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
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.
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
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
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 One Comment 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
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
Dec 16, 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 Leave a 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)...
Nov 25, 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 ...
Nov 4, 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,
Oct 21, 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
Sep 22, 2019