Core EM - Emergency Medicine Podcast

By Core EM

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Core EM Emergency Medicine Podcast

Episode Date
Episode 177.0 – Hemoptysis
14:26
An overview and management tips of hemoptysis in the ED. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD
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Show Notes

OVERVIEW:
  • Definition:
    • expectoration/ coughing of blood originating from tracheobronchial tree
  • Sources:
    • Bronchial arteries (90%): under systemic circulatory pressure to supply supporting structures of the lung → heavier bleeding
    • Pulmonary arteries (5%): under low pressure to supply alveoli → milder bleeding
    • Nonbronchial arteries (5%): intercostal arteries, coronary arteries, thoracic/ upper/ inferior phrenic arteries
  • Quantification:
    • Mild: <20mL/ 24h
    • Massive defined anywhere from >300mL-1L/ 24hr
    • Mortality: 38% for massive (>500mL/ 24hr) vs 4.5% for nonmassive
  • Etiology (in adults):
    • Feb 17, 2020
Episode 176.0 – Pneumonia Updates
10:03
We go over the recent updates in the workup and management of pneumonia. Hosts: Brian Gilberti, MD Audrey Tse, MD
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Show Notes

2007 Infectious Diseases Society of America/American Thoracic Society Criteria for Defining Severe Community-acquired Pneumonia Validated definition includes either one major criterion or three or more minor criteria
  • Minor criteria
    • Respiratory rate > 30 breaths/min PaO2/FIO2 ratio<250 Multilobar infiltrates Confusion/disorientation
    • Uremia (blood urea nitrogen level > 20 mg/dl)
    • Leukopenia* (white blood cell count , 4,000 cells/ml)
    • Thrombocytopenia (platelet count , 100,000/ml)
    • Hypothermia (core temperature , 368 C) Hypotension requiring aggressive fluid
    • resuscitation
  • Major criteria
    • Septic shock with need for vasopressors
    • Respiratory failure requiring mechanical ventilation

A special thanks to our Infectious Diseases Editor: Angelica Cifuentes Kottkamp, MD Infectious Diseases & Immunology NYU School of Medicine

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Jan 27, 2020
Episode 175.0 – Posterior Circulation Stroke
15:24
Diagnosing and managing one of our critical diagnoses - posterior stroke. Hosts: Mukul Ramakrishnan, MD Audrey Bree Tse, MD
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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   https://coreem.net/core/posterior-circulation-stroke/  

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Jan 13, 2020
Episode 174.0 – Homelessness
21:45
We discuss one of the most complex problems we face – Homelessness Hosts: Kelly Doran, MD Audrey Tse, MD Brian Gilberti, MD
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Show Notes

Special Thanks To: Dr. Kelly Doran, MD MHS Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue ___________________________ References: Doran, K.M.  Commentary: How Can Emergency Departments Help End Homelessness?  A Challenge to Social Emergency Medicine. Ann Emerg Med. 2019;74:S41-S44. Doran, K.M., Raven, M.C. Homelessness and Emergency Medicine: Where Do We Go From Here? Acad Emerg Med. 2018;25:598-600. Salhi, B.A., et al. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med. 2018;25:577-93. U.S. Department of Housing and Urban Development, Annual Homeless Assessment Report to Congress. Available at: https://www.hudexchange.info/resource/5783/2018-ahar-part-1-pit-estimates-of-homelessness-in-the-us/ U.S. Interagency Council on Homelessness. Home, Together Federal Strategic Plan to Prevent and End Homelessness. https://www.usich.
Dec 16, 2019
Episode 173.0 – Blunt Neck Trauma
12:28
We go into one of the more complex injuries – blunt neck trauma. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD
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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
Nov 25, 2019
Episode 172.0 – Ankle Sprains
11:05
We dissect one of the most common injuries we see in the ER -- ankle sprains Hosts: Brian Gilberti, MD Audrey Bree Tse, MD
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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
Nov 04, 2019
Episode 171.0 – Vaping Associated Lung Injury
16:03
An overview of Vaping Associated Lung Injury (VALI) Hosts: Audrey Bree Tse, MD Larissa Laskowski, DO Brian Gilberti, MD
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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)
  1. Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset AND
  2. Pulmonary infiltrate,
Oct 21, 2019
Episode 170.0 – Septic Arthritis
11:26

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
Sep 23, 2019
Episode 169.0 – Febrile Seizures
9:02
A look at the most common type of seizures in the young pediatric population.
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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 pati...
Aug 26, 2019
Episode 168.0 – Lyme Disease
15:07
A review for the emergency physician of this common disease that can take many forms.
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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,
Jul 30, 2019
Episode 167.0 – Malaria
9:17

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:
[caption id="attachment_8759" align="aligncenter" width="417"] Ashley 2018[/caption]
  • Most common manifestations of severe malaria affect the brain, lungs, and kidneys
    • Patients with cerebral malaria can present encephalopathic or comatose, some severe enough to exhibit extensor posturing, or seizures
    • Can have acute lung injury with a quarter of these patients progressing to ARDS
    • Can have AKI from ATN and resultant acidosis
  • Labs may be unremarkable but watch for anemia and thrombocytopenia
    • Hgb <5 has an OR = 4.9 for death
    • Severe thrombocytopenia has an OR = 2.8
    • Anemia + Thrombocytopenia has an OR = 13.8 (Lampah 2015,
Jul 15, 2019
Episode 166.0 – Acute Otitis Media
9:46

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,
Jul 01, 2019
Episode 165.0 – Foot Fractures
14:18
A look at foot fractures – which can be splinted and which may need to go to the OR.
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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)
Jun 17, 2019
Episode 164.0 – Debriefing
27:42
A discussion with Dr. McNamara and Dr. Leifer on the essentials and beyond of debriefing
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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
Jun 03, 2019
Episode 163.0 – Croup
6:13
A look at one of the most common and potentially concerning upper respiratory infections in children.
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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” (https://www.mdcalc.com/westley-croup-score)
    • Chest wall retractions
    • Stridor
    • Cyanosis
    • Level of consciousness
    • Air entry
Management
  • Mild Croup
    • Occasional barking cough,
May 20, 2019
Episode 162.0 – Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
9:50
A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED
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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 = <10% TBSA
    • TEN = >30% TBSA
    • SJS/ TEN Overlap = 10-30% TBSA
  • Incidence is estimated at around 9 per 1 million people in the US
  • Mortality is 10% for SJS and 30-50% for TEN
    • Mainly 2/2 sepsis and end organ dysfunction.
  • SJS can occur even without a precipitating medication
    • Infection can set it off especially in patients with risk factors including HIV, lupus, underlying malignancy, and genetic factors
    • SATAN for the most common drugs
      • Sulfa, Allopurinol, Tetracyclines, Anticonvulsants, and NSAIDS
    • Anti-epileptics include carbamazepine, lamictal, phenobarb, and phenytoin
  • Can have a curious course
    • Hypersensitivity reaction can develop while taking medication, or even one to four weeks after exposure
    • In pediatric population, mycoplasma pneumonia and herpes simplex have been identified as precipitating infections
  • Patients often have a prodrome 1-3 days prior to the skin lesions appearing
    • May complain of fever, myalgias, headaches, URI symptoms, and malaise
  • Rash may be the sole complaint
May 06, 2019
Episode 161.0 – Opioid Epidemic
14:26
A look at the opioid epidemic and what ED providers can do to combat this formidable foe.
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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.
  • 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: Apr 22, 2019
Episode 160.0 – Measles
12:54
In this episode, we discuss the recent measles outbreak and how ED providers can best prepare to treat this almost vanquished foe.
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Show Notes

       
References: CDC Measles for Health Care Providers.  https://www.cdc.gov/measles/hcp/index.html#lab. Gladwin M, Trattler B.  Orthomyxo and Paramyxoviridae.  In: Clinical Microbiology Made Ridiculously Simple.  4th ed.  Miami, FL: MedMaster, Inc; 2009: 240-243. Hussey G, Klein M.  A Randomized, Controlled Trial of Vitamin A in Children with Severe Measles.  N Engl J Med.  1990; 323: 160-164.doi: 10.1056/NEJM199007193230304. Nir, Sarah Mailin and Gold, Michael.  “An Outbreak Spreads Fear: Of Measles, of Ultra-Orthodox Jews, of Anti-Semitism.”  New York Times [New York City] 03/29/2019. https://www.nytimes.com/2019/03/29/nyregion/measles-jewish-community.html
A massive thanks to: Shweta Iyer, MD: NYU Langone 3rd year Pediatric Emergency Medicine Fellow.
Apr 08, 2019
Episode 159.0 – Acute Decompensated Heart Failure
5:57
In this episode, we discuss acute decompensated heart failure and how to best manage these dyspneic patients in the ED.
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Show Notes

  • Features that increase the probability of heart failure. (Wang 2005)
  • B-lines seen in pulmonary edema.

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Mar 22, 2019
Episode 158.0 – Boxer’s Fracture
5:33
In this episode, we discuss Boxer's fractures and how to best manage them in the ED.
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Podcast Video

https://youtu.be/UreET5eLHas

Show Notes

Background:
  • 40% of all hand fractures
  • A metacarpal fracture can occur at any point along the bone (head, neck, shaft, or base)
  • “Boxer’s” fractures classically at neck
  • Most common mechanism: direct axial load with a clenched fist
  • Most common metacarpal injured is the 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
Mar 08, 2019
Episode 157.0 – Farewell
2:36
Aug 13, 2018
Episode 156.0 – Updates in Community Acquired Pneumonia
5:41
This week we dive into a recent article highlighting a major update in the treatment of community acquired pneumonia (CAP)
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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.

Jul 30, 2018
Episode 155.0 – Journal Update
12:46
Episode 154.0 – Femoral Shaft Fractures
5:32

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)


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Jul 16, 2018
Episode 153.0 – Morning Report Pearls VI
9:41
Jul 09, 2018
Episode 152.0 – Penetrating Neck Trauma
14:20
This week, we discuss penetrating neck trauma and some pearls and pitfalls in management.
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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

Jul 02, 2018
Episode 151.0 – Cauda Equina Syndrome
5:04
This week we discuss the difficult to diagnose and high morbidity cauda equina syndrome.
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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,

Jun 25, 2018
Episode 150.0 – Journal Update
8:17
This week we review some recent publications on steroids in pharyngitis and the VAN assessment in stroke.
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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

[caption id="attachment_7311" align="aligncenter" width="2560"] Stroke Workflow 2017 (REBEL EM)[/caption]

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

Jun 18, 2018
Episode 149.0 – Simplified Approach to Peds Trauma
15:40
This week the podcast features a lecture from Dr. Frosso Admakos - Assistant Residency Director at Metropolitan Hospital in NYC
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Show Notes

Take Home Points
  1. 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
  2. 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
  3. Tachycardia should be assumed to be compensated shock until proven otherwise. Don’t write tachycardia off as anxiety
  4. 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

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University of Maryland EM: Retrograde Intubation


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Jun 11, 2018
Episode 148.0 – ACEP VTE Clinical Policy 2018
10:16
This episode reviews the highlights from the recent ACEP clinical policy on acute VTE management in the ED.
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Show Notes

Take Home Points

  1. The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing.
  2. 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.
  3. 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.
  4. 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
  5. Patients with DVT can be started on a NOAC and discharged from the ED
[caption id="attachment_7115" align="aligncenter" width="501"] sPESI Tool (MDCalc.com)[/caption] [caption id="attachment_7114" align="aligncenter" width="508"]Jun 04, 2018
Episode 147.0 – Salicylate Toxicity
10:05
This episode reviews the identification and management of patients with salicylate toxicity.
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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

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Episode 146.0 – Morning Report Pearls V
7:33

Show Notes

Take Home Points

  1. 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
  2. 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
  3. 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!
[caption id="attachment_7050" align="aligncenter" width="814"] Hard Signs in Penetrating Neck Injury (Sperry 2013)[/caption] [caption id="attachment_7051" align="aligncenter" width="1040"] Management Algorithm for Penetrating Neck Injury (Sperry 2013)[/caption...
May 21, 2018
Episode 145.0 – All NYC EM 14 Pearls
10:27
May 14, 2018
Episode 144.0 – Acute Rhinosinusitis
9:58
This week we dive into rhinosinusitis exploring the recommendations of who needs antibiotics and who doesn't.
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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.

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Core EM: Acute Rhinosinusitis

TheNNT.com: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults

TheNNT.com: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis


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May 07, 2018
Episode 143.0 – Testicular Torsion
9:22
This week we review the presentation, examination and diagnosis of testicular torsion.
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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,

Apr 30, 2018
Episode 142.0 – Morning Report Pearls IV
7:48

Show Notes

Take Home Points
  1. 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
  2. Consider DSI to facilitate pre-oxygenation. Ketamine is your go to drug here
  3. 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
  4. 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: Apr 23, 2018

Episode 141.0 – Journal Update
11:17
Apr 16, 2018
Episode 140.0 Disutility of Orthostatics in volume Loss
7:23
This week we discuss the disutility of orthostatic vital signs as a diagnostic tool in patients with suspected volume loss.
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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.

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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: Apr 09, 2018
Episode 139.0 – Ear Foreign Body Removal
13:06
This week we welcome back Andy Little from Doctors Hospital in Columbus, Ohio to chat about ear foreign body removal.
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Show Notes

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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


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Apr 02, 2018
Episode 138.0 – EEMCrit Pearls
11:07
Mar 26, 2018
Episode 137.0 – How to Build a Great Presentation
35:11
Mar 19, 2018
Episode 136.0 HIV Related Infections in the ED
9:56

Show Notes

[caption id="attachment_6764" align="aligncenter" width="742"] HIV Associated Infections Based on CD4 Count (cooperhealth.org)[/caption] 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

Mar 12, 2018
Episode 135.0 – Occult Causes of Non-Response to Vasopressors
10:25
This podcast reviews how clinicians should think about patients who's shock isn't responding to our typical management options.
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Mar 05, 2018
Episode 134.0 – Morning Report Pearls III
7:22

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

Feb 26, 2018
Episode 133.0 – Initial Trauma Assessment
18:08

Show Notes

Take Home Points
  1. Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures
  2. Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team
  3. Complete the primary survey (ABCDEs) and address immediate life threats
  4. Round out your assessment with a good medical history and remember to complete a comprehensive head-to-toe exam

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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 pres...

Feb 19, 2018
Episode 132.0 – Air Embolism
8:58
This week we dive into the rare but potentially fatal, and difficult to diagnose, air embolism.
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Show Notes

Take Home Points
  1. 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.
  2. 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.
  3. 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


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Feb 12, 2018
Episode 131.0 – Spontaneous Bacterial Peritonitis (SBP)
8:59

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: Feb 05, 2018

Episode 130.0 – Morning Report Pearls II
6:02

Show Notes

Take Home Points
  1. 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
  2. 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.
  3. Lots of meds can lead to a myasthenia gravis exacerbation. Carefully review meds before prescribing for interactions

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CDC: Research on Doxycycline and Tooth Staining

Core EM: Episode 96.0 - Carbon Monoxide Poisoning

Sinai EM: Succinycholine in Myasthenia Gravis


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Jan 29, 2018
Episode 129.0 – Toxic Alcohols
20:28
We welcome Meghan Spyres back to the podcast to discuss toxic alcohol ingestion diagnosis and management.
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Show Notes

Take Home Points
  1. 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.
  2. Fomepizole is the critical antidote for toxic alcohol ingestions but, patients are likely going to require dialysis as well.
  3. 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


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Jan 22, 2018
Episode 128.0 – Hip Dislocations
17:44
This week, we sit down with Billy Goldberg - senior faculty at NYU/Bellevue, to discuss some nuances of hip dislocation management.
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Show Notes

Read More

Core EM: Hip Dislocation

OrthoBullets: Hip Dislocation

EMin5: Hip Dislocation


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Jan 15, 2018
Episode 127.0 – Idiopathic Intracranial Hypertension
14:14
This week we talk about the subacute headache and the dangerous, can't miss diagnoses of cerebral venous thrombosis and IIH
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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.

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WikEM: Idiopathic Intracranial Hypertension

WikEM: Jan 08, 2018

Episode 126.0 – Flexor Tenosynovitis
8:57

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.

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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: Dec 18, 2017

Episode 125.0 – Morning Report Pearls I
5:39
This week we discuss some critical pearls and teaching points from our morning report conference.
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Show Notes

FOAMCast: Episode 17 - The Spleen!

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Dec 11, 2017
Episode 124.0 – Metformin-Associated Lactic Acidosis
5:51

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: Dec 04, 2017

Episode 123.0 – Paracentesis Journal Update
6:57

Show Notes

Take Home Points
  1. 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
  2. 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
  3. 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: ...

Nov 27, 2017
Episode 122.0 – True Knee Dislocations
7:34
This week we discuss the tibio-femoral knee dislocation focusing on identification of the dangerous complications.
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Show Notes

Take Home Points

  1. 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
  2. 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
  3. 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

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OrthoBullets: Knee Dislocation

Radiopaedia: Knee Dislocation

EM: RAP: Obese Patient and Knee Dislocations

Core EM: Nov 20, 2017

Episode 121.0 – Pancreatitis
13:41

Show Notes

[caption id="attachment_6188" align="aligncenter" width="593"] Ranson's Criteria for Pancreatitis-Associated Mortality (Rosen's)[/caption]

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

Nov 13, 2017
Episode 120.0 – Bites and Stings
8:43

Show Notes

Take Home Points
  1. 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.
  2. The brown recluse spider is found in the Midwest and presents as local pain and swelling but carries the risk of a necrotic ulcer
  3. 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.
  4. 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.

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WikEM: Nov 06, 2017

Episode 119.0 – Journal Update

Show Notes

Take Home Points
  1. 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.
  2. Supplemental O2 is not necessary in the management of AMI patients with an O2 sat > 90% and, may be harmful
  3. 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.
  4. 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.

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Core EM: ED POCUS in OHCA - The REASON Study

ALiEM: Oct 30, 2017

Episode 118.0 – Acute Cholangitis
7:53

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)

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Radiopaedia: Acute cholangitis

Core EM: Cholangitis


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Oct 23, 2017
Episode 117.0 – Acute Cholecystitis
9:27

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.

Oct 16, 2017
Episode 116.0 – Button Battery Ingestion
9:37
This podcast discusses the presentation and management of button battery ingestions in kids.
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Show Notes

[caption id="attachment_5973" align="aligncenter" width="1050"] NBIH Button Battery Ingestion Algorithm[/caption] [caption id="attachment_5971" align="aligncenter" width="836"] Button Battery XR (scielo.br)[/caption]

Take Home Points

  1. Button battery ingestions are extremely dangerous. Necrosis, perforation and erosion into vessels can occur in as little as 2 hours
  2. ALL esophageal button batteries should be removed within 2 hours of presentation to minimize mucosal damage
  3. Consider button battery ingestion in children presenting with dysphagia, refusal to eat and hematemesis
  4. 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 But...

Oct 10, 2017
Episode 115.0 – Wernicke’s Encephalopathy
12:12

Show Notes

Take Home Points
  1. Consider the diagnosis in all patients with nutritional deficiencies, not just alcoholics.
  2. Look for ophthalmoplegia, ataxia and confusion in patients that have risk factors for thiamine deficiency.
  3. 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.
  4. 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
Oct 02, 2017
Episode 114.0 – Evaluation of the Alcohol Intoxicated Patient
14:12

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!
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EM Docs: EM@3AM Alcohol Intoxication

EM Updates: Emergency Management of the Agitated Patient

Life in the Fastlan...

Sep 25, 2017
Episode 113.0 – Preeclampsia + Eclampsia
10:39
This podcast takes a deep dive into the presentation, diagnosis and management of preeclampsia and eclampsia.
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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: Sep 18, 2017

Episode 112.0 – Herpes Zoster
6:35

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


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Sep 11, 2017
Episode 111.0 – Snake Bites
17:49
Sep 04, 2017
Episode 110.0 – Advanced RSI Topics
9:49
This week we dive into some advanced topics in RSI including patient positioning and pre-intubation resuscitation.
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Show Notes

Take Home Points
  1. Bed up head elevated position for intubation may reduce intubation related complications.
  2. Patients who are hypotensive or at risk of hypotension should be aggressively resuscitation prior to intubation with fluids and liberal use of pressors
  3. Shock patients would be intubated with decreased induction agent dose, preferably ketamine, and increased paralytic dose.
[caption id="attachment_3153" align="alignright" width="437"] Bed-Up-Head-Elevated Positioning[/caption]

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 ...

Aug 21, 2017
Episode 109.0 – Renal + GU Emergencies
7:46
This week we discuss some quick pearls from our conference covering an array of renal and GU pathologies.
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Show Notes

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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


Aug 14, 2017
Episode 108.0 – Intubation in In-Hospital Cardiac Arrest
10:59
Should we intubate patients in cardiac arrest? We discuss this topic and some basics of running a good arrest.
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Show Notes

Take Home Points
  1. Intra-arrest intubation does not appear to improve outcomes. For most patients, support with BVM, or possibly an LMA, is adequate.
  2. Instead of securing an advanced airway, focus on the two things that clearly make a difference in outcomes - good compressions and defibirillation
  3. Good compressions should be fast and hard and you must minimize interruptions in compressions to minimize interruptions in perfusion
  4. 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 Offlo...

Jul 31, 2017
Episode 107.0 – Angioedema
8:26
Prompted by the recent CAMEO trial publication on icatibant, we dive into angioedema with a focus on airway management.
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Show Notes

Take Home Points

  1. Airway management is paramount, expect a challenging intubation and consider controlling the airway early
  2. 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.
  3. If the patient has urticaria and pruritus, the process is likely histamine mediated and will respond to typical anaphylaxis treatment
  4. Finally, observe the patient for progression of swelling and don’t forget to stop the inciting medication

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Core EM: Angioedema

EMCrit: Podcast 145 – Awake Intubation Lecture from SMACC

ERCast: Angioedema

REBEL EM: Icatibant Doesn’t I...

Jul 24, 2017
Episode 106.0 – Procedural Sedation and Analgesia II
This week we drop into some of the nitty gritty on PSA including preparation and patient assessment as well as discuss some common pitfalls.
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Show Notes

Take Home Points

  1. 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.
  2. Always do a complete setup including consideration of different agents, dosage calculations, preparation of airway equipment and reversal agents.
  3. 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.
  4. 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

Jul 17, 2017
Episode 105.0 – Initial Antibiotic Choice in Cellulitis
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
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Show Notes

[caption id="attachment_5536" align="aligncenter" width="857"] SSTI Flow Diagram (Stevens 2014)[/caption]

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


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Jul 10, 2017
Episode 104.0 – Procedural Sedation and Analgesia
Jul 03, 2017
Episode 103.0 – Priapism
This week we talk about priapism focusing on emergency department management.
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Show Notes

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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


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Jun 26, 2017
Episode 102.0 – Valsalva Maneuver in SVT
This week we welcome Andy Little onto the show to discuss the modified Valsalva maneuver for breaking SVT.
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Show Notes

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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

[embed]https://www.youtube.com/watch?v=8DIRiOA_OsA[/embed]

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


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Jun 19, 2017
Episode 101.0 – Major Burns
This week we dive into some of the initial considerations in the resuscitation of major burn patients.
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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.
[caption id="attachment_5397" align="aligncenter" width="823"] Rule of 9's[/caption]

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Jun 12, 2017
Episode 100.0 – Our 100th Episode!
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.
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Jun 05, 2017
Episode 99.0 – Journal Update
This week we discuss 3 articles recently reviewed in our conference - LOV-ED study, Validation of Step-By-Step and Therapeutic Hypothermia.
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Show Notes

Take Home Points
  1. 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.
  2. 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.
  3. 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.
[caption id="attachment_5306" align="aligncenter" width="500"] The Step-By-Step Algorithm[/caption] [caption id="attachment_5307" align="aligncenter" width="500...
May 29, 2017
Episode 98.0 – Cardioversion in Recent Onset AF
This week we delve into the argument for cardioversion in recent-onset AF as well as the logistics of getting it done.
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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.

May 22, 2017
Episode 97.0 – Methemoglobinemia
This week we discuss the rare but life-threatening methemoglobinemia with a focus on recognition and use of the antidote.
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Show Notes

Take Home Points

  • MetHb –emia occurs as a results of various medications including amyl nitrite, dapsone, nitroprusside, phenazopyridine, sodium nitrite and topical anesthetics like benzocaine
  • Patients will present with cyanosis, short of breath, fatigue, dizziness, weakness and ultimately CNS depression and death at higher concentrations.
  • If you have a cyanotic/hypoxic patient that does not respond to supplemental oxygen, be concerned for MetHb and send a co-oximetry panel.
  • If the level is <25% and the patient is asymptomatic you can observe, but if the level is >25% or the patient is symptomatic, you will treat with the antidote methylene blue given as a bolus of 1-2 mg/kg over 5 minutes
  • And as always, make sure to call your local poison center to get your toxicologists involved. They can help with dosing, and they are also an important player of the public health component in cases such as these, to make sure this is an isolated incident and we don’t have a repeat of the 11 blue men situation.

Price DP. Chapter 127. Methemoglobin Inducers. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e New York, NY: McGraw-Hill; 2011. Accessed April 19, 2017.

May 15, 2017
Episode 96.0 – Carbon Monoxide Poisoning
This week we do a brief review on recognizing CO monoxide poisoning and expertly managing it.
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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 pois...
May 08, 2017
Episode 95.0 – Local Anesthetic Systemic Toxicity (LAST)
This week we discuss the identification, prevention and treatment of local anesthetic systemic toxicity.
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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


May 01, 2017
Episode 94.0 – Mammal Bites
This week we talk about mammal bites - dogs, cats and humans - with a focus on wound closure, antibiotics and rabies prophylaxis.
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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


Apr 24, 2017
Episode 93.0 – Meningitis

Show Notes

[caption id="attachment_5041" align="aligncenter" width="948"] CSF Analysis (LITFL)[/caption]

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

Apr 17, 2017
Episode 92.0 – Dialysis Emegencies
This week we discuss some of the many dialysis-related emergencies we frequently see in the ED.
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Show Notes

Take Home Points

  1. 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.
  2. 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.
  3. Peritoneal dialysis patients are at risk for bacterial peritonitis.  In a PD patient that appears infected, get a peritoneal fluid sample and start antibiotics
  4. 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: Apr 10, 2017

Episode 91.0 – Journal Update – AKI + IV Contrast
This week we discuss a recent article in Annals of EM on contrast induced nephropathy and whether the phenomena is real or dogma.
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Show Notes

[caption id="attachment_4940" align="aligncenter" width="673"] ACR Table on CIN - FOAMCast[/caption]

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:

Apr 03, 2017
Episode 90.0 – Acute Rhinosinusitis
This week we dive into acute rhinosinusitis focusing on diagnosis and discussing the absence of utility for antibiotics in most patients.
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Show Notes

Take Home Points
  1. Sinusitis is a clinical diagnosis. Patients typically present with purulent nasal discharge and facial pain or other URI symptoms.
  2. The vast majority of patients with acute rhino sinusitis will be viral in nature and will not benefit from antibiotics
  3. 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

Mar 27, 2017
Episode 89.0 – Epistaxis

Show Notes

Take Home Points
  1. 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.
  2. 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.
  3. Third line of treatment would be to try some soaked gauze, but this time with TXA. Can’t hurt to try!
  4. 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.
[caption id="attachment_4775" align="aligncenter" width="885"] Epistaxis Tray[/caption]

Show Notes

LITFL: Mar 20, 2017

Episode 88.0 – Simplified Approach to Tachydysrhythmias

Show Notes

Take Home Points

  1. 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
  2. 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.
  3. 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

Mar 13, 2017
Episode 87.0 – Journal Review (Ketorlac Dosing + POKER Trial)
This week we discuss two recent journal articles - the POKER trial and the ketorlac analgesic ceiling
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Show Notes

Take Home Points

  1. 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.
  2. 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: Mar 06, 2017

Episode 86.0 – Anti-D Immunoglobulin (RhoGam) in Early Pregnancy
Do patients with 1st trimester bleeding need to get anti-D immunoglobulin if they're Rh negative? We dive into the topic this week.
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Show Notes

Take Home Points

  1. 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
  2. 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
  3. 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: Feb 27, 2017

Episode 85.0 – Challenging Deliveries
This week we discuss three common complications of delivery: cord prolapse, nuchal cord and shoulder dystocia.
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Show Notes

Take Home Points

  1. 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.
  2. Nuchal cord is common but likely not too dangerous. Just gently unwrap the umbilical cord and the fetus should be just fine
  3. 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

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Core EM: Shoulder Dystocia

emDocs:

Feb 20, 2017
Episode 84.0 – Traumatic ICH Management
This week we look at TBI and discuss some of the pitfalls and pearls in early management of traumatic ICH.
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Show Notes

Take Home Points
  1. 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.
  2. 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
  3. 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.
  4. 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.
  5. 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
  6. Finally, make sure to reverse any anticoagulant the patient may have on board ...
Feb 13, 2017
Episode 83.0 – Lumbar Radiculopathy
This week we discuss a bit about back pain and specifically, lumbar radiculopathy with a focus on causes and red flags.
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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


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Feb 06, 2017
Episode 82.0 – ED Management of Seizures
This week we discuss the ED management of seizures focusing on treatment and workup particularly of a 1st seizure episode.
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Show Notes

Take Home Points

  1. 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.
  2. 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
  3. 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.
  4. 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.
  5. 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.
Jan 30, 2017
Podcast 81.0 – Visualization
Jan 23, 2017
Episode 80.0 – Penetrating Chest Trauma
This week we feature a short primer on penetrating chest trauma focusing on circulation first over airway and breathing.
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Show Notes

Take Home Points
  1. 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.
  2. 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.
  3. 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.
  4. 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.

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Larry Mellick: Open Thoracotomy Video

Jan 16, 2017
Episode 79.0 – The Traumatized Airway
This week we discuss facial trauma and the disasters it can cause to your airway management.
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Show Notes

Take Home Points
  1. 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.
  2. 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.
  3. 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.
  4. 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: Jan 09, 2017

Episode 78.0 – Effect of Conservative vs. Conventional Oxygen Use on Mortality
This week we discuss the OXYGEN-ICU trial exploring the effect of excess oxygen on ICU mortality.
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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.

Jan 02, 2017
Episode 77.0 – Give TXA Now!
This week the podcast features a talk Jenny Beck-Esmay gave at the 11th All NYC EM Conference entitled "Give TXA Now!"
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Show Notes

Take Home Points
  1. Giving TXA provides a significant mortality benefit to the any trauma patient requiring massive transfusion with an NNT = 7 for mortality
  2. TXA must be given early. Give within 1 hour of injury if possible but the benefit remains up to 3 hours out
  3. TXA administration: 1 gram as a bolus followed by 1 gram over the next 8 hours
Show Notes Intensive Care Network: Karim Brohi on TXA in Trauma EMCrit: Podcast 67 - Tranexamic Acid (TXA) Core EM: CRASH-2 Tranexamic Acid in Major Trauma References

CRASH-2 trial collaborators. Effects of tanexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a ransomised placebo-controlled trial. Lancet 2010; 376: 23-32. PMID: 20554319

Guerriero C et al.

Dec 19, 2016
Episode 76.0 – The Lisfranc Injury

Show Notes

Take Home Points
  1. A Lisfranc injury is a midfoot injury that results in displacement of one or more of the metatarsal bones from tarsus. 
  2. XR will show widening of the space between the 1st and 2nd metatarsals. Getting contralateral XR may help you identify this.
  3. Even if you don’t see that widening on the XR, the patient could still have a Lisfranc injury. If they cannot walk due to pain, get a weight bearing XR or CT scan to look further.
  4. Once the injury is identified, the patient must be strict non-weightbearing. Place them in a posterior splint and get orthopedics involved either in the ED or for prompt follow up as the patient will probably need surgery.
[caption id="attachment_4236" align="aligncenter" width="571"]Foot Bones (Google Images) Foot Bones (Google Images)[/caption] [caption id="attachment_4237" align="aligncenter" width="801"]Dec 12, 2016
Episode 75.0 – Fluid Responsiveness + Resuscitation
This week we do a little spaced repetition on adrenal insufficiency and then discuss fluid responsiveness and resuscitation.
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Show Notes

Read More

Marik PE. Fluid responsiveness and the six guiding principles of fluid resuscitation. Crit Care Med 2016. PMID: 26571187

LITFL: Adrenal Insufficiency

EMCrit: Podcast 64 - Assessing Fluid Responsiveness with Dr. Paul Marik

Core EM: Adrenal Crisis

Core EM: Episode 15.0 - Adrenal Crisis

References

Cavallaro F et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systemic review and meta...

Dec 05, 2016
Episode 74.0 – Gastroesophogeal Reflux (GERD)

Show Notes

Take Home Points
  1. GERD pain can mimic or co-exist with the more deadly causes of chest pain.  Be sure to consider all the serious causes of chest pain, get an EKG and maybe a chest XR while you go about symptom management.
  2. Respond to a treatment doesn’t prove a diagnosis.  GERD pain may get better with nitro and ACS pain may get better with a GI cocktail.  Keep an open mind while seeing these patients.
  3. Standard treatment for GERD includes an antacid and H2 blocker and maybe a PPI.  Keep in mind that a PPI takes a while to work, so be sure to give something faster acting in the ED
  4. And last, for these patients, take those few extra minutes for some counseling on lifestyle modifications.  All medications come with side effects, so be sure to address things like diet, smoking and weight loss while you have a captive audience.

Read More
Nov 28, 2016
Episode 73.0 – PE in Syncope Study
This week we dive into the controversies surrounding the PESIT study looking at the prevalence of PE in admitted patients with syncope
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Show Notes

Read More

EMLit of Note: The Impending Pulmonary Embolism Apocolypse

St. Emlyn’s: JC – Prevelance of PE in Patients with Syncope

EM Nerd (EMCrit): The Case of the Incidental Bystander

Pulm CCM: PESIT Investigators: The Incidence of PE in Those Hospitalized Following First Syncope

References

Hutchinson BD et al. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. Am J Rad 2015; 205(2):271-7. PMID: 26204274


Nov 21, 2016
Episode 72.0 – Upper GI Bleeding

Show Notes

Take Home Points
  1. Respect the UGIB. These patients can bleed a lot. Even if they’re not actively hemorrhagic in front of you, realize that they can open up at any time and decompensate
  2. Get your consultants on board early. A skilled endoscopist is your friend as they can get control of bleeding. Don’t forget IR for TIPS in variceal bleeds and general surgery in bleeding ulcers.
  3. Activate your massive transfusion protocol if the patient is unstable and give the patient PRBCs, FFP and platelets as indicated. Reverse any anticoagulants as well.
  4. Give all patients with confirmed or suspected variceal bleeding antibiotics - typically, ceftriaxone. This intervention saves lives and decreases morbidity.
Read More

LITFL: EBM Upper GI Haemorrhage

EMCrit: Episode 5: Upper GI Bleed Guidelines

Nov 14, 2016
Episode 71.0 – Acute Pulmonary Edema
22:36
Nov 07, 2016
Episode 70.0 – Baclofen Withdrawal

Show Notes

Take Home Points

  1. Baclofen withdrawal is a rare complication of intrathecal baclofen pumps. It’s presentation mimics sepsis and alcohol withdrawal and is characterized by hemodynamic instability, hyperthermia, increased spasticity, confusion, altered mental status and seizures. Patients can develop rhabdo from the spasticity and, eventually, can develop multi system organ dysfunction.
  2. Treating baclofen withdrawal with oral baclofen is unlikely to work even at large oral doses because only a tiny amount gets into the CSF where it needs to act for withdrawal to be treated
  3. Baclofen withdrawal can be emergently treated with increasing benzodiazepine doses, propofol infusions and baclofen administered via a lumbar puncture. Ultimately, these patients all need consultation with either neurosurgery or interventional pain management to interrogate the device and surgically correct the issue.

Read more

EM: RAP November 2015: Lin Sessions Intrathecal Pumps

REBEL EM: Baclofen Withdrawal

Oct 31, 2016
Episode 69.0 – Antibiotics in COPD Exacerbations
This week we discuss why we use antibiotics in COPD exacerbations and whether we should continue to do so.
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Show Notes

Take Home Points
  1. Most COPD exacerbations are caused by infectious etiologies. While these can be viral, there’s also a decent chance it was caused by an overgrowth of bacteria that chronically colonize these patients.
  2. Strong evidence from systematic reviews demonstrates that antibiotic use reduces in-hospital mortality and decreases treatment failure
  3. The GOLD group recommends antibiotics be given to patients who have increased dyspnea, increased sputum volume and increased sputum purulence or require non-invasive or invasive ventilation for their exacerbation.
  4. Finally, a short course of antibiotics - either ampicillin, doxycycline or azithromycin is adequate for management.
Read More

GOLD Reports: Diagnosis, Management and Prevention 2016

Berg RMG, Plovsing RR. The hardships of being a Sith Lord: implications of the biopsychosocial model in a space opera. Adv Physiol Educ 2016; 40: 234-6. PMID: 27105743

Johannes M et al.

Oct 24, 2016
Episode 68.0 – Hiccups
7:08

Show Notes

Take Home Points
  1. Hiccups, or singultus, are caused by a reflex arc involving the vagus nerve, CNS and phrenic nerve.  If you remember the path of these nerves, you can remember that possible bad pathologies that could cause a patient to present with prolonged hiccups.
  2. Physical maneuvers are the first line for solving the hiccups.  Try things that will interrupt respiration or stimulate the vagus nerve.  We like the modified valsalva in which the patient blows on a syringe, because it’s pretty easy to get the patient to do.
  3. Last, medication options for hiccups include antipsychotics, anticonvulsants, muscle relaxers and dopamine agonist.  Generally, we start with chlorpromazine 25-50 mg PO or IM.
Read More

Steger M et al.  Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther 2015; 42(9):1037-50. PMID 26307025


Read More
Oct 17, 2016
Episode 67.0 – Feedback
This week we review pearls from our Grand Rounds from George Willis, MD talking about feedback.
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Show Notes

Read More St. Emlyn's: #TTCNYC Resources for Feedback Talk

Read More
Oct 10, 2016
Episode 66.0 – Boerhaave Syndrome
This week, we discuss Boerhaave syndrome focusing on making the diagnosis and managing the patient.
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Show Notes

Take Home Points
  1. Keep esophageal rupture on your differential for deadly causes of chest, epigastric or back pain.  We don’t see it often, but it’s a real thing. 
  2. Boerhaave Syndrome is the spontaneous rupture of the esophagus that is caused by a sudden increase in intraesophageal pressure, as seen in forceful vomiting.  So, if the patient presents with the right symptoms and any vomiting in their history, keep this diagnosis in mind.  Other causes you might see, though less common, are childbirth, seizure, prolonged coughing or laughing, or weightlifting.
  3. ED management is essentially ABCs and broad spectrum antibiotics, and maybe even antifungals.
  4. As soon as you make this diagnosis, get you CT surgeon on board as the length of time to definitive treatment is directly related to mortality.
Read More

Radiopaedia: Boerhaave Syndrome

LITFL: Roast Duck and Juniper Beer


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Oct 03, 2016
Episode 65.0 – Pericarditis
This week we discuss the diagnosis and management of pericarditis with a focus on not missing the hidden STEMI.
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Show Notes

Read More

ECG Case of the Week (Amal Mattu): Acute STEMI vs. Pericarditis Part 1 + Part 2

REBEL EM: Colchicine for Treatment of Pericarditis

SOCMOB: Pericarditis: Treatment and Diagnosis Pocket Card

FOAMcast: Episode 54 - The Pericardium

Core EM: Pericarditis

[caption id="attachment_3758" align="aligncenter" width="619"]Pericarditis PV Card (Chris Bond (socmob.
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                                                <td class=Sep 26, 2016
Episode 64.0 – Rate Control in Atrial Fibrillation
This week we discuss an age-old debate: Calcium Channel Blockers or Beta Blockers for rate control in atrial fibrillation.
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Show Notes

CoreEM: Recent Onset Atrial Fibrillation

ALiEM: Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers?

ALiEM: Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED

Fromm C, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015 Apr 22. PMID 25913166


Read More
Sep 19, 2016
Episode 63.0 – Discharge Glucose Levels
This week we discuss a recent article looking at the relevance of d/c glucose levels to patient revisits and subsequent hospitalization
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Show Notes

Driver BE et al. Discharge glucose is not associated with short-term adverse outcomes in emergency department patients with moderate to severe hyperglycemia. Ann Emerg Med 2016. PMID: 27353284


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Sep 12, 2016
Episode 62.0 – VFib and Pulseless VTach

Show Notes

Take Home Points

  1. In cardiac arrest, the most important interventions are to deliver electricity quickly when it’s indicated and to administer good high-quality compressions with minimal interruptions to maximize your compression fraction.
  2. Medications like epinephrine and amiodarone have never been shown to improve good neurologic outcomes in the ACLS recommended doses. Don’t focus on them.
  3. Consider pre-charging your defibrillator to minimize pauses in CPR and maximize your chance for ROSC
  4. Finally, remember that as Emergency Physicians, we are specialists in the resuscitation of cardiac arrests. ACLS is just a starting point. Push your understanding of taking care of these patients so you can deliver the best care possible

Additional Reading

Core EM: Ventricular Tachycardia

Core EM: Sep 05, 2016

Episode 61.0 – Hypokalemia

Show Notes

Take Home Points

  1. Hypokalemia has a wide variety of presentations ranging from generalized weakness, to paralysis, to cardiac arrhythmia or cardiac arrest.
  2. When you discover hypokalemia, be sure to check and EKG. Think about underlying causes of hypokalemia, because it is rarely a solo event.
  3. Treat with oral potassium supplementation of 40-60 orally every 4-6 hours for mild hypokalemia and 10-20 mEq/hour IV for severe or symptomatic hypokalemia.

Additional Reading

LITFL: Hypokalemia

LITFL: Hypokalemic Periodic Paralysis

Core EM: Hypokalemia


Read More
Aug 29, 2016
Episode 60.0 – Aggressive Resuscitation of Diabetic Ketoacidosis
This week we discuss how to aggressively resuscitate patients with DKA as well as dispelling some dogmatic teachings on the topic.
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Show Notes

Take Home Points
  1. DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis.
  2. Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5
  3. The insulin bolus isn’t necessary and appears to cause more episodes of hypokalemia. Just start insulin as an infusion at 0.14 units/kg
  4. Be vigilant about cerebral edema. Any change or deterioration in mental status should prompt treatment and evaluation. Mannitol in the euvolemic, normotensive patient and 3% hypertonic saline in the hypotensive/hypovolemic patient
  5. Finally, don’t forge to always hunt down the underlying cause of the DKA. Infection and non-compliance is the most common so liberally administer broad spectrum antibiotics if you’ve got even a hint of infection brewing
[embed]https://www.youtube.com/watch?v=P9sKk4JZmso[/embed]

Additional Reading

Aug 22, 2016
Episode 59.0 – Severe Decompensated Hyperthyroidism
This week we discuss the recognition, diagnosis and treatment of severe decompensated hyperthyroidism or thyroid storm.
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Show Notes

Take Home Points
  1. Decompensated hyperthyroidism is a rare, life-threatening condition.  It can develop in patients with long-standing untreated hyperthyroidism and is often precipitated by another event such as an infection, surgery, or trauma.
  2. Patients present with tachycardia, fever, altered mental status and GI symptoms.  Keep thyroid storm in mind if a patient has a history of hyperthyroidism or if things just aren’t making sense with your patient, you can’t find a fever source, they have fever and new afib, things like that. You’re going to use a clinical scoring tool like the Burch-Wartofsky scoring system to make the diagnosis.
  3. Treatment is three-fold. First treat the peripheral effects with propranolol.  Then prevent further synthesis of thyroid hormone with PTU and corticosteroids.  And last prevent the further release of thyroid hormone with iodine.  Be sure to hold off on giving the iodine until at least 1 hour after the patient receives PTU to avoid worsening the hyperthyroid.
[caption id="attachment_3597" align="aligncenter" width="778"]Aug 15, 2016
Episode 58.0 – Hyponatremia

Show Notes

EM Cases: Podcast 60: Emergency Management of Hyponatremia

References

Adrogue HJ, Maidas NE. Hyponatremia. NEJM 2000; 342(21): 1581-9. PMID: 10824078

Moritz ML, Ayus JC. 100 cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metab Brain Dis 2010; 25: 91-6. PMID: 20221678


Read More
Aug 08, 2016
Episode 57.0 – Phenobarbital in Alcohol Withdrawal
This week we discuss the role of phenobarbital in the management of severe alcohol withdrawal.
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Show Notes

CIWA Score References

Riggan MA et al. Regarding "Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study." J Emerg Med 2016; 50 (6): 895-8. PMID: 27221017

Rosenson J et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study. J Emerg Med 2013; 44(3): 592-8. PMID: 2299978


Read More
Aug 01, 2016
Episode 56.0 – Sedation of the Agitated Patient
This week we discuss pearls from a talk from Reuben Strayer on sedation of the agitated patient focusing on patient and staff safety.
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Show Notes

Strayer Sedation Continuum Slide

Strayer Summary Slide

EM Updates: The Ketamine Brain Continuum

LITFL: Behavioral Emergencies

Core EM: Parenteral Benzodiazepines

References

Calver L et al. The safety and effectiveness of droperidol for sedation of acute behavioral disturbance in the Emergency Department. Ann Emerg Med 2015; 66(3): 230-8. PMID: 25890395

Jul 25, 2016
Episode 55.0 – Platelet Transfusion in Intracerebral Hemorrhage
This week we dive into the PATCH trial investigating the role of platelet transfusions in patients with spontaneous ICH on antiplatelet meds
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Show Notes

Modified Rankin Scale (mRS)

Read More

REBEL EM: The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage?

St. Emlyn’s: JC - Platelets for Intracranial Haemorrhage

EM Lit of Note: Put the Platelets Away in ICH

References

Baharoglu MI et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral hemorrhage associated with anti platelet therapy (PAtCH): a randomized, open-label, phase 3 trial. Lancet 2016. ePub


Jul 18, 2016
Episode 54.0 – Preoxygenation
This week we discuss some of the critical issues in preparation, preoxygenation and positioning in RSI.
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Show Notes

Read More

EM Updates: Intubation Checklist

Core EM: Episode 4.0 - Perimortem C-section, Procedural Sedation and Airway Pearls

Core EM: Episode 6.0 - Airway Workshops

Sales JC et al. The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med 2013; 20(1): 71-8. PMID: 23574475

[caption id="attachment_3464" align="aligncenter" width="1011"]LEMON Mnemonic Device LEMON Mnemonic Device[/caption] [caption id="attachment_3463" align="aligncenter" width="1020"]MOANS Mnemonic Device M...
Jul 11, 2016
Episode 53.0 – Low-dose tPA in Ischemic Stroke
This week we discuss a recent study published in the NEJM on low-dose tPA vs standard-dose in acute ischemic stroke.
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Jul 04, 2016
Episode 52.0 – Anaphylaxis
This week we review anaphylaxis, the importance of epinephrine/adrenaline and how to use it properly.
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Show Notes

[caption id="attachment_3303" align="aligncenter" width="624"]Anaphylaxis Definition Anaphylaxis Definition[/caption] Read More Tran TP, Muelleman RL: Allergy, Hypersensitivity, Angioedema, and Anaphylaxis, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 119: p 1543-1560.

YouTube: Epinephrine Auto-Injector Use

The SGEM: #57: Should I Stay or Should I Go (Biphasic Anaphylactic Response)

Core EM: Biphasic reactions in emergency department patients with allergic reactions or anaphylaxis

  References

Grunau BE et al. Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis.

Jun 27, 2016
Episode 51.0 – Analgesia in Renal Colic
This week we dive into a recent article on pain control in renal colic and how it affects our management.
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Show Notes

Read More

Core EM: Optimal First Line Analgesia in Ureteric Colic

ALiEM: Top 10 reasons NOT to order a CT scan for suspected renal colic

REBEL EM: Does Use of Tamsulosin in Renal Colic Facilitate Stone Passage

Core EM: Medical Expulsive Therapy (MET) in Renal Colic

Wang RC. Managing Urolithiasis. Ann Emerg Med 2015 PMID: 26616536

References

Pathan SA et al. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multi group, randomized controlled trial. Lancet 2016. PMID: Jun 20, 2016

Episode 50.0 – Gastric Lavage
This week we look at the rarely used, but potentially life-saving, procedure of gastric lavage.
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Show Notes

[caption id="attachment_3240" align="aligncenter" width="653"]Gastric Lavage Indications (Goldfrank's Toxicology Ch 7) Gastric Lavage Indications (Goldfrank's Toxicologic Emergencies Ch 7)[/caption] [caption id="attachment_3242" align="aligncenter" width="1022"]Gastric Lavage Risk Assessment (Goldfrank's Toxicologic Emergencies Ch 7) Gastric Lavage Risk Assessment (Goldfrank's Toxicologic Emergencies Ch 7)[/caption] [caption id="attachment_3241" align="aligncenter" width="607"]Gastric Lavage Placement (Goldfrank's Toxicologic Emergencies Ch 7) Gastric Lavage Placement (Goldfrank's Toxicologic Emergencies Ch 7)[/caption]

References

Adams BK et al. Prolonged gastric emptying half-time and gastric hypo motility after drug overdose. Am J Emerg Med 2004; 22: 548-554. PMID: 15666259

Benson BE et al. Position paper update: gastric lavage for gastrointestinal decontamination.

Jun 06, 2016
Episode 49.0 – Alcohol Withdrawal

Show Notes

Yip L. Chapter 77. Ethanol. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e. New York, NY: McGraw-Hill; 2011.

EmCrit Podcast: Delirium Tremens

Life in the Fast Lane: Alcohol Withdrawal

The Poison Review: CPC: alcohol withdrawal with delirium tremens and a significant missed diagnosis

EM Updates: Avoid Alcohol Withdrawal Admissions

MDCalc: CIWA


May 30, 2016
Episode 48.0 – Anticholinergic Poisoning
This week we delve into the anticholinergic toxidrome with a focus on management and the use of physostigmine.
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Show Notes

Howland M. Antidotes in Depth (A12): Physostigmine Salicylate. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e . New York, NY: McGraw-Hill; 2011.

Velez LI, Feng SY: Anticholinergics, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 150: p 1970-5.

[caption id="attachment_3127" align="aligncenter" width="640"]Anticholinergic Infographic (BrianandKloss.com) Anticholinergic Infographic (BrianandKloss.com)[/caption] [caption id="attachment_3128" align="aligncenter" width="573"]Drugs Exhibiting Anticholinergic Toxicity (Rosen's) Drugs Exhibiting Anticholinergic Toxicity (Rosen's)[/caption]

Read More
May 23, 2016
Episode 47.0 – TMJ Dislocation
This week we review mandible dislocations and reduction approahces focusing on the new "syringe" technique.
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Show Notes

Read More

ALiEM: Tick of the Trade: Extra-oral reduction technique of anterior mandible dislocation

Gorchynski J et al.  The "syringe" technique: a hands-free approach for the reduction of acute nontraumatic temporomandibulardislocations in the emergency department.  J Emerg Med. 2014; 47(6):676-81. PMID 25278137

  [caption id="attachment_3121" align="aligncenter" width="598"]Syringe Technique Step 1 Syringe Technique Step 1[/caption] [caption id="attachment_3122" align="aligncenter" width="600"]Syringe Technique Step 2 Syringe Technique Step 2[/caption] [caption id="attachment_3123" align="aligncenter" width="595"]May 16, 2016
Episode 46.0 – Grand Rounds (Ilene Claudius) – Pediatric SOB
This week, the podcast features a full length talk from our Grand Rounds series. This talk was given by Ilene Claudius on pediatric SOB
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Show Notes

Irazuzta JE et al. High-dose magnesium sulfate infusion for severe asthma in the emergency department: efficacy study. Crit Care Med 2016; 17: e29-e33. PMID: 26649938

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May 09, 2016
Episode 45.0 – Controversies in SSTI Management
This week we review a number of controversial topics in SSTI management with a focus on the role of antibiotics in abscess management.
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Show Notes

Core EM: Predictors of failed outpatient cellulitis treatment

EM Nerd: The Case of the Pragmatic Wound

REBEL EM: Trimethoprim-sulfamethoxazole for uncomplicated skin abscesses

EM Lyceum: Abscess, “Answers”

References

Peterson D et al. Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients with Uncomplicated Cellulitis. Acad Emerg Med 2014; 21: 526-31. PMID: 24842503

Talan DA et al. Trimethoprim-Sulfamethoxazole versus placebo for uncomplicated skin abscesses. NEJM 2016; 374(9): 823-32.

May 02, 2016
Episode 44.0 – Tick Borne Illnesses
Apr 25, 2016
Episode 43.0 – Delayed ICH in Head Trauma Patients on Blood Thinners
This week we review delayed ICH in patients with head trauma on blood thinners and discuss the role of repeat imaging and admission.
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Show Notes

Nishijima DK et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and perjury warfarin or clopidogrel use. Ann Emerge Med 2012; 59(6): 460-8. PMID: 22626015

Menditto VG et al. Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 2012; 59(6): 451-5. PMID: 22244878

Miller J et al. Delayed intracranial hemorrhage in the anticoagulated patient: a systematic review. J Trauma Acute Care Surg 2015; 79: 310-3. PMID: 26218702


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Apr 18, 2016
Episode 42.0 – Ventilation in the Intubated Asthmatic
Apr 11, 2016
Episode 41.0 – Non-Genital Herpetic Infections
This week we look at herpetic infections of the eye and skin focusing on diagnosis and management.
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Show Notes

Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev 2010. PMID: 21154352 American Academy of Ophthalmology: Herpes Simplex Virus Keratitis Treatment Guideline

Read More
Apr 04, 2016
Episode 40.0 – Dental Emergencies
Mar 28, 2016
Episode 39.0 – Killer Back Pain
This podcast reviews highlights from a grand rounds talk given by Michael Bond on Killer back pain.
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Show Notes

Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med 2015; 66: 148-53. PMID: 25578887

Screen Shot 2016-02-03 at 8.28.41 PM

Screen Shot 2016-02-03 at 8.29.13 PM


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Mar 21, 2016
Episode 38.0 – Sexually Transmitted Infections
Mar 14, 2016
Episode 37.0 – Ovarian Pathology
This week we discuss ovarian pathology focusing on ovarian torsion and tubo-ovarian abscess.
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Show Notes

Pediatric EM Morsels: Ovarian Torsion EM Lyceum: Ovarian Torsion Beigi, R.H. (2015). Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Beigi, R.H. (2015). Management and complications of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Hart, D, Lipsky, A. Acute Pelvic Pain in Women. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 266-272. Lee D, Swaminathan A. Sensitivity of Ultrasound for the Diagnosis of Tubo-Ovarian Abscess: A Case Report and Literature Review. J Emerg Med. 2011 vol 40 (2): 170-5. PMID: 20466506 Tibbles, CD. Selected Gynecologic Disorders. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 1355-1362.

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Mar 07, 2016
Episode 36.0 – C-Spine Injuries
This week's podcast delves into cervical spine injuries and the findings found on CT imaging of the cervical spine.
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Show Notes

Core EM: C-Spine Injuries + CT Interpretation Schwartz DT. Section 5. Cervical Spine. In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008. http://accessemergencymedicine.mhmedical.com/ (via NYU Health Sciences Library)

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Feb 29, 2016
Episode 35.0 – The Problem with Door to Balloon Time
This week we discuss an article on door to balloon time and focus on the EPs role in patients who present with ST elevations on their EKG.
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Show Notes

Fanari Z et al. Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential risks and role of quality improvement. Mayo Clin Proc 2015. PMID: 26549506

REBEL EM: December 2015: All Cardiology REBELCast


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Feb 22, 2016
Episode 34.0 – Trauma in Pregnancy
This week, we cover the physiologic changes in pregnancy and how they affect trauma management.
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Show Notes

EMCrit: Peri-Mortem C-Section

emDocs.net: Resuscitation of the Pregnant Trauma Patient – Pearls and Pitfalls

Core EM: Peri-Mortem C-Secton

Core EM: Podcast 4.0

[embed]https://www.youtube.com/watch?v=lW0-2t_CGbk[/embed] [caption id="attachment_2659" align="aligncenter" width="533"]Medications in Pregnancy Medications in Pregnancy[/caption]

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Feb 15, 2016
Episode 33.0 – Post-partum Hemorrhage
This week, we review the management of post-partum hemorrhage focusing on identifying the cause, resuscitation and directed medical therapy.
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Show Notes

Core EM: Shoulder Dystocia Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82. PMID: 24360351 Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82. [caption id="attachment_2670" align="alignright" width="1093"]Drugs for the Management of Uterine Atony - Roberts + Hedges Drugs for the Management of Uterine Atony - Roberts + Hedges[/caption]

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Feb 08, 2016
Episode 32.0 – Reading C-Spine CTs
This is part I of a 2 part series on C-spine CT scans. In part 1, we discuss the basic ins and outs of reading the C-spine CT.
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Show Notes

Core EM: The ABCs of Reading C-Spine CTs

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Feb 01, 2016
Episode 31.0 – Rocuronium vs. Succinycholine
This podcast is a recorded lecture from our conference on why Rocuronium should be the go to drug for RSI in the ED.
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Show Notes

[caption id="attachment_2583" align="aligncenter" width="558"]Sydney HEMS Sux Contraindications Sydney HEMS Sux Contraindications[/caption] Read More: Strayer RJ. Rocuronium versus succinylcholine: Cochrane synopsis reconsidered. Ann Emerg Med 2011; 58(2): 217-8 Strayer RJ. Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 345-6. Mallon WK et al. Response to Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 346-7. Strayer RJ. (2010, January 14). Screencast: Rocuronium vs. Succinylcholine in 8 minutes. Retrieved from http://emupdates.com/2010/01/14/rocuronium-vs-succinylcholine/ References
  1. Sluga M, Ummenhofer W, Studer W, Siegemund M, Marsch SC. Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: a prospective, randomized trial in emergent cases. Anesth Analg 2005; 101:1356 – 61.
  1. McCourt KC, Salmela L, Mirakhur RK, et al. Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia. Anaesthesia 1998;53:867–71.
  1. Laurin EG, Sakles JC, Panacek EA, Rantapaa AA, Redd J.
Jan 25, 2016
Episode 30.0 – Pediatric C-spine Injuries
This episode delves into pediatric c-spine injuries focusing on the question of who needs imaging?
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Show Notes

Leonard JC et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med 2011; 58(2): 145-55. PMID: 21035905

ERCast: Pediatric C-spine Clearnace

[caption id="attachment_2587" align="aligncenter" width="666"]PECARN Decision Rule PECARN Decision Rule[/caption] [caption id="attachment_2588" align="aligncenter" width="743"]PECARN Paramater Definitions PECARN Paramater Definitions[/caption] [caption id="attachment_2589" align="aligncenter" width="668"]PECARN ORs PECARN ORs[/caption]

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Jan 18, 2016
Episode 29.0 – Dementia, Delirium and Ischemic CVA
This week we discuss the work up for dementia and delirium as well as a bit on ischemic CVA management.
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Show Notes

SAEM Geriatric Guidelines (includes screening tools for delirium): GEMCast: Diagnosing and Managing Delirium in Older Adults Gioia, LC et al. Blood pressure management in acute intracerebral hemorrhage: current evidence and ongoing controversies. Curr Opin Crit Care. 2015; 21(2):99-106. PMID: 25689125 Miller J et al. Management of hypertension in stroke. Ann Emerg Med. 2014; 64(3): 248-55. PMID: 24731431 EM Nerd: A Truncated Summation of the Adventure of the Cardboard Box Ed in the ED WDYS: Talking about tPA – Expert and Community Commentary  

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Jan 11, 2016
Episode 28.0 – Suicide Assessment
This week we review some of the different aspects used in assessment of the suicidal patient who presents to the ED.
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Jan 04, 2016
Episode 27.0 – Endovascular Therapy for Ischemic CVA
Are you ready for endovascular therapy in ischemic CVA? We discuss some of the ins and outs focusing on the MR CLEAN trial.
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Show Notes

Montori VM et al. Randomized trials stopped early for benefit: a systematic review. JAMA 2005; 294(17): 2203-9. PMID: 16264162

EMCrit: Podcast 116 - the tPA for Ischemic Stroke Debate

EM Nerd: A Truncated Summation of the Adventure of the Cardboard Box (Reviews the major endovascular treatment studies)


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Dec 28, 2015
Episode 26.0 – Grand Rounds: Dying in the ED (feat. Ashley Shreves)
This week's podcast is a full length recording of Ashley Shreves' Grand Rounds talk at Bellevue Hospital on dying in the ED.
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Show Notes

All NYC EM Podcast: Ashley Shreves - Pathway to a Peaceful Death

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Dec 14, 2015
Podcast 25.0 – Temporary Transvenous Pacemakers
Emergent placement of a temporary TV pacer is a life-saving procedure. We review the procedure along with some pearls along the way.
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Show Notes

Bessman ES: Emergency Cardiac Pacing, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 15:p 277-300.

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EM Updates: Electromechanical Dissociation

LITFL: Temporary Transvenous Cardiac Pacing

[embed]https://www.youtube.com/watch?v=GPAXS7FyQHQ[/embed] [caption id="attachment_2312" align="alignleft" width="480"]Robert's + Hedges - TV Pacemaker Equipment Robert's + Hedges - TV Pacemaker Equipment[/caption]

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Dec 07, 2015
Episode 24.0 – Hepatic Encephalopathy
This podcast is a brief discussion on hepatic encephalopathy: How it presents, the utility of ammonia levels and what else to look out for.
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Nov 30, 2015
Episode 23.0 – SBO
This week we review small bowel obstruction presentation, diagnosis and management.
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Show Notes

5 Minute Sono: Small Bowel Obstruction EM Lyceum: GI Imaging FOAMCast: Episode 23 – SBO and Mesenteric Ischemia

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Nov 23, 2015
Episode 22.0 – Extra-Abdominal Causes of Abdominal Pain
This week we'll discuss some common causes of abdominal pain that originate in extra-abdominal pathology.
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Show Notes

Life in the Fast Lane: Metabolic Causes of Abdominal Pain

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Nov 16, 2015
Podcast 21.0 – Esophageal Food Impaction + Peds Appy
This week podcast focuses on esophageal food impaction and pearls + pitfalls in the diagnosis of peds appendicitis.
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Show Notes

Score_PAS

REBEL Cast: November 2015: All Vascular Access Episode

Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855

Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002; 37(6): 877-81. PMID: 12037754

Ross MJ et al. Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound. Acad Emerg Med 2015; 21(5): 538-42. PMID: 24842505

Parienti JJ et al. Intravascular complications of central venous catheterization by insertion site. NEJM 2015. PMID: 26398070


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Nov 09, 2015
Episode 20.0 – AVNRT
On this podcast we review some background on AVNRT and focus on Emergency Department management.
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Show Notes

AVNRT with Aberrancy vs. VT

REBEL EM: SVT with Aberrancy Versus VT

Amal Mattu’s ECG Case of the Week: August 26th, 2013

Valsalva Maneuver

ALiEM: Tricks of the Trade: Valsalva Maneuver By Using a 10cc Syringe

St. Emlyn’s: JC The REVERT Trial

Adenosine in AVNRT

Larry Mellick: Treating SVT with Adensoine

ALiEM: Trick of the Trade: Combining Adenosine with the Flush

Verapamil in AVNRT

RAGE Podcast: Rage Session Two

ERCast Podcast: Nov 02, 2015

Episode 19.1 – Numeracy (feat. Brian Freeze)
Bonus Podcast - Grand Rounds from 9/23/15 featuring Brian Freeze MD on Numeracy. Lecture is part of the Chief Resident Incubator Program
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Oct 30, 2015
Episode 19.0 – More Influenza + Peds FB Aspiration
Pearls and take home messages from our weekly conference. This week, we review talks on influenza and pediatric foreign body aspiration.
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Show Notes

Influenza [caption id="attachment_2206" align="aligncenter" width="465"]Populations at High Risk for Severe Influenza - IDSA Populations at High Risk for Severe Influenza - IDSA[/caption]

ALiEM: Neuraminidase Inhibitors for Influenza - The Truth, The Whole Truth, and Nothing But the Truth. Finally.

EM Lit of Note: Remember, Tamflu is Still Junk.

EM Lit of Note: Which Review of Tamflu Data do You Believe?

Jefferson T et al. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ 2014. PMID: 24811411...

Oct 26, 2015
Episode 18.1 – Music in Medicine (feat. Jeremy Faust)
This bonus podcast is from our Grand Rounds series. Here, Jeremy Faust gives a great talk on the role of Music in Medicine.
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Show Notes

References
Platz, F. and Kopiez, R., "When the first impression counts: Music performers, audience, and the evaluation of stage entrance behavior", Musicae Scientiae 17, No. 2 (2013), pp. 167-197
Acad Emerg Med. 2012 Oct;19(10):1166-72. Epub 2012 Oct 4. Predictors of parent satisfaction in pediatric laceration repair. Lowe DA, Monuteaux MC, Ziniel S, Stack AM.
Proc Natl Acad Sci U S A. 2013 Sep 3;110(36):14580-5. Epub 2013 Aug 19.
Sight over sound in the judgment of music performance. Tsay CJ.
Med Educ. 2013 Aug;47(8):842-50.  Music lessons: revealing medicine's learning culture through a comparison with that of music. Watling C, Driessen E, van der Vleuten CP, Vanstone M, Lingard L.
The New Yorker. October 3, 2011. Personal Best. Top athletes and singers have coaches. Should you? Atul Gawande.
ANZ J Surg. 2013 Jun;83(6):477-80. Epub 2013 Apr 26.
Improving the impact of didactic resident training with online spaced education. Gyorki DE, Shaw T, Nicholson J, Baker C, Pitcher M, Skandarajah A, Segelov E, Mann GB.
Psychol Sci Public Interest. 2013 Jan;14(1):4-58. Improving Students' Learning With Effective Learning Techniques: Promising Directions From Cognitive and Educational Psychology. Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT.
Resuscitation. 2010 May;81(5):631. Epub 2010 Feb 26.
Oct 23, 2015
Episode 18.0 – Influenza Testing + Epistaxis
This week we discuss some information on influenza testing in the ED and management of epistaxis.
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Show Notes

Show Notes

EMCrit: Dominating the Vent I http://emcrit.org/lectures/vent-part-1/

EMCrit: Dominating the Vent II http://emcrit.org/podcasts/vent-part-2/

ALiEM: Neuraminidase Inhibitors for Influenza - The Truth, The Whole Truth, and Nothing But the Truth. Finally.

EM Lit of Note: Remember, Tamflu is Still Junk.

EM Lit of Note: Which Review of Tamflu Data do You Believe?

Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013; 31: 1389-92. PMID: 23911102

Derkay CS et al. Posterior nasal packing. Are Intravenous antibiotics really necessary? Arch Otolaryngol 1989; 115: 439-41. PMID: 2923686

Oct 19, 2015
Episode 17.0 – Asthma and COPD
Pearls from our weekly conference discussing severe asthma and COPD exacerbations.
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Show Notes

Shownotes

EMCrit: Delayed Sequence Intubation

REBEL EM: The Crashing Asthmatic

EM:RAP: The Rule of 2s

Abdo WF, Heunks LM. Oxygen-induced hypercapnia in COPD: myths and facts. Critical Care 16(5):323. PMID: 23106947

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Oct 12, 2015
Episode 16.0 – ALTE
Pearls from our conference discussing apparent life-threatening events (ALTE).
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Show Notes

Shownotes

Mittal MK et al. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012; 28(7): 599-605. PMID: 22743742

Kaji AH et al. Apparent life-threatening event: multi center prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med 2013; 61(4): 379-87. PMID: 23026786


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Oct 05, 2015
Episode 15.0 – Adrenal Crises + D-dimer in Aortic Dissection
Pearls from a core content talk on adrenal emergencies, a journal update looking at D-dimer in aortic dissection and some acid/base cases.
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Show Notes

Shownotes Asha SE, Miers JW. A systematic review and meta-analysis of D-dimer as a rule-out test for suspected acute aortic dissection. Ann Emerg Med 2015. PMID: 25805111 Dierks DB et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med 2015; 65: 32-42. PMID: 25529153 Acid-Base Cases   Quick questions & answers:
  1. For acute respiratory acidosis or alkalosis, how much does the pH change for every 10mm change of PCO2?
  2. What is the Winter’s formula?
  3. For stable chronic respiratory acidosis, for every 10 mm increase in PCO2, how much should the pH decrease by?
For each of the following cases, please analyze the acid-base status (i.e. anion gap metabolic acidosis, respiratory alkalosis, non-AG metabolic acidosis with respiratory acidosis, etc…) for further discussion in the workshop.
1) A 25 year old woman is found at home c/o thirst,
Sep 28, 2015
Episode 14.0 – Grand Rounds with Mike Stone – US Guided Nerve Blocks
This is a full length recording of Mike Stone's Grand Rounds at Bellevue Hospital on Ultrasound Guided Nerve Blocks for Regional Anesthesia
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Show Notes

Regional Anesthesia Resources

The Ultrasound Podcast: Nerve Blocks Archive

ASAHQ: Standards for Basic Anesthetic Monitoring

Cook County Regional: Chapter on Local Anesthetics

Anesthesiology News: Nerve Injury After Peripheral Nerve Block

[caption id="attachment_1883" align="aligncenter" width="600"]Template for Peripheral Nerve Blocks Template for Peripheral Nerve Blocks[/caption] [caption id="attachment_1884" align="aligncenter" width="599"]Sep 21, 2015
Episode 13.0 – Diabetic Ketoacidosis: A Case
Lily Abrukin (Chief Resident) and Swami discuss the care of a critically ill patient with DKA.
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Episode 12.0 – Transfusions + Procedures

Show Notes

Cricothyrotomy Resources

EMCrit: EMCrit Wee - Mind Blowing Cricothyrotomy Video

ACEP Now: Tips and Tricks for Performing Cricothyrotomy

Tube Thoracostomy

University of Maryland EM: Tube Thoracostomy

Lateral Canthotomy Resources

Rowh AD et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med 2015. 48(3):325-330. PMID: 25524455

Larry Mellick: Emergency Lateral Canthotomy and Cantholysis


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Sep 07, 2015
Episode 11.1 – Andy Sloas on Infant Emergencies
This is a full length talk from our Grand Rounds series featuring Andy Sloas of the PEM ED Podcast on Infant Emergencies.
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Show Notes

ACEP: THE MISFITS [caption id="attachment_1750" align="aligncenter" width="516"]THE MISFITS - Sick Kids Mnemonic THE MISFITS - Sick Kids Mnemonic[/caption]

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Sep 04, 2015
Episode 11.0 – TEE in Cardiac Arrest and PE Risk Stratification
Pearls from our weekly resident conference - discussion of PE risk stratification and TEE in cardiac arrest
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Show Notes

Ultrasound in Cardiac Arrest Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation 2008; 78: 135-40. PMID: 18486300 Ultrasound Podcast: Ultrasound guided CPR Part 1. How we’re doing it wrong. Ultrasound Podcast: Ultrasound guided CPR Part 2. TEE & US = New pulse check

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Aug 31, 2015
Episode 10.0 – Aortic Dissection + Syncope
Pearls from a core content talk on aortic dissection, syncope workshop and journal update on ATLS.
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Show Notes

Resources Aortic Dissection Hagan PG et al. The international registry of acute aortic dissection (IRAD): New insights into an old disease. JAMA 2000; 283: 897-903. PMID: 10685714 Rosman HS et al. Quality of history taking in patients with aortic dissection. Chest 1998; 114(3): 793-5. PMID: 9743168 All NYC EM Podcast: Rob Rogers – Aortic Dissection Syncope EM Lyceum: Syncope, Answers Amal Mattu: ECG Weekly Steve Smith: Dr. Smith’s ECG Blog Journal Update - ATLS Wiles MD. ATLS: Archaic Trauma Life Support? Anaes 2015; 70: 893-906. PMID: 26152249

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Aug 24, 2015
Episode 9.1 – The Evolution of Pain Management with Sergey Motov
Aug 21, 2015
Episode 9.0 – Peds Cardiology + Pericardial Effusions
Pearls, pitfalls and take home points from the NYU/Bellevue EM Residency weekly conference.
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Show Notes

Vaillancourt S. et al. Repeated Emergency Department Visits Among ChildrenAdmitted With Meningitis or Septicemia: A Population-Based Study. Ann Emerg Med 2015; 65(6): 625-631. PMID: 25458981 EMCrit: Rapid Ultrasound for Shock and Hypotension – the RUSH Exam. Verma V et al. The utility of routine admission chest X-ray films on patient care. Eur J Intern Med 2011; 22(3): 286-8. PMID: 21570649 EMCrit: Opiate-Free ED with Sergey Motov

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Aug 17, 2015
Episode 8.0 – Chest Pain
Recapping pearls from our weekly conference. This week, we discussed pearls on chest pain.
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Show Notes

How to Build a Great Talk

Chest Pain Workshop

Episode 7.0 – Hyperkalemia + Rate Control in AFib
Aug 03, 2015
Episode 6.0 – Airway Workshops
Jul 27, 2015
Episode 5.0 – Pearls from Howie Mell
Podcast 5.0 features pearls from Howie Mell's Grand Rounds talk "48 Tweets on 24 Topics"
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Show Notes

Ovarian Hyperstimulatoin Syndrome (OHSS) Braude P, Rowell P. ABC of subfertility – Assisted conception III – problems with assisted conception. BMJ 2003; 327: 920-923. PMC: 218823 Backboards ACEP Clinical Policy Statement: EMS Management of Patients with Potential Spinal Injury EM Cases: Episode 66 Backboard and Collar Nightmares from the Emergency Medicine Update Confernce. Tranexamic Acid (TXA) HIPPO EM: “Stop the Bleeding!” – TXA in Prehospital Care The Skeptics Guide to EM: SGEM#80: CRASH-2 (Classic Paper) INSERT LINK TO OUR CRASH 2 REVIEW Nasal Oxygen During Efforts Securing a Tube (NO DESAT) EP Monthly: NO DESAT!

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Jul 20, 2015
Episode 4.0 – Perimortem C-Section, Procedural Sedation and Airway Pearls
Episode 4.0 features pearls on perimortem C-sections, procedural sedation and an interview with Reuben Strayer on Airway Nightmares
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Show Notes

Perimortem C-Section Links EMCrit: Perimortem C-Section Procedural Sedation Links EM Updates: Emergency Department Procedural Sedation Checklist V2 EM Updates: The Procedural Sedation Screencast Trilogy EMCrit: Procedural Sedation Resources Airway Nightmares EM Updates: Direct vs. Video Laryngoscopy in 10 Minutes  

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Jul 13, 2015
Episode 3.0 – Disaster Management + ID Topics
11:20

Show Notes

General ID Workshop Take Home Points
  1. Know your local antibiogram. This is the best way to tailor your management to your patient.
  2. Search for recent old cultures from your patients and order antibiotics based on this information.
Skin + Soft Tissue Take Home Points
  1. Antibiotics aren’t required for most simple abscesses. I+D and if no overlying cellulitis, no antibiotics needed.
  2. Not all abscesses need packing. If they’re small and on the extremeties, it’s reasonable to leave them unpacked.
  3. Not all patients need MRSA coverage for cellulitis. Most cellulitis without abscess is strep.
  4. Necrotizing Fasciitis can be tough to pick up. The LRINEC scoring system is one method to help. Most patients will be toxic but look for pain that's out of proportion to the examination.
Relevant Links AliEM - The Not-So-Sick Health-Care Associated Pneumonia Patient: New Treatment Strategy EM Lyceum - Abscess Disaster Management
Jul 06, 2015
Episode 2.0 – Sepsis, Ebola, Endocarditis and More!
21:12
This podcast highlights pearls, pitfalls and take home points from our conference on ID emergencies as well as a sepsis update for 2015
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Show Notes

[caption id="attachment_717" align="alignleft" width="1800"]SIRS Criteria SIRS Criteria[/caption] Read More REBELCast: Sepsis Care in 2015 References Tattevin P et al. Does this patient have Ebola virus disease? Intensive Care Med 2014; 40(11): 1738-41. PMID: 25183574 Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001; 345(19): 1368-77. PMID: 11794169 The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. NEJM 2014; 370(18): 1683-93. PMID: 24635773 ARISE Investigators. Goal-directed resuscitation for patients with early septic shock. NEJM 2014; 371(16): 1496-506. PMID: 25272316 Mouncey PR et al. Trial of early, goal-directed resuscitation for septic shock. NEJM 2015; 327(14): 1301-11.
Jun 29, 2015
Episode 1.1 – Jay Lemery on Wilderness Medicine in 2015
41:59
This talk was given by Jay Lemery in May 2015 when he came out from Denver for Grand Rounds. Jay is an associate professor of EM at Denver Health as well as the past president of the Wilderness Medicine Society. This talk is about what Wilderness Medicine is in 2015. "Wilderness Medicine is about providing care in austere environments."
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Jun 22, 2015
Episode 1.0 – Electrical and Lightning Injuries
10:45
This podcast highlights pearls and take home points from Chris McStay's grand rounds talk on Electrical and Lightning Injuries from our Wilderness Medicine Grand Rounds on May 6th, 2015.
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May 09, 2015
Episode 0.0 – The Intro
4:08
Episode 0.0: Intro to the Core EM Podcast. Every Monday we'll release a podcast featuring pearls, pitfalls and critical take home messages from our weekly resident conference.
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May 08, 2015