February 17, 2020
An overview and management tips of hemoptysis in the ED. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD Download Leave a 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: 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
January 27, 2020
We go over the recent updates in the workup and management of pneumonia. Hosts: Brian Gilberti, MD Audrey Tse, MD 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 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
January 13, 2020
Diagnosing and managing one of our critical diagnoses - posterior stroke. Hosts: Mukul Ramakrishnan, MD Audrey Bree Tse, MD Download Leave a 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
December 16, 2019
We discuss one of the most complex problems we face – Homelessness Hosts: Kelly Doran, MD Audrey Tse, MD Brian Gilberti, MD Download Leave a 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: U.S. Interagency Council on Homelessness. Home, Together Federal Strategic Plan to Prevent and End Homelessness. Read More
November 25, 2019
We go into one of the more complex injuries – blunt neck trauma. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD 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)
November 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 Download Leave a Comment 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
October 21, 2019
An overview of Vaping Associated Lung Injury (VALI) Hosts: Audrey Bree Tse, MD Larissa Laskowski, DO Brian Gilberti, MD Download Leave a Comment 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
September 23, 2019
An overview of septic arthritis. Download Leave a 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 per...
August 26, 2019
A look at the most common type of seizures in the young pediatric population. 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 ant...
July 30, 2019
A review for the emergency physician of this common disease that can take many forms. Download Leave a Comment Tags: Infectious Diseases Show Notes 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)
July 15, 2019
An in depth review of this notorious parasite. 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
July 1, 2019
A look at this common and controversial topic. 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
June 17, 2019
A look at foot fractures – which can be splinted and which may need to go to the OR. Download Leave a Comment Tags: Orthopedics Show Notes 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
June 3, 2019
A discussion with Dr. McNamara and Dr. Leifer on the essentials and beyond of debriefing Download Leave a 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 Mor...
May 20, 2019
A look at one of the most common and potentially concerning upper respiratory infections in children. Download Leave a 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 4th 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” ( * 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,
May 6, 2019
A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED Download Leave a Comment Tags: Critical Care, Dermatology Show Notes * 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 = 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,
April 22, 2019
A look at the opioid epidemic and what ED providers can do to combat this formidable foe. 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: * 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: * Buprenorphine Induction Pamphlet Read More
April 8, 2019
In this episode, we discuss the recent measles outbreak and how ED providers can best prepare to treat this almost vanquished foe. Download One Comment Tags: Infectious Diseases, Pediatrics Show Notes       References: CDC Measles for Health Care Providers. 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. 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
March 22, 2019
In this episode, we discuss acute decompensated heart failure and how to best manage these dyspneic patients in the ED. 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
March 8, 2019
In this episode, we discuss Boxer's fractures and how to best manage them in the ED. Download One Comment Tags: Orthopedics, Trauma Podcast Video 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 5th * 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: Referral: * May have mild deformity or decreased functionality...
August 13, 2018 Download 5 Comments Read More
July 30, 2018
This week we dive into a recent article highlighting a major update in the treatment of community acquired pneumonia (CAP) 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
July 23, 2018
This week we discuss three recent articles looking at esmolol in refractory VF, c-spine clearance and antibiotics after abscess drainage 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
July 16, 2018
This week we review femoral shaft fractures with a focus on assessment and analgesia 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
July 9, 2018
More amazing pearls from our Bellevue morning report series. 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
July 2, 2018
This week, we discuss penetrating neck trauma and some pearls and pitfalls in management. Download Leave a 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
June 25, 2018
This week we discuss the difficult to diagnose and high morbidity cauda equina syndrome. 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
June 18, 2018
This week we review some recent publications on steroids in pharyngitis and the VAN assessment in stroke. 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
June 11, 2018
This week the podcast features a lecture from Dr. Frosso Admakos - Assistant Residency Director at Metropolitan Hospital in NYC Download Leave a 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
June 4, 2018
This episode reviews the highlights from the recent ACEP clinical policy on acute VTE management in the ED. 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 ( PERC Decision Tool ( 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.
May 28, 2018
This episode reviews the identification and management of patients with salicylate toxicity. 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. 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. 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. 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 Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Read More
April 30, 2018
This week we review the presentation, examination and diagnosis of testicular torsion. 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
April 23, 2018
This week we discuss more pearls from our morning report conference on APE, SAH and caustic ingestions. 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
April 16, 2018
This week we discuss some recent publications relevant to EM: ADRENAL, Idarucizumab and Time to Furosemide. 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? 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
April 9, 2018
This week we discuss the disutility of orthostatic vital signs as a diagnostic tool in patients with suspected volume loss. 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
April 2, 2018
This week we welcome back Andy Little from Doctors Hospital in Columbus, Ohio to chat about ear foreign body removal. 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
March 26, 2018
This week we review pearls from the EEMCrit conference back in January 2018. 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
March 19, 2018
This podcast discusses an 8 step process for building better presentations. Download One Comment Show Notes Resources: P Cubed Presentations Presentation Zen Presentation Zen: Simple Ideas on Presentation Design and Delivery Keynotable Read More
March 12, 2018
This week we discuss some pearls and pitfalls when caring for HIV+ patients in the ED. Download Leave a Comment Tags: AIDS, HIV, Infectious Diseases, PCP, TB, Tuberculosis Show Notes HIV Associated Infections Based on CD4 Count ( Total Lymphocyte Count  = (% lymphocytes x WBC count)/100 TLC 1200 cells/mm3 correlated with CD4 count of < 200 cells/mm3 with a maximal sensitivity of 72.2%, and specificity of 100% TLC1500 cells/mm3 correlated with CD4 count of 200 – 499 cells/mm3 with a maximal sensitivity of 96.7% and specificity of 100% TLC 1900 cells/mm3 correlated with CD4 count of ≥ 500 cells/mm3 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
March 5, 2018
This podcast reviews how clinicians should think about patients who's shock isn't responding to our typical management options. 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
February 26, 2018
More pearls from our fantastic morning report series. 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
February 19, 2018
This week we dive in to the initial trauma assessment. 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
February 12, 2018
This week we dive into the rare but potentially fatal, and difficult to diagnose, air embolism. 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
February 5, 2018
This week we explore the presentation, diagnosis and management of SBP. 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/mm3 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
January 29, 2018
Another set of high-yield pearls coming out of our morning report conferences. 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
January 22, 2018
We welcome Meghan Spyres back to the podcast to discuss toxic alcohol ingestion diagnosis and management. 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
January 15, 2018
This week, we sit down with Billy Goldberg - senior faculty at NYU/Bellevue, to discuss some nuances of hip dislocation management. Download Leave a Comment Tags: Orthopedics, Trauma Show Notes Read More Core EM: Hip Dislocation OrthoBullets: Hip Dislocation EMin5: Hip Dislocation Read More
January 8, 2018
This week we talk about the subacute headache and the dangerous, can't miss diagnoses of cerebral venous thrombosis and IIH 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
December 18, 2017
This week we discuss the uncommon but must make diagnosis of flexor tenosynovitis 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. 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
December 11, 2017
This week we discuss some critical pearls and teaching points from our morning report conference. Download One Comment Tags: Fluoroquinolones, Pneumonia, Spleen Show Notes FOAMCast: Episode 17 - The Spleen! Read More
December 4, 2017
This week we discuss a quick case leading into the management of MALA. 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
November 27, 2017
This week we dive into a recent journal article questioning whether we should tap all ascites. 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
November 20, 2017
This week we discuss the tibio-femoral knee dislocation focusing on identification of the dangerous complications. 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
November 13, 2017
This week we dive into the diagnosis and management of pancreatitis in the ED 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
November 6, 2017
This week we discuss common bites, stings and envenomations. 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
October 30, 2017
This week we review 4 articles discussed in our conference in the last month. 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 Sonograph...
October 23, 2017
Part II of II on gallbladder disorders finishing up with acute cholangitis. 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
October 16, 2017
Part I of II on gallbladder pathology starting with cholecystitis. 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
October 10, 2017
This podcast discusses the presentation and management of button battery ingestions in kids. Download Leave a Comment Tags: Button Battery, GI, Pediatrics Show Notes NBIH Button Battery Ingestion Algorithm Button Battery XR ( 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
October 2, 2017
This week we sit down with toxicologist Meghan Spyres to talk about Wernicke's Encephalopathy. 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
September 25, 2017
This week we discuss the initial approach to assessment of the alcohol intoxicated patient. 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
September 18, 2017
This podcast takes a deep dive into the presentation, diagnosis and management of preeclampsia and eclampsia. 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 MgSO4 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. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014: 178: 2282-2302 Read More
September 11, 2017
This week we discuss the presentation and management of herpes zoster. 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
September 4, 2017
This week we discuss the presentation and management of native US snake bites with Dr. Meghan Spyres 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
August 21, 2017
This week we dive into some advanced topics in RSI including patient positioning and pre-intubation resuscitation. Download Leave a 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
August 14, 2017
This week we discuss some quick pearls from our conference covering an array of renal and GU pathologies. 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
July 31, 2017
Should we intubate patients in cardiac arrest? We discuss this topic and some basics of running a good arrest. 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
July 24, 2017
Prompted by the recent CAMEO trial publication on icatibant, we dive into angioedema with a focus on airway management. 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
July 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. 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
July 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 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
July 3, 2017
This week we dive into the various common agents used in procedural sedation and analgesia in the ED. 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
June 26, 2017
This week we talk about priapism focusing on emergency department management. 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
June 19, 2017
This week we welcome Andy Little onto the show to discuss the modified Valsalva maneuver for breaking SVT. 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
June 12, 2017
This week we dive into some of the initial considerations in the resuscitation of major burn patients. 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
June 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. 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. 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. 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. 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% 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. 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. 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
April 24, 2017
This week we talk about mammal bites - dogs, cats and humans - with a focus on wound closure, antibiotics and rabies prophylaxis. 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
April 17, 2017
This week we cover a workshop from our conference on CNS infections focusing on meningitis. Download 2 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
April 10, 2017
This week we discuss some of the many dialysis-related emergencies we frequently see in the ED. 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
April 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. 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
March 27, 2017
This week we dive into acute rhinosinusitis focusing on diagnosis and discussing the absence of utility for antibiotics in most patients. 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
March 20, 2017
This week we discuss the ED management of anterior and posterior epistaxis. 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
March 13, 2017
This week, we review a simplified approach to determining the rhythm on an EKG with a tachydysrhythmia. 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
March 6, 2017
This week we discuss two recent journal articles - the POKER trial and the ketorlac analgesic ceiling 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
February 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. 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
February 20, 2017
This week we discuss three common complications of delivery: cord prolapse, nuchal cord and shoulder dystocia. 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
February 13, 2017
This week we look at TBI and discuss some of the pitfalls and pearls in early management of traumatic ICH. 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 c...
February 6, 2017
This week we discuss a bit about back pain and specifically, lumbar radiculopathy with a focus on causes and red flags. 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
January 30, 2017
This week we discuss the ED management of seizures focusing on treatment and workup particularly of a 1st seizure episode. 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
January 23, 2017
This week, the podcast features a talk on Visualization given at the All NYC EM conference in October 2016. 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
January 16, 2017
This week we feature a short primer on penetrating chest trauma focusing on circulation first over airway and breathing. 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
January 9, 2017
This week we discuss facial trauma and the disasters it can cause to your airway management. 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
January 2, 2017
This week we discuss the OXYGEN-ICU trial exploring the effect of excess oxygen on ICU mortality. 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
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