 90% and, may be harmful Until further study and prospective validation has been performed, we’re not going to recommend embracing the Canadian decision instrument on predicting dysrhythmias after a syncopal event. Finally, our agreement on what cardiac standstill is isn’t great. We need a unified definition going forward to teach our trainees and for the purposes of research. Read More Core EM: ED POCUS in OHCA – The REASON Study ALiEM: Management of Syncope EM Nerd: The Case of the Liberated Radicals ScanCrit: O2 Not Needed in Myocardial Infarction Core EM: Predicting Dysrhythmia after Syncope Gaspari R et al. Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital and in-ED Cardiac Arrest. Resuscitation 2016; 109: 33 – 39. PMID: 27693280 References Wilson PM et al. Is Tachycardia at Discharge from the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study.Ann Emerg Med. 2017. PMID: 28238501 Hofmann R et al. Oxygen Therapy in Suspected Acute Myocardial Infarction. NEJM 2017. PMID: 28844200 Thiruganasambandamoorthy V et al. Predicting short-term risk of arrhythmia among patients with syncope: the Canadian syncope arrhythmia risk score. Acad Emerg Med 2017. PMID: 28791782 Hu K et al. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med 2017. PMID: 28870394 Read More

Oct 23, 2017

Part II of II on gallbladder disorders finishing up with acute cholangitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_118_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder , Gastroenterology , General Surgery , GI Show Notes Take Home Points Cholangitis is an acute bacterial infection of the bile ducts resulting from common bile duct obstruction and is potentially life-threatening (mortality 5-10%, acute bacterial infection of the bile ducts Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic. Look for RUQ tenderness with peritoneal signs and fever A normal ultrasound does not rule out acute cholangitis Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery) Read More Radiopaedia: Acute cholangitis Core EM: Cholangitis Read More

Oct 16, 2017

Part I of II on gallbladder pathology starting with cholecystitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_117_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder , Gastroenterology , General Surgery , GI Show Notes Take Home Points Acute cholecystitis is an inflammation of the gallbladder and is a clinical diagnosis. Imaging can be helpful but US and CT can both have false negatives. Lab tests are insensitive and non-specific and, as such, they can neither rule in or rule out the diagnosis. Treatment focuses on fluid resuscitation when indicated, supportive care, antibiotics and surgical consultation for cholecystectomy Although uncommon, be aware that patients can develop gangrene, necrosis and perforation as well as frank sepsis and require aggressive resuscitation Read More Core EM: Acute Cholecystitis Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205. Leschka S et al. Chapter 5.1: Acute abdominal pain: diagnostic strategies In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008. Menu Y, Vuillerme MP. Chapter 5.5: Non-traumatic Abdominal Emergencies: Imaging and Intervention in Acute Biliary Conditions In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008. Read More

Oct 10, 2017

This podcast discusses the presentation and management of button battery ingestions in kids. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_116_0_Final_Cut.m4a Download One Comment Tags: Button Battery , GI , Pediatrics Show Notes NBIH Button Battery Ingestion Algorithm Button Battery XR (scielo.br) Take Home Points Button battery ingestions are extremely dangerous. Necrosis, perforation and erosion into vessels can occur in as little as 2 hours ALL esophageal button batteries should be removed within 2 hours of presentation to minimize mucosal damage Consider button battery ingestion in children presenting with dysphagia, refusal to eat and hematemesis Co-ingestion of a button battery with a magnet requires emergency removal regardless of where it is in the GI system Read More National Capital Poison Center: NBIH Button Battery Ingestion Triage and Treatment Guideline Pediatric EM Morsels: Button Battery Ingestion St. Emlyn’s: Button Batteries – Hide and Seek in the Emergency Department ENT Blog: Lithium Disc Battery Danger for Kids Read More

Oct 2, 2017

This week we sit down with toxicologist Meghan Spyres to talk about Wernicke's Encephalopathy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_115_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Abuse , Thiamine , Toxicology , Wernicke's Encephalopathy Show Notes Take Home Points Consider the diagnosis in all patients with nutritional deficiencies, not just alcoholics. Look for ophthalmoplegia, ataxia and confusion in patients that have risk factors for thiamine deficiency. Don’t think that it can’t be Wernicke’s because the triad isn’t complete; any two of the components (dietary deficiency, oculomotor abnormalities, cerebellar dysfunction or altered mental status) makes the diagnosis. Treat Wernicke’s with an initial dose of 500 mg of thiamine IV and admit for continued parenteral therapy. Read More LITFL: Thiamine Deficiency EMRAP: Remember to Take Your Vitamins ALiEM: Mythbusting the Banana Bag Read More

Sep 25, 2017

This week we discuss the initial approach to assessment of the alcohol intoxicated patient. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_114_0_Final_Cut.m4a Download One Comment Tags: Alcohol Intoxication , Chronic Alcoholism , Wernicke's Encephalopathy Show Notes Take Home Points Chronic drinkers and even just acutely intoxicated patients are at risk of many medical emergencies including life threatening trauma, infections, metabolic derangements and tox exposures. Don’t dismiss them as “just drunk” Undress these patients and perform a thorough head to toe examination, focusing on looking for e/o trauma and infection. Get as much history as you can and be sure to ask about their drinking habits and etoh w/d hx to risk stratify them in your brain Always check FS glucose and replete glucose as needed. Consider giving your chronic intoxicated patients thiamine injections semi-regularly to prevent WE, and look for e/o the triad in your patients as it can be easily overlooked and deadly if missed! Read More EM Docs: EM@3AM Alcohol Intoxication EM Updates: Emergency Management of the Agitated Patient Life in the Fastlane: Ethanol Intoxication, Abuse and Dependence Read More

Sep 18, 2017

This podcast takes a deep dive into the presentation, diagnosis and management of preeclampsia and eclampsia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_113_0_Final_Cut.m4a Download Leave a Comment Tags: Eclampsia , Hypertensive Disorders of Pregnancy , Obstetrics , Preeclampsia Show Notes Take Home Points Suspect preeclampsia in any pregnant women presenting with epigastric/RUQ pain, severe or persistent headache, visual disturbances, nausea or vomiting, shortness of breath, increased edema or weight gain Evaluate for preeclampsia by looking at the blood pressure, urine for protein and obtaining a panel to evaluate for HELLP syndrome Severe preeclampsia and eclampsia are treated with bolus and infusion of MgSO 4 Emergency delivery is the “cure” for preeclampsia and eclampsia. Consult obstetrics early for an evaluation for delivery Don’t forget to consider preeclampsia and eclampsia in the immediate postpartum period Read More Core EM: Preeclampsia and Eclampsia LITFL: Preeclampsia and Eclampsia LITFL: Eclampsia EM Curious: ED Management of Severe Preeclampsia Houry DE, Salhi BA. Acute Complications of Pregnancy. In: Marx, J et al, ed. Rosen’s Emergency Medicine. 8 th ed. Philadelphia, PA: Elsevier Saunders; 2014: 178: 2282-2302 Read More

Sep 11, 2017

This week we discuss the presentation and management of herpes zoster. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_112_0_Final_Cut.m4a Download Leave a Comment Tags: Infectious Diseases , Varicella Show Notes Take Home Points Classically, herpes zoster will present with rash and pain in a dermatomal distribution Immunocompromised patients are at greater risk for significant complications of zoster, including visceral dissemination and zoster ophthalmicus Appropriate therapy includes antiviral therapy within 72 hours of onset of symptoms and analgesia for acute neuritis Disseminated zoster and zoster ophthalmicus threatening sight should be treated with IV antivirals Read More Emergency Medicine Ireland: Tasty Morsels of EM 073: FRCEM Varicella Life in the Fast Lane: Herpes zoster ophthalmicus Core EM: Herpes Zoster Read More

Sep 4, 2017

This week we discuss the presentation and management of native US snake bites with Dr. Meghan Spyres https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_111_0_Final_Cut.m4a Download Leave a Comment Tags: Rattlesnakes , Snake Bites , Snake Envenomation , Toxicology , Vipers Show Notes Read More ALiEM: Envenomations: Initial Management of Common US Snakebites Read More

Aug 21, 2017

This week we dive into some advanced topics in RSI including patient positioning and pre-intubation resuscitation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_110_0_Final_Cut.m4a Download One Comment Show Notes Take Home Points Bed up head elevated position for intubation may reduce intubation related complications. Patients who are hypotensive or at risk of hypotension should be aggressively resuscitation prior to intubation with fluids and liberal use of pressors Shock patients would be intubated with decreased induction agent dose, preferably ketamine, and increased paralytic dose. Bed-Up-Head-Elevated Positioning Show Notes EMCrit: Podcast 104 – Laryngosocpe as a Murger Weapon (LAMW) Series – Hemodynamic Kills Life in the Fastlane: Intubation, hypotension and shock Core EM: Bed Up Head Elevated Position for Airway Management Video REBEL EM: Critical Care Updates: Resuscitation Sequence Intubation – Hypotension Kills (Part 1 of 3) ALiEM: The Dirty Epi Drip: IV Epinephrine When You Need It emDocs: Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI Swaminathan A, Mallemat H. Rocuronium Should Be the Default Paralytic in Rapid Sequence Intubation. Ann Emerg Med 2017. PMID: 28601274 Khandelwal N et al. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016; 122(4): 1101-7. PMID: 26866753 Read More

Aug 14, 2017

This week we discuss some quick pearls from our conference covering an array of renal and GU pathologies. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_109_0_Final_Cut.m4a Download Leave a Comment Tags: GU , Renal , Urology Show Notes Read More Core EM: Testicular Torsion Core EM: Podcast Episode 92.0 – Dialysis Emergencies Al Sacchetti: ED Repair of Bleeding Dialysis Shunt EM: RAP: Episode 107 – Dialysis Emergencies EMBlog Mayo Clinic: How to Stop a Post-Dialysis Site Bleeding emDocs: Managing Fistula Complications in the Emergency Department References Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID: 22217895 Read More

Jul 31, 2017

Should we intubate patients in cardiac arrest? We discuss this topic and some basics of running a good arrest. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_108_0_Final_Cut.m4a Download Leave a Comment Tags: Advanced Airway Management , Cardiac Arrest , Critical Care , Resuscitation Show Notes Take Home Points Intra-arrest intubation does not appear to improve outcomes. For most patients, support with BVM, or possibly an LMA, is adequate. Instead of securing an advanced airway, focus on the two things that clearly make a difference in outcomes – good compressions and defibirillation Good compressions should be fast and hard and you must minimize interruptions in compressions to minimize interruptions in perfusion Don’t forget that a great resuscitation requires great preparation. Take whatever time you have to discuss with your team and assign roles. Read More Rebel EM: In-hospital Cardiac Arrest – The First 15 Minues Core EM: Proper Defibrillator Pad Placement + Dual Sequential Defibrillation REBEL EM: Beyond ACLS: Cognitively Offloading During a Cardiac Arrest REBEL EM: Beyond ACLS: POCUS in Cardiac Arrest REBEL EM: Beyond ACLS: CPR, Defibrillation and Epinephrine REBEL EM: Beyond ACLS: Pre-Charging the Defibrillator Read More

Jul 24, 2017

Prompted by the recent CAMEO trial publication on icatibant, we dive into angioedema with a focus on airway management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_107_0_Final_Cut.m4a Download Leave a Comment Tags: ACE Inhibitors , Allergy/Immunology , Angioedema , Icatibant Show Notes Take Home Points Airway management is paramount, expect a challenging intubation and consider controlling the airway early When controlling the airway, consider an awake approach and fiberoptics if available. Always be prepared for the can’t intubate, can’t oxygenate scenario with a double set up. If the patient has urticaria and pruritus, the process is likely histamine mediated and will respond to typical anaphylaxis treatment Finally, observe the patient for progression of swelling and don’t forget to stop the inciting medication Read More Core EM: Angioedema EMCrit: Podcast 145 – Awake Intubation Lecture from SMACC ERCast: Angioedema REBEL EM: Icatibant Doesn’t Improve Outcomes in ACE-I Induced Angioedema The SGEM: Icatibant Bites the Dust – For ACE-I Induced Angioedema Read More

Jul 17, 2017

This week we drop into some of the nitty gritty on PSA including preparation and patient assessment as well as discuss some common pitfalls. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_106_0_Final_Cut.m4a Download Leave a Comment Tags: Pitfalls , Procedural Sedation , PSA Show Notes Take Home Points Always perform a full pre-PSA evaluation including an airway assessment. Time of last meal shouldn’t delay your sedation based on the best available evidence. Always do a complete setup including consideration of different agents, dosage calculations, preparation of airway equipment and reversal agents. PSA serious adverse events are rare but you still must be prepared for them. Careful agent selection and dosing can help prevent issues but, know your outs. If apnea develops, do some basic maneuvers before you reach for the BVM or laryngoscope. Remember OOPS as in “oops, my patient went apneic.” Oxygen on, pull the mandible forward and sit the patient up. This fixes most issues Show Notes Core EM: Procedural Sedation and Analgesia Resources EM Updates: Emergency Department Procedural Sedation Checklist v2 REBEL EM: Complications of Procedural Sedation Bellolio MF et al. Incidence of adverse events in adults undergoing procedural sedation in the emergency department: a systematic review and meta-analysis. Acad Emerg Med 2016; 23: 119-34. PMID: 26801209 Read More

Jul 10, 2017

This week we dissect a JAMA article on the whether it's necessary to add TMP-SMX to cephalexin in the treatment of uncomplicated cellulitis https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_105_0_Final_Cut.m4a Download Leave a Comment Tags: Cellulitis , IDSA , Infectious Diseases , MRSA Show Notes SSTI Flow Diagram (Stevens 2014) EM Lit of Note: Double Coverage, Cellulitis Edition Pharm ER Tox Guy: Uncomplicated Cellulitis? Consider Strep-Only Coverage Core EM: Cellulitis Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis 2014; 59(2): e10-52. PMID: 24973422 Read More

Jul 3, 2017

This week we dive into the various common agents used in procedural sedation and analgesia in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_104_0_Final_Cut.m4a Download 2 Comments Tags: Anesthesia , Critical Care , Procedural Sedation , PSA Show Notes Show Notes Core EM : Parenteral Benzodiazepines Core EM: Procedural Sedation and Analgesia Resources EM Updates: Ketamine Brain Continuum First 10 EM: Managing laryngospasm in the emergency department Read More

Jun 26, 2017

This week we talk about priapism focusing on emergency department management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_103_0_Final_Cut.m4a Download One Comment Tags: GU , Priapism , Urology Show Notes Read More Dr. Mutara Jubara: Ultrasound Guided Dorsal Penile Nerve Block McCollough M, Sharieff GQ: Genitourinary and Renal Tract Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 174: p 2205-2223. Davis JE, Silverman MA. Urologic Procedures; in Roberts JR: Roberts and Hedges’ Clinical Procedures in Emergency Medicine, ed 6. 2014, (Ch) 55: p 1113-1154 Govier FE et al. Oral terbutaline for the treatment of priapism. J Urol 1994;151: 878-9. PMID: 8126815 Priyadarshi S. Oral terbutaline in the management of pharmacologically induced prolonged erection. Int J Impot Res. 2004;16:424-426. PMID: 14999218 Read More

Jun 19, 2017

This week we welcome Andy Little onto the show to discuss the modified Valsalva maneuver for breaking SVT. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_102_0-AVNRT_Final_Cut.m4a Download Leave a Comment Tags: Adenosine , AVNRT , Cardiology , SVT , Tachydysrhythmia Show Notes Read More Rebel EM: The REVERT Trial – A Modified Valsalva Maneuver to Convert SVT SGEM: This is a SVT and I’m Gonna Revert It Using a Modified Valsalva Manoeuvre Appelboam A et al. Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias (REVERT): A Randomised Controlled Trial. Lancet 2015. PMID: 26314489 Read More

Jun 12, 2017

This week we dive into some of the initial considerations in the resuscitation of major burn patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_101_0_Final_Cut.m4a Download Leave a Comment Tags: Carbon Monoxide , Cyanide , Major Burns , Trauma Show Notes Take Home Points Be prepared to intubate early, the patency of the airway can decline quickly and without warning. If there is any concern for burns to face/neck or smoke inhalation, consider taking control of the airway early. Review the rule of 9s and the parkland formula to direct your large volume fluid resus. Remember the parkland formula directs you to use 4 mL x %TBSA x weight (kg). Half in the first 8 hours and the second half over the next 16 hours. Given the large volume here it’s probably best to use LR or another balanced solution. Do a thorough trauma eval to make sure you don’t miss any other injuries and be sure to watch for developing compartment syndrome And last, consider the need to treat for CO and/or cyanide poisoning. Poor cardiac function, cardiac arrest or a high lactate can be clues to cyanide poisoning and just start 100% O2 while you wait for a co-ox, since CO tox is pretty likely. Rule of 9’s Read More MD Calc: Parkland Formula for Burns LITFL: Trauma! Major Burns LITFL: Releasing the Roman Breast Plate Parvizi D et al. The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: things to keep in mind. Burns 2014; 40: 241-5. PMID: 24050977 Hettiaratchy S, Dziewulski P. ABC of Burns: Introduction. BMJ 2004; 328: 1366-8. PMID: 15178618 Hettiaratchy S, Papini R. ABC of Burns: Initial Management of a Major Burn: I – Overview. BMJ 2004; 328: 1555-7. PMID: 15217876 Hettiaratchy S, Papini R. ABC of Burns: Initial Management of a Major Burn II – Assessment and Resuscitation . BMJ 2004; 329: 101-3. PMID: 15242917 Read More

Jun 5, 2017

It's been 2 years and 100 podcasts. Jenny and Swami take a minute to talk about the Core EM project and our future directions. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_100_0_Final_Cut.m4a Download One Comment Read More

May 29, 2017

This week we discuss 3 articles recently reviewed in our conference - LOV-ED study, Validation of Step-By-Step and Therapeutic Hypothermia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_99_0_Final_Cut.m4a Download Leave a Comment Tags: ARDS , Cardiac Arrest , Lung Protective Ventilation , Mechanical Ventilation , OHCA , Step-By-Step Protocol , Therapeutic Hypothermia , TTM Show Notes Take Home Points The step-by-step approach to managing febrile infants is a reliable decision instrument to identify patients at low risk for invasive bacterial infections. Caution in the group of patients 22-28 days of age. The LOV-ED study shows an association between employing a lung-protective ventilation strategy in the ED and decreased complications from mechanical ventilation. Best available evidence says that we should embrace this approach in the ED. Cooling to 33 degrees is no better than cooling to 36 degrees. However, shooting 36 degrees is more difficult than we may have thought. We have to continue to be vigilant about maintaining patients in the target temperature range and avoiding fever. The Step-By-Step Algorithm Lung-Protective Ventilation Protocol (LOV-ED Study) Read More The SGEM: SGEM #171: Step-by-Step Approach to the Febrile Infant REBEL EM: The Benefit of Lung Protective Ventilation in the ED Should Be LOV-ED Taming the SRU: A Crack in the Ice? An In-Depth Breakdown of the TTM Trial References Gomez B et al. Validation of the Step-by-Step Approach in the Management of Young Febrile Infants. Pediatrics. 2016 Aug. PMID: 27382134 Fuller BM et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med 2017. PMID: 28259481 Bray JE et al. Changing target temperature from 33oC to 36oC in the ICU management of out-of-hospital cardiac arrest: a before and after study. Resuscitation 2017; 113: 39-43. PMID: 28159575 Read More

May 22, 2017

This week we delve into the argument for cardioversion in recent-onset AF as well as the logistics of getting it done. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_98_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation , Atrial Flutter , Cardiology , Cardioversion Show Notes Read More Core EM: Podcast 64.0 – Rate Control in AF Core EM: Recent Onset Atrial Fibrillation Core EM: 30-Day Outcomes After Aggressive AF Management in the ED The SGEM: SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol References Nuito I et al. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA 2014; 312(6): 647-9. PMID: 25117135 Stiell IG et al. Association of the Ottawa aggressive protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation and flutter. Can J Emerg Med 2010; 12(3): 181-91. PMID: 20522282 Stiell IG et al. Outcomes for Emergency Department Patients with Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals. Ann Emerg Med 2017. PMID: 28110987 Read More

May 15, 2017

This week we discuss the rare but life-threatening methemoglobinemia with a focus on recognition and use of the antidote. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_97_0_Final_Cut.m4a Download 2 Comments Tags: Methemoglobin , Toxicology Show Notes Take Home Points MetHb –emia occurs as a results of various medications including amyl nitrite, dapsone, nitroprusside, phenazopyridine, sodium nitrite and topical anesthetics like benzocaine Patients will present with cyanosis, short of breath, fatigue, dizziness, weakness and ultimately CNS depression and death at higher concentrations. If you have a cyanotic/hypoxic patient that does not respond to supplemental oxygen, be concerned for MetHb and send a co-oximetry panel. If the level is <25% and the patient is asymptomatic you can observe, but if the level is >25% or the patient is symptomatic, you will treat with the antidote methylene blue given as a bolus of 1-2 mg/kg over 5 minutes And as always, make sure to call your local poison center to get your toxicologists involved. They can help with dosing, and they are also an important player of the public health component in cases such as these, to make sure this is an isolated incident and we don’t have a repeat of the 11 blue men situation. Price DP. Chapter 127. Methemoglobin Inducers. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e New York, NY: McGraw-Hill; 2011. Accessed April 19, 2017. Methemoglobinemia Signs and Symptoms Methemoglobinemia Treatment Read More

May 8, 2017

This week we do a brief review on recognizing CO monoxide poisoning and expertly managing it. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_96_0_Final_Cut.m4a Download Leave a Comment Tags: CO , Inhaled Toxins , Toxicology Show Notes Take Home Points CO poisoning happens most often from common are accidental exposures from faulty home heaters, camp stoves and indoor use of gas powered generators, structure fires and intentional exposure like in suicide attempts. Patients with a mild exposure will present with symptoms like headache, nausea, vomiting, dizziness, vision blurring, palpitations, confusion or myalgias. More severe exposures may produce Altered mental status. seizures, coma, dysrythmias, myocardial ischemia, metabolic acidosis, syncope and vital sign abnormalities including hypotension and, eventually, cardiac arrest. To help distinguish the vague symptoms of a patient who may have chronic exposure ask about things like whether symptoms improve in different environments or whether they have sick pets, as human viral illness generally don’t affect our dogs and cats. If you’re concerned about CO send a co-ox panel. City dwellers may have a baseline carboxyhemoglobin of 1-2% and smokers around 6-10% but others should really have no carboxyhemoglobin. Treatment is supplemental O2 which can be stopped when symptoms improve. For severe symptoms and for pregnant patients, consider hyperbarics to prevent long term sequelae and to protect the fetus. As always, consider discussing the case with your local poison center to help decide whether a patient warrants transfer for hyperbarics. LITFL: Carbon Monoxide Poisoning EMCrit: Podcast 122 – Cardiac Arrest after the Toxicology of Smoke Inhalation with Lewis Nelson FOAMcast: Episode #1: EMCrit Episode #122 – Cyanide and Carbon Monoxide Toxicity Nelson LS, Hoffman RS: Inhaled Toxins, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 159: p 2036-2045. Tomaszewski C. Chapter 125. Carbon Monoxide. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e New York, NY: McGraw-Hill; 2011. Accessed April 19, 2017. Read More

May 1, 2017

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

Apr 24, 2017

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

Apr 17, 2017

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

Apr 10, 2017

This week we discuss some of the many dialysis-related emergencies we frequently see in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_92_0_Final_Cut.m4a Download One Comment Tags: Dialysis , ESRD , Nephrology Show Notes Take Home Points On any dialysis patient, make sure to do a good assessment of their access site. If it’s a fistula, assess for a thrill, for any warmth/induration/erythema and make sure they have distal sensation and perfusion. If it’s a catheter, evaluate for any signs of infection—so warmth, erythema or discharge. Bleeding is a big concern. If the patient is bleeding from their access, start with direct pressure to the bleeding site, then move on to topical thrombotic agents and if needed throw a figure 8 stitch with a 5-0 proline on a non-cutting needle. Peritoneal dialysis patients are at risk for bacterial peritonitis. In a PD patient that appears infected, get a peritoneal fluid sample and start antibiotics Dialysis patients are susceptible to dialysis disequilibrium syndrome which can present as altered mental status, focal neurological deficits or even frank coma or seizures after dialysis. Make sure to consider a broad differential in these patients and start with a solute load such as an amp or two of D50 while starting your work up. Core EM: Hyperkalemia Core EM: Episode 7.0 – Hyperkalemia + Rate Control in AFib Al Sacchetti: ED Repair of Bleeding Dialysis Shunt EM: RAP: Episode 107 – Dialysis Emergencies EMBlog Mayo Clinic: How to Stop a Post-Dialysis Site Bleeding emDocs: Managing Fistula Complications in the Emergency Department Read More

Apr 3, 2017

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

Mar 27, 2017

This week we dive into acute rhinosinusitis focusing on diagnosis and discussing the absence of utility for antibiotics in most patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_90_0_Final_Cut.m4a Download Leave a Comment Tags: ENT , Rhinosinusitis , Sinusitis , URI Show Notes Take Home Points Sinusitis is a clinical diagnosis. Patients typically present with purulent nasal discharge and facial pain or other URI symptoms. The vast majority of patients with acute rhino sinusitis will be viral in nature and will not benefit from antibiotics Patients with prolonged symptoms, more than 7-10 days, without improvement or continued fevers past 2-3 days should be considered for antibiotic treatment as should those who are immunocompromised. Show Notes Melio FR, Berge LR. Upper Respiratory Tract Infections, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 75: p 965-79. The NNT: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults The NNT: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Lemiengre MB et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012. PMID: 23076918 Ahovuo-Saloranta A et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2008. PMID: 18425861 Read More

Mar 20, 2017

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

Mar 13, 2017

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

Mar 6, 2017

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

Feb 27, 2017

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

Feb 20, 2017

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

Feb 13, 2017

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

Feb 6, 2017

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

Jan 30, 2017

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

Jan 23, 2017

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

Jan 16, 2017

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

Jan 9, 2017

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

Jan 2, 2017

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

Dec 19, 2016

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

Dec 12, 2016

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

Dec 5, 2016

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

Nov 28, 2016

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

Nov 21, 2016

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

Nov 14, 2016

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

Nov 7, 2016

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

Oct 31, 2016

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

Oct 24, 2016

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

Oct 17, 2016

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

Oct 10, 2016

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

Oct 3, 2016

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

Sep 26, 2016

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

Sep 19, 2016

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

Sep 12, 2016

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

Sep 5, 2016

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

Aug 29, 2016

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

Aug 22, 2016

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

Aug 15, 2016

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

Aug 8, 2016

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

Aug 1, 2016

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

Jul 25, 2016

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

Jul 18, 2016

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

Jul 11, 2016

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

Jul 4, 2016

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

Jun 27, 2016

This week we review anaphylaxis, the importance of epinephrine/adrenaline and how to use it properly. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_52_0_Final_Cut.m4a Download One Comment Tags: Allergic Reactions , Allergy , Anaphylaxis , Epinephrine Show Notes Anaphylaxis Definition Read More Tran TP, Muelleman RL: Allergy, Hypersensitivity, Angioedema, and Anaphylaxis, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 119: p 1543-1560. YouTube: Epinephrine Auto-Injector Use The SGEM: #57: Should I Stay or Should I Go (Biphasic Anaphylactic Response) Core EM: Biphasic reactions in emergency department patients with allergic reactions or anaphylaxis References Grunau BE et al. Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis. Ann Emerg Med 2014; 63(6): 736-44. PMID: 24239340 Grunau BE et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis is Not Associated with Decreased Relapses. Ann Emerge Med 2015; 66(4): 381-9. PMID: 25820033 Read More

Jun 20, 2016

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

Jun 6, 2016

This week we look at the rarely used, but potentially life-saving, procedure of gastric lavage. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_50_0_Final_Cut.m4a Download Leave a Comment Tags: Gastric Emptying , Gastric Lavage , Toxicology Show Notes Gastric Lavage Indications (Goldfrank’s Toxicologic Emergencies Ch 7) Gastric Lavage Risk Assessment (Goldfrank’s Toxicologic Emergencies Ch 7) Gastric Lavage Placement (Goldfrank’s Toxicologic Emergencies Ch 7) References Adams BK et al. Prolonged gastric emptying half-time and gastric hypo motility after drug overdose. Am J Emerg Med 2004; 22: 548-554. PMID: 15666259 Benson BE et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Tox 2013; 51: 140-6. PMID: 23418938 Gude AB, Hoegberg LCG. Chapter 7. Techniques Used to Prevent Gastrointestinal Absorption. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e . New York, NY: McGraw-Hill; 2011. Hoffman RS. Does consensus equal correctness? Clin Tox 2000; 38(7): 689-90. PMID: 11192453 Kulig K et al. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985; 14(6): 562-9. PMID: 2859819 Merigian KS et al. Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med 1990; 8: 479-83. PMID: 1977400 Pond SM et al. Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aus 1995; 163: 34-9. PMID: 7565257 Read More

May 30, 2016

This week we take a look at alcohol withdrawal with a focus on recognition and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_49_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Withdrawal , Ativan , Benzodiazipines , Delirium Tremens , Ethanol , Thaimine , Valium Show Notes Yip L. Chapter 77. Ethanol. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e. New York, NY: McGraw-Hill; 2011. EmCrit Podcast: Delirium Tremens Life in the Fast Lane: Alcohol Withdrawal The Poison Review: CPC: alcohol withdrawal with delirium tremens and a significant missed diagnosis EM Updates: Avoid Alcohol Withdrawal Admissions MDCalc: CIWA Read More

May 23, 2016

This week we delve into the anticholinergic toxidrome with a focus on management and the use of physostigmine. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_48_0_Final_Cut.m4a Download Leave a Comment Tags: Anticholinergic , Diphenhydramine , Physostigmine , TCA , Toxicology Show Notes Howland M. Antidotes in Depth (A12): Physostigmine Salicylate. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e . New York, NY: McGraw-Hill; 2011. Velez LI, Feng SY: Anticholinergics, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 150: p 1970-5. Anticholinergic Infographic (BrianandKloss.com) Drugs Exhibiting Anticholinergic Toxicity (Rosen’s) Read More

May 16, 2016

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

May 9, 2016

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

May 2, 2016

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

Apr 25, 2016

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

Apr 18, 2016

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

Apr 11, 2016

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

Apr 4, 2016

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

Mar 28, 2016

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

Mar 21, 2016

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

Mar 14, 2016

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

Mar 7, 2016

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

Feb 29, 2016

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

Feb 22, 2016

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

Feb 15, 2016

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

Feb 8, 2016

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

Feb 1, 2016

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

Jan 25, 2016

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

Jan 18, 2016

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

Jan 11, 2016

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

Jan 4, 2016

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

Dec 28, 2015

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

Dec 14, 2015

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

Dec 7, 2015

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

Nov 30, 2015

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

Nov 23, 2015

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

Nov 16, 2015

This week we'll discuss some common causes of abdominal pain that originate in extra-abdominal pathology. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_22_0_Abdominal_Pain_Final_Cut.m4a Download Leave a Comment Tags: Abdominal Pain Show Notes Life in the Fast Lane: Metabolic Causes of Abdominal Pain Read More

Nov 9, 2015

This week podcast focuses on esophageal food impaction and pearls + pitfalls in the diagnosis of peds appendicitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_21_0_Final.m4a Download Leave a Comment Tags: Appendicitis , Food Impaction , Pediatrics Show Notes REBEL Cast: November 2015: All Vascular Access Episode Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855 Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002; 37(6): 877-81. PMID: 12037754 Ross MJ et al. Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound. Acad Emerg Med 2015; 21(5): 538-42. PMID: 24842505 Parienti JJ et al. Intravascular complications of central venous catheterization by insertion site. NEJM 2015. PMID: 26398070 Read More

Nov 2, 2015

On this podcast we review some background on AVNRT and focus on Emergency Department management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_20_0_Final.m4a Download 2 Comments Tags: AVNRT , PSVT , REVERT Trial , Tachydysrhythmias Show Notes AVNRT with Aberrancy vs. VT REBEL EM: SVT with Aberrancy Versus VT Amal Mattu’s ECG Case of the Week: August 26th, 2013 Valsalva Maneuver ALiEM: Tricks of the Trade: Valsalva Maneuver By Using a 10cc Syringe St. Emlyn’s: JC The REVERT Trial Adenosine in AVNRT Larry Mellick: Treating SVT with Adensoine ALiEM: Trick of the Trade: Combining Adenosine with the Flush Verapamil in AVNRT RAGE Podcast: Rage Session Two ERCast Podcast: How to run a code Appleboam A et al. Postural mdodification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised trial. Lancet 2015. PMID: 26314489 Read More

Oct 30, 2015

Bonus Podcast - Grand Rounds from 9/23/15 featuring Brian Freeze MD on Numeracy. Lecture is part of the Chief Resident Incubator Program https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_19_1_Numeracy_Final.m4a Download Leave a Comment Tags: Chief Resident Incubator , Numeracy , Statistics Read More

Oct 26, 2015

Pearls and take home messages from our weekly conference. This week, we review talks on influenza and pediatric foreign body aspiration. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_19_0_Final.m4a Download Leave a Comment Tags: Aspiration , Foreign Body , Influenza , Oseltamivir , Tamfiflu Show Notes Influenza Populations at High Risk for Severe Influenza – IDSA ALiEM: Neuraminidase Inhibitors for Influenza – The Truth, The Whole Truth, and Nothing But the Truth. Finally. EM Lit of Note: Remember, Tamflu is Still Junk. EM Lit of Note: Which Review of Tamflu Data do You Believe? Jefferson T et al. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ 2014. PMID: 24811411 Dobson J et al. Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. Lancet 2015; 385(9979): 1729-37. PMID: 25640810 Foreign Body Aspiration Brown JC et al. The utility of adding expiratory of decubitus chest radiographs to the radiographic evaluation of suspected pediatric airway foreign bodies. Ann Emerg Med 2013; 61: 19-26. PMID: 22841172 Foltran F et al. Foreign bodies in the airways: a meta-analysis of published papers. Int J Pediatric Otorhinolaryngol 2012; 76 Suppl 1: S12-9. PMID: 22333317 Read More

Oct 23, 2015

This bonus podcast is from our Grand Rounds series. Here, Jeremy Faust gives a great talk on the role of Music in Medicine. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_18_1-Music_in_Medicine_feat_Jeremy_Faust_.m4a Download Leave a Comment Tags: Grand Rounds , Music Show Notes References Platz, F. and Kopiez, R., “When the first impression counts: Music performers, audience, and the evaluation of stage entrance behavior”, Musicae Scientiae 17, No. 2 (2013), pp. 167-197 Acad Emerg Med. 2012 Oct;19(10):1166-72. Epub 2012 Oct 4. Predictors of parent satisfaction in pediatric laceration repair. Lowe DA, Monuteaux MC, Ziniel S, Stack AM. Proc Natl Acad Sci U S A. 2013 Sep 3;110(36):14580-5. Epub 2013 Aug 19. Sight over sound in the judgment of music performance. Tsay CJ. Med Educ. 2013 Aug;47(8):842-50. Music lessons: revealing medicine’s learning culture through a comparison with that of music. Watling C, Driessen E, van der Vleuten CP, Vanstone M, Lingard L. The New Yorker. October 3, 2011. Personal Best. Top athletes and singers have coaches. Should you? Atul Gawande. ANZ J Surg. 2013 Jun;83(6):477-80. Epub 2013 Apr 26. Improving the impact of didactic resident training with online spaced education. Gyorki DE, Shaw T, Nicholson J, Baker C, Pitcher M, Skandarajah A, Segelov E, Mann GB. Psychol Sci Public Interest. 2013 Jan;14(1):4-58. Improving Students’ Learning With Effective Learning Techniques: Promising Directions From Cognitive and Educational Psychology. Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Resuscitation. 2010 May;81(5):631. Epub 2010 Feb 26. The use of popular audio in CPR (TUPAC)–Does music improve compliance with recommended chest compression rates? Naushaduddin M, Holdgate A, Ung S. Science. 1965 Nov 19;150(3699):971-9. Pain mechanisms: a new theory. Melzack R, Wall PD. http://www.dailymail.co.uk/news/article-2715109/Despite-pain-half-mothers-enjoy-childbirth-admit-differently-time.html Pediatr Emerg Care. 2008 Dec;24(12):836-8. Emergency department waiting room stress: can music or aromatherapy improve anxiety scores? Holm L, Fitzmaurice L. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. (Hole Lancet 2015). 72 randomized trials. Lancet. 2015 Aug 12. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Hole J, Hirsch M, Ball E, Meads C. . Ann Emerg Med. 1991 Apr;20(4):348-50. A randomized, controlled trial of the use of music during laceration repair. Menegazzi JJ, Paris PM, Kersteen CH, Flynn B, Trautman DE. Anaesthesia. 1992 May;47(5):438-9. The effect of music on ketamine induced emergence phenomena. Kumar A, Bajaj A, Sarkar P, Grover VK. Cochrane Database Syst Rev. 2013 Oct 25;10:CD004843. Music for pain relief. Cepeda MS, Carr DB, Lau J, Alvarez H. Cochrane Database Syst Rev. 2014;12:CD006902. doi: 10.1002/14651858.CD006902.pub3. Epub 2014 Dec 9. Music interventions for mechanically ventilated patients. Bradt J, Dileo C. Read More

Oct 19, 2015

This week we discuss some information on influenza testing in the ED and management of epistaxis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_18_0_Final_Version.m4a Download Leave a Comment Tags: Epistaxis , Influenza Show Notes Show Notes EMCrit: Dominating the Vent I http://emcrit.org/lectures/vent-part-1/ EMCrit: Dominating the Vent II http://emcrit.org/podcasts/vent-part-2/ ALiEM: Neuraminidase Inhibitors for Influenza – The Truth, The Whole Truth, and Nothing But the Truth. Finally. EM Lit of Note: Remember, Tamflu is Still Junk. EM Lit of Note: Which Review of Tamflu Data do You Believe? Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013; 31: 1389-92. PMID: 23911102 Derkay CS et al. Posterior nasal packing. Are Intravenous antibiotics really necessary? Arch Otolaryngol 1989; 115: 439-41. PMID: 2923686 Pepper C et al. Prospective study of the risk of not using prophylactic antibiotics in nasal packing for epistaxis. J Laryng Otology 2012: 257-9. PMID: 22214602 Biggs TC et al. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl 2013; 95: 40-2. PMID: 23317726 Read More

Oct 12, 2015

Pearls from our weekly conference discussing severe asthma and COPD exacerbations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_17_0_Final.m4a Download 4 Comments Tags: Asthma , BPAP , COPD , NIPPV , Respiratory Show Notes Shownotes EMCrit: Delayed Sequence Intubation REBEL EM: The Crashing Asthmatic EM:RAP: The Rule of 2s Abdo WF, Heunks LM. Oxygen-induced hypercapnia in COPD: myths and facts. Critical Care 16(5):323. PMID: 23106947 Read More

Oct 5, 2015

Pearls from our conference discussing apparent life-threatening events (ALTE). https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_16_Final.m4a Download Leave a Comment Tags: ALTE , Pediatrics Show Notes Shownotes Mittal MK et al. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012; 28(7): 599-605. PMID: 22743742 Kaji AH et al. Apparent life-threatening event: multi center prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med 2013; 61(4): 379-87. PMID: 23026786 Read More

Sep 28, 2015

Pearls from a core content talk on adrenal emergencies, a journal update looking at D-dimer in aortic dissection and some acid/base cases. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_15_0_Final.m4a Download Leave a Comment Tags: Acid Base , Adrenal Gland , Adrenal Insufficiency , Aortic Dissection , Congenital Adrenal Hyperplasia , D-dimer Show Notes Shownotes Asha SE, Miers JW. A systematic review and meta-analysis of D-dimer as a rule-out test for suspected acute aortic dissection. Ann Emerg Med 2015. PMID: 25805111 Dierks DB et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med 2015; 65: 32-42. PMID: 25529153 Acid-Base Cases Quick questions & answers: For acute respiratory acidosis or alkalosis, how much does the pH change for every 10mm change of PCO2? What is the Winter’s formula? For stable chronic respiratory acidosis, for every 10 mm increase in PCO2, how much should the pH decrease by? For each of the following cases, please analyze the acid-base status (i.e. anion gap metabolic acidosis, respiratory alkalosis, non-AG metabolic acidosis with respiratory acidosis, etc…) for further discussion in the workshop. 1) A 25 year old woman is found at home c/o thirst, shortness of breath, and spasms of her arms and legs. Vital signs: BP 90/50 mmHg; pulse 155/min; RR 32/min; afebrile; RA O2 sat 98%. 137 84 18 274 Calcium 9.6 2.4 29 1.2 VBG: 7.66 / 25.5 / 29.1 What is the acid base abnormality? What abnormality is responsible for her neuromuscular symptoms? What other electrolyte abnormalities would you expect? How should she be treated? 2) A 21 yo female presented to ED after reportedly ingesting an entire bottle of pills (drug and formulation unknown) and now complaints oftinnitus, nausea, and vomiting. Exam: A, O x3, Pupils – dilated, reactive, Neuro – no hyperreflexia, rigidity or clonus Lungs – + tachypnea, CV – tachycardia, no murmurs, skin nl VS: BP 92/67, HR 100/min, RR 18/min, T 98.6, RA O2 sat 99% 135 104 12 145 3.8 11 0.9 Ca 7.8 ABG: 7.47 / 14 /109 /10 3) A 56 yo female with a past medical history of heroin use (on methadone maintenance therapy) and chronic ETOH use presents with chest pain, shortness of breath, body aches, as well as nausea, vomiting and diarrhea. VS: BP 164/84, HR 112/min, RR 22/min, T 98, RA O2 sat 98% MS – awake, alert and oriented x2, CV – tachycardic, RR no m, abd nl, skin nl 136 98 7 277 3.4 19 0.9 4) 53 y/o M referred to the ED for severely elevated BP of 235/135. He c/o 1 week of polydipsia, polyuria, fatigue, and some dyspnea on exertion. No known PMH but has no doctor evaluation for many years. VS: BP 191/94, HR 88/min, RR 18/min, T 97.4 143 89 23 253 2.3 45 1.0 ABG: 7.56 / 53.6 / 65.4 lactate 3.2 5) A 62 y/o M with h/o stage IIIa rectal ca s/p diverting ileostomy 5 months ago & currently on chemotherapy presented with 3 days of repeated vomiting, watery diarrhea, and generalized weakness. VS: BP 80/47, HR 100/min, RR 26/min, T 95 o , RA O2 sat 96% PE: thin M, tired appearing 121 86 166 164 4.4 8 13.6 VBG: 7.04 / 31 / 28.6 bicarb 7.9 WBC 7.5 / 14/41.8 / 180K 6) 66 y/o M presented to the ED because of alcohol withdrawal. VS: BP 144/98, HR 130/min, RR 22/min, T 98.3, RA O2 sat 97% 141 102 8 85 ABG on O2 7.45 / 24 / 136 4.3 13 0.7 7) A 32 y/o F with hx of DM x 20 yrs on canagliflozin presented to the ED c/o polyuria x 2 days, epigastric pain, and not feeling well. VS: BP 139/77, HR 112/min, RR 32/min, T 98.5, RA O2 sat 99% 135 104 17 191 3.4 3 0.4 7.06 / 11 / 125 8) A 55 y/o M with history of asthma but non-compliant with all medications and follow up presented to the ED with asthma exacerbation over the past few days. He appears to be SOB, able to speak to you & complete his sentences. + mild accessory muscle usage, mild wheezing VS: BP 150/90, P = 115/min, R = 30/min, T = 98 , RA O2 sat 87% ABG: 7.22 / 85 / 55 143 102 25 99 —————————— 3.8 36 1.3 9) A 70 y/o M with h/o COPD presented with 2 days of vomiting and weakness. VS: BP 150/ 85, HR 100/min, RR 18/min , T 99, RA O2 sat 90% 136 85 28 65 7.19 / 60 / 55 bicarb 25 ——————————- 4.1 25 1.4 AST/ALT 150 / 100 Alb 2.5 10) A 37 y/o M presents to the ED in a coma. VS: BP 110/80, HR 125/min, RR 30/min, T 97, O2 sat 99% on RA 142 | 104 | 15 | 89 7.05 / 15 / 115 bicarb 5 ————————————— 3.9 | 5 | 1.9 Read More

Sep 21, 2015

This is a full length recording of Mike Stone's Grand Rounds at Bellevue Hospital on Ultrasound Guided Nerve Blocks for Regional Anesthesia https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_14_0_Grand_Rounds_Stone_Nerve_Blocks_Final.m4a Download Leave a Comment Tags: Nerve Blocks , Ultrasound Show Notes Regional Anesthesia Resources The Ultrasound Podcast: Nerve Blocks Archive ASAHQ: Standards for Basic Anesthetic Monitoring Cook County Regional: Chapter on Local Anesthetics Anesthesiology News: Nerve Injury After Peripheral Nerve Block Template for Peripheral Nerve Blocks Femur Fracture Analgesia Checklist Read More

Sep 14, 2015

Lily Abrukin (Chief Resident) and Swami discuss the care of a critically ill patient with DKA. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_13_0_Final.m4a Download 5 Comments Tags: DKA , Hyperkalemia Show Notes Diabetic Ketoacidosis LITFL: EBM Diabetic Ketoacidosis emDocs: Myths in DKA Management REBEL EM: Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis? Hyperkalemia LITFL: Hyperkalaemia Core EM: Hyperkalemia Core EM: Podcast 7.0 Intubation in Severe Metabolic Acidosis EMCrit: Podcast 3 – Laryngoscope as a Murder Weapon Series – Ventilatory Kills – Intubating the Patient with Severe Metabolic Acidosis Core EM: Podcast 4.0 Read More

Sep 7, 2015

This week we discuss some of the dangers of blood transfusions and pearls from our procedure workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_12_Final.m4a Download Leave a Comment Tags: Blood Transfusions , Cricothyroidotomy , Lateral Canthotomy , Tube Thoracostomy Show Notes Cricothyrotomy Resources EMCrit: EMCrit Wee – Mind Blowing Cricothyrotomy Video ACEP Now: Tips and Tricks for Performing Cricothyrotomy Tube Thoracostomy University of Maryland EM: Tube Thoracostomy Lateral Canthotomy Resources Rowh AD et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med 2015. 48(3):325-330. PMID: 25524455 Larry Mellick: Emergency Lateral Canthotomy and Cantholysis Read More

Sep 4, 2015

This is a full length talk from our Grand Rounds series featuring Andy Sloas of the PEM ED Podcast on Infant Emergencies. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_11_1_Final.m4a Download Leave a Comment Tags: Pediatric Resuscitation Show Notes ACEP: THE MISFITS THE MISFITS – Sick Kids Mnemonic Read More

Aug 31, 2015

Pearls from our weekly resident conference - discussion of PE risk stratification and TEE in cardiac arrest https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_11_0_Final.m4a Download Leave a Comment Tags: Cardiac Arrest , Pulmonary Embolism , TEE Show Notes Ultrasound in Cardiac Arrest Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation 2008; 78: 135-40. PMID: 18486300 Ultrasound Podcast: Ultrasound guided CPR Part 1. How we’re doing it wrong . Ultrasound Podcast: Ultrasound guided CPR Part 2. TEE & US = New pulse check Read More

Aug 24, 2015

Pearls from a core content talk on aortic dissection, syncope workshop and journal update on ATLS. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_10.m4a Download 2 Comments Tags: Aortic Dissection , ATLS , Cardiovascular , Syncope Show Notes Resources Aortic Dissection Hagan PG et al. The international registry of acute aortic dissection (IRAD): New insights into an old disease. JAMA 2000; 283: 897-903. PMID: 10685714 Rosman HS et al. Quality of history taking in patients with aortic dissection. Chest 1998; 114(3): 793-5. PMID: 9743168 All NYC EM Podcast: Rob Rogers – Aortic Dissection Syncope EM Lyceum: Syncope, Answers Amal Mattu: ECG Weekly Steve Smith: Dr. Smith’s ECG Blog Journal Update – ATLS Wiles MD. ATLS: Archaic Trauma Life Support? Anaes 2015; 70: 893-906. PMID: 26152249 Read More

Aug 21, 2015

Full length Grand Rounds recording from Sergey Motov's talk - "The Evolution of Pain Management in the ED: From Poppy Seeds to Ketamine https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_9_1_Final_Version.m4a Download Leave a Comment Tags: Ketamine , Opioid Free ED , Pain Management Show Notes Pain Free ED Site ACEP Now: Non-Opioid Pain Medications to Consider for Emergency Department Patients EMCrit: Opiate-Free ED with Sergey Motov Read More

Aug 17, 2015

Pearls, pitfalls and take home points from the NYU/Bellevue EM Residency weekly conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_9_0_Final.m4a Download Leave a Comment Tags: Pediatric Cardiology , Pericardial Tamponade Show Notes Vaillancourt S. et al. Repeated Emergency Department Visits Among ChildrenAdmitted With Meningitis or Septicemia: A Population-Based Study. Ann Emerg Med 2015; 65(6): 625-631. PMID: 25458981 EMCrit: Rapid Ultrasound for Shock and Hypotension – the RUSH Exam . Verma V et al. The utility of routine admission chest X-ray films on patient care. Eur J Intern Med 2011; 22(3): 286-8. PMID: 21570649 EMCrit: Opiate-Free ED with Sergey Motov Read More

Aug 10, 2015

Recapping pearls from our weekly conference. This week, we discussed pearls on chest pain. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_Episode_8.m4a Download Leave a Comment Tags: ACS , Chest Pain Show Notes How to Build a Great Talk The Teaching Course Podcast: How to Build a Talk – Part I The Teaching Course Podcast: How to Build a Talk – Part II Chest Pain Workshop Core EM: Chief Complaint – Chest Pain REBEL EM: Is it time to start using the HEART pathway in the Emergency Department? EMCast November 2014: Low Risk Chest Pain Backus BE et al. Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department . Curr Card Rev 2011; 7: 2-8. PMC: 3131711 Mahler SA et al. The HEART Pathway Randomized Trial Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge . Circ Cardiovasc Qual Outcomes March 2015; 8 (2): 195 – 203. PMID: 25737484 The HEART Pathway (Mahler 2015) Journal Update Goldberg H et al. Oral steroids for actue radiculopathy due to a herniated disk – a randomized clinical trial. JAMA 2015; 313(19): 1915-23. PMID: 25988461 Read More

Aug 3, 2015

This week we discuss the management of hyperkalemia + a journal update on beta blockers vs Ca channel blockers in AF https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_7_Final.m4a Download Leave a Comment Tags: Atrial Fibrillation , Hyperkalemia Show Notes Core EM: Hyperkalemia REBEL EM: Is Kayexalate Useful in the Treatment of Hyperkalemia in the Emergency Department? Core EM: Diltiazem vs. Metoprolol for Rate Control in Atrial Fibrillation Read More

Jul 27, 2015

Pearls and take home points from our challenging airway workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_6_Finial.m4a Download Leave a Comment Tags: Airway , Challenging Airway , DSI Show Notes Highlighted Resources EMCrit: Podcast 40 – Delayed Sequence Intubation (DSI) EMCrit Wee: Mind Blowing Cricothrotomy Video EP Monthly: NO DESAT! EMCrit: Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer EMUpdates: Optimize the Head During Laryngoscopy Read More

Jul 20, 2015

Podcast 5.0 features pearls from Howie Mell's Grand Rounds talk "48 Tweets on 24 Topics" https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_5.m4a Download Leave a Comment Tags: Grand Rounds , Howie Mell Show Notes Ovarian Hyperstimulatoin Syndrome (OHSS) Braude P, Rowell P. ABC of subfertility – Assisted conception III – problems with assisted conception. BMJ 2003; 327: 920-923. PMC: 218823 Backboards ACEP Clinical Policy Statement: EMS Management of Patients with Potential Spinal Injury EM Cases: Episode 66 Backboard and Collar Nightmares from the Emergency Medicine Update Confernce. Tranexamic Acid (TXA) HIPPO EM: “Stop the Bleeding!” – TXA in Prehospital Care The Skeptics Guide to EM: SGEM#80: CRASH-2 (Classic Paper) INSERT LINK TO OUR CRASH 2 REVIEW Nasal Oxygen During Efforts Securing a Tube (NO DESAT) EP Monthly: NO DESAT! Read More

Jul 13, 2015

Episode 4.0 features pearls on perimortem C-sections, procedural sedation and an interview with Reuben Strayer on Airway Nightmares https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_4_0_Final_Version.m4a Download Leave a Comment Tags: Airway , Perimortem C-section , Procedural Sedation , RSI Show Notes Perimortem C-Section Links EMCrit: Perimortem C-Section Procedural Sedation Links EM Updates: Emergency Department Procedural Sedation Checklist V2 EM Updates: The Procedural Sedation Screencast Trilogy EMCrit: Procedural Sedation Resources Airway Nightmares EM Updates: Direct vs. Video Laryngoscopy in 10 Minutes Read More

Jul 6, 2015

Episode 3.0 covers a variety of topics from our ID workshops and Disaster Management Grand Rounds https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_3_0-ID_Workshops_Disaster-Final.mp3 Download Leave a Comment Tags: Blast Injuries , Disaster Management , Infectious Diseases , Pneumonia , Skin and Soft Tissue Infections Show Notes General ID Workshop Take Home Points Know your local antibiogram. This is the best way to tailor your management to your patient. Search for recent old cultures from your patients and order antibiotics based on this information. Skin + Soft Tissue Take Home Points Antibiotics aren’t required for most simple abscesses. I+D and if no overlying cellulitis, no antibiotics needed. Not all abscesses need packing. If they’re small and on the extremeties, it’s reasonable to leave them unpacked. Not all patients need MRSA coverage for cellulitis. Most cellulitis without abscess is strep. Necrotizing Fasciitis can be tough to pick up. The LRINEC scoring system is one method to help. Most patients will be toxic but look for pain that’s out of proportion to the examination. Relevant Links AliEM – The Not-So-Sick Health-Care Associated Pneumonia Patient: New Treatment Strategy EM Lyceum – Abscess Disaster Management START Triage System Blast Related Traumatic Brain Injury: Military Acute Concussion Evaluation (MACE) Read More

Jun 29, 2015

This podcast highlights pearls, pitfalls and take home points from our conference on ID emergencies as well as a sepsis update for 2015 https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_Episode_2.mp3 Download Leave a Comment Tags: Ebola , Endocarditis , Infectious Diseases , Myocarditis , Sepsis Show Notes SIRS Criteria Read More REBELCast: Sepsis Care in 2015 References Tattevin P et al. Does this patient have Ebola virus disease? Intensive Care Med 2014; 40(11): 1738-41. PMID: 25183574 Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001; 345(19): 1368-77. PMID: 11794169 The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. NEJM 2014; 370(18): 1683-93. PMID: 24635773 ARISE Investigators. Goal-directed resuscitation for patients with early septic shock. NEJM 2014; 371(16): 1496-506. PMID: 25272316 Mouncey PR et al. Trial of early, goal-directed resuscitation for septic shock. NEJM 2015; 327(14): 1301-11. PMID: 25776532 Read More

Jun 22, 2015

This talk was given by Jay Lemery in May 2015 when he came out from Denver for Grand Rounds. Jay is an associate professor of EM at Denver Health as well as the past president of the Wilderness Medicine Society. This talk is about what Wilderness Medicine is in 2015. "Wilderness Medicine is about providing care in austere environments." https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_1_1.mp3 Download Leave a Comment Tags: Wilderness Medicine Read More

May 9, 2015

This podcast highlights pearls and take home points from Chris McStay's grand rounds talk on Electrical and Lightning Injuries from our Wilderness Medicine Grand Rounds on May 6th, 2015. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core-EM-Podcast-1_0-Final.mp3 Download One Comment Tags: Electrical Injuries , Lightning Injuries , Wilderness Medicine Read More

May 8, 2015

Episode 0.0: Intro to the Core EM Podcast. Every Monday we'll release a podcast featuring pearls, pitfalls and critical take home messages from our weekly resident conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core-EM-Podcast-0_0-Intro-Final.mp3 Download 2 Comments Tags: Introduction Read More