• 0:16 — Podcast Introduction
• 1:08 — Episode Introduction
• 7:30 — Malaria
• 13:55 — Dengue
• 17:33 — Enteric Fever (Typhoid/Paratyphoid)
• 20:53 — Leptospirosis
• 22:43 — Clinical Presentations
• 26:33 — Diagnostic Testing
• 33:17 — Treatment
• 38:59 — Special Populations & Risk Pitfalls
• 43:05 — Closing Pearls & Outro

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• Introduction – 0:11
• Article Overview – 2:02
• Top 5 Bedside Steps – 7:54
• Sodium Channel Blockade – 9:26
• Hyperkalemia – 11:53
• SVT with Aberrancy – 12:47
• WPW & Accessory Pathway – 13:34
• AFib with Accessory Pathway – 14:09
• Monomorphic VT – 19:01
• Polymorphic VT / Torsades – 20:08
• Bidirectional VT – 21:29
• Pacemaker-Mediated Tachycardia – 22:30
• Pre-Hospital Considerations – 24:52
• Stable vs. Unstable Assessment – 27:58
• Diagnostic Studies – 29:42
• Treatment – 38:00
• Risk Management Pitfalls – 44:49
• Wrap-Up – 49:44

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• Introduction & Welcome — 0:17
• Jack's Background in Healthcare AI — 0:58
• Brief History of AI — 3:57
• The "Perfect Storm" That Created Modern AI — 5:48
• From General to Specialized: Fine-Tuning AI for Medicine — 7:04
• LLM Confidence & the Sycophancy Problem — 13:01
• The Benchmark Problem — 14:25
• Building Your Own Personal AI Benchmark — 17:44
• Can You "Turn Off" AI Sycophancy? — 20:00
• RAG Systems & How Specialty AI Tools Work — 22:09
• Choosing the Right AI Tool for Clinical Use — 26:18
• Why 95% of AI Pilots Fail in Deployment— 28:10
• How to Ask AI Questions Well (Prompt Quality) — 31:25
• Knowledge Base Currency & Sam's Drug Withdrawal Test — 35:06
• Closing & Contact Info — 37:12

• Introduction & Welcome (0:15)
• Guest Introduction (0:55)
• Epidemiology of Severe TBI (2:37)
• Pathophysiology: Primary vs. Secondary TBI (4:24)
• Types of Hemorrhage and Hematomas (5:25)
• Classification (7:31)
• Mild vs. Moderate vs. Severe TBI
• Impact Loading vs. Inertial Loading
• Differential Diagnosis (9:22)
• Prehospital Care (9:42)
• Emergency Department History (13:33)
• Diagnostics (15:13)
• CT Scan and the A-B-B-B-C Approach
• Repeat CT Timing
• Bedside Ultrasound for Optic Nerve Sheath Diameter
• Pupillometry
• Biomarkers
• Treatment (24:52)
• Airway Management
• Ventilation and CO2 Targets
• Hyperosmolar Therapy: Hypertonic Saline and Mannitol
• Cerebral Perfusion Pressure
• Blood Pressure Goals
• Temperature Management
• Coagulopathy Management
• Seizure Prophylaxis and EEG Monitoring
• Tiered ICP Management (35:29)
• Surgical Indications (38:40)
• Prognosis (40:33)
• Special Topics (41:30)
• Sports Injuries and CTE
• Tranexamic Acid (CRASH-3 Trial)
• Wrap-Up (43:46)

Subscribers, take the CME test here.

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

00:00 - Introduction & Welcome

01:21 - Episode Overview: Acute Coronary Occlusion

02:06 - Why This Topic Matters: Statistics & New Guidelines

03:35 - Nomenclature: ACO vs STEMI/NSTEMI

06:15 - Differential Diagnosis for STEMI

07:41 - Pre-Hospital Care & EMS Role

11:37 - Patient History & Presenting Symptoms

12:28 - Physical Examination Findings

14:54 - EKG: The Most Important Test

17:00 - STEMI Definition & Criteria

20:32 - STEMI Equivalents: Scarbosa Criteria

22:40 - Smith Modified Scarbosa Criteria

24:10 - Hyperacute T Waves

25:30 - Posterior STEMI

28:40 - De Winter Sign

29:38 - Non-STEMI EKG Findings

31:30 - AVR ST Elevation

32:47 - Wellens Syndrome

33:54 - Reciprocal ST Segment Changes

36:15 - Inferior MI Patterns

37:54 - Laboratory Testing

39:51 - Imaging: Chest X-Ray & Echocardiography

42:25 - Supplemental Oxygen: What the Evidence Shows

44:50 - Analgesia & Pain Management

46:35 - Pharmacotherapy: Aspirin & Antiplatelet Agents

49:18 - Reperfusion Therapies & Thrombolytics

53:05 - Cardiac Arrest in STEMI Patients

53:55 - Closing Remarks & CME Information

• 0:15 Introduction
• 0:51 Guest Introduction
• 1:20 Jeff's Background
• 2:00 Current Work
• 3:37 How He Got Started
• 6:57 Pre-Litigation vs. Expert Witness
• 8:01 Four Components of Malpractice Cases
• 13:55 Case Review Statistics
• 17:11 When Cases Get Filed
• 18:58 Common Patterns in Cases
• 19:55 Documentation Best Practices
• 22:06 Shift Handoff Problems
• 25:56 Bounce Backs
• 27:25 Medical Record Volume
• 30:00 Audit Trails
• 32:53 Communication with Consultants
• 41:35 Conflicting Documentation
• 43:46 Getting Started in This Work
• 47:37 Closing

Syphilis cases have surged 42% in the US, making it critical for emergency physicians to recognize and treat this "great masquerader." In this episode, hosts Sam Ashoo and Dr. T.R. Eckler break down the January 2026 Emergency Medicine Practice article on syphilis diagnosis and management. They cover the rising prevalence in high-risk populations, the four clinical stages (primary, secondary, latent, and tertiary), special presentations like neurosyphilis and congenital syphilis, and practical diagnostic approaches. With a national penicillin shortage, they discuss alternative treatment options including doxycycline and post-exposure prophylaxis. The conversation also addresses the dark history of the Tuskegee Study and its lasting impact on medical ethics. Whether you're seeing more cases in your ED or want to sharpen your diagnostic skills, this episode provides actionable insights for frontline providers.

[0:00] Opening/Introduction

[0:11] Host Welcome & Resources

[0:50] Episode Introduction

[1:30] Epidemiology & Rising Cases

[4:30] Risk Factors & Screening

[6:30] Pathophysiology & Transmission

[9:30] Primary Syphilis

[12:30] Secondary Syphilis

[15:30] Tertiary & Latent Syphilis

[18:30] Neurosyphilis

[22:30] Congenital Syphilis

[25:30] Ocular & Otic Syphilis

[28:30] Differential Diagnosis & Pre-hospital Care

[31:30] History & Physical Examination

[34:30] Diagnostic Testing Overview

[38:30] Testing Details & Titers

[41:30] Treatment: Penicillin & Alternatives

[43:30] Closing

Episode Outline:

• [0:00] Introduction
• Welcome and show overview by Sam Ashoo
• Mention of resources at ebmedicine.net
• [0:46] Episode Start
• Hosts introduce themselves: Sam Ashoo and Dr. T.R. Eckler
• Dr. Eckler’s background and experience with cannabis cases in Colorado
• [1:16] Topic Introduction
• Focus on diagnosis and management of cannabis-related emergencies
• Prevalence and importance in emergency medicine
• [1:34] Legal Landscape
• Overview of cannabis legality across states
• Medicinal vs. non-medicinal use
• [3:03] Increase in ED Visits
• Statistics: ~1 million cannabis-related ED visits annually
• Demographics: younger population most affected
• [3:52] Synthetics and Challenges
• Discussion of synthetic cannabinoids and their risks
• Issues with detection and legality
• [4:50] Clinical Spectrum
• Range of presentations: from nausea/vomiting to psychosis and seizures
• Impact on different age groups
• [6:34] FDA-Approved Uses
• Cannabis-derived products approved for specific medical conditions
• [7:20] Physiology and Pathophysiology
• Cannabinoid receptors (CB1 and CB2) and their effects
• Differences between plant-derived and synthetic cannabinoids
• [9:10] Chronic Use and Withdrawal
• Downregulation of receptors, withdrawal symptoms, and persistent nausea
• [10:20] Product Forms and Delivery Methods
• Smoking, edibles, oils, tinctures, suppositories, topicals, etc.
• Risks associated with concentrated forms (e.g., wax, oils)
• [12:00] Clinical Effects by System
• Psychiatric: anxiety, psychosis, paranoia
• Cardiovascular: tachycardia, MI risk, QT prolongation
• Pulmonary, renal, metabolic, dental, and ocular effects
• [13:50] Cannabinoid Hyperemesis Syndrome (CHS)
• Phases: prodrome, hyperemesis, recovery
• Hot showers as a diagnostic clue
• [16:00] Withdrawal Syndrome
• Symptoms and timeline
• Exacerbation with synthetic cannabinoids
• [18:15] Counseling and Management
• Importance of cessation and patient education
• Timeline for symptom improvement
• [18:42] Differential Diagnosis
• Broad differential for persistent nausea/vomiting and abdominal pain
• Importance of considering other causes
• [20:55] Diagnostics and Testing
• Limitations of drug screens (false positives/negatives)
• Importance of EKG, labs, and imaging as indicated
• [23:10] Treatment Approaches
• First-line: benzodiazepines, antiemetics (ondansetron, metoclopramide)
• Second-line: butyrophenones (haloperidol, droperidol), olanzapine
• Capsaicin as adjunct therapy
• [29:50] Complications and Special Considerations
• Risks of undertreatment (e.g., Boerhaave syndrome, aspiration)
• Pediatric and pregnant populations: unique risks and reporting requirements
• [36:00] Five Practice-Changing Takeaways
• Elicit cannabis use history
• Know testing limitations
• Consider ECG and appropriate labs
• Use butyrophenones when indicated
• Admit if symptoms are refractory
• [39:00] Conclusion

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

00:00 Introduction to Emergency Medicine

00:21 Welcome and Holiday Greetings

01:16 Special Guest Introduction

01:41 Discussion on Pediatric Emergency Medicine

04:55 Epidemiology of Measles

08:16 Challenges in Diagnosing Measles

14:27 Mumps: Symptoms and Complications

27:36 Rubella: Risks and Symptoms

29:28 Varicella: Symptoms and Precautions

33:12 Differential Diagnosis and Conclusion

35:14 Using Inductive Reasoning in Medical Diagnosis

35:40 Recognizing Purpuric Rash and Its Implications

36:22 Guidance for EMS Colleagues on Handling Fever and Rash

37:14 Importance of Communication and Relationships with EMS

39:12 Decontamination and PPE Protocols for EMS

42:34 Detailed Patient Assessment in the ED

46:06 Diagnostic Testing and Clinical Diagnosis

49:20 Reporting Responsibilities and Treatment Protocols

01:01:19 Addressing Vaccine Controversies and Public Trust

01:06:25 Conclusion and Additional Resources

Check out Dr Horeczko's podcast - Pediatric Emergency Playbook

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

1. Epidemiology & Background

• Rising ED visits related to alcohol use.
• Mortality rates and spectrum of patient presentations.
• Importance of high suspicion and complexity of cases.
• Pathophysiology & Mechanisms
• Alcohol metabolism and neurochemical changes.
• Differential diagnosis: Conditions that mimic alcohol withdrawal.
• Prehospital & EMS Considerations
• Role of EMS in triage and initial management.
• Use of sobering centers vs. ED transport.
• Prehospital administration of benzodiazepines (IM midazolam).
• History & Risk Assessment
• Key questions to assess risk for alcohol withdrawal syndrome.
• Importance of patient history, medication use, and comorbidities.
• Discussion on patient honesty and rapport.
• Physical Exam & Scoring Systems
• DSM-5 criteria for alcohol withdrawal.
• Use of CIWA-AR, BAWS, and PAWSS scoring systems.
• Importance of objective measurement for monitoring and disposition.
• Complications & Special Presentations
• Complicated alcohol withdrawal: Hallucinosis, seizures, delirium tremens.
• Diagnostic workup: Labs, imaging, and co-ingestions.
• Special populations: End-stage liver disease, pregnancy, intubated patients.
• Treatment Strategies
• Mainstay: Benzodiazepines (types, dosing, and protocols).
• Phenobarbital: Indications, dosing, and evidence.
• Adjunctive therapies: Thiamine, glucose, magnesium.
• Alternative/adjunct medications: Gabapentin, ketamine, dexmedetomidine, baclofen.
• Clinical Pearls & Practice Changes
• Early, aggressive therapy to prevent complications.
• Symptom-based vs. fixed-schedule treatment.
• Gabapentin as an alternative or adjunct.
• Anti-craving medications for relapse prevention.
• Disposition & Protocols
• Use of scoring systems for safe discharge, observation, or admission.
• Importance of protocolized approaches and community resources.
• Summary & Take-Home Points
• Five key practice-changing points.
• Clinical pathway.

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• Introduction and guest background
• Host welcome, show context
• Dr. Lara Zibners’ credentials
• EB Medicine involvement
• Personal stories and clinical experience
• Memorable tetanus and pertussis cases
• Vaccine advocacy
• Rare disease encounters
• Diphtheria: overview, presentation, treatment
• Toxigenic vs. non-toxigenic, “bull neck”
• Cardiac, neurologic complications
• Antitoxin, antibiotics, public health
• Pertussis: symptoms, vaccine, treatment
• “100-day cough,” apnea in infants
• Waning immunity, boosters
• Azithromycin, treat contacts
• Tetanus: risk, presentation, management
• Clostridium ubiquity, no outbreaks
• Muscle spasms, autonomic instability
• Airway, sedation, antibiotics
• Key ED takeaways and pearls
• Early suspicion, isolation
• ICU admission for severe cases
• Vaccination, reporting
• Resources and article summary
• Appendix, clinical pathway
• ebmedicine.net reference
• CME, further reading
• Guest’s podcast plug and closing remarks
• “Unstable Vitals” podcast
• Where to listen
• Thank you, sign-off

Check out Dr Zibner's podcast Unstable Vitals

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

Introduction

• Welcome and host introductions
• Brief overview of the episode’s topic
• Resources and CME reminder

Article Overview

• Source: Emergency Medicine Practice, October 2025
• Authors: The Simcoes
• Importance of evidence-based review

Clinical Context & Epidemiology

• Frequency and rarity of adrenal insufficiency
• Diagnostic challenges and statistics
• Importance of recognizing adrenal crisis

Pathophysiology

• Primary, secondary, and tertiary adrenal insufficiency
• Causes and mechanisms
• Key anatomical and physiological concepts

Differential Diagnosis

• Overlap with other diseases (infections, autoimmune, endocrine, psychiatric, cardiac, GI, etc.)
• Importance of considering adrenal crisis in complex cases

Prehospital Care

• EMS recognition and limitations
• Importance of medication history and emergency kits
• Legal and logistical barriers to prehospital hydrocortisone

Emergency Department Evaluation

• Recognizing symptoms and prioritizing care
• Role of EMR and clinical decision support
• Key history and risk factors (medications, steroid use, opioid use, comorbidities)

Physical Examination

• Specific and nonspecific findings
• Cushingoid features vs. primary adrenal insufficiency signs

Diagnostic Workup

• Laboratory studies (cortisol, ACTH, renin, aldosterone, TSH, etc.)
• Imaging considerations
• Gold standard tests and their limitations in the ED

Treatment

• Immediate administration of hydrocortisone
• Dosing for adults and pediatrics
• Supportive care (fluids, glucose, treating underlying cause)
• Sick day dosing and home management

Special Populations

• Pregnancy considerations
• Septic shock and adrenal crisis

Common Pitfalls & Takeaways

• Delaying steroids for labs/diagnosis
• Importance of high suspicion and early treatment
• Key trivia and learning points

ClosingSummary and final thoughts

• Reminders for further reading and CME
• Farewell and next episode teaser

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

Background & Regional Differences

• Dr. Dvorin’s clinical journey from New England to New Orleans.
• Noticing increased use of corticosteroids for common conditions in the Southeast.
• Discussion of how steroid prescribing practices vary by region and setting.

Inappropriate Steroid Use

• Common conditions where steroids are often inappropriately prescribed (sinus infections, bronchitis, sciatica, rashes, plantar fasciitis, etc.).
• Trends showing increased steroid prescribing over time.
• Similar patterns observed in emergency, urgent care, and primary care settings.

Risks and Side Effects of Short-Term Steroid Use

• Short-term steroids can cause significant side effects: infection, sepsis, bone fractures, thromboembolism, psychiatric effects, hyperglycemia.
• Dose-response relationship: higher doses and repeated use increase risks.
• Some side effects (e.g., bone loss) may persist beyond two months.

Patient Communication & Shared Decision-Making

• Importance of discussing risks with patients, tailored to individual risk factors (e.g., diabetes, psychiatric history, age).
• Strategies for educating patients and managing expectations.
• The role of patient education videos and resources.

Impact of Provider Education & Quality Metrics

• Ochsner Health’s initiatives to reduce inappropriate steroid use.
• Use of CME, quality dashboards, and feedback to clinicians.
• Evidence that education and reporting can reduce unnecessary prescriptions.

Special Populations & Scenarios

• Considerations for pediatric patients and repeated dosing.
• Challenges when specialists recommend steroids for certain conditions (e.g., sciatica, neurosurgery cases).
• The need for evidence-based practice and inter-provider communication.

Medical-Legal Considerations

• Lawsuits related to steroid side effects (e.g., fat atrophy, infection).
• Importance of documentation and informed consent.

Alternatives & Symptom Management

• Focusing on treating the patient’s most bothersome symptoms.
• Non-steroid options and the value of patient education about illness duration and expectations.

Resources

• Mention of Dr. Dvorin’s educational video on corticosteroid side effects (available on YouTube).
• Reminder of EB Medicine’s journals and resources for further learning.

Conclusion

• Key takeaway: “Do no harm” and practice evidence-based medicine.
• Encouragement for clinicians to review their prescribing habits and educate patients.

Ochsner "Side effects from corticosteroids" Video: https://www.youtube.com/watch?v=PdMJ9HYxkck

Topic Introduction

• Focus: Status Epilepticus in Adults
• Reference to recent pediatric episode
• Article authors: Dr. Marquez, Dr. Kaur, Dr. Lay

Why Status Epilepticus Matters

• Teaching value and clinical challenge
• Team-based care and multidisciplinary involvement

Guidelines and Evidence

• Review of major guidelines (International League Against Epilepsy, Neurocritical Care Society, American Epilepsy Society)
• Key trials: EcLiPSE, ConSEPT, ESETT
• Updated definition of status epilepticus

Classification and Diagnosis

• Convulsive vs. non-convulsive status
• Importance of repeated neurologic exams
• Diagnostic challenges and mimics (e.g., syncope, psychogenic seizures)

Etiology and Workup

• Acute vs. non-acute causes
• Common triggers: medication noncompliance, metabolic issues, infections, trauma
• Importance of sleep patterns and ammonia levels
• The NORSE acronym (new onset refractory status epilepticus)

Prehospital and ED Management

• Airway, breathing, circulation priorities
• Early pharmacologic intervention (IM midazolam preferred in prehospital)
• Gathering history and medication information
• Positioning and airway protection

Diagnostics

• Laboratory workup: glucose, CBC, metabolic panel, drug levels, pregnancy test
• Imaging: non-contrast CT, MRI, ultrasound, lumbar puncture
• EEG: spot vs. continuous monitoring

Treatment Approach

• First-line: Benzodiazepines (lorazepam, midazolam)
• Second-line: Levetiracetam, valproate, fosphenytoin, phenobarbital, lacosamide
• Third-line: Continuous infusions (midazolam, propofol, pentobarbital, thiopental, ketamine)
• Dosing pearls and importance of rapid escalation

Special Populations

• Pregnancy (eclampsia: magnesium as first-line)
• Substance-induced status epilepticus (e.g., isoniazid toxicity and pyridoxine)
• Brief mention of pediatric management and the PD stat app

Risk Management Pitfalls

• Non-convulsive status is common and easily missed
• Importance of weight-based dosing
• Need for formal EEG in ambiguous cases
• Don’t assume non-adherence is the only cause in known epileptics
• Always consider higher level of care for status patients

Clinical Pathway

• Stepwise approach to medication and escalation
• Emphasis on having a pathway/checklist for these high-stress cases

Conclusion

• Recap of key points
• Thanks to authors and listeners
• Reminder to visit ebmedicine.net for CME and resources

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

• 00:00 Introduction and Welcome
• 00:54 Meet Dr. Ali Chaudhary
• 01:41 The State of Emergency Medicine
• 03:29 Understanding Locum Tenens
• 05:45 Financial Benefits of Locum Work
• 08:40 Balancing Family Life with Locum Work
• 12:54 Locum Work Logistics and Misconceptions
• 17:34 Maximizing Travel Perks as a Contractor
• 18:07 Adjusting to New Hospitals and EMRs
• 19:32 The Hassles of Credentialing
• 20:48 Navigating Locum Staffing Companies
• 22:27 Understanding Your Worth and Negotiation
• 25:14 The Importance of Organization
• 27:41 About Our Locum Staffing Company
• 29:59 Practical Tips for Malpractice Insurance
• 31:09 Final Thoughts and Contact Information

For more about Dr. Ali Chaudhary: https://thelocums.com/

00:00 Introduction and Welcome

01:09 Meet Dr. Lauren Page Black: Sepsis Expert

01:56 Sepsis Statistics and Impact

04:16 Understanding Sepsis Definitions

09:56 Screening Tools for Sepsis

13:57 Pre-Hospital Sepsis Recognition

19:33 Clinical Examination and Diagnostics

24:03 The Role of Lactate and Procalcitonin

27:40 Clinical Gestalt and Imaging in Diagnosis

29:21 CMS Bundle Requirements and Updates

34:02 Fluid Type Preferences in Sepsis

36:49 Antibiotic Timing and Selection

43:43 Vasopressors and Steroids in Sepsis Management

50:18 Special Populations and Future Directions

53:44 Conclusion and Resources

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net 

• Introduction to Dr. Christina Shenvi
• Why Focus and Time Management Matter
• Experiences coaching medical students and professionals
• The importance of managing mind, time, and attention
• Applicability to both career and personal life
• Framework for Focus
• Three-step framework: Prioritize, Strategize, Focus
• Explanation of prioritization
• Mapping personal and professional activities to priorities
• Deep Work vs. Shallow Work
• Defining deep work and shallow work
• Strategies for categorizing and scheduling tasks
• Time-blocking and protecting focus time
• Overcoming Distraction
• The psychology of distraction and procrastination
• The impact of digital devices and social media on attention
• The variable reward system of social media and its addictive nature
• Strategies to Improve Focus
• Clearing mental, physical, and digital environments
• The importance of a distraction-free workspace
• Systems for capturing and organizing tasks
• The Pomodoro method and using time pressure
• Building a Personal System
• Experimenting with different task management tools
• Adapting systems to personal needs and preferences
• Daily Practice and Training Focus
• Reviewing and updating task lists daily
• Chunking email and shallow work to specific times
• Training the brain to focus like a muscle
• Special considerations for people with ADHD
• Resources and Contact
• Dr. Shenvi’s website and online course (timeforyourlife.org)
• Invitation to connect for coaching or further learning

For more about Christina Shenvi : https://timeforyourlife.org/

• Welcome and brief overview of the episode
• Promotion of EB Medicine’s $1 for 7-day trial offer

• Seizures make up ~1% of ED visits and ~3% of EMS calls
• High-risk and high-stakes condition requiring rapid action
• Status epilepticus now defined as ≥5 minutes of seizure activity
• ILAE’s T1 and T2 timelines help define when to treat and when damage begins

• Top contributors:
• Fever/infection
• Structural CNS abnormalities
• Toxic ingestions
• Genetic/metabolic disorders
• Additional factors by age:
• Infants: febrile seizures, chromosomal issues, trauma
• School-age: autoimmune disorders
• Adolescents: eclampsia, hypertension, functional disorders
• Always consider non-accidental trauma

• IM midazolam is effective and recommended (RAMPART trial)
• Other options: intranasal, rectal, or IV benzodiazepines
• Early benzodiazepine administration improves outcomes
• Importance of airway support, glucose check, and EMS flexibility
• Parent-administered home meds (e.g. rectal diazepam) can be helpful

• Prioritize ABCs: Airway, Breathing, Circulation, Consciousness
• Use end-tidal CO₂ to monitor ventilation if available
• Point-of-care glucose is essential
• Labs: CMP, Mg, Phos, lactate, drug levels, pregnancy test (when indicated)
• Imaging: Head CT if concern for trauma, shunt malfunction, or focal signs
• Case examples highlight pitfalls and diagnostic delays

• Benzodiazepines remain the cornerstone
• Lorazepam preferred IV agent (0.1 mg/kg)
• Midazolam preferred if no IV access (IN, IM, or IO)
• Diazepam is also effective, especially rectally
• Be mindful of respiratory depression and the need for airway control

• Based on ESETT trial:
• Levetiracetam, fosphenytoin, and valproate have similar efficacy
• Levetiracetam favored for safety and ease of use
• Fosphenytoin may be avoided in trauma or toxicity
• Valproate not recommended in mitochondrial disease
• Phenobarbital reserved for refractory cases only

• Definition: persistent seizures despite first- and second-line agents
• Requires sedation and likely intubation
• Infusion options:
• Midazolam (preferred for flexibility)
• Propofol (short-term use only due to risk of infusion syndrome)
• Pentobarbital (rare, ICU-level care)
• Need for continuous EEG to assess seizure activity

• Neonates:
• Watch for subtle signs (lip smacking, bicycling, tongue thrusting)
• Broad differential includes asphyxia, infection, metabolic errors
• Febrile Status Epilepticus:
• Higher risk of CNS infections, especially if unvaccinated
• Consider lumbar puncture if indicated
• Electrolyte/Metabolic Triggers:
• Treat hypoglycemia, hyponatremia, and hypocalcemia directly
• Use 3% saline or dextrose as appropriate

• Many children will require ICU-level care
• Some known epilepsy patients may go home if back to baseline
• Ensure rescue medications are up to date (rectal/intranasal benzos)
• Consider “clonazepam bridge” for short-term seizure prevention
• Collaborate with neurology for medication adjustment and follow-up

• Keep treatment tables and dosing references accessible
• Early, aggressive treatment can prevent long-term harm
• Episode closes with gratitude to article authors and a reminder to visit EBMedicine.net

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the June 2025 Emergency Medicine Practice article, Emergency Department Management of Patients With Thyroid Emergencies

• Introduction to Thyroid Emergencies
• Understanding Decompensated Hypothyroidism
• Thyroid Storm: The Other Extreme
• Differential Diagnosis and Complications
• Medication Triggers and Patient History
• Physical Examination Findings
• Laboratory Analysis
• Scoring Systems and Risk Assessment
• Introduction to Treatment Approaches
• Managing Decompensated Hypothyroidism
• Treating Thyroid Storm
• Special Considerations and Populations
• Risk Management Pitfalls

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

• Importance of maintaining medication schedule for Parkinson's patients
• Strategies for ensuring patients receive their medications promptly
• Overview of Carbidopa Levodopa's mechanism of action

• Description of the disease mechanism
• Importance of assessing respiratory function
• Diagnostic alternatives like the negative inspiratory force test and counting test
• Discussion on appropriate emergency department actions and treatments including steroids, plasmapheresis, and IVIG

• Description of the disease mechanism
• Description of the typical patient demographic
• Discussion on the varied presentation of MS
• Treatment strategies including high-dose steroids and Baclofen

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net 

• Discussing Trauma in Emergency Medicine
• Personal Experiences with Trauma
• The Impact of Suppression
• Defining Trauma and Its Effects
• Integration vs. Disintegration
• Debriefing and Coping Mechanisms
• The Driveway Debrief
• Nurse and Physician Dynamics
• Reflective Solitude vs. Isolation
• Creating Narratives During Trauma
• Dropping Anchor Technique
• Body-Oriented Resets
• Post-Incident Rituals
• Addressing Lowercase t Traumas
• Therapy and Trauma Pathways

For more about Rob Orman and physician coaching: https://roborman.com/

Hypernatremia (High Sodium Levels)

• Definition: Sodium level greater than 145 mEq/L
• Breakdown into three categories based on total body water status
• Hypovolemic Hypernatremia
• Euvolemic Hypernatremia
• Hypervolemic Hypernatremia
• Common causes and conditions associated

Hyponatremia (Low Sodium Levels)

• Definitions: Mild (130-135 mEq/L), Moderate (125-129 mEq/L), Profound (< 125 mEq/L)
• Breakdown into three categories
• Pseudo Hyponatremia
• Hypovolemic Hyponatremia
• Euvolemic Hyponatremia
• Hypervolemic Hyponatremia
• Common causes and conditions associated

Treatment Guidelines and Strategies

• Emphasizing slow correction to avoid complications like cerebral edema and osmotic demyelination syndrome
• Suggested treatment rates for acute and chronic conditions

Special Considerations

• Addressing severe cases and the importance of proper diagnostics
• Pre-hospital care considerations and scenarios
• Pediatrics and consideration of child abuse in sodium disorders

Five Things That Will Change Your Practice

• Central lab sodium values over point-of-care for accuracy
• Rectal temperature checks in endurance athletes
• Loop diuretics for hypervolemic hyponatremia (e.g., CHF patients)
• Enteral treatment for hypernatremia, if possible
• Considering COVID-19 as a possible cause for new onset SIADH

• Dr. Patrick O'Malley's Journey in Emergency Medicine
• The Laceration Course: Origins and Evolution
• The EM Docs Side Hustle Facebook Group
• The Patient That Changed My Life

• The Laceration Course, The Abscess Course, and more...
• EM Docs Side Hustle Facebook Group
• Patrick O'Malley, MD: LinkedIn

• Common Etiologies of Knee Pain
• Risk Factors and Statistics
• Infectious Causes of Knee Pain
• Pre-Hospital Care and EMS
• History and Physical Exam
• Imaging Guidelines
• Ottawa Knee Rule and X-Ray Necessity
• Imaging Modalities for Knee Effusion
• Ultrasound for Tendon Injury and Arthrocentesis
• CT and MRI in Knee Injury Diagnosis
• Lab Tests for Septic Knee Diagnosis
• Treatment Options for Knee Conditions
• Knee Immobilizers: When and How to Use Them
• Steroid Injections in the Emergency Department
• Managing Traumatic Knee Injuries

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

Interview with Dr. Ashley Wiseman

• Introduction of Dr. Wiseman: Emergency physician specializing in rural ER.
• Dr. Wiseman’s Background: Overview of her work and responsibilities in rural hospitals and academia.
• Experience in Rural Medicine: 
• Contrast with urban and academic practice.
• Stories of practical challenges and learning experiences in remote areas like Kotzebue, Alaska.

Practicing Skills in Rural Medicine

• Discussion of skill retention: Importance of continuously applying and practicing critical skills.
• Resources and Training: Role of fellowship, networking, and practical experiences for skill enhancement.

Advocacy for Rural Emergency Medicine

• Work with ACEP: Dr. Wiseman’s efforts in advocating for rural EM at the national level.
• Collaboration Between Rural and Academic Centers: Importance of knowledge exchange and mutual support.

Focus on Traumatic Intracranial Hemorrhage (ICH)

• Introduction to the February Article: Traumatic ICH in rural settings.
• Key Points from the Article:
• Importance of basic neurocritical care practices.
• Practical adjustments and simplified approaches in care.
• Dr. Wiseman’s Contribution: How her experiences shaped the content and practical advice for rural medicine.

Conclusion

• Upcoming Contributions: Announcing more contributions and resources from Dr. Wiseman.
• Access the In Rural Life (IRrL*) content here.
• Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

If you practice in a rural environment, you know that managing a patient with traumatic ICH can present challenges with diagnostic and treatment resources, personnel, training, and transport. Dr. Weisman has created resources for emergency clinicians, IRrL* (In Rural Life*) that EB Medicine is proud to share with subscribers.   

Resources for emergency clinicians managing patients with traumatic ICH in rural settings include: 

• Checklist for Managing Traumatic Intracranial Hemorrhage in Rural Life (IRrL): 7 steps to providing neurocritical care in resource-limited settings.
• Simulation for Critical Access Neurocritical Care: Saving Brain Hours from Tertiary Care: A customizable simulation designed for you and your team to practice managing patients with brain injury.

• Pathophysiology
• Types of Traumatic Brain Injuries
• Pre-Hospital Care
• Critical History and Physical Examination
• Neurological Assessment and Monitoring
• Laboratory and Imaging Studies
• Emergency Department Treatment
• Surgical Interventions and Considerations
• Patient DemographicsSummary of major points discussed
• Reminder for continued vigilance and the importance of early consultation

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net 

• Patient Demographics and Case Scenarios:
• Types of patients prone to alkali exposure
• Causes and scenarios leading to alkali exposure (e.g., accidental, intentional, social media challenges)
•  Poison control reports and statistics
• Types and Effects of Exposure: 
• Different types of exposure: ingestion, ocular, dermal
• Effects of ingestion, particularly in children and young adults
• Pre-hospital Care and First Response:
• Importance of decontamination
• Safety measures for EMS personnel
• Steps to take in pre-hospital care
• History and Physical Examination: 
• Key points to focus on during history taking
• Important signs and symptoms to check
• Laboratory and Diagnostic Testing: 
• Overview of useful lab tests and imaging
• Role of EKG and chest x-ray
• Importance of early consultation with poison control
• Endoscopy and CT Imaging: 
• Use of endoscopy to classify injuries and guide treatment
•  Role of CT imaging
•  Complementary use of endoscopy and CT
• Treatment Approaches:
• Initial resuscitation and airway management
• Use of steroids and other medications like antibiotics, H2 antagonists, and topical mitomycin C
• When and how to use NG tubes
• Special Populations and Long-term Considerations: 
• Special considerations for children
• Risks associated with laundry detergent pods
• Long-term complications, including strictures and increased risk of esophageal cancer
• Conclusion: 
• Summary of major points discussed
• Reminder for continued vigilance and the importance of early consultation

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

1. Discussion on EMIC

  - Overview of the collaborative

  - Background and formation during the pandemic in late 2021

2. Growth of EMIC

  - Expansion from three members to over 500

  - Focus areas: Education, mentorship, opportunity

3. Achievements of EMIC

  - Examples of innovations and initiatives born from EMIC

  - Pitch event at ACEP annual conference and other engagements

4. Importance of Physicians in Innovation

  - Internal and external factors

  - Benefits of physicians leading innovation efforts in healthcare

5. Opportunities for Collaboration

  - Engaging with healthcare startups and companies

  - Expanding collaborations and growing the network

6. EMIC Fellowship

  - Ideal candidates

  - Application process and benefits

  - Success stories and projects undertaken

7. Long-Term Vision for EMIC

  - Goals for future growth and expansion

  - Bridging gaps between industry and physicians for better patient care

8. Membership Details

  - How to join EMIC

  - Benefits of membership

For more about the EM Innovation Collaborative... https://www.eminnovationcollaborative.org/

• Introduction to Acute Mesenteric Ischemia
• Statistics on prevalence and mortality
• Pathophysiology and EtiologyMesenteric artery embolism
• Mesenteric artery thrombosis
• Mesenteric venous thrombosis
• Non-occlusive mesenteric ischemia
• Diagnosis
• Management and Treatment
• Special Populations
• Pediatric patients
• Pregnant patients
• Elderly patients

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net 

• Prevalence and Importance of Back Pain in the ED
• Differential Diagnosis and Serious Pathologies
• Patient Expectations and Management Strategies
• Missed Serious Pathologies and Their Implications
• Conflicting Evidence and Treatment Protocols
• Pathologies Causing Low Back Pain
• Mechanical and Infectious Causes
• Red Flags and Risk Factors
• Pre-Hospital Care and EMS Considerations
• History and Physical Examination
• Laboratory Testing and Inflammatory Markers
• Introduction to Imaging in Back Pain
• Common Findings in Imaging
• Choosing Wisely Campaign and Imaging Guidelines
• Patient Expectations and Imaging
• CT and MRI: When and Why
• Ultrasound in Back Pain Diagnosis
• Treatment Options for Back Pain
• NSAIDs and Other Pharmacologic Treatments
• Non-Pharmacologic Management
• Risk Management and Pitfalls

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

• 00:00 Welcome and Introduction
• 00:13 Free Subscription for Emergency Medicine Residents
• 01:05 Introduction to Pediatric Emergency Medicine Practice
• 01:37 Discussion on Acute Scrotal Pain
• 02:35 Testicular Torsion: Key Insights
• 09:50 Differential Diagnosis for Acute Scrotal Pain
• 17:21 Diagnostic Indicators of IgA Vasculitis
• 17:44 Pre-Hospital Care for Severe Pain
• 18:13 The Twist Score for Torsion
• 18:44 Emergency Department Evaluation
• 20:04 Ultrasound in Diagnosing Torsion
• 29:44 Operative Management and Other Conditions
• 31:41 Manual Detorsion Techniques
• 32:37 Risk Management and Key Takeaways
• 34:19 Conclusion and Final Thoughts

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net 

00:00 Introduction and Episode Overview

01:10 Meet Ryan Johnson: Clinical Pharmacist

02:06 Role of Clinical Pharmacists in Emergency Medicine

05:03 IV Fluid Shortage: Causes and Impact

05:56 Institutional Strategies to Mitigate IV Fluid Shortages

14:52 Provider-Level Solutions for Fluid Conservation

22:11 Pharmacy and Nursing Staff Roles in Fluid Management

26:34 Advanced Measures and Federal Guidelines

34:40 Conclusion and Final Thoughts

Resources mentioned in the podcast:

• (Brigham and Women's Protocol) Patiño, A. M., Marsh, R. H., Nilles, E. J., Baugh, C. W., Rouhani, S. A., & Kayden, S. (2018). Facing the shortage of IV fluids — a Hospital-Based Oral Rehydration strategy. New England Journal of Medicine, 378(16), 1475–1477. https://doi.org/10.1056/nejmp1801772
• Vizient shares conservation strategies for potential IV fluid supply disruption caused by Hurricane Helene https://newsroom.vizientinc.com/en-US/releases/releases-vizient-shares-conservation-strategies-for-potential-iv-fluid-supply-disruption-caused-by-hurricane-helene

00:00 Introduction to Dr. Julia Draper

01:03 Experiencing the Hurricane

03:19 Immediate Aftermath and Hospital Challenges

11:22 Dealing with Water and Supply Shortages

20:48 Community and External Support

24:10 Ongoing Efforts and Future Plans

27:51 Conclusion and Final Thoughts

• Understanding Maladaptive Perfectionism
• Case Example and Discussion
• Adaptive vs Maladaptive Perfectionism
• Personal Experiences and Legal Challenges
• Dealing with Negative Outcomes
• Strategies for Managing Perfectionism in the ED
• Handling Overwhelming Shifts
• Managing Expectations in the ED
• A Soul-Crushing Day in the ED
• Finding Meaning in Moments of Crisis
• The Importance of Meaningful Work
• Operationalizing Meaning in Your Shift
• The Driveway Debrief: Transitioning from Work to Home
• Preparing for the Next Shift
• Conclusion and Next Episode Teaser

For more from Rob Orman, MD check out Orman Physician Coaching

•  Introduction and Announcements
• Elder Abuse and Neglect: An Overview
• Risk Factors and Reporting
• Pre-Hospital and Emergency Department Considerations
• Screening Tools and Physical Examination
• Documentation and Disposition
• Cultural Considerations and Future Directions
• Conclusion and Resources

Suspected Elder Abuse should be reported to one of these organizations:

• ADULT PROTECTIVE SERVICES - Living at home
• LONG-TERM CARE OMBUDSMAN - Living in a long term care facility

• Meet Dr. Adam Goodcoff
• The Role of Physicians on Social Media
• Legal Considerations for Physicians on Social Media
• Employer Policies and Social Media
• Creating Engaging Content
• Balancing Professionalism and Personal Life on Social Media
• Navigating Negative Comments and Trolls
• Handling Low Engagement and Negative Feedback
• Becoming a Medfluencer: Tips and Strategies
• Connecting with Adam and Final Thoughts

Epidemiology

• Common Presentation of Sickle Cell Disease in the ED
• Screening and Diagnosis Differences
• Epidemiology: 200,000 ED Visits Annually, 85% for Pain

Pathophysiology

• Life Expectancy and Complications
• Vado-Occlusive Crises and Pathophysiology
• Sequestration Crisis in Sickle Cell Patients
• Acute Chest Syndrome and Priapism

Clinical Management

• Treatment Advocacy and Pain Management
• Patient History and Examination Importance
• Imaging Recommendations
• Laboratory Studies and Findings
• Emergency Department Care Protocols

Advanced Treatment Options

• Intravenous (IV) Fluids Guideline
• Management of Priapism
• Role of Exchange Transfusion
• Acute Chest Syndrome Details
• Approach in Rural and Critical Access Hospitals

Special Populations

• Pregnant Patients with Sickle Cell Disease
• Increased Risks and Complication Management

Overview of Dialysis Complications

• Key Dialysis ComplicationsCardiovascular Disease
• Congestive Heart Failure
• Pericarditis and Cardiac Tamponade
• Neurological Sequelae
• Gastrointestinal Complications
• Hypotension
• Dialysis Disequilibrium Syndrome
• Air Embolism and Chloramine Toxicity

Disaster Preparedness

• Vascular Access ComplicationsHemorrhage risks and treatment
• Thrombosis, stenosis, and aneurysms
• Infection risks and management

Pre-Hospital Care

• ED History Differential diagnosis
•  Key questions to ask dialysis patients
• Examination Physical Exam Tips

Treatments

• Risk Management PitfallsCommon Pitfalls to Avoid

Conclusion

Current State of Opioid Epidemic

• Overview of overdose deaths and trends.
• Data and statistics about opioid overdose mortality rates.
• Three Waves of Opioid Overdose Deaths in the U.S.

Opioid Classifications and Urine Drug Testing

• Types of opioids: synthetic, semi-synthetic, and natural.
• Urine drug testing limitations and false positives/negatives.
• Practical use and research on co-ingestions

Emergency Medical Services (EMS) and Pre-Hospital Care

• Importance of ABCs in acute opioid overdose cases.
• Naloxone usage trends and an empirical approach.
• Anecdotal insights on changing naloxone administration dosages.

Clinical Management in the Emergency Department

Buprenorphine Initiation

• Protocols for initiating buprenorphine in ED settings.
• Assessment using the Clinical Opiate Withdrawal Scale (COWS).
• Safe dosing procedures for buprenorphine.

Withdrawal and Overdose Care

• Laboratory testing recommendations.
• Capnography and VBG in overdose management.
• The role of end-tidal CO2 monitoring and respirations.

Methadone vs. Buprenorphine Considerations

• Methadone to buprenorphine transition protocols.
• Personal testimonials and clinical experiences in managing overdoses and withdrawal symptoms.

Patient Discharge and Follow-upPreparation of discharge prescriptions.

• Referral to addiction medicine clinics and resources.
• Educating patients on continued treatment and harm reduction.

• Understanding Career Cycles and Embracing Change
• The Importance of Career Reflection and Making Trades
• Navigating Career Satisfaction and Preventing Burnout
• Proactive Career Management and Reflection Strategies
• Exploring Career Alternatives and Rediscovering Joy in Medicine
• Balancing Work, Love, Play, and Health for a Satisfying Life
• When to Seek Coaching for Career Guidance
• Practical Tools for Self-Reflection and Taking Action
• Closing Thoughts and Resources for Emergency Physicians

• Diving Into Ketamine Use in Emergency Medicine
• Understanding Ketamine: From Origins to Emergency Use
• Exploring the Ketamine Brain Continuum
• Ketamine Dosing and Administration Techniques
• Combining Ketamine with Neuroleptic Medications
• Practical Approaches to Ketamine for Pain Management
• Innovative Pain Management and Ketamine Use
• Procedural Sedation with Ketamine: Techniques and Considerations
• Addressing Agitation and Sedation in Emergency Situations
• Navigating Intubation Strategies: DSI and Ketamine-Only Approaches
• Ketamine's Role in Treating Asthma, Status Epilepticus, and Alcohol Withdrawal
• Exploring Ketamine for Treatment-Resistant Depression
• Concluding Remarks on Ketamine's Versatility in Emergency Medicine

• Introduction
• Understanding Suicidal Ideation and Self Harm in Youths
• Screening Tools and Approaches
• Ask Suicide-Screening Questions (ASQ) Toolkit
• Columbia Suicide Severity Rating Scale (C-SSRS)
• Prehospital Care
• Managing Patients in the ED
• Dealing with Challenging Populations
• Lethal Means Counseling
• Emerging Tools in Suicide Risk Identification
• Suicide Risk Screening Pathway
• Disposition and Referrals
• National 988 Suicide & Crisis Lifeline 

• Introduction
• The Evolution of BRUE
• Understanding BRUE Guidelines
• The Importance of Pre-Hospital Care in BRUE Cases
• Investigating the Event: Questions to Ask
• Medical and Family History: Key Factors
• Environmental and Social Considerations
• Definitions and Risk Assessment
• Physical Examination
• Risk Stratification: Low Risk vs. High Risk Patients
• Management: What to Do and What Not to Do
• High Risk Population: Studies and Recommendations
• The Importance of Communication and Decision Making
• 5 Things That Will Change Your Practice

Prevalence and Impact

Understanding the Causes

Medications That Can Cause Constipation

Dealing with Fecal Impaction

Understanding Stercoral Colitis

Pre-Hospital Care

ED History and Physical Exam

Diagnostic Studies and Imaging

• X-Ray
• CT Scans
• Advanced Testing

Treatment Options for Constipation

• Enemas
• Osmotic Laxatives and Stool Softeners

Special Considerations: Pregnant, Pediatric, and Hospice Patients

Prescription Medications for Constipation

Clinical Pathway for Constipation Management

Guideline Changes

Pathophysiology

Etiology and Definitions

Prehospital Care

ED History and Physical

• Diagnostic StudiesAge 0-21 Days
• Age 22-28 Days
• Age 29-60 Days

Lumbar Puncture

Viral Testing

Urinalysis

Shared Decision Making

Disposition

• Pathophysiology
• Presenting Symptoms
• Differential Diagnosis
• Specific Acute Causes
• PE
• Sepsis
• RVMI
• PPV
• ARDS
• COVID-19
• Specific Chronic Causes
• CTEPH
• Left Heart Failure
• Congenital Heart Disease
• LVAD
• Lung Disease Group 3 Pulmonary Hypertension
• Pulmonary Arterial Hypertension
• Prehospital Care
• ED history and Physical
• Biomarkers
• ECG (table 5)
• Imaging
• Echo
• CT
• MRI
• Treatment
• Revascularization
• Respiratory Support
• Vasopressors and Inotropes



• Epidemiology
• Evidence
• Causes
• Risk Factors
• Differential Diagnosis
• Prehospital Care
• ED History and Physical Exam
• Labs
• Imaging
• ED BP Management
• Specific Ischemic Stroke Therapies
• Specific Hemorrhagic Stroke Therapies

Epidemiology and Nomenclature

Prehospital Care

ED History and Physical Exam

• Infants Age <2 Months
• Children Age 2 Months to 2 Years
• Children >2 Years
• Adolescents

Urinalysis

• Clean Catch Protocol
• Catheterization
• Suprapubic Aspiration

Blood Cultures and CSF

Biomarkers (CRP and ESR)

Treatment

Distinguishing Viral vs Bacterial Pneumonia

Imaging

Antibiotic Treatment

Vaccination

Steroids

Atypical Presentations

Check out the clinical pathways at https://www.ebmedicine.net/pathways

Epidemiology

Prehospital Care

ED History and Physical Exam

Diagnostic Studies

• Labs
• EKG
• Imaging
• Urine Toxicology Testing

Treatment

• Hemodialysis
• Activated Charcoal
• Whole Bowel Irrigation
• Gastric Lavage
• Ipecac

Drug Specific Therapies

• Acetaminophen
• Alcohols
• Anticholinergics
• Beta Blockers
• Calcium Channel Blockers
• Cholinergic Agents
• Digoxin
• Iron
• Opioids
• Salicylates
• Sedative Hypnotics
• Sulfonylureas
• Laundry Pods

Check out the clinical pathways at https://www.ebmedicine.net/pathways

Epidemiology

Differential diagnosis

Prehospital care

ED history and physical exam

Diagnostic studies

• Point of care testing
• Labs
• Imaging

Treatment

• IV fluids, the 2-bag system
• Mild DKA
• Moderate to severe DKA
• Potassium and phosphate supplementation
• Magnesium and calcium
• Sodium bicarbonate
• Hypoglycemia
• HHS
• Monitoring

Complications

• Cerebral edema
• Intubation

Insulin pumps

Disposition

Summary

Highlights

• EBUC - Management of Acute Asthma Exacerbations in Urgent Care
• EMP - Evidence-Based Emergency Department Management of Methamphetamine Toxicity
• PEMP - Trauma Extra - Blunt Thoracic Injuries (coming Nov. 15th)

Check out the clinical pathways at https://www.ebmedicine.net/pathways

Substance Use In Adolescents

Epidemiology

Risk Factors

Differential Diagnosis

Prehospital Care

ED History and Physical Exam

Urine Drug Screen

Treatment

• Marijuana
• Alcohol
• Methaphetamines
• MDMA
• Cocaine
• Opioids

Disposition

Migraine and Other Primary Headaches

Epidemiology

Cluster Headaches

Medication Overuse Headache

Nerve Blocks

• Greater Occipital
• Sphenopalatine Ganglion

Pregnant Patients

Disposition

Check out the clinical pathway at https://clinicalpathways.ebmedicine.net

Etiology/pathophysiology

Risk factors

Differential diagnosis

Prehospital care

ED history and physical exam

Diagnostic studies

• Laboratory testing
• Imaging studies

Treatment

• Transfusion
• Coagulation reversal
• Embolization

Special Populations

• Pediatrics
• Pregnant patients
• Elderly patients

Scoring systems

Disposition

Check out the clinical pathway at https://clinicalpathways.ebmedicine.net

Etiology/pathophysiology

Risk factors

Differential diagnosis

Prehospital care

ED history and physical exam

Diagnostic scoring systems

Pregnant patients 

Diagnostic studies

• ECG
• D-Dimer
• Troponin & BNP
• Chest x-ray
• CT 
• V/Q scans
• MRI
• US

Treatment

• IV fluids
• Anticoagulation
• Vasopressors
• Thrombolytics
• Thrombectomy
• ECMO

Disposition

Check out the clinical pathway at https://clinicalpathways.ebmedicine.net

Epidemiology

Nomenclature

Etiology

Differential diagnosis

Prehospital care

ED history and physical

Diagnostics

• ECG
• Labs
• Imaging (X-ray, CT, US, MRI)

Treatment 

Special populations

• COVID-19
• Athletes
• MIS-C

Epidemiology

Etiology

Differential diagnosis

Prehospital care

History and physical 

Diagnostics

Treatment

• Acute decompensated heart failure
• Acute ischemic stroke
• Acute coronary syndrome
• Intracerebral hemorrhage
• Subarachnoid hemorrhage
• Aortic dissection
• Hypertensive encephalopathy
• Severe pre-eclampsia and eclampsia

Controversies

• Arterial line placement
• Beta blockers and cocaine

Risk management caveats

Summary

Epidemiology

Etiology - types of ingestions

Anatomy - common locations by age

• Food impaction
• Sharp objects
• Button batteries
• Magnets
• Colorectal foreign bodies

Prehospital care

History and Physical

Imaging

Expectant management

Endoscopic removal

Non-endoscopic techniques

Body Packing

Glucagon

Gastric button batteries

Summary



• Personal foundation 
• Regular check-ins
• Becoming an expert in… 
• Job stress
• Living beneath your means
• Recharging and shift work
• Bad outcomes
• Physician lounge
• Learning to say no
• Set a reminder

More at Orman Physician Coaching 

The interactive Clinical Pathways have launched and they are available for free! 

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the March 2023 Emergency Medicine Practice article on Emergency Department Management of Infective Endocarditis-Associated Stroke

Epidemiology

Pathophysiology

Populations at Risk

Complications

• Intracranial hemorrhage
• Aneurysms
• Heart block

Prehospital Care

ED History and Examination

Imaging

Antibiotic Therapy

Surgical Treatment

Special Populations

Summary

The interactive Clinical Pathways have launched and they are available for free! 

—

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the February 2023 Pediatric Emergency Medicine Practice article on Pediatric Electrolyte Emergencies: Recognition and Management in the Emergency Department

—

History

Point-of-care testing

I/O lines

Presentation, differential, and treatment of:

• Hyponatremia
• Hypernatremia
• Hypokalemia
• Hyperkalemia
• Hypocalcemia
• Hypercalcemia
• Hypomagnesemia
• Hypophosphatemia

The interactive Clinical Pathways have launched and they are available for free! 

___

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2023 Pediatric Emergency Medicine Practice article on the Responsible and Safe Use of Opioids in Children and Adolescents in the Emergency Department

DEA-X Waiver Repeal:

• The Mainstreaming Addiction Act
• The Medication Access and Training Expansion Act (MATE)
• FOAMed post

Opioids in Children and Adolescents: 

Introduction

• Epidemiology and Statistics 

Medication safety at home

Escalation of pain meds at home

Naloxone prescriptions

Medications in children

• Codeine
• Tramadol
• NSAIDs
• Local anesthetics and nerve blocks
• Intranasal meds: Ketamine and fentanyl

Opioids and sedation

Regional anesthesia

Chronic pain

The interactive Clinical Pathways have launched and they are available for free! 

—

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2022 Emergency Medicine Practice article on the Management of Allergic Reactions and Anaphylaxis in the Emergency Department. 

Intro

• The number of ED visits and hospitalizations
• Studies show up to 57% of anaphylactic reactions are not recognized, and epinephrine is not administered in up to 80% of cases. 

Criteria

• 2006 Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN)
• WAO revised the criteria in 2020 
• Delphi group and Brown et al

Pathophysiology

Epidemiology

• Most common causes in children and adults
• More than half of deaths from anaphylaxis occur within the first hour of symptom onset

Prehospital Care

• Give epi, H1 blockers
• Mainstay = recognition

ED Care

• Airway
• Epinephrine
• Decontamination
• H1 and H2 blockers
• Corticosteroids
• Biphasic reactions
• Glucagon

Special Cases

• Alpha-gal
• Scombroid
• Kounis syndrome

1) The interactive Clinical Pathways have launched and they are available for free! 

2) 2023 E/M coding guidelines are in effect. See the summary here. 

___

In this episode, Sam Ashoo, MD, interviews Ara Festekjian, MD, one of the authors of the November 2022 Pediatric Emergency Medicine Practice article on Pediatric Septic Shock in the Emergency Department

Introduction: How common is sepsis in kids and what is the mortality rate in the US?

Definitions

• Septic shock
• Sepsis associated organ dysfunction
• Sepsis-3
• Compensated vs uncompensated shock

Etiology

• Neonate
• Central line and VP shunts
• Asplenia
• Immunocompromised children

Differential Diagnosis

Prehospital Care

ED Evaluation

• History
• Examination
• Septic shock + cardiogenic shock
• Warm vs cold shock
• Evolution of physical exam findings

Diagnostics

• Labs
• Imaging

Treatment

• IV/IO placement
• Fluid boluses
• Antibiotics 
• Pressors 
• Airway management 

Special Populations

• Febrile neutropenia
• Newborns with septic shock

Controversies

• Fluid volume
• Fluid type
• Antibiotic timing
• Corticosteroids

Epidemiology

• Historical data
• Since COVID, tracking "influenza-like illness" has been complicated
• Influenza deaths and age
• Annual mortality 

Outbreaks

Transmission

Classification

• Influenza A, B, and C
• Hemagglutinin and neuraminidase subgroups
• Antigenic drift and shift

Pathophysiology

• Transmission
• Incubation 
• Secondary infection
• H3N2

Vaccines

• Egg-based, cell-based, and recombinant influenza vaccines
• CDC recommendations
• Patients aged >65 years

Differential Diagnosis

Complications

Testing

• When is it indicated? 
• What types of tests are available? 
• Testing in periods of low and high prevalence

Treatment

• High-risk conditions that suggest treatment 
• Antiviral medications 
• Oseltamivir: NNT and NNH
• Resistance patterns

Billing and Coding

Pathophysiology: Non-pitting edema of respiratory or GI tract

• Histamine meditated, bradykinin mediated, or idiopathic
• Acquired, inherited, or idiopathic
• Do they present differently? (Urticaria, speed of onset)

Histamine Mediated

• Most common form: 40%-70%
• Can be triggered by NSAIDs
• Can be induced by physical mechanism like cold, vibration
• Is rash a reliable method of distinguishing the types?

Bradykinin Mediated

• May progress slowly
• Can be inherited or acquired
• Common triggers include ACE inhibitors and TPA

Table 1 Differential Diagnosis

Prehospital Care

• Protect airway
• Epi, steroids, antihistamines
• Avoid CPAP

ED History

• Figure 2: Distinguishing characteristics of histamine vs bradykinin mediated

ED Exam

• Importance of repetitive exams
• Airway examination
• Laryngoscopy?

Diagnostics

• Figure 6: Flow diagram of ED workup
• Labs
• Imaging

Treatment

• Airway: Intubation
• Medication

Special Populations

• Pediatric
• Pregnant/lactating patients

Controversies

• TXA

Disposition

Why ocular injuries? Why did you pick this topic?

What kind of injuries are included and at what age are they most common?

Injury zones and terminology

Differential Diagnosis

• What should we keep in mind when we are confronted with an ocular injury? (Table 3)

Prehospital Care

• What do our EMS colleagues need to keep in mind when transporting a child with an ocular injury?
• How can they help us in the ED?

ED Evaluation

• History: What's important to know?
• Physical: Visual acuity and eye exam
• Diagnostics: Slit lamp, ocular pressure, US, CT, MRI

Treatment

• Lid lacerations: Who repairs and when?
• Orbital fractures: What should we be looking for? Why is it different in children? When does repair typically occur?
• Corneal abrasions
• Corneal foreign body
• Chemical injuries: Irrigate with what and for how long?
• Traumatic hyphema: Treatment, disposition
• Traumatic iritis: Treatment, outcome
• Open globe injuries
• Retrobulbar hematoma - First 10 EM

Special Populations

• Hemophilia, Von Willebrand disease
• Sickle cell and trait
• Neonates and infants
• Contact lenses

Controversies and Cutting Edge

• Ketamine
• Tetanus
• NSAIDs, topical?
• Topical anesthetics
• Visual acuity apps

• Career Disillusionment: What is it? How do we combat it? Should we combat it? 
• A frog in boiling water... 
• Burnout
• Two questions to ask yourself
• How coaching can help
• The advice trap
• A framework to explore your career and life goals

More at Orman Physician Coaching. 

Episode Outline:

How common are pediatric firearm injuries? 

What is the most common location of these injuries? 

Is there much literature published on this topic?

Epidemiology 

• What’s been the trend in pediatric firearm injuries over the past 10 years? 
• Do we have any idea how/why these are occurring (ie, accidental, intentional, etc)

Terminology: For those unfamiliar with firearms (table 1)

Ballistics: Mechanisms of damage. 

Pre-hospital care

• Trauma center transport
• Prehospital hemorrhage control -- Combat application tourniquet, anything else? 

ED Evaluation

• SIPA -- What is it and why use it? 
• Primary survey -- Tachycardia -> delayed cap refill -> hypotension in children? 
• Secondary Survey
• Diagnostic Studies: 
• Damage Control Resuscitation
• Wound Care -- Do we remove projectiles? Can they stay in? 
• Antibiotics 
• Joint Involvement
• Compartment Syndrome -- 3 As vs 6 Ps
• Rhabdomyolysis

Controversies

• CTA for all injuries? 
• Hemostatic devices -- Any role for these in the ED? 

EM/Critical care practice - what’s that like? 

EM Coach - what is it? 

Artificial Intelligence -

• What is it and how does EM Coach use it? 
• The algorithm
• How did you create it? 
• What does it do? 
• The evidence behind it

How and where to access EM Coach

Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department 

EMplify - Sept 2022

Episode Outline:

Differential Diagnosis

• What is the differential diagnosis for this scenario in the ED?
• Are these diagnoses mutually exclusive ?

EMS/Prehospital Care

• What role do EMS providers play in the recognition of trafficking?

ED Evaluation

• What are common presentations/complaints that may represent trafficking?
• Examination: Privacy, use of a separate room, how do we accomplish this with minors?
• Ground rules: What does this mean? How do you state this in your practice? Do you find this dissuades patients form reporting?
• Technology: What if they are on the phone?
• History - HEADS-ED
• Physical examination - Findings that lead to suspicion, documentation best practices.

Diagnostic Studies

• Imaging: Any role for this?
• Lab testing: STI, anything else?
• Screening tools: Trauma-informed care, PEARR tool
• Local laws differ by state. How do we handle this with patients? Does it dissuade reporting?
• "Rescuing mentality" and what that means in the ED

Treatment 

• Medical
• Beyond medicines: Local services, national hotline

Special Populations

Diagnosis: What to chart? 

National Human Trafficking Hotline 

https://humantraffickinghotline.org/

Topics include:

• What is the International Medical Corps (IMC) and what does it do?
• What has IMC been doing in the U.S.?
• What is involved in disaster response?
• What has IMC been doing in Ukraine?
• What are the conditions like in Ukraine now?
• How does bombing of civilian areas affect Ukraine and the IMC projects?
• How can we support IMC efforts?
• How can we volunteer with the IMC?
• How does IMC balance long-term efforts and short-term relief to prevent harm to communities?
• How has the war in Ukraine effected surrounding areas?
• What has been most frustrating and most rewarding for you in your work with IMC?
• How did you start your career in disaster medicine and how would someone interested in it follow your footsteps?

Links

IMC Website

IMC Jobs

Roster Positions

Roster position - MD

Roster position - Nurse 

Roster position - Nurse Practitioner 

Roster position - Midwife 

Disaster Medicine

The Nuts & Bolts of Global EM, free e-book

Managing Acute Cardiac Valvular Emergencies in the Emergency Department

EMplify - August 2022

Episode Outline:

Why Valvular disease? 

• How common is it? 
• How often do we see it in the ED? 
• Which valves are we talking about? 

Aortic Valve Disease

• Types and causes

Mitral Valve Disease

• Types and causes

Tricuspid and Pulmonic Disease

Differential Diagnosis

• acute coronary syndromes (ACS)
• pulmonary embolism
• tamponade
• chronic obstructive pulmonary disease (COPD)
• pneumonia
• pneumothorax

Prehospital Care

• Evaluation of chest pain
• History
• Shock 

ED Evaluation

History

• Aortic Stenosis
• Aortic Regurgitation
• Mitral Stenosis
• Mitral Regurgitation

Physical exam findings 

Diagnostic Testing 

• Labs
• ECG
• CXR
• Bedside US
• Formal ECHO

Treatment

Special Populations

• Prosthetic valves
• Pregnant patients

See Episode Page

COVID-19

• Public health emergency extended
• Cases increasing
• Medications and Vaccinations available
• Pharmacists prescribing COVID medications
• CDC COVID Therapeutics website
• HHS COVID Therapeutics Locator

Monkeypox

• Cases increasing
• Vaccination
• Testing
• FOAMED post on Diagnosis and Treatment
• PPE
• Science Direct article on Monkeypox 3I Tool

Medication Shortages

• Benzodiazepines
• FOAMED post on benzodiazepine equivalence
• American Society of Health System Pharmacists (ASHP)

988 Crisis Line

Baby Formula Shortage

Topics discussed include:

• Which vaccines are currently approved by the FDA and recommended by the CDC.
• The difference between the MEN ACWY vaccine and the meningococcal B vaccine.
• What the current recommendations are for those exposed.
• Challenges for healthcare providers treating patients who have been exposed or have symptoms.

Further reading:

Hogan AN, Brockman II CR, Santa Maria A. Emergency department management of adults with infectious meningitis and encephalitis. Emerg Med Pract. 2022 Apr;24(4):1-24. Epub 2022 Apr 2. PMID: 35315604.

CDC Meningococcal Disease and Vaccination.

As always, we value your feedback. Please take our listener survey.

See the episode page for more details.

Topics discussed include: 

• Which troponin assay are you currently using and what are its limits of detection? 
• Do delta troponin results only count if they increase? 
• If the test result is indeterminate, then what? repeat in 1 hr (European standard), repeat in 3 hours (depending on chest pain onset), or just admit if the HEAR(T) score is high? 
• What does one negative troponin on presentation mean? No death in 30 days to 1 year but still missed MI?
• And more... 

• Anand A, et al; HiSTORIC Investigators†. High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial. Circulation. 2021 Jun 8;143(23):2214-2224. doi: 10.1161/CIRCULATIONAHA.120.052380. Epub 2021 Mar 23. PMID: 33752439; PMCID: PMC8177493.
• Chapman AR, et al. Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary Syndrome. JAMA. 2017 Nov 21;318(19):1913-1924. doi: 10.1001/jama.2017.17488. Erratum in: JAMA. 2018 Mar 20;319(11):1168. Soerensen NA [corrected to Sorensen NA]. PMID: 29127948; PMCID: PMC5710293.
• Chenevier-Gobeaux C, et al. Multi-centre evaluation of recent troponin assays for the diagnosis of NSTEMI. Pract Lab Med. 2018 Feb 26;11:23-32. doi: 10.1016/j.plabm.2018.02.003. PMID: 30014015; PMCID: PMC6045566.
• Chiang CH, Chiang CH, Lee GH, Qian F, Chen SC, Lee CC. Time to Implement the European Society of Cardiology 0/1-Hour Algorithm. Ann Emerg Med. 2020 Nov;76(5):690-692. doi: 10.1016/j.annemergmed.2020.05.038. PMID: 33097132; PMCID: PMC7575504.
• McCarthy CP, Januzzi JL Jr. Increasingly Sensitive Troponin Assays: Is Perfect the Enemy of Good? J Am Heart Assoc. 2020 Dec;9(23):e019678. doi: 10.1161/JAHA.120.019678. Epub 2020 Nov 26. PMID: 33238785; PMCID: PMC7763764.
• Neumann JT, et al. Application of High-Sensitivity Troponin in Suspected Myocardial Infarction. N Engl J Med. 2019 Jun 27;380(26):2529-2540. doi: 10.1056/NEJMoa1803377. PMID: 31242362.
• Miller J, Cook B, Singh-Kucukarslan G, Tang A, Danagoulian S, Heath G, Khalifa Z, Levy P, Mahler SA, Mills N, McCord J. RACE-IT - Rapid Acute Coronary Syndrome Exclusion using the Beckman Coulter Access high-sensitivity cardiac troponin I: A stepped-wedge cluster randomized trial. Contemp Clin Trials Commun. 2021 Apr 23;22:100773. doi: 10.1016/j.conctc.2021.100773. PMID: 34013092; PMCID: PMC8114080.

What is cognitive reframing you ask? It is a tool for dealing with a particularly difficult event. In our case, we discuss the “near miss” medical case and how it impacted a physician. Then we discuss how the use of cognitive reframing can help improve our perception of these “near miss” events in medicine. We also discuss what this tool can do for our longevity in medicine, regardless of our career choices. So take a listen. You may be surprised how this tool can be used in all aspects of your life.

Rob Orman refers to a videos he created for a client for the post-shift power-down. You can find it and other helpful videos on his YouTube channel.

Also, if you would like to learn more about Dr Rob Orman’s coaching services, visit his home page .

As always, we value your feedback. Please take our listener survey.

See the episode page for more details.

Procedural Sedation and Analgesia in the Emergency Department

EMplify – June 2022

Episode Outline:

1.Procedural sedation and analgesia (PSA): terminology

2.Levels of sedation

• Minimal
• Moderate
• Deep
• General anesthesia

3.Prehospital care

4.ED care: patient assessment

• ASA class system
• Complications
• Equipment needed (Table 1)
• Larson maneuver (Figure 2)

5.Procedural technique

• Current ACEP and AAP recommendations
• Data for 1- or 2-physician sedation

6.Preprocedural fasting

• Do we even need to consider this in PSA?

7.Capnography

8.Oxygen supplementation

9.Preprocedural opioids

10.Preprocedural sedatives

11.Anticholinergics

12.Antiemetics

13.Treatment (Table 2)

• Fentanyl
• Remifentanil
• Midazolam
• Nitrous oxide
• Propofol
• Ketamine
• Ketofol
• Etomidate

14.Reversal agents

• Naloxone
• Flumazenil

15.Special populations

• Pediatrics
• Pregnancy
• Geriatrics

16.Cutting edge

• Dexmedetomidine

You can read more about Med Global and their efforts in Ukraine, on their home page:

https://medglobal.org/ukraine/

We would love to have your feedback. Please take the listener survey:

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Thanks for being a listener.

• Caused by double stranded DNA virus, genus orthopoxvirus, closely related to smallpox and cowpox.
• Discovered in 1958 in monkeys with first human case recorded in 1970 in the Democratic Republic of Congo. (CDC) 
• It is a zoonotic disease , meaning it is transmitted from animal to humans, with primary reservoir in squirrels, Gambian poached rats, dormice, different species of monkeys and others. 
• First reported in the U.S. in 2003. Cases were related to pet prairie dogs that had been housed with monkeypox virus infected African rodents, imported from Ghana (WHO)
• There are 2 clades (having evolved from same ancestral line) of the disease. The current outbreak is from the West African lineage. (WHO)
• West African – milder disease, 1-3% fatality
• Congo Basin – severe disease, 10% fatality 
• Due to the similarity in the viruses, immunization against smallpox has been found to prevent infection with monkeypox. The WHO believes that increasing frequency of worldwide infection may be related to waning immunity against smallpox, since that disease was eradicated in 1980 and the vaccine is no longer popularly used. 

Transmission

• Animal to human – contact with sick or dead animals, ingesting poorly cooked meat of infected animals.
• Human to human -” Human-to-human transmission is thought to occur primarily through large respiratory droplets. Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required. Other human-to-human methods of transmission include direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens.” (CDC)

Symptoms

• Initial 1-3 days – fever, lymphadenopathy, back pain, headache, myalgias, fatigue
• 2-4 weeks of rash progression: macules -> papules -> vesicles -> pustules -> scabs
• The pox rash starts on the face and spreads to the rest of the body.

Testing

• Detection is by PCR testing, ideally of body fluid contained in the pox blisters.
• Test kits are available through local U.S. Health Departments and the CDC. All suspected cases should be reported to local authorities.

Treatment

• Treatment includes vaccinating anyone who has been exposed with the smallpox vaccine (ring vaccination). The general population is no longer routinely vaccinated due to side-effects of the smallpox vaccine.
• No current recommendation exists for antiviral therapy or smallpox immunoglobulin therapy.  
• See CDC recommendations 

Prevention

• The JYNNEOS vaccine was FDA approved in 2019 for adults > 18 against both smallpox and monkeypox. It is a 2 dose non-replicating attenuated virus that does not produce a lesion, and therefore can not cause transmission to others. The CDC Advisory Committee on Immunization Practices is currently evaluating vaccine data with a formal recommendation pending. Media reports note the U.S. government has ordered millions of doses. 
• The original smallpox vaccine (DRYVAX) is no longer in production. However, a second generation clone, ACAM2000, is produced by Synofi and approved by the FDA. The WHO notes that smallpox vaccine is 85% effective in preventing monkeypox.
• Vaccination is recommended for lab workers and anyone exposed to monkeypox. The CDC recommends vaccination within 4 days of exposure to prevent disease, with ACAM2000. However, vaccination between days 4-14 is also recommended to reduce disease severity. 
• Vaccination does carry risks. The CDC estimates “Based on past experience, it is estimated that between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening complications from the vaccine” (ACAM2000) but notes that disease fatally is 1-10% outweighing the risk of vaccination. 

Further Reading

• Current WHO Outbreak Tracker
• CDC Monkeypox Reference
• Johns Hopkins Monkeypox Reference

This episode is a conversation between Dr. T.R. Eckler and Dr. Sam Ashoo about airway management and how it has changed in their practice over the last decade. This podcast makes reference to the EB Medicine course – Current Topics in Airway Management: Mechanical Ventilation, Supraglottic Airway Devices, and Intubating Patients With COVID-19, which can be found here:

https://www.ebmedicine.net/airway-training

We would love to have your feedback. Please take the listener survey:

https://www.surveymonkey.com/r/ZQRWQFW

Thanks for being a listener.

Episode 69 – Emergency Department Management of Cellulitis and Other Skin and Soft-Tissue Infections (https://www.ebmedicine.net/topics/infectious-disease/emergency-medicine-skin)

EMplify – May 2022

Episode Outline:

1. Why cellulitis/skin infections?

2. Terminology

• Erysipelas vs cellulitis vs fasciitis
• Purulent cellulitis

3. Most common pathogens

4. Special situations

5. Necrotizing infection classification system – is this helpful in the ED, and if so, why?

6. Differential – unilateral vs bilateral presentation

7. Prehospital care

8. ED evaluation

• History – what should we be asking?
• Examination: SSTI vs NSTI

9. Diagnostics

• POCUS: “cobblestoning” and fluid collection
• Xray: subcutaneous gas
• CT: when is this helpful?

10. Labs

• Blood cultures – if given the option, are they helpful? 
• Wound cultures – any role for these? 
• Routine labs (CBC, BMP, etc) – are they helpful? 
• LRINEC score – what is it and should we be using it? 

11. Treatment 

• NSTI antibiotics 
•  Abscesses 

12. Special populations 

• IV drug users 
• Diabetic patients 
• Immunocompromised patients 

13. Wound irrigation and loop drainage 

14. Disposition 

Take the listener survey:

https://www.surveymonkey.com/r/ZQRWQFW

More on the Dr Lorna Green Legislation here:

https://www.ebmedicine.net/ebmblog/general-emergency-medicine/news-updates/dr-lorna-breen-health-care-provider-protection-act/

EMplify -- April 2022

Interview with the Author: Andrew N. Hogan, MD

1.Meningitis vs encephalitis

• Why this topic?
• What do the words mean? What's the difference?

2.Bacterial meningitis

• How common is it in the US? Is it more common in third world countries?
• Mortality rate in the US
• Causes – if Neisseria and H influenzae improved post vaccination, why not S pneumoniae disease ? (Table 1)

3.Viral meningitis

• How common is it in the US?
• What are the common causes? (Table 2)

4.Viral encephalitis

• Same prognosis as viral meningitis?
• Same organisms as viral meningitis? (Table 2)
• Does COVID-19 cause this illness?

5.Fungal infections

• Who gets these?
• 60% die? 1 million cases a year, 600K deaths?

6.Prehospital care:

• What does EMS need to know?
• How do they protect themselves from being exposed?
• How can they help us make the diagnosis?
• EMS is giving antibiotics in some areas?
• PEP

7.ED evaluation: History

8.ED evaluation: Physical exam

9.Diagnostics: CSF

• What's large volume? Is it safe?
• Cell counts on tubes 1+4, all the time or only if traumatic and obviously bloody?
• Is opening pressure helpful?
• CSF lactate level – can this be run in a normal lactic acid analyzer?
• PCR/NAAT testing

10.Serum labs

• What is helpful?
• Serum PCR
• Serum cryptococcal antigen

11.Imaging 

• Is CT imaging before LP still necessary? Can we be selective?
• Is MRI helpful in the ED, or is there a role in encephalitis?

12.Treatment

• Antibiotics
• Steroids: Who gets them? When? Are there downsides of giving them?

13.Special populations

• Autoimmune disease
• Lacking childhood vaccines
• Healthcare associated infections

14.Cutting edge

15.Disposition

EMplify – March 2022

Interview with the Authors: Nicole Yuzuk, DO, Joseph Bove, DO, and Riddhi Desai, DO

Episode Outline:

1.Why is this an important topic in EM? 

2.Hemorrhage etiologies and definition

3.Headache etiologies, both common and the more dangerous (ICH)

4.Fever and infection

• Mastitis
• Endometritis

5.Preeclampsia/eclampsia 

• Definition, diagnosis, risk factors (Table 1)

6.HELLP syndrome

• Definition, diagnosis (Table 2)

7.Peripartum cardiomyopathy

• Time of onset, how to make the diagnosis, risks (Table 3)

8.Prehospital care

• IV fluids
• TXA
• AMS evaluation
• Chest pain
• Fever/hypotension 

9.ED evaluation 

• History (what kind of things should we remember to ask?) 
• Physical exam (what should we be paying attention to?) 

10.Diagnostic studies

• Hemorrhage (exam, vitals, labs, US)
• Headache (labs, imaging – what type?)
• Fever and infection (labs, imaging – US or CT, antibiotics)
• Cardiopulmonary complaints (labs, imaging, ECG)

11.Treatment

• Hemorrhage 
• Headache (CVT)
• Infection (mastitis, endometritis, wound Infection)
• Preeclampsia, eclampsia, HELLP, seizures
• Cardiomyopathy

12.What about breastfeeding mothers? 

13.Controversies and cutting edge

• Endovascular therapy
• Thromboelastography

EMplify – February 2022

Emergency Department Management of Acute Asthma Exacerbations

Interview with the authors: Steven M. Hochman, MD, and Brandon Somwaru, DO

Episode Outline:

• Epidemiology
• Risk factors for death from asthma (Table 1)
• Triggers for asthma attacks
• Variants of asthma (Table 2)
• Differential diagnosis (Table 3)
• Can PE be a trigger for an acute asthma attack? 
• Prehospital care
• ED care: history (what should we ask?)
• ED care: physical exam (what are we looking for?)
• Classifying mild/moderate/severe asthma 
• Lab studies
• POCUS (Table 5 and Figure 3)
• Peak expiratory flow
• ETCO2 capnography and capnometry
• Chest x-ray
• Treatment (Table 6)
• Medications
• Oxygen
• SABA vs LABA
• What about MDIs?
• Continuous nebs?
• Anticholinergics
• Steroids (IV, oral, inhaled; prednisone vs dexamethasone)
• Magnesium sulfate
• Epinephrine
• Terbutaline
• Ketamine
• NIPPV
• Intubation pearls and pitfalls (Table 8)
• Special populations
• Pediatrics 
• Pregnancy
• COVID-19 
• Controversies and cutting edge
• Biologics
• Fractional exhaled nitric oxide
• Heliox 
• High flow nasal cannula
• Delayed sequence intubation
• ECMO
• Disposition

• Why joint pain ?
• Differential Diagnosis 
• Mono vs Poly Articular Presentation? Figure 1
• Infectious, degenerative, autoimmune, crystal deposition, reactive, traumatic
• Septic Arthritis-
• Bimodal incidence 
• Risks
• Septic arthritis is polyarticular in 15% to 20% of cases, and in these cases, the mortality is high
• Gonococcal 
• Highest risk
• Commonly affected joints
• Symptomatic or asymptomatic infection 
• Lyme Arthritis
• Viral – Zika, chikungunya, human parvovirus B19, hepatitis
• Degenerative osteoarthritis 
• Autoimmune
• Gout
• CPPD
• Prehospital 
• ED History – table 2, table 4
• ED exam 
• Labs – do we need them? 
• Imaging
• Arthrocentesis – Table 5
• Treatment
• Special Populations
• Prostheses 
• Immunocompromised 
• HIV
• Clinical Pathway

Announcements:

• The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,
• This month get a $50 Amazon Gift Card with all orders over $300 at https://www.ebmedicine.net
• Check out the newly redesigned FOAMed blog at https://www.ebmedicine.net/ebmblog/

Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management

Interview with author: Anthony Hackett, MD

Thoracic Aortic Syndromes

• Dissection, Intramural Hematoma, and Penetrating Aortic Ulcers
• Pathophysiology
• Intima, media, and adventitia
• Epidemiology and classification 
• Debakey vs Stanford classification- do we still use Debakey ? 
• Risk Factors
• Prehospital Care – what should EMS be looking for? 
• ED Care
• History 
• HTN, Pulse defecits, Chest Pain, Syncope?Table 3
• ADD-RS score
• Exam
• Diagnostics
• Labs
• EKG – STEMI? 
• Imaging
• CXR
• Echo 
• CT
• MRI
• Aortogram
• Treatment
• BP management
• Heart Rate
• Shock
• Surgery – Who goes and when? 
• Special populations
• Pregnancy
• Controversies
• D-Dimer

Announcements:

• The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,
• Also, this month use code ACEP21! and get 20% of all orders at https://www.ebmedicine.net

Emergency Department Management of Rib Fractures

Author: Patrick Maher, MD

Episode Outline:

• Why rib fractures?
• Anatomy
• Fig 1
• Pre-hospital
• ED evaluation
• History 
• Physical Exam
• Imaging
• Nexus Chest Decision Instrument in Blunt Trauma
• ACR criteria for imaging
• CT vs xray
• Ultrasound 
• Treatment
• Meds
• Binders
• Kinesiotaping – Fig 4
• Respiratory support
• Operative fixation
• Special Populations
• Elderly
• Cancer patients
• Pediatrics
• Disposition
• Battle Score
• Rib Score
• FVC 

Announcements:

• The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,
• Also, this month use code SB25 and get a $25 Starbucks gift card when you subscribe at ebmedicine.net

Emergency Dept. Management of Cervical Spine Injuries

Authors: 

Geoffrey Jara-Alamonte, MD

Chandni Pawar, MD

Epidemiology

Anatomy (Figure 2 +3)

Spinal Cord Injury Injury (Table1)

• Primary
• Secondary

Differential Diagnosis

Prehospital Care - selective immobilization

ED evaluations

• History
• Physical Exam (Table 6)
• Imaging
• Vascular Injury - Modified Denver Criteria (table 9)
• Treatment
• Special Populations
• Pediatrics

Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !! Also, this month use code SB25 and get a $25 Starbucks gift card when you subscribe at ebmedicine.net !

Abnormal Uterine Bleeding in the Emergency Department

Authors:

Tazeen Abbas, MD

Abbas Husain, MD, FACEP

• Physiology review
• Terminology
• Differentiating Causes: PALM-COEIN
• Structural: Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia
• Non-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise specified
• Other causes: thyroid disease, hyperprolactinemia, stress, weight loss and anorexia, heavy exercise
• Age Based Differential
• 12-18
• Immaturity of the hypothalamic-pituitary- ovarian axis
• Sexually transmitted infections
• Coagulopathies, and bleeding disorders (von Willibrand disease)
• 19-39
• polyps
• fibroids
• malignancy
• PCOS
• Age 40 and older
• endometrial atrophy
• malignancy
• History
• Physical Exam
• Diagnostic Studies
• Treatment
• Unstable
• Stable
• Special Cases
• DOACs
• Prepubescent girls
• genital injuries

Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !!

August 2021 Pediatric Emergency Medicine Practice

Less Lethal Law Enforcement Weapons

Authors: Jessica Osterman, MD , Cara Buchanan, MD

What kinds of less-lethal weapons are law enforcement using?

• Pepper spray
• Conducted Electrical Weapons (CEWs)
• K-9s
• Beanbag guns
• Rubber bullets
• Stingballs

Differential Diagnosis

Prehospital Care

Trauma Informed Care

Conductive Electrical Weapons – Taser

Chemical Irritants- Pepper Spray, Tear Gas

K9 Injuries

Kinetic Impact Projectiles- Rubber Bullets, Beanbags, Sting Balls/Grenades

Sounds:

Police Siren https://freesound.org/people/MultiMax2121/sounds/156869/

Ambulance https://freesound.org/people/sofialomba/sounds/469413/

Angry Man https://freesound.org/people/ebcrosby/sounds/334439/

Taser https://freesound.org/people/The_Chemical_Workshop/sounds/403252/

Taser https://freesound.org/people/Greub/sounds/402636

Coughs https://freesound.org/people/freesound/sounds/25301/

Dog Bark https://freesound.org/people/ivolipa/sounds/337101/

Grenade https://freesound.org/people/superfreq/sounds/268101/

Last Updated on April 29, 2022

Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !!

HIV- An Interview With Dr. Daniel Egan

See the EB Medicine Article @ https://www.ebmedicine.net/topics/infectious-disease/HIV

• Why HIV? 
• 2018 , 1,2 million people living with HIV, almost 40k new infections
• People living with HIV visit the ED 3 x per year on average
• HIV infected patients accounted for 6 in 1000 ED visits in 2017
• New Transmission of HIV, Figure 1
• What does acute infection look like ?
• What about chronic infection ?The chronic phase can last 10 years or more and be asymptomatic.
• Are people with HIV more likely to develop: CAD, COPD, DVT and why?
• What if they are on medication for HIV?
• Screening in the ED, everyone? Do they have to have symptoms or risks?
• What does universal screening mean?
• What does risk based screening mean?
• What are the risk factors? What if I see someone on PrEP who is in the ED for an unrelated complaint?
• History
• Ask about cd4 and viral load and last test
• Ask about he of opportunistic infections
• Ask about medication side effects
• What else?
• Exam
• Labs – rapid testing, 4th gen, viral load and cd4, etc
• Imaging
• Treatment
• Table 1
• Highly effective and reduces transmission
• Medication side effects (we don’t have to dwell on each Med and side effect and just reference the charts)
• hep B virus deactivation
• System Based Disease
• Heart Failure and CAD
• PCP (role of LDH)
• TB
• COPD
• Renal Disease – stones , radiolucent
• Neurologic- CVA, cryptococcal meningitis, toxo, progressive multi focal leukoencephalopathy, HAND
• GI – diarrhea causes, c diff, hep C
• Heme- cytopenia
• Endocrine – metabolic syndrome
• Musculoskeletal
• Psychiatric table 3
• Derm
• Special Circumstances
• PEP
• PrEP

Announcements

1. Traumatic Hemorrhage in the ED- with Dr Scott Weingart - April 13th, 8pm EST Free ! Register now: https://www.crowdcast.io/e/traumatic-hemorrhagic/register
2. Pandemic Preparedness publication is coming soon.
3. Mt Sinai COVID-19 Treatment Protocols have been updated and are available for free here: https://www.ebmedicine.net/topics/COVID-19/Protocols
4. The Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com

Management of Suspected Rabies Exposure in the Emergency Department - An Interview with Dr. Bess Storch

Epidemiology:

• Fatality rate of over 99%
• Half of cases occur in children
• 95% of cases are in resource limited countries, 35% in India
• 99% caused by infected dogs (worldwide)
• In the US, cases are predominantly bat variant

Why this topic?

• "In a recent survey of licensed physicians, less than half could identify rabies transmission routes, the correct PEP schedule, and the correct anatomic administration sites."

Pathophysiology:

• What causes it? The RNA virus Lyssavirus
• How is it transmitted?
• How does it reach the brain?

ED Evaluation:

• What does it look like clinically?
• 5 stages- incubation, prodrome, acute neurologic phase, coma death
• Why doesn’t everyone just get vaccinated?
• What patient medical history is important ? Steroids, chloroquine
• What animals are high risk?
• What about pets and quarantine?
• What about rodents ?
• Is there any role for labs or imaging ?
• What is the treatment regimen for those who are unvaccinated? And vaccinated?
• What about people who are immunosuppressed?
• Children?
• Pregnant?
• Recently traveled?

Management of Acute Urinary Retention in the Emergency Department

1. An algorithmic approach to urinary retention.
2. Relieve the obstruction 

• Foley
• Cudet cather
• Silicone catheter
• Suprapubic catheter

1. Determine the cause - 

• Structural
• Medications / Toxicologic
• Neurologic
• Infectious

1. Alpha blockers
2. Antibiotics
3. Slow vs rapid bladder decompression
4. Admit or discharge
5. Phimosis and Paraphimosis

Announcements:

1. New Airway Course Available: Current Topics in Airway Management: Mechanical Ventilation, Supraglottic Airway Devices, and Intubating Patients With COVID-19
2. Upcoming Live Course: Dr. Scott Weingart - Traumatic Hemorrhage - April 13th., 8-9pm, EST
3. Look for the "Key Points And Pearls From 2020" coming to your inbox or mailbox next month !

Community Acquired Pneumonia - An Interview with Dr. Matthew DeLaney, FACEP

1. Pneumonia and nomenclature : healthcare associated vs hospital associated

2. COVID-19 and antibiotics

3. Bacteriology - Strep is only 10-15% of hospitalized pneumonia, Viral pneumonia is about 20% (pre covid)

4. Conditions that predispose to pneumonia

• chronic lung disease (chronic obstructive pulmonary disease, bronchiectasis)
• smoking
• older age
• immuno-compromise
• proton-pump inhibitors, H2 blockers, and antipsychotic agents

5. Is there a historical or exam item most likely to be indicative of pneumonia?

6. How good is a CXR?

7. When should I consider a CT if the CXR is normal?

8. Procalcitonin

9. Blood cultures, sputum cultures, urine antigens- are these helpful?

10. CURB-65 vs PSI

11. Antibiotics- table 3 major and minor, history of prior infection, and doxy for everyone !

12. Duration - 5 days works

13. A walk through the pathway

Evaluation and Management of ST-Segment Elevation Myocardial Infarction in the Emergency Department

Authors

Marshall Frank, DO, MPH, FACEP

Carson Sanders, BS, NRP, CCEMT-P

Bryan P. Berry, MD, BCEM, FACEP

Topics

Epidemiology

Pathophysiology

Prehospital care

Emergency Dept Evaluation

• History
• Physical

Imaging

Labs

Electrocardiogram

• aVR
• Posterior Leads
• LBBB
• Serial ECGs
• Reciprocal Changes
• Pericarditis vs STEMI

Treatment

• Oxygen
• Opioids
• Antiplatelet Agents
• Nitroglycerin
• Beta Blockers
• Reperfusion
• PCI
• Thrombolytics
• Dysrhythmias
• Anticoagulants

Transfers

Special Circumstances

• Gender
• Age
• Cocaine

Have questions or comments on the podcast? Write us at emplify@ebmedicine.net .

Rhabdomyolysis: Evidence- Based Management in the Emergency Department

Authors:

Gi Xiang Lee, MD

David Duong MD, MS, FACEP

Topics:

Evidence Review

Biology & Pathophysiology

Differential Diagnosis

Pre-hospital care

Emergency Department Evaluation

• History
• Physical Examination
• Labs

Treatment

Special Populations

Disposition

Have questions or comments on the podcast? Write us at emplify@ebmedicine.net .

Don’t forget about the $50 Amazon card with any order over $300 through 12/31/20.

Use code AMAZON20

An Evidence-Based Approach to Nonoperative Management of Traumatic Hemorrhagic Shock in the Emergency Department

Authors:

Christopher Pitotti, MD, FACEP

Jason David, MD

Topics:

The Lethal Triad

Prehospital Care

• Tourniquets - Placement and Pitfalls
• Stop The Bleed
• Hemostatic Dressings
• TXA
• Temperature Management

ED Assessment

• Shock Recognition
• Predictors of Massive Transfusion
• Imaging
• Ultrasound - eFAST
• CT
• Labs
• Viscoelastic Clot Testing
• Treatment
• REBOA- Resuscitative Endovascular Balloon Occlusion of the Aorta
• CPR
• Resuscitative Thoracotomy
• Airway - Intubation
• Breathing
• Circulation
• Massive Transfusion
• Crystalloid
• Blood Products

Special Populaations

Have questions or comments on the podcast? Write us at emplify@ebmedicine.net .

Management of Deep Vein Thrombosis in the Emergency Department

Authors:

Shane R. Sergent, DO, FAAEM, FACOEP, FAWM, RDMS

Michael Galuska, MD, FACEP, FAAEM

John Ashurst, DO, MSc, FACEP, FACOEP

Topics:

Epidemiology

Causes:

• Unprovoked

• Provoked

Risk Factors

Testing

• D-dimer

• Ultrasound

Anticoagulation

• Heparins

• DOACs

• Warfarin

• Other

Special Populations

• Malignancy

• Pregnancy

• Elderly

• Distal Calf DVT

Have questions or comments on the podcast? Write us at emplify@ebmedicine.net .

This issue of Pediatric Emergency Medicine Practice is available at no cost here:

https://www.ebmedicine.net/topics/ethics/trasnsgender-gender-diverse-children

Topics:

• What is the difference between gender and sexual orientation?
• What are some of the terms we may encounter (current or retired)?
• How does a lack of knowledge / competency regarding care for transgender and gender diverse (TGD) youth create barriers to effective care? Or negatively affect the quality of care these patients receive?
• What is the best way to approach a transgender patient in the ER?
• There are a number of ways transgender patient may alter their appearance. Why are these methods relevant (complications) and how do I ask about them?
  • Tucking
  • Packing
  • Binding
• What medical gender-affirming therapies are currently available? And what complications can they cause?
  • Pubertal suppression
  • Feminizing or masculinizing hormones
  • Contraception
• Is gender-affirming surgery used in this population ? What types (chest, genital) ?
• STI’s and Pregnancy are still considerations, correct?
• What are some of the problems that transgender youth have an increased risk of?
  • Substance abuse
  • Suicide
  • Self harm
  • Anxiety
  • Depression
  • Eating disorders
  • Physicians and sexual violence
  • Family rejection
  • Homelessness
  • Food insecurity
  • Poverty
• What are some helpful resources if I want to learn more?
  • UCSF Center for Excellence for Transgender Health (https://prevention.ucsf.edu/transhealth)
  • PFLAG (https://pflag.org/)

Learn more about EBMedicine and subscribe to Emergency Medicine Practice or Pediatric Emergency Medicine Practice here: https://www.ebmedicine.net/

Topics:

• Definition and new classification methods.
• Changes in at-risk patients in the U.S.
• History and Examination
• Imaging
  • Chest Xray
  • Trans-throacic Echocardiography (TTE)
  • Trans-esophagel Echocardiography (TEE)
  • CT Angiography
  • MRI
• Bacteriology
• Antibiotics
• Summary

Write us at emplify@ebmedicine.net

Host- Health In Harlem radio show (WHCR 90.3 FM)and podcast

Topics:

• History of racism in medicine
  • Niggerology
  • Experimentation on Women
  • Pain thresholds, endurance to harsh environments, food and water
• Institutional Review Boards (IRBs) and their role in racism
• Non-compliant patients
• Believing your patient
• Poor outcomes in medicine due to racial bias
• Bereaving families
• Racism among physicians and providers
  • Micro agressions
  • What it’s like to experience racism as a physician.
• Next steps.

Leave us a voicemail at 678-336-8466, ext 128

Write us at emplify@ebmedicine.net

Topics:

• ARDS
• COVD-19
  • Lung Compliance
  • Prone Positioning
• Metabolic Derangements
  • DKA
• Capnography and Waveform Analysis

Leave us a voicemail at 678-336-8466, ext 128

Write us at emplify@ebmedicine.net

Topics:

• Ventilator Modes
  • Volume Assist vs Pressure Support
• Tidal Volumes
  • Tidal Volume Measurement Tables
• Inspiratory / Expiratory Ration
• FiO2: How much oxygen do we need?
• COPD Patients
  • Permissive Hypercapnia
  • Volume vs Respiratory Rate Adjustments
• Asthma Patients
  • Respiratory Rate Adjustments

Leave us a voicemail at 678-336-8466, ext 128

Write us at emplify@ebmedicine.net

EMplify June 2020

Multi-system Inflammatory Syndrome in Children (MIS-C) with COVID-19: An Interview with Dr. Ilene Claudius and Dr. Mohsen Saidinejad.

• What is it and when did we discover it as an entity?
• Have either of you treated anyone with the disease?
• Discussion of different cohorts of patients with MIS-C.
• Definition of MIS-C.
• Shock: cardiogenic and distributive shock presentations.
• Fever, is 4 days required?
• Discussion of where in the COVID-19 illness MIS-C occurs.
• Is clinical shock a requirement?
• Screening criteria (labs) and the Children’s Hospital Of Philadelphia pathway.
• What is available as treatment?
  • A discussion of IVIG
  • Steroids
  • Cytokine blockers
  • Remdesivir
• Why IVIG?
• Complications of the disease.
• Why are there more cases in New York?
• How has MIS-C changed your practice of testing children?
• Is there utility in testing for COVID-19 infection or antibodies in these cases?

Resources:EB Medicine Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians

EB Medicine COVID-19: The Impact on Pediatric Emergency Care

Children’s Hospital of Philadelphia Clinical Pathway for MIS-C.

Have questions or comments on the podcast? Leave us a voicemail at 678-336-8466, ext 128 or write us at emplify@ebmedicine.net .

EMplify June 2020

Rural Emergency Medicine and COVID-19: An Interview with Dr. Harry Wingate and Dr. Ken Gramyk.

• The rural experience in Georgia and Idaho.
• Covering both the ED and inpatient areas.
• Transfers.
• Schedule and ED operation changes.
• Practicing in a resource limited environment.
• Volume changes during the pandemic.
• Employee furloughs and staffing changes.
• EMS availability and transfers.
• Telemedicine.

Have questions or comments on the podcast? Leave us a voicemail at 678-336-8466, ext 128 or write us at emplify@ebmedicine.net .

It did not begin this week, this year, or this century. It did not catch us by surprise. But it certainly is a crisis of pandemic proportion. And we cannot sit in silence.

People of color in our communities have been deemed unequal, unworthy of justice, unworthy of life itself. I would love to say that the practice of medicine puts us above racism. But that would be a lie. I would love to say that the Hippocratic oath makes us behave differently, see the world differently, and treat people of color justly. But that too, would be a lie.

Today Black Americans are suffering, and that pain is boiling over, becoming a torrent of injustice that we can no longer ignore. And our response cannot be silence.

I don’t know the solution, but I am listening and learning.

I don’t know a way to relieve the pain, as a fellow human or as a physician, but I will sit and be present.

I don’t know the depth of the suffering, but I lament the loss of George Floyd, Breonna Taylor, Ahmaud Arbery, and countless others.

Martin Luther King Jr. said:

“The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.”

So today, I want to be clear. We, at EB Medicine, stand with our brothers and sisters of color.

--------------------------------------

Leave us a voicemail at 678-336-8466, ext 128

Write us at emplify@ebmedicine.net

EMplify May 2020 – The New Orleans Experience and Palliative Care : An Interview with Dr. Ashley Shreves

EBMedicine Live Webinars:

Thursday, June 4th - Life-threatening Headaches + current considerations due to COVID-19

Wednesday, June 17th – A New Timing-and-Triggers Approach to Diagnosing Causes of Acute Dizziness

Click the link to register: https://www.crowdcast.io/e/20200606/register

Leave us a voicemail at 678-336-8466, ext 128

Write us at emplify@ebmedicine.net

Contact us:

emplify@ebmedicine.net

1-678-336-8466, ext. 128

Emergency Department COVID Management Protocols: One Institution’s Experience and Lessons Learned

1. Laboratory Testing and Imaging
2. Disposition/admission Criteria
3. Cardiac Arrest Protocol
4. Medication Treatment Guidelines
   • Anticoagulation Protocol
5. Intubation Protocol
6. Nonaerosolized Asthma Protocol
7. Acute Dyspnea/Palliative Care Treatment
   • Death Management Talking Points
8. COVID-19 Smart Phrases / Discharge Plan for Likely COVID-19 Patients
9. Guidelines for Prone Positioning of Nonintubated Patients
10. Critical Care for ED COVID-19 Patients

EMplify April 2020 – Colby Redfield, MD

Contact us:

emplify@ebmedicine.net

1-678-336-8466, ext. 128

COVID-19 Topics:

1.Triage Tent Implementation (02:35)

2.Telemedicine – In the tent, in the department, and in follow up. (08:45)

3. PPE (16:30)

• Reusing N95s
• Using elastomeric full and half face respirators
• CDC, FDA, Osha

4. EMS (22:44)

• Crew Safety
• Criteria for transport
• Viral filters
• Handoff to the ED

Helpful Links:

1. Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians

https://www.ebmedicine.net/topics/infectious-disease/COVID-19

2. Reusable Facemasks and COVID-19

https://adminem.com/reusable-facemasks-and-covid-19/

3. University of Florida Halyard H600 masks

https://anest.ufl.edu/clinical-divisions/mask-alternative/

https://ufhealth.org/news/2020/uf-health-anesthesiology-team-devises-respirator-mask-made-existing-hospital-materials

MDCalc's new COVID-19 resource center: https://www.mdcalc.com/covid-19

EBMedicine's COVID-19 article with recent updates: https://www.ebmedicine.net/topics/infectious-disease/COVID-19

Time Stamps:

00:00- Discussion of new tools for COVID-19: calculators, risk factors and odds ratios, labs, etc.

40:02- Discussion of the New York City COVID-19 crisis.

Time Stamps:

01:29 Dr. Andrea Duca introduction.

02:05 What were your shifts like at the start of the epidemic?

04:50 Were you testing patients for CoOVID-19 initially?

05:08 Were the COVID-19 tests completed in-house or sent out to a government lab?

05:35 The arrival of the first cases. Then… and now.

07:03 What percent of your daily volume is due to COVID-19 patients?

08:17 Are COVID-19 patients diverted to a regional facility?

09:13 Are you still testing patients for COVID-19 today?

09:57 What is your current medication protocol?

10:35 Which antivirals are you currently using?

10:54 Hydroxychloroquine

11:14 Do you use non-invasive ventilation?

13:35 What kind of isolation do you use, airborne or droplet?

14:46 Do you put on new PPE as you go room to room?

15:21 What PPE do you currently use?

15:38 When did you create dirty and clean zones in the emergency department?

16:45 Do you have a dirty and clean side in the waiting room?

17:03 What is your annual emergency department volume? Daily volume?

18:04 How many treatment rooms are in your emergency department?

18:38 What percent of patients are admitted? Do you have borders?

19:54 Where do discharged patients go?

20:14 Have you personally been infected?

20:58 Do you test your staff who are ill? What is your protocol for infected staff?

22:46 What percent of the ED staff were sick at any given time? And inpatient nurses?

24:00 How did you deal with so many inpatient nurses being sick?

24:36 What are your surgeons, who cannot operate, currently doing?

25:35 Are you running out of non-invasive ventilation equipment?

26:20 Summary of current workflow for infected staff.

26:36 How do you use ultrasound for COVID-19 patients in the ED?

29:50 What criteria must a patient meet to be discharged?

31:00 EMS and their role in community screening.

32:20 What are you looking for on ultrasound examination?

34.42 What size chest tube are you utilizing for a pneumothorax in a patient with positive pressure ventilation?

26:33 What inpatient location are patients sent to? By what criteria?

37:05 Have you seen any infected pregnant patients or staff?

38:02 Have you seen any infected children?

38:43 Are you still testing patients? How many times are you testing them?

39:21 What psychological support do you have for staff?

42:25 What would you have liked to know early on, that yo

This episode, designed specifically for emergency clinicians, discusses Coronavirus COVID-19, including:

• The cause and history of the virus
• How it’s transmitted/spread and prevention methods
• Tools for management and treatment in the ED
• Which patients should be tested for Coronavirus
• The role of telehealth, and when patients should go to the ED
• Using vital signs to triage patients in the ED
• And more!

00:00 Intro

01:01 Why should we care about Coronavirus?

02:22 What is zoonotic transmission?

03:56 SARS and MERS and previous coronaviruses.

04:38 What are typical Coronavirus symptoms?

04:55 What is R0 (R naught)?

06:46 Why is there so much concern about this Coronavirus strain?

10:05 Is there concern that COVID-19 is more lethal?

12:45 What tools do we have to combat pandemics? Containment

14:38 Treatment and vaccines

16:32 Fecal oral transmission

19:01 Airborne and droplet transmission

21:20 Recommendations for the public

22:00 Recommendations for healthcare workers

23:24 Who should get tested?

24:47 How to get patients tested?

25:51 What do you do with a patient you want to be tested?

30:28 Closing

Introduction:

• Do both vomiting and diarrhea have to be present? No
  • 1996 AAP guidelines, 2016 ACG guidelines, and 2017 IDSA guidelines all note diarrhea illness but may be vomiting predominant.
• Studies use more vague definitions like:
  • > 1 episode of vomiting and/or > 3 episodes of diarrhea in 24 hours without known chronic cause like inflammatory bowel disease.
  • Diarrhea is at least 3 unformed stools per day.
  • Acute episode <14 days
  • Persistent episode 14-29 days
  • Chronic diarrhea >29 days
• Patients in the ED may present with only some of these symptoms depending their time in course of illness.

Literature Review:

• There is abundant literature on pediatric AGE but sparse research on AGE in adults. Therefore, many recommendations are extrapolated from the pediatric literature.

Causes:

• 70% of US cases are estimated to be caused by viruses, norovirus being most common.
  • o 26% norovirus
  • o 18% rotavirus
• Among bacterial causes:
  • o 5.3% Salmonella, most common
  • o 5.3% Clostridium
  • o 3% Campylobacter
  • o 3% parasitic infections
• Large portion, 51%, have no cause identified. (In ED patients)
• Interestingly, 79% of cases never have a cause identified (not ED specific)
• In ED patients, only 25% ever have a cause identified, this increases to 49% when a stool sample is obtained. (not ED specific)
• Food poisoning is responsible for 5% of AGE but results in 30% of deaths. Most commonly:
  • Salmonella, Clostridium perfringens, and Campylobacter
  • Majority of foodborne illness is still viral, mostly norovirus
• E Coli is normal in the gut, but two most common causes are:
  • Shiga toxin Ecoli (STEC) AKA enterohemorrhagic Ecoli (EHEC) - causes Hemolytic Uremic Syndrome in 5-10%
  • Entertoxigenic Ecoli (ETEC) - causes traveler's diarrhea
  • Both cause self-limited illness.

Alternate Diagnoses:

• Appendicitis: In the peds literature, misdiagnosis of appendicitis as AGE leads to 47% absolute increased risk of perforation. Suggestive findings include:
  • Migration of pain to RLQ
  • RLQ tenderness on exam (initial or repeat)
  • Absence of diarrhea
  • Pain not improved with episodes of diarrhea
  • Negative factors include multiple ill family members, recent international travel, presence of diarrhea (as defined above).
• Ciguatera Fish Poisoning
  • Toxin produced by algae consumed by reef fish like grouper, red snapper, sea bass and Spanish mackerel.
  • Symptoms begin 6-24 hours post ingestion.
  • Fish tastes normal.
  • Patients may develop neurological symptoms like paresthesias, generalized pruritis, and reversal of hot/cold sensation.
  • Symptoms resolve spontaneously, and treatment with mannitol is controversial.
• Scombroid Poisoning
  • Ingesting fish in the Scombroidae family - mackerel, bonito, albacore, and skipjack - that have been stored improperly
  • Bacteria produce histidine decarboxylase which converts histidine to histamine
  • Causes abdominal cramps and diarrhea, and may cause metallic bitter or peppery taste in mouth, and facial flushing within 20-30 min of ingestion
  • Can be confused with allergic reaction
  • Symptoms resolve in 6-8 hours
  • Notification of health dept may prevent others from being infected.
• Page 5 Table 1- Distinguishing Factors in the Differential Diagnosis of AGE

History:

• Table 2, page 6 has key questions to ask.
• Onset, timing, number of stools, presence of blood, fever, quality of abdominal pain and location, recent antibiotics, etc.
• Extremes of age, immunosuppression, and pregnancy should be identified. Mortality is highest in the patients >65 yo.

Physical Exam:

• We talked about RLQ abd pain, but what about bloody stool?
• An observational study of 889 adults and 151 pediatric with AGE showed that a negative fecal occult test showed accurately excluded invasive bacterial etiology with a NPV 87% in adults and 96% in children. But PPV was only 24%.

Laboratory Testing and Imaging:

• Dehydration is the biggest contributor to mortality, especially in the very young and elderly.
• Lab evaluation for dehydration is recommended in these populations.
• No consistent association between lab abnormalities and bacterial etiology.
• WBC and differential does not differentiate bacterial vs viral, but may help in identifying severity of illness.
• Hemoglobin and platelets are helpful if HUS is suspected.
• Stool Cultures:
  • 2017 IDSA guidelines recommends them in patients with fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis, noting these patients are at higher risk of bacterial infection. Specifically, Salmonella, shigella, Campylobacter, and Yersinia
  • 2016 ACG guidelines recommend them for patients with watery diarrhea and moderate to severe illness with fever for at least 72 hours.
  • Consider them for immunocompromised patients and those with recent abx use or hospitalization.
• C Difficile testing is recommended for all patients with AGE who are age >2 with a history of recent abx use or recent hospitalization
• Blood cultures are recommended for patients <3 months old and any patient with signs of sepsis.
• Imaging is generally plain film to exclude free air of surgical abdomen, or CT with contrast to evaluate for complications of AGE like aortitis, mycotic aneurysm, toxic megacolon, abscess, or perforation.

Hydration:

• Oral rehydration is preferred. Oral rehydration solutions in patients tolerating oral fluids.
  • ORS packets
  • Pedialyte, Hydralyte, etc
  • Sports drinks are safe but have less potassium. Higher sugar solutions can be diluted 50%
  • Coconut water
  • Half strength apple juice has been studied in pediatrics and decreased treatment failure.
• IV hydration for patients with severe dehydration, hypovolemic shock, septic shock, or failed oral rehydration.
• Don't forget to replace electrolytes if giving IV hydration.

Meds:

• Ondansetron (Zofran) reduces need for IV hydration in peds. (0.15mg/kg oral liquid) but doesn't reduce hospitalizations or return visits (low numbers)
• No benefit to higher dose ondansetron.
• IV ondansetron vs metoclopramide performance is similar in peds.
• No benefit in studies to giving dexamethasone, or dimenhydrinate (dramamine)
• Proshlorperazine 10mg IV was shown to be superior to promethazine 25mg IV for symptom relief in adults, with less sedation
• No suggestions regarding medication choice from guidelines.
• Sniffing isopropyl alcohol soaked pads twice q 2min was shown superior vs placebo in controlling nausea, but effect is gone at 30 minutes.
• Ginger is reported to be helpful at 250mg QID in pregnant patients and post op patient. No data in AGE.
• Loperamide is recommended as an adjunct to abx by the ACG. Risk is too high in patients <3 yo and 3-12 with moderate dehydration, blood stool, or severe disease.
• Loperamide is also contraindicated if STEC is suspected, due to increased development of HUS
• Probiotics may reduce diarrhea by one day.
• World Health Organization recommends zinc supplements for children with diarrhea. In the US only recommended to reduce duration in severely malnourished children age 6mos-5yo.

Antibiotics:

• Patients with traveler's diarrhea from Latin America, Caribbean, and Africa will improve faster with abx therapy. Azithromycin 1gm PO x 1, Cipro 750 mg PO x 1, or Cipro 500mg PO BID x 3 days.
• Patients with traveler's diarrhea from South Asia and Southeast Asia have increased strains of fluoroquinolone resistant Campylobacter. Aizthromycin 1gm PO x 1 or 500mg PO daily for 3 days is recommended.
• Great chart Table 4, page 12, on abx recommendations.
• Shellfish ingestion - Doxy, Azithomycin, or Cipro.
• C Diff - first line is oral vancomycin 125 mg PO QID for 10 days or Fidaxomicin 200mg PO BID for 10 days. Metronidazole is less effective due to resistance and is only used if the above is not available.
...]]> false https://podcast.show/emplify/episode/55599332/ 55599332 http://www.blubrry.com/emplify/episode/55599332/ EB Medicine Thu, 06 Feb 2020 09:59:00 -0500 Please take our listener survey at https://forms.gle/spMwHJS795Qnfgww7

Diabetic Hyperglycemic Emergencies: A Systematic Approach, by H. Evan Dingle, MD and Corey Slovis, MD, FACP, FACEP, FAAEM, FAEMS

American Diabetes Association (ADA) and International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines are reviewed in addition to the references used by each consensus statement. Also, a primary literature review was conducted with particular attention given to prospective studies.

Topics reviewed include:

• Etiology and pathophysiology of DKA and HHS
• Precipitating causes
• Differential diagnosis
• Diagnostic studies
  • ECG
  • Lab
  • Imaging
• Treatment
  • IV fluids
  • Insulin therapy
  • Potassium
  • Sodium bicarbonate
  • Phosphate
• Pediatrics
  • IVF changes
  • Insulin changes
  • Cerebral edema
• Airway management
• Euglycemia DKA
• Thrombosis and anticoagulation.

Time stamps:

• 00 Introduction
• 1:34 Cases
• 21:47 Summary of key points
• 26:37 Closing

 

]]> false https://podcast.show/emplify/episode/54107830/ 54107830 http://www.blubrry.com/emplify/episode/54107830/ EB Medicine Fri, 10 Jan 2020 18:37:00 -0500
Show Notes

 

Please click here and take our listener survey

Emergency Department management of Non-St Segment Elevation Myocardial Infarction, by Drs Julianna Jung and Sharon Bord.

• Chest pain is the second most common complaint
• Over 6.4 million visits to US EDs annually include chest pain.
• 25% will be diagnosed with ACS
• 1/3 will have STEMI, 2/3 NSTEMI.

Guidelines reviewed include those from:

• AHA/ACC
• ACEP
• European Society of Cardiology
• In addition to reviewing the primary literature each of them used as a basis for their recommendations.

 

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Please click here and take our listener survey

Part 1: Definitions
• Myocardial Infarction: elevated cardiac biomarkers (aka troponin) with clinical evidence of acute myocardial ischemia (aka signs and symptoms, ECG changes, abnormal imaging, or coronary thrombosis at cath or autopsy).
• Myocardial injury, unfortunately also can be abbreviated as MI, but not in our discussion. This term refers solely to cases where biomarker elevation is present without any other clinical evidence for ischemia.

STEMI definition from the European Society of cardiology:

1. ST elevation >1mm in two or more contiguous leads other than V2-V3
2. ST elevation in V2-V3
   1. > 2.5mm in med < 40 yrs old
   2. >2 mm in men > 40 yrs old
   3. >1.5mm in woman, regardless of age.

MACE= Major Adverse Cardiovascular Event: including re-infarction, stroke, dysrhythmia, heart failure, cardiogenic shock, and death.

Part 2 : Why do we care?
• In-hospital mortality rates are about the same for STEMI and NSTEMI, about 10%.
• 1-year fatality rate in NSTEMI is more than double that of STEMI, at about 25%
Part 3: Pathophysiology
• Type 1 MI (Infarction) is caused by atherosclerotic plaque rupture.
• Type 2 MI is the "mismatch" due to an imbalance in myocardial oxygen supply and demand. This can be the result of hypotension, tachycardia, sepsis, PE, etc.
Part 4: Pre-hospital care
• Prehospital ECGs decrease time to intervention. (PCI) in STEMI
• Early administration of aspirin decreases mortality and complications of MI (all types). (19), and is safe in the pre-hospital setting (20) - only 45% of get it during EMS transport, so room for improvement here (21)
Part 5: ED evaluation: Some of the interesting highlights History
• Diaphoresis
• Vomiting
• Radiation of pain to both arms or shoulders
• Radiation of pain to right shoulder
• Although teaching has been that women have atypical presentations, a 2016 study did not support it. However, it did find that elderly patients and those with diabetes may present atypically. (dyspnea, fatigue, nausea, or epigastric pain)
Past Medical History
• Family and personal history of CAD
• Other medical diagnoses
• Tobacco use
• Illicit substance abuse
• Age (CAD prevalence in age<40 is 1%, age >80 is 25%)
• ** HIV - find citing
  • 8. Grunfeld C, Delaney JA, Wanke C, et al. Preclinical atherosclerosis due to HIV infection: carotid intima-medial thickness measurements from the FRAM study. AIDS (London, England). 2009;23(14):1841–9. [PMC free article] [PubMed] [Google Scholar]
  • 9. Holloway CJ, Ntusi N, Suttie J, et al. Comprehensive cardiac magnetic resonance imaging and spectroscopy reveal a high burden of myocardial disease in HIV patients. Circulation. 2013;128(8):814–22. [PubMed] [Google Scholar]
• ** Cancer with hx of radiation to the chest
Exam
• Neurological neurologic deficit may point to aortic dissection
• Friction rub may be heard
• New murmur associated with papillary muscle rupture.
Diagnostics
• Telemetry
• ECG. Patterns to know…
• Troponin... you should get it
Scoring systems
• Heart Score
• Grace
• TIMI
Imaging in the ED
• CXR
• CT angiography, CT PE, CCTA
• Echocardiography - POC or formal
Part 6: Medications
• Oxygen (if sat <90%)
• Morphine (no)
• Nitrates
• Aspirin
• Antiplatelet agents
  • PSY12 inhibitors
  • IIb/IIIa inhibitors
• Heparins
• Beta Blockers
• Statins
Part 7: Revascularization

Immediate/urgent revascularization is recommended for all patients with NSTEMI who show signs of clinical instability, including refractory angina, sustained ventricular dysrhythmias, new or worsening heart failure, or shock (AHA class Ia recommendation; ESC class Ic recommendation). Otherwise, there is no clear benefit to immediate revascularization on all NSTEMI patients.

Part 8: The Specials…
• Women
• Black Patients
• Young Patients
• Diabetics
• Cocaine Users
]]> false https://podcast.show/emplify/episode/53730200/ 53730200 http://www.blubrry.com/emplify/episode/53730200/ EB Medicine Mon, 30 Dec 2019 13:23:03 -0500 Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness. This episode reviews risk factors for apnea and severe bronchiolitis; discusses treatments/therapies and provides evidence-based recommendations for the management of pediatric patients with bronchiolitis.

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Pathophysiology
• Bronchiolar narrowing and obstruction is caused by:
  • Increased mucus secretion
  • Cell death and sloughing
  • Peri-bronchiolar lymphocytic infiltrate
  • Submucosal edema
• Smooth muscle constriction seems to have a limited role, perhaps explaining the lack of response to bronchodilators.
• Median duration of illness is 12 days in children <24 months
• 18% still ill at 3 weeks.2
• 9% still ill at 4 weeks.2
Etiology
• RSV accounts for 50-80% of cases, but rare in children >2 yo.3
  • Late fall epidemic peaking Nov-March, in the US.4
• Human Metapneumovirus (HMPV) accounts for 3-19% 5,6
  • Similar seasonal variation to RSV.
• Parainfluenza, influenza, adenoviruses, coronaviruses, rhinoviruses, and enteroviruses are other causes.4-6
• Rhinoviruses have been shown to play a larger role in Asthma.7
Presentation
• The American Academy of Pediatrics defines it as any of the following in infants: 1
  • Rhinitis
  • Tachypnea
  • Wheezing
  • Cough
  • Crackles
  • Use of accessory muscles
  • Nasal flaring
Differential Diagnosis
• Emergent Causes
  • Infection: pneumonia, chlamydia, pertussis
  • Foreign body: aspirated or esophageal
  • Cardiac anomaly: congestive heart failure, vascular ring
  • Allergic reaction
  • Bronchopulmonary dysplasia exacerbation
• Non-acute Causes
  • Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia
  • Gastroesophageal reflux disease
  • Mediastinal mass
  • Cystic fibrosis
• Clinical Pearls
  • Vomiting, wheezing, and coughing associated with feeding; consider GERD.
  • Wheezing associated with position changes; consider tracheomalacia or great vessel anomalies.
  • Wheezing exacerbated by flexion of neck and relieved by neck hyperextension; consider vascular ring.
  • Multiple respiratory tract infections and failure to thrive; consider cystic fibrosis or immunodeficiency.
  • Wheezing with heart murmur, cardiomegaly, cyanosis, exertion or sweating with feeding; consider cardiac disease.
  • Sudden onset of wheezing and choking; consider foreign body.
Risk Factors for Severe Bronchiolitis
• Age < 6-12 weeks11-13
• Prematurity < 35-37 weeks’ gestation11-13
• Underlying respiratory illness such as bronchopulmonary dysplasia1
• Significant congenital heart disease; immune deficiency including HIV, organ or bone marrow transplants, or congenital immune deficiencies14,15
• Altered mental status (impending respiratory failure)
• Dehydration due to inability to tolerate oral fluids
• Ill appearance12
• Oxygen saturation level ≤ 90%1
• Respiratory rate: > 70 breaths/min or higher than normal rate for patient age1,12
• Increased work of breathing: moderate to severe retractions and/or accessory muscle use1
• Nasal flaring
• Grunting
Risk Factors for Apnea
• Full-term birth and < 1 month of age16,17
• Preterm birth (< 37 weeks’ gestation) and age < 2 months post birth11-13,17
• History of apnea of prematurity
• Emergency department presentation with apnea17
• Apnea witnessed by a caregiver17
Diagnostic Testing
• Xray
  • Radiographs increase the likely hood of a physician giving antibiotics, even if the X-ray is negative.18-20
  • Routine radiography is discouraged, but may be helpful when severe disease requires further evaluation or exclusion of foreign body.
• Viral testing is not necessary for the diagnosis but may help when searching for the cause of fever in young infants.
  • 2016 ACEP fever guidelines note that positive viral testing can impact further workup of fever for a serious bacterial infection (SBI).21
• In infants <28 days, serious bacterial infection is high, even in patients with bronchiolitis: 10% (RSV+) and 14% (RSV -)22. Standard fever evaluation is recommended.
• In the 28-60 day old group, SBI rates were 5.5% (RSV+) and 11.7% (RSV-). All were UTIs.22 Urinalysis is recommended.
Emergency Department Treatment
• Oxygen
  • Keep O2 saturation >90%
  • Clinicians may choose not to use continuous pulse oximetry (weak recommendation due to low-level evidence and reasoning)1
• Fluids
  • IV or NG administration of fluids to combat dehydration, until respiratory distress and tachypnea resolve.
• Suctioning
  • Routine use of “deep” suctioning may not be beneficial and may be harmful.1
  • Nasal suction should be used to help infants with respiratory distress, poor feeding or sleeping.
• Bronchodilators1,25,26
  • Generally nor recommended for routine use.
  • May trial in infants with:
  • Severe bronchiolitis (these were excluded in the studies).
  • History of prior wheezing.
  • Family history of atopy/asthma in an older infant.
• Anticholinergic Agents (ipratropium bromide)
  • No evidence for improvement in bronchiolitis.31-34
• Corticosteroids
  • AAP1, Cochrane Review27, and PECARN28 study all recommend against, finding no evidence for improvement.
  • One small study (70 patients) found a benefit utilising 1 mg/kg oral dexamethasone followed by 0.6 mg/kg daily for 5 days. However, the study limited by size and increased prevalence of family history of atopy.
  • Recommendations remain against use in first time wheezers with bronchiolitis.
• Racemic Epinephrine
  • Not recommended1. Further study needed.
• Racemic Epinephrine + Oral Dexamethasone
  • Pediatric Emergency Research Canada trial at 8 Canadian pediatric EDs involving 800 infants aged 6 weeks to 12 months with bronchiolitis found that the epinephrine-dexamethasone group had a lower admission rate over 7 days than the placebo group (17.1% vs 26.4%). This was not statistically significant. Further study needed. 30
• Hypertonic Saline
  • AAP guidelines do not recommend use in the ED but note clinicians may utilize it in the inpatient setting. 1
  • Cochrane reviews in 2013 and 2017 found some inpatient benefit, but a conflicting publication found it may worsen cough.35-37
• High Flow Nasal Cannula (HFNC)
  • Several small pediatric ICU studies show a benefit in severe cases. No large ED randomized trials exist, to date.
  • Study protocols included weight based or age based flow rates.
• Nasal CPAP
  • Shows benefit in pediatric ICU settings. Evidence vs HFNC is limited.
Disposition
• Consider admission if any of the following are present:
  • Risk for apnea
  • Risk for severe bronchiolitis
  • Respiratory distress, particularly if it interferes with feeding
  • Hypoxia (oxygen saturation ≤ 90%)
  • Decreased feeding and/or dehydration
  • An unreliable caregiver (ie, unable to ensure patient care and appropriate 24-hour follow-up)
• All patients with severe bronchiolitis should be admitted.
]]> false https://podcast.show/emplify/episode/52731109/ 52731109 http://www.blubrry.com/emplify/episode/52731109/ EB Medicine Wed, 04 Dec 2019 13:21:00 -0500 Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta.

Nachi: For our regular listeners, you probably noticed a lapse in recent episodes as we pulled away from our usual monthly releases.

Jeff: With both of us having increasing demands on our time -- myself with business school and the busiest 21 month old in the world and Nachi with yet another entrepreneurial endeavor on the horizon -- we decided that it would be best to pass the podcast on to another host, so EMplify can continue to create and deliver the high quality materials that you deserve.

Nachi: We have obviously really enjoyed creating this podcast and working closely with EB Medicine to produce it. We are deeply appreciative of you, our listeners, and your wonderful feedback and comments over the years. Without you, there would be no point in us working so hard on this.

Jeff: And keep the feedback coming as we hand the reins to Dr. Sam Ashoo as the new host of EMplify. Dr. Ashoo is an Emergency Physician based out of Tallahassee Florida with a keen interest in informatics who has been featured on several other podcasts you may have heard. We can’t think of a better person to take over for EMplify. I’m sure you’ll really like him and the content he produces. Well, with that, let’s get started on our final scheduled episode of EMplify!

Nachi: As we are just about to see one of the busiest travel days of the year, that would be the Wednesday before Thanksgiving, we thought there would be no better time to discuss the September 2019 issue of EMP: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls.

Jeff: This was a fantastic issue, thanks to the hard work by Drs. DeLaney and Greene, both of the University of Alabama Birmingham School of Medicine. Thanks as well to the peer editors, Dr. Knight, and Dr. Hill of the University of Cincinnati.

Nachi: And I think you have a bit of a disclosure for this month...

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Jeff: Well, this is a first! Finally at the point in my career where I can announce a disclosure, though it’s more of a potential conflict of interest than an actual disclosure, but certainly still worth noting. I currently spend some of my time working for STAT-MD - which is an airline consultation service run by the Center for Emergency Medicine and UPMC. Though I’m certainly a junior member of the team, in some sense, I’ve responded nearly 500 inflight emergencies over the last two years.

Nachi: And this definitely places you are in a particularly nice position to share some information with our listeners this month, and I’ll have some questions scattered throughout the episode for you too.

Jeff: Sounds great, so let’s dive in, starting with what I think is the most important point - qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal concerns.

Nachi: I couldn’t agree more, so let me reiterate, please trust the evidence. And volunteer to help should you hear the call. We’ll get to this in a bit but there is little medicolegal concern and you owe it to the sick passenger to help.

Jeff: So what are the chances you are called - well, they are not particularly high, but certainly not negligible either. In 2019, of the 4 billion passengers expected to fly, there will be an estimated 60,000 medical emergencies. That means there will be about 1 emergency per every 604 flights.

Nachi: So, I fly about 4 times a month for work. At 4 times per month, over the next 12 years I can expect about one medical emergency. Already excited! Let’s start with some physiology. Cabin pressurization varies, but is typically equivalent to an altitude of 8000 feet.

Jeff: And this has a huge effect, in one study of healthy volunteers, this change in pressure resulted in a 4-10 point decrease in oxygen saturation and a 35 point drop in arterial oxygen partial pressure from 95 mm Hg to 60.

Nachi: In another study of healthy volunteers on a long haul flight, this change caused 7% of passengers to report symptoms consistent with acute altitude illness.

Jeff: Due to the principles of Boyle’s law, decreased cabin pressure also causes expansion of gases within anatomical spaces in the body such as the eye, GI tract, sinuses, middle ear, etc. This expansion can potentially threaten surrounding structures.

Nachi: So there must be guidelines for those recent post-op for flying - right?

Jeff: There certainly are, but I don’t think we need to get into the weeds on this one since nobody listening will likely be doing pre-flight screenings. I think one thing to remember here, is that though cabins are pressurized to several thousand feet, they CAN be pressurized even further if necessary. The airlines don’t do this because it takes a tremendous quantity of fuel to do so, but if pressurization will defer a diversion, this option may peak their interest. Though an anecdote, the only time I’ve ever suggested it is on a flight from someone recent post-op eye surgery who went blind midflight. We pressurized the cabin from 8000 to 4000 and then finally to sea level and his vision returned. Pretty cool stuff. But getting back to the text, next we have air quality. Only 50% of inflight air is recirculated, all of the flow is compartmentalized between sections of rows, and all the air is run through a HEPA filter. The authors note that the air is actually comparable to that of an operating room.

Nachi: Then why are people always getting sick after flying…?

Jeff: Well it’s hard to prove, but experts believe that most post flight respiratory illnesses are likely caused by exposure to fomites on high-risk surfaces of airplanes and in airports - like the trays on the seat back.

Nachi: Interesting.

Jeff: It’s also worth noting that the air is quite dry, though this is unlikely to produce any clinically significant events. Most of the dehydration that occurs is more likely due to inadequate water intake and excess caffeine and alcohol consumption depending on the time of day.

Nachi: Don’t judge. Even though it may be 8 am, some of our night shift locums friends may prefer an airport cocktail after a long week away.

Jeff: Oh I’m definitely not judging, facts only over here. Anyway, let’s move on to a little epidemiology.

Nachi: Syncope and cardiac events account for a large proportion of in-flight emergencies, with cardiac events accounting for the largest percentage of diversions.

Jeff: Gi, endocrine and respiratory emergencies follow syncope and cardiac events, with specific percentages varying based on which study you look at.

Nachi: Thankfully obstetric emergencies are relatively rare, accounting for less than 0.1% of all emergencies.

Jeff: Trauma and substance abuse related complaints have also been reported, but represent only a small percentage of inflight emergencies.

Nachi: I think that covers the main pathologies you may encounter. Next we should touch upon the actual responders. Physicians reportedly respond 44% of the time, followed by nurses at 20% and EMS providers at about 4%. Interestingly, despite physicians being there only 44% of the time, they were involved in the care for over 70% of diversions.

Jeff: It might seem crazy, but that’s definitely my experience. Many physicians, especially non-ED physicians are not familiar with caring for the acutely ill. Additionally, most physicians are very uncomfortable actually witnessing someone syncopize and then immediately checking vitals and finding the passenger to be bradycardic and hypotensive as is the case with many patients immediately after a vasovagal syncopal episode. I cannot tell you how many times we get called by pilots considering diversion based on a physician’s request only to have the symptoms completely resolve in just 10 minutes. Be patient, this is a common in flight pathology.

Nachi: Your experience has not failed you - data from your own group showed that 31% of cases resolved before arrival. Even in cases where EMS was requested, patients were only transported 37% of the time and of those, only 8% were actually admitted for further work up. Death is also a very rare phenomenon, occurring in only 0.3% of cases.

Jeff: Alright, so let’s move onto the actual logistics of responding. Each airline has its own protocols and policies with respect to medical responders - some will require credentials, others may not. In some instances, you may be the first responder, in others, the flight crew may have already been in contact with their ground based medical control.

Nachi: In terms of supplies, the FAA requires an emergency medical kit and an AED on all commercial flights. These kits cannot be opened without direction from a medical professional on the ground or on board.

Jeff: And while airlines may add additional drugs at their discretion, the FAA mandates certain supplies. You can remember these supplies by thinking of the 5 A’s - asthma, allergy, altered mental status, ACS, and ACLS. The 5 As should help you remember the bronchodilators, epinephrine, antihistamine, dextrose, nitroglycerine, aspirin, and lidocaine as the one antiarrhythmic available. Of course, there are also gloves, an IV start kit, and a few other basic supplies.

Nachi: AEDs are also required and have been since 2001 and amazingly when a shock was delivered in flight, 40% survived to hospital discharge with a good outcome.

Jeff: Just as on the ground, shockable rhythms do wel...]]> false https://podcast.show/emplify/episode/49132419/ 49132419 http://www.blubrry.com/emplify/episode/49132419/ EB Medicine Fri, 20 Sep 2019 15:10:00 -0400 Dr. Susan Kirelik, a concussion specialist and emergency medicine physician, discusses the key points of concussion diagnosis and management from the perspective of the emergency medicine clinician. The topics covered include:

• The signs and symptoms of concussion and how it is diagnosed in the ED
• The initial evaluation of a patient presenting with a head injury, including tools for determining when neuroimaging is indicated
• Screening tools for the evaluation of patients with suspected concussion, such as the VOMS examination and the SCAT5 and Child SCAT5 tools
• Management of patients in the ED after making a concussion diagnosis and the role of rest, antiemetics, and acute pain management for these patients
• The importance of aftercare instructions when discharging concussed patients, in the context of new guidelines for concussion recovery
• The risk factors for prolonged recovery from concussion and resources for concussion recovery
• Patients seeking concussion clearance in the ED
• Addressing patient or parent questions about the long-term complications of concussion, such as second impact syndrome, the potential for cumulative effects of multiple concussions, and risk for CTE (chronic traumatic encephalopathy)

Susan B. Kirelik is the Medical Director of the Rocky Mountain Pediatric OrthoONE Center for Concussion and is an attending pediatric emergency medicine physician at the Rocky Mountain Hospital for Children in Denver, Colorado.

Read the article: Concussion in the Emergency Department: A Review of Current Guidelines - Trauma EXTRA Supplement (Trauma CME) References

McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838- 847. (Consensus statement)

Meeuwisse WH, Schneider KJ, Dvorak J, et al. The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport. Br J Sports Med. 2017;51(11):873-876. (Conference summary)

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort study; 42,412 patients)

Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. (Prospective cohort study; 3121 patients)

Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42(10):2479-2486. (Cross-sectional study; 64 patients)

Links to tools and publications mentioned in the podcast:

PECARN Pediatric Head Trauma: Official Visual Decision Aid for Clinicians

Vestibular/Ocular-Motor Screening (VOMS) for Concussion

SCAT5 tool

Child SCAT5 tool

REAP concussion management (NOTE: this is the new URL for “center4concussion.com,” which is mentioned in the podcast)

Tip sheets for educators, parents, and healthcare providers on managing concussion recovery in the classroom

]]> false https://podcast.show/emplify/episode/47631400/ 47631400 http://www.blubrry.com/emplify/episode/47631400/ EB Medicine Tue, 06 Aug 2019 11:16:18 -0400 Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs.

Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms.

Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico.

Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology.

Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants.

Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality.

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Jeff: Fair enough, we’ll take what we can get.

Nachi: Well, I’m sure more of those studies are still coming.

Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin.

Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising.

Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism.

Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile.

Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins.

Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S.

Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many.

Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition.

Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis.

Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation.

Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours, is taken twice daily. Note the drastically reduced half-life as compared to warfarin, which has a half-life of up to 60 hours.

Nachi: The RE-LY trial for afib found that taking 150 mg of Dabigatran BID had a lower rate of stroke and systemic embolism than warfarin with a similar rate of major hemorrhage. Dabigatran also had lower rates of fatal and traumatic intracerebral hemorrhage than warfarin.

Jeff: A separate RCT found similar efficacy in treating acute VTE and preventing recurrence compared with warfarin, with reduced rates of hemorrhage!

Nachi: Less monitoring, less hemorrhage, similar efficacy, I’m sold!!!

Jeff: Slow down, there’s lots of other great agents out there, let’s get through them all first...

Nachi: Ok, so next up we have the Factor Xa inhibitors, Rivaroxaban, apixaban, edoxaban, and betrixaban.As the name suggests, these medications work by directly inhibiting the clotting of factor Xa, which works in the clotting cascade to convert prothrombin to thrombin.

Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment. After taking 15 mg BID for the first 21 days, rivaroxaban is typically dosed at 20 mg daily with adjustments for reduced renal function.

Nachi: The Rocket AF trial found that rivaroxaban is noninferior to warfarin for stroke and systemic embolism prevention without a significant difference in risk of major bleeding. Interestingly, GI bleeding may be higher in the rivaroxaban group, though the overall incidence was very low in both groups at about 0.4% of patients per year.

Jeff: In the Einstein trial, patients with VTE were randomized to rivaroxaban or standard therapy. In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Continuing therapy beyond the acute period resulted in similar rates of VTE recurrence and bleeding episodes to treatment with aspirin alone.

Nachi: Next we have apixaban, tradename Eliquis. Apixaban is approved for afib and the treatment of venous thromboembolism. It’s typically dosed as 10 mg BID for 7 days followed by 5 mg BID with dose reductions for the elderly and those with renal failure.

Jeff: In the Aristotle trial, when compared to warfarin, apixaban was superior in preventing stroke and systemic embolism with lower mortality and bleeding. Rates of major hemorrhage-related mortality were also nearly cut in half at 30 days when compared to warfarin.

Nachi: For the treatment of venous thromboembolism, the literature shows that apixaban has a similar efficacy to warfarin in preventing recurrence with less bleeding complications.

Jeff: Unfortunately, with polypharmacy, there is increased risk of thromboembolic and hemorrhage risks, but this risk is similar to what is seen with warfarin.

Nachi: And as compared to low molecular weight heparin, apixaban had higher bleeding rates without reducing venous thromboembolism events when used for thromboprophylaxis. It’s also been studied in acute ACS, with increased bleeding and no decrease in ischemic events.

Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. It’s recommended that edoxaban be given parenterally for 5-10 days prior to starting oral treatment for VTE, which is actually similar to dabigatran. It has similar levels of VTE recurrence with fewer major bleeding episodes compared to warfarin. It has also been used with similar effects and less major bleeding for stroke prevention in afib. In the setting of cancer related DVTs specifically, as compared to low molecular weight heparin, one RCT showed lower rates of VTE but higher rates of major bleeding when compared to dalteparin.

Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Because it’s utility is limited to venous thromboembolism prophylaxis in mostly medically ill inpatients, it’s unlikely to be encountered by emergency physicians very frequently.

Jeff: As a one sentence FYI though - note that in recent trials, betrixaban reduced the rate of VTE with equivalent rates of bleeding and reduced the rate of stroke with an increased rate of major and clinically relevant non-major bleeding as compared to enoxaparin.

Nachi: Well that was a ton of information and background on the DOACs. Let’s move on to your favorite section - prehospital medicine.

Jeff: Not a ton to add here this month. Perhaps, most importantly, prehospital providers should specifically ask about DOAC usage, especially in trauma, given increased rates of complications and potential need for surgery. This can help with destination selection when relevant. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage.

Nachi: Extremely important to identify DOAC use early. Once the patient arrives in the ED, you can begin your focused history and physical. Make sure to get the name, dose, and time of last administration of any DOAC. Pay particular attention to the med list and the presence of CKD which could point to altered DOAC metabolism.

Jeff: In terms of the physical and initial work up - let the sites of bleeding or potential sites of bleeding guide your work up. And don’t forget about the rectal exam, which potentially has some added value here - since DOACs increase the risk of GI bleeding.

Nachi: Pretty straight forward history and physical, let’s talk diagnostic studies.

Jeff: First up is CT. There are no clear cut guidel...]]> false https://podcast.show/emplify/episode/45403657/ 45403657 http://www.blubrry.com/emplify/episode/45403657/ EB Medicine Mon, 08 Jul 2019 14:12:00 -0400 Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery.

Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing.

Jeff: Thankfully, this month’s author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month’s evidence-based article.

Nachi: And don’t forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let’s dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30.

Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go…

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Nachi: Nah! Just some definitions, nothing personal!

Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits!

Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery.

Jeff: Well that’s kind worrisome.

Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!!

Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled!

Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia.

Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark.

Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017.

Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs.

Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group.

Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in.

Nachi: As far as types of procedures go – while there are many, there are 3 major ones being done in the US and these are the lap sleeve gastrectomy, Roux-en-Y gastric bypass, and lap adjustable gastric banding. In 2017, these were performed 60%, 18%, and 3% of the time.

Jeff: And sadly, no two procedures were created alike and you must familiarize yourself with not only the procedure but also its associated complications.

Nachi: So we have a lot to cover! overall, these surgeries are relatively safe with one 2014 review publishing a 10-17% overall complication rate and a perioperative 30 day mortality of less than 1%.

Jeff: Before we get into the ED specific treatment guidelines, I think it’s worth discussing the procedures in more detail first. Understanding the surgeries will make understanding the workup, treatment, and disposition in the ED much easier.

Nachi: Bariatric procedures can be classified as either restrictive or malabsorptive, with restrictive procedures essentially limiting intake and malabsorptive procedures limiting nutrient absorption. Not surprisingly, combined restrictive and malabsorptive procedures like the Roux-en-y gastric bypass tend to be the most effective.

Jeff: Do note, however that 2013 guidelines do not recommend one procedure over another and leave that decision up to local surgical expertise, patient specific risk factors, and treatment goals.

Nachi: That’s certainly an important point for the candidate patient. Let’s start by discussing the lap gastric sleeve. In this restrictive procedure, 80% of the greater curvature of the stomach is excised producing early satiety and weight loss from decreased caloric intake. This has been shown to have both low mortality and a low overall rate of complications.

Jeff: Next we have the lap adjustable gastric band. This is also a restrictive procedure in which a plastic band is placed laparoscopically around the fundus leaving behind a small pouch that can change in size as the reservoir is inflated and deflated percutaneously.

Nachi: Unfortunately this procedure is associated with a relatively high re-operation rate – one study found 20% of patients required removal or revision.

Jeff: Even more shockingly, some series showed a 52% repeat operation rate.

Nachi: 20-50% chance of removal, revision, or other cause for return to ER - those are some high numbers. Finally, there is the roux-en-y gastric bypass. As we mentioned previously this is both a restrictive and a malabsorptive procedure. In this procedure, the duodenum is separated from the proximal jejunum, and the jejunum is connected to a small gastric pouch. Food therefore transits from a small stomach to the small bowel. This leads to decreased caloric intake and decreased digestion and absorption.

Jeff: Those are the main 3 procedures to know about. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty. The biliopancreatic diversion is used infrequently but is one of the most effective procedure in treating diabetes, though it does have an increased risk of complications. Expect to see this mostly in those with BMIs over 50.

Nachi: Now that you have a sense of the procedures, let’s talk complications, both general and specific.

Jeff: Of course, it should go without saying that this population is susceptive to all the typical post-operative complications such as venous thromboembolic disease, atelectasis, pneumonia, UTIs, and wound complications.

Nachi: Because of their typical comorbidities, CAD and PE are still the leading causes of mortality, especially within the perioperative period.

Jeff: Also, be on the lookout for self-harm emergencies as patients with known psychiatric disorders are at increased risk following bariatric surgery.

Nachi: Surgical complications are wide ranging and can be grouped into early and late complications. More on this later…

Jeff: Nutritional deficiencies are common enough to warrant pre and postoperative screening. Thiamine deficiency is one of the most common deficiencies. This can manifest within 1-3 months of surgery as beriberi or later as Wernicke encephalopathy. Symptoms of beriberi include peripheral neuropathy, ataxia, muscle weakness, high-output heart failure, LE edema, and respiratory distress.

Nachi: All of that being said, each specific procedure has it’s own unique set of complications that we should discuss. Let’s start with the sleeve gastrectomy.

Jeff: Early complications of sleeve gastrectomy include staple-line leaks, strictures, and hemorrhage. Leakage from the staple line typically presents within the first week, but can present up to 35 days, usually with fevers, tachycardia, abdominal pain, nausea, vomiting sepsis, or peritonitis. This is one of the most serious and dreaded early complications and represents an important cause of morbidity with an incidence of 3-7%.

Nachi: Strictures commonly occur at the incisura angularis of the remnant stomach and are usually due to ischemia, leaks, or twisting of the gastric pouch. Patients with strictures usually have n/v, reflux, and intolerance to oral intake.

Jeff: Hemorrhag...]]> false https://podcast.show/emplify/episode/44511928/ 44511928 http://www.blubrry.com/emplify/episode/44511928/ EB Medicine Thu, 06 Jun 2019 09:53:20 -0400 Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy.

Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago!

Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.”

Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence.

Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic.

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Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians.

Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology.

Nachi: All valid points, but let’s dive in too some actual detail.

Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly.

Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die.

Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit.

Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes.

Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit!

Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum.

Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain.

Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list.

Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO.

Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population

Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group.

Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though.

Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%.

Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly.

Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly.

Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy

Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players.

Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth.

Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause.

Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic.

Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy.

Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed.

Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy.

Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January?

Jeff: We sure did! Take another listen if that doesn’t ring a bell.

Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ.

Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias.

Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especia...]]> false https://podcast.show/emplify/episode/43727107/ 43727107 http://www.blubrry.com/emplify/episode/43727107/ EB Medicine Fri, 03 May 2019 20:49:00 -0400 Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry

Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department.

Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression?

Nachi: That would certainly be all of our listeners!

Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval?

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Nachi: Again, just about all of our listeners I’m sure!

Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes?

Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in.

Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University.

Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside.

Jeff: Quite the team, from a variety of backgrounds.

Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt.

Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23%

Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode.

Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable.

Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions.

Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history.

Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest.

Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks.

Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning.

Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes.

Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD.

Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder.

Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself.

Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.”

Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt.

Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan.

Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%.

Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers...

Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients.

Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men.

Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older.

Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression.

Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide.

Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US.

Nachi: That’s an incredible amount and much more than I would have guessed.

Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals.

Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often.

Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods.

Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts

Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another.

Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study.

Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation.

Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality.

Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization.

Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations.

Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions.

Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations.

Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in...]]> false https://foamed.ebmedicine.net/podcast/episode-27-emergency-department-diagnosis-and-treatment-of-sexually-transmitted-diseases-pharmacology-cme-and-infectious-disease-cme/ 86604260 http://www.blubrry.com/emplify/episode/86604260/ EB Medicine Tue, 02 Apr 2019 11:38:04 -0400 false https://podcast.show/emplify/episode/42222836/ 42222836 http://www.blubrry.com/emplify/episode/42222836/ EB Medicine Fri, 01 Mar 2019 14:27:00 -0500 Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management.

Nachi: With no gold standard diagnostic test and with complications ranging from simple ectopic beats to fulminant cardiac failure and death, this isn’t an episode you’ll want to miss.

Jeff: Before we begin, let me give a quick shout out to our incredible group of authors from New York -- Dr. Eric Morley, Dr. Bryan English, and Dr. David Cohen of Stony Brook Medicine and Dr. William Paolo, residency program director at SUNY Upstate. I should also mention their peer reviewers Drs. Jennifer Maccagnano and Ashley Norse of the NY institute of technology college of osteopathic medicine and UF Health Jacksonville, respectively.

Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST.

Jeff: Clearly a large undertaking for a difficult topic to come up with solid evidence based recommendations.

Nachi: For sure. Let’s begin with some epidemiology, which is admittedly quite difficult without universally accepted diagnostic criteria.

Jeff: As you likely know, despite advances in motor vehicle safety, trauma remains a leading cause of death for young adults. In the US alone, each year, there are about 900,000 cases of cardiac injury secondary to trauma. Most of these occur in the setting of vehicular trauma.

Nachi: And keep in mind, that those injuries don’t occur in isolation as 70-80% of patients with blunt cardiac injury sustain other injuries. This idea of concomitant trauma will be a major theme in today’s episode.

Jeff: It certainly will. But before we get there, we have some more definitions to review - cardiac concussion and contusion, both of which were defined in a 1989 study. In this study, cardiac concussion was defined as an elevated CKMB with a normal echo, while a cardiac contusion was defined as an elevated CKMB and abnormal echo.

Nachi: Much to my surprise, though, abnormal echo and elevated ck-mb have not been shown to be predictive of adverse outcomes, but conduction abnormalities on ekgs have been predictive of development of serious dysrhythmia

Jeff: More on complications in a bit, but first, returning to the idea of concomitant injuries, in one autopsy study of nearly 1600 patients with blunt trauma - cardiac injuries were reported in 11.9% of cases and contributed to the death of 45.2% of those patients.

Nachi: Looking more broadly at the data, according to one retrospective review, blunt cardiac injury may carry a mortality of up to 44%.

Jeff: That’s scary high, though I guess not terribly surprising, given that we are discussing heart injuries due to major trauma...

Nachi: The force may be direct or indirect, involve rapid deceleration, be bidirectional, compressive, concussive, or even involve a combination of these. In general, the right ventricle is the most frequently injured area due to the proximity to the chest wall.

Jeff: Perfect, so that's enough background, let’s talk differential. As you likely expected, the differential is broad and includes cardiovascular injuries, pulmonary injuries, and other mediastinal injuries like pneumomediastinum and esophageal injuries.

Nachi: Among the most devastating injuries on the differential is cardiac wall rupture, which not surprisingly has an extremely high mortality rate. In terms of location of rupture, both ventricles are far more likely to rupture than the atria with the right atria being more likely to rupture than the left atria. Atrial ruptures are more survivable, whereas complete free wall rupture is nearly universally fatal.

Jeff: Septal injuries are also on the ddx. Septal injuries occur immediately, either from direct impact or when the heart becomes compressed between the sternum and the spine. Delayed rupture can occur secondary to an inflammatory reaction. This is more likely in patients with a prior healed or repaired septal defects.

Nachi: Valvular injuries, like septal injuries, are rare. Left sided valvular damage is more common and carries a higher mortality risk. In order, the aortic valve is more commonly injured followed by the mitral valve then tricuspid valve, and finally the pulmonic valve. Remember that valvular damage can be due to papillary muscle rupture or damage to the chordae tendineae. Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema.

Jeff: Next on the ddx are coronary artery injuries, which include lacerations, dissections, aneurysms, thrombosis, and even MI secondary to increased sympathetic activity and platelet activity after trauma. In one review, dissection was the most commonly uncovered pathology, occurring 71% of the time, followed by thrombosis, which occured only 7% of the time. The LAD is the most commonly injured artery followed by the RCA.

Nachi: Pericardial injury, including pericarditis, effusion, tamponade, and rarely rupture, is also certainly on the differential.

Jeff: In terms of dysrhythmias, sinus tachycardia is the most common dysrhythmia, with other rhythms, including PVC / PAC / and afib being found only 1-6% of the time.

Nachi: And while conduction blocks are rare, a RBBB is the most commonly noted, followed by a 1st degree AVB.

Jeff: Though also rare, commotio cordis deserves it’s own section as its the second most common cause of death in athletes < 18 who are victims of blunt trauma. Though only studied in swine models, it’s hypothesized that the impact to the chest wall during T-wave upstroke can precipitate v-fib.

Nachi: Aortic root injuries usually occur at the insertion of the ligamentum arteriosum and isthmus. Such injuries typically result in aortic insufficiency.

Jeff: And the last pathology on the differential requiring special attention is a myocardial contusion. Again, no standard definition exists, with some diagnostic criteria including simply chest pain and increasing cardiac enzymes, and others including cardiac dysfunction, ecg abnormalities, wall motion abnormalities, and an elevation of cardiac enzymes.

Nachi: Certainly a pretty broad differential… before moving on to the work up, Jeff why don’t you get us started with prehospital care?

Jeff: Prehospital management should focus on rapid identification and stabilization of life threatening injuries with expeditious transport as longer prehospital times have been associated with increased mortality in trauma. Immediate transport to a Level I trauma center should be the highest priority for those with suspected blunt cardiac injury.

Nachi: In terms of who specifically should be transporting the patient, a Cochrane review evaluated the utility of ALS vs BLS transport in trauma. There is reasonably good data to support BLS over ALS, even when controlling for trauma severity. Moreover, when airway management is needed, advanced airway techniques by ALS crews were associated with decreased odds of survival. Regardless of who is there, the message is the same: focus not on interventions, but instead on rapid transport.

Jeff: And if it does happen to be an ALS transport crew, without delaying transport, pain management with fentanyl is both safe and reasonable and preferred over morphine. Post opiate hypotension in prehospital trauma patients is a rare but documented complication.

Nachi: And if the prehospital team is lucky enough, or maybe unlucky enough, i don’t know, to have a credentialed provider who can perform ultrasound for those suspected of having a blunt cardiac injury, the general prehospital data on ultrasound is sparse. As of now, it’s difficult to conclude if prehospital US improves care for trauma patients.

Jeff: Interestingly, the system I work in has prehospital physicians, who do carry US, but I can’t think of a major trauma where ultrasound changed any of the decisions we made.

Nachi: Right, and I think that just reinforces the main point here: there may be a role, we just don’t have the data to support it at this time.

Jeff: Great, let’s move onto ED care, beginning with the H&P.

Nachi: On history, make sure to elucidate if there is any chest pain, and if it’s onset was before or after the traumatic event. In addition, make sure to ask about dyspnea, fatigue, palpitations, and lightheadedness.

Jeff: And don’t forget to get the crash details from the EMS crew before they depart! As a side note, for anyone taking oral boards in a few months, don’t forget to ask the EMS crew for the details!!!

Nachi: A definite must for oral boards and for your clinical practice.

Jeff: In terms of the physical, tachycardia is the most common abnormality in blunt cardiac injury. In those with severe injury, you may note refractory hypotension secondary to cardiogenic shock. But don’t be reassured by normal vitals, especially in the young, who may be compensating well despite being quite ill.

Nachi: Fully undress the patient to appropriately inspect and percuss the chest wall - looking for signs of previous cardiac surgeries or pacemaker placement, as well as to auscultate for new murmurs which may be a sign of valvular injury.

Jeff: Similarly, as concomitant injuries are common, inspect the abdomen, looking for ecchymosi...]]> false https://podcast.show/emplify/episode/41424637/ 41424637 http://www.blubrry.com/emplify/episode/41424637/ EB Medicine Fri, 01 Feb 2019 06:00:00 -0500 Shownotes

Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re tackling an incredibly important topic - evaluation and management of life threatening headaches in the Emergency Department.

Nachi: Fear not, this will not simply be “who needs a head CT episode”; we’ll cover much more than that. Listen closely as this is an important topic, with huge consequences for mismanagement.

Jeff: Absolutely. As some quick background - headaches account for 3% of all ED visits in the US, with 90% being benign primary headaches and less than 10% being secondary to other causes like vascular, infectious, or traumatic etiologies. It’s within these later 10% that we are looking for the red flag signs to identify the potentially life-threatening headaches.

Nachi: And to do so, Dr. David Zodda and Dr. Amit Gupta, PD and APD at Hackensack University Medical and Trauma Center, and their colleague Dr. Gabrielle Procopio, a PharmD, have done a fantastic job parsing through the literature, which included over 500 abstracts, 89 full text articles, guidelines from ACEP and the American Academy of Neurology, as well as canadian and european neurology guidelines, to summarize the best evidence based recommendations for you all.

Jeff: We would be remiss to not also mention Dr. Mert Erogul of Maimonides Medical Center and Dr. Steven Godwin, Chair of Emergency Medicine at the University of Florida College of Medicine.

Nachi: Alright, so let’s get started with some definitions and pathophysiology. The international classification of headache disorders 3, or ICHD-3, classifies headaches into primary, secondary, and cranial neuropathies.

Jeff: Primary headache disorders include migraine, tension, and cluster headaches. Secondary headaches include those secondary to vascular disorders, traumatic disorders, and disorders in hemostasis. These are the potentially life threatening headaches that can have a mortality has high as 50%.

Nachi: And the final category includes cranial neuropathies, such as trigeminal neuralgia.

Jeff: And I think we can safely say that that wraps up our discussion in this episode on cranial neuropathies, moving on….

Nachi: Headaches result from traction to or irritation of the meninges and blood vessels, which are the only innervated central nervous system structures. Activation of specific nerve ganglion complexes by neuropeptides like -- substance P and calcitonin gene-related peptide -- are thought to contribute to head pain.

Jeff: It is important to note that all headache pain shares common pain pathways, thus response to pain medications does not exclude potential life threatening secondary causes of headache. This led to the ACEP guideline which states just that..

Nachi: I feel like that deserves ding sound as it's a critically important point. To repeat, just because a pain medication relieves a headache, that does not exclude dangerous secondary causes!

Jeff: And what are the life threatening headaches? Life-threatening headaches include subarachnoid hemorrhage, cervical Artery Dissection, which includes both vertebral Artery Dissection and carotid artery dissection, cerebral Venous Thrombosis, idiopathic intracranial hypertension, giant cell arteritis, and posterior reversible encephalopathy syndrome, or PRES.

Nachi: Slow down for a second and let’s not skip over your favorite section.. Let’s talk pre hospital care for headache patients.

Jeff: Good call! Pre-hospital care is fairly straightforward and includes a primary survey, conducting a focused neurologic exam, and assessing for red flag signs, which include focal neurologic deficits, sudden onset headache, new headache in those over 50, neck pain or stiffness, changes in visual Acuity, fever or immunocompromised State, history of malignancy, pregnancy or postpartum status, syncope, and seizure. That’s quite a list. For a visual reference, see Table 3 in the print issue.

Nachi: And patients with neurologic deficits or severe sudden-onset headaches, should be transported immediately to the nearest available stroke center. Tylenol should be offered for pain management. Avoid opioids and nsaids.

Jeff: Upon arrival to the emergency department, history and physical should include your standard vitals, testing neurologic function, cranial nerve testing, head and neck exam, as well as a fundoscopic exam. As was the case for your pre-hospital colleagues, you should also assess for red flag signs for life-threatening headaches. Check out tables 2, 3, and 4 for more details here.

Nachi: With respect to Vital Signs, in the setting of an acute headache, severe hypertension should prompt a search for signs of end-organ damage such as hypertensive encephalopathy, intracranial Hemorrhage, PRES, and preeclampsia in pregnant women. Additionally, fever, and especially fever and neck stiffness, should raise concern for CNS infection.

Jeff: For your neurologic examination, make sure to include assessments of motor strength, coordination, reflexes, sensory function, and gait. Don't forget that lesions involving the anterior circulation, such as dysarthria, cognitive impairment, and Horner syndrome may be indicative of a carotid artery dissection, whereas dizziness, vision changes, and limb weakness may be due to a vertebral Artery Dissection.

Nachi: And for cranial nerve testing - pay particular attention to cranial nerves 2, 3 and 6. For cranial nerve 2 - look out for an afferent pupillary defect, or a marcus-gunn pupil, which is seen in optic neuritis, giant cell artertitis, and central retinal artery occlusion. For CN3, oculomotor nerve palsies raise concern for a posterior communicating aneurysm and SAH. And lastly, CN6 palsies, which often presents with diplopia on lateral gaze , are often seen with intracranial idiopathic hypertension and cerebral venous thrombosis, in addition to impaired visual acuity, visual field defects, and tunnel vision.

Jeff: For the head and neck exam, remember that a partial horner syndrome, with miosis and ptosis without anhidrosis, may be indicative of a cervical artery dissection. Unfortunately, if the patient presents acutely, their only complaint may be pain, as the neurologic sequelae may take days to develop.

Nachi: Additionally, with respect to the head and neck exam, evaluate the patient for tenderness and beading along the temporal artery.

Jeff: One review noted that temporal artery beading actually had the highest likelihood ratio for GCA, 4.6, whereas temporal artery tenderness only had a LR of 2.6

Nachi: And the last physical exam maneuver you should ideally perform is a fundoscopic exam for papilledema, which is often seen in IIH, malignant hypertension, and CVT.

Jeff: Perfect so that rounds out the physical, next we have diagnostic studies. Most importantly, routine lab testing is typically of low utility in aiding in the diagnosis of headache.

Nachi: Even ESR and CRP in the setting of possible giant cell arteritis have poor sensitivity and specificity to diagnose it. So even if the ESR and CRP are negative, if the suspicion for GCA is high enough, it should be treated and you should get a biopsy.

Jeff: Do consider adding on a venous or arterial carboxyhemoglobin in the right clinical scenario, as CO poisoning represents an important cause of headache you wouldn’t want to miss. This is especially important at this time of year when heating systems are working overtime here in the states.

Nachi: And hopefully you have a co-oximeter, so you can even check this non-invasively.

Jeff: Interestingly, there may be a unique role for a d-dimer here as well. Several small studies have used the d-dimer to risk stratify patients with possible CVT. In one study a d-dimer level < 500 mcg/L had a 97% sensitivity and a negative predictive value of 99% - not bad!

Nachi: Pretty impressive performance characteristics. I think that about wraps up lab work. Let’s talk radiology.

Jeff: Though low yield, CT utilization is estimated at 2.5-10% of non-traumatic headaches. A non-con CT should be reserved for those with suspicion for an intracranial hemorrhage, while a contrast CT would be required in those in whom there is concern for an infectious process or space occupying lesion.

Nachi: CT angio or MRI should be used in cases of possible cervical artery dissection. MRI also is the neuroimaging of choice for PRES, which is more sensitive for cerebral edema than CT.

Jeff: Similarly, MRV is recommended in those with a concerning story for CVT.

Nachi: To help guide your emergent neuroimaging utilization, ACEP suggests imaging in those with headache and an abnormal finding on neuro exam, those with new and sudden-onset severe headache, HIV positive patients with new headache, and those over 50 with a new headache.

Jeff: With that in mind, let’s dive a bit deeper into the use of CT for SAH, a topic which doesn’t get a ding sound, but is certainly critically important. Recent literature have found that a CT within 6 hours of symptom onset has a sensitivity and specificity and negative predictive value of 100%. In addition, one 2016 study demonstrated a LR of 0.01 in those with a negative HCT within 6 hours. These are really important results because that means SAH is essentially ruled out with a negative study.

Nachi: Unfortunately, the 2008 ACEP guideline and 2012 AHA guidelines still recommend a lumbar puncture in those being worked up for SAH. Luckily the ACEP guideline is currently being revised so your decision to forego the LP with a negative HCT in the fi]]> false https://podcast.show/emplify/episode/40672545/ 40672545 http://www.blubrry.com/emplify/episode/40672545/ EB Medicine Wed, 02 Jan 2019 14:33:00 -0500  

Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic…

Nachi: … woah wait, slow down for a minute, before we begin this month’s episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback.

Jeff: And we’re actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary.

Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward.

Jeff: With that, let’s get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management.

Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke’s, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine.

Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database.

Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature.

Jeff: It’s great to know that there is good literature on this topic. It’s incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time.

Nachi: Oh, and speaking of being worth your time…. Don’t forget that if you’re listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy.

Jeff: Let’s get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities.

Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage.

Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities.

Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes.

Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience bleeding in their first trimester. Not all of these will go on to miscarriages, though the risk does increase with maternal age. And of those that miscarry, nearly 50% were due to fetal chromosomal abnormalities.

Nachi: So can we prevent a miscarriage, once the patient is bleeding…?

Jeff: Short answer, no, longer answer, we’ll get to treatment in a few minutes. For now, let’s continue outlining the various first trimester emergencies. Next up, ectopic pregnancy…

Nachi: An ectopic pregnancy is implantation of a fertilized ovum outside of the endometrial cavity. This occurs in up to 2% of pregnancies. About 98% occur in the fallopian tube. Risk factors for an ectopic pregnancy include salpingitis, history of STDs, history of PID, a prior ectopic, and smoking.

Jeff: Interestingly, with respect to smoking, there is a dose-relationship between smoking and ectopic pregnancies. Simple advice here: don’t smoke if you are pregnant or trying to get pregnant.

Nachi: Pretty sound advice. In addition, though an IUD is not a risk factor for an ectopic pregnancy, if you do become pregnant while you have in IUD in place, over half of these may end up being ectopic.

Jeff: It’s also worth mentioning a more obscure related disease pathology here – the heterotopic pregnancy -- one in which there is an IUP and an ectopic pregnancy simultaneously.

Nachi: Nausea and vomiting, though not as scary as miscarriages or an ectopic pregnancy, represent a fairly common pathophysiologic response in the first trimester -- with the vast majority of women experiencing nausea and vomiting. And as we mentioned earlier, only 3% of these progress to hyperemesis gravidarum.

Jeff: And while nausea and vomiting clearly sucks, they seem to actually be protective of pregnancy loss, with a hazard ratio of 0.2.

Nachi: Although this may be protective of pregnancy loss, nausea and vomiting can really decrease the quality of life in pregnancy -- with one study showing that about 25% of women with severe nausea and vomiting had actually considered pregnancy termination. 75% of those women also stated they would not want to get pregnant again because of these symptoms.

Jeff: So certainly a big issue.. Two other common first trimester emergency are asymptomatic bacteriuria and UTIs. In pregnant patients, due to anatomical and physiologic changes in the GU tract – such as hydroureteronephrosis that occurs by the 7th week and urinary stasis due to bladder displacement – asymptomatic bacteriuria is a risk factor for developing pyelonephritis.

Nachi: And pregnant women are, of course, still susceptible to the normal ailments of young adult women like acute appendicitis, which is the most common surgical problem in pregnancy.

Jeff: Interestingly, based on epidemiologic data, pregnant women are less likely to have appendicitis than age-matched non-pregnant woman. I’d like to think that there is a good pathophysiologic explanation there, but I don’t have a clue as to why that might be.

Nachi: Additionally, the RLQ is the the most common location of pain from appendicitis in pregnancies of all gestational ages. Peritonitis is actually slightly more common in pregnant patients, with an odds ratio of 1.3.

Jeff: Alright, so I think we can put that intro behind us and move on to the differential.

Nachi: When considering the differential for abdominal pain or vaginal bleeding in the first trimester, you have to think broadly. Among gynecologic causes, you should consider miscarriage, septic abortion, ectopic pregnancy, corpus luteum cyst, ovarian torsion, vaginal or cervical lacerations, and PID. For non-gynecologic causes, you should also consider appendicitis, cholecystitis, hepatitis, and pyelonephritis.

Jeff: In the middle of that laundry list you mentioned there is one pathology which I think merits special attention - ovarian torsion. Don’t forget that patients undergoing ovarian stimulation as part of assisted reproductive technology are at a particularly increased risk due to the larger size of the ovaries.

Nachi: Great point. Up next we have prehospital care...

Jeff: Always a great section. First, prehospital providers should attempt to elicit an ob history. Including the number of weeks’ gestation, LMP, whether an IUP has already been confirmed, prior hx of ectopic, and a...]]> false https://podcast.show/emplify/episode/39856562/ 39856562 http://www.blubrry.com/emplify/episode/39856562/ EB Medicine Sat, 01 Dec 2018 11:13:23 -0500  

Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic that is ripe for review this time of year. We’re talking Influenza… Diagnosis and Management.

Nachi: Very appropriate as the cold is settling in here in NYC and we’re already starting to see more cases of influenza. Remember that as you listen through the episode, the means we’re about to cover one of the CME questions for those of you listening at home with the print issue handy.

Jeff: This month’s issue was authored by Dr. Al Giwa of the Icahn School of Medicine at Mount Sinai, Dr. Chinwe Ogedegbe of the Seton Hall School of Medicine, and Dr. Charles Murphy of Metrowest Medical Center.

Nachi: And this issue was peer reviewed by Dr. Michael Abraham of the University of Maryland School of Medicine and by Dr. Dan Egan, Vice Chair of Education of the Department of Emergency Medicine at Columbia University.

Jeff: The information contained in this article comes from articles found on pubmed, the cochrane database, center for disease control, and the world health organization. I’d say that’s a pretty reputable group of sources. Additionally, guidelines were reviewed from the american college of emergency physicians, infectious disease society of america, and the american academy of pediatrics.

Nachi: Some brief history here to get us started -- did you know that in 1918/1919, during the influenza pandemic, about one third of the world’s population was infected with influenza?

Jeff: That’s wild. How do they even know that?

Nachi: Not sure, but also worth noting -- an estimated 50 million people died during that pandemic.

Jeff: Clearly a deadly disease. Sadly, that wasn’t the last major outbreak… fifty years later the 1968 hong kong influenza pandemic, H3N2, took between 1 and 4 million lives.

Nachi: And just last year we saw the 2017-2018 influenza epidemic with record-breaking ED visits. This was the deadliest season since 1976 with at least 80,000 deaths.

Jeff: The reason for this is multifactorial. The combination of particularly mutagenic strains causing low vaccine effectiveness, along with decreased production of IV fluids and antiviral medication because of the hurricane, all played a role in last winter’s disastrous epidemic.

Nachi: Overall we’re looking at a rise in influenza related deaths with over 30,000 deaths annually in the US attributed to influenza in recent years. The ED plays a key role in outbreaks, since containment relies on early and rapid identification and treatment.

Jeff: In addition to the mortality you just cited, influenza also causes a tremendous strain on society. The CDC estimates that epidemics cost 10 billion dollars per year. They also estimate that an epidemic is responsible for 3 million hospitalized days and 31 million outpatient visits each year.

Nachi: It is thought that up to 20% of the US population has been infected with influenza in the winter months, disproportionately hitting the young and elderly. Deaths from influenza have been increasing over the last 20 years, likely in part due to a growing elderly population.

Jeff: And naturally, the deaths that we see from influenza also disproportionately affect the elderly, with up to 90% occurring in those 65 or older.

Nachi: Though most of our listeners probably know the difference between an influenza epidemic and pandemic, let’s review it anyway. When the number of cases of influenza is higher than what would be expected in a region, an epidemic is declared. When the occurrence of disease is on a worldwide spectrum, the term pandemic is used.

Jeff: I think that’s enough epidemiology for now. Let’s get started with the basics of the influenza virus. Influenza is spread primarily through direct person-to-person contact via expelled respiratory secretions. It is most active in the winter months, but can be seen year-round.

Nachi: The influenza virus is a spherical RNA-based virus of the orthomyxoviridae family. The RNA core is associated with a nucleoprotein antigen. Variations of this antigen have led to the the 3 primary subgroups -- influenza A, B, and C, with influenza A being the most common.

Jeff: Influenza B is less frequent, but is more frequently associated with epidemics. And Influenza C is the form least likely to infect humans -- it is also milder than both influenza A or B.

Nachi: But back to Influenza A - it can be further classified based on its transmembrane or surface proteins, hemagglutinin and neuraminidase - or H and N for short. There are actually 16 different H subtypes and 9 different N subtypes, but only H1, H2, H3, and N1 and N2 have caused epidemic disease.

Jeff: Two terms worth learning here are antigen drift and anitgen shift. Antigen drift refers to small point mutations to the viral genes that code for H and N. Antigen shift is a much more radical change, with reassortment of viral genes. When cells are infected by 2 or more strains, a new strain can emerge after genetic reassortment.

Nachi: With antigen shift, some immunity may be maintained within a population infected by a similar subtype previously. With antigen drift, there is loss of immunity from prior infection.

Jeff: The appearance of new strains of influenza typically involves an animal host, like pigs, horses, or birds. This is why you might be hear a strain called “swine flu”, “equine flu”, or “avian flu”. Close proximity with these animals facilitates co-infection and genetic reassortment.

Nachi: I think that’s enough basic biology for now, let’s move on to pathophysiology. When inhaled, the influenza virus initially infects the epithelium of the upper respiratory tract and alveolar cells of the lower respiratory tract. Viral replication occurs within 4 to 6 hours. Incubation is 18 to 72 hours. Viral shedding is usually complete roughly 7 days after infection, but can be longer in children and immunocompromised patients.

Jeff: As part of the infectious process and response, there can be significant changes to the respiratory tract with inflammation and epithelial cell necrosis. This can lead to viral pneumonia, and occasionally secondary bacterial pneumonia.

Nachi: The secondary bacterial pathogens that are most common include Staph aureus, Strep pneumoniae, and H influenzae.

Jeff: Despite anything you may read on the internet, vaccines work and luckily influenza happens to be a pathogen which we can vaccinate against. As such, there are 3 methods approved by the FDA for producing influenza vaccines -- egg-based, cell-based, or recombinant influenza vaccine. Once the season’s most likely strains have been determined, the virus is introduced into the medium and allowed to replicate. The antigen is then purified and used to make an injection or nasal spray.

Nachi: It isn’t easy to create vaccines for all strains. H3N2, for example, is particularly virulent, volatile, and mutagenic, which leads to poor prophylaxis against this particular subgroup.

Jeff: In fact, a meta-analysis on vaccine effectiveness from 2004-2015 found that the pooled effectiveness against influenza B was 54%, against the H1N1 pandemic in 2009 was 61%, and against the H3N2 virus was 33%. Not surprisingly, H3N2 dominant seasons are currently associated with the highest rates of influenza cases, hospitalizations, and death.

Nachi: Those are overall some low percentages. So should we still be getting vaccinated? The answer is certainly a resounding YES.. Despite poor protection from certain strains, vaccine effectiveness is still around 50% and prevents severe morbidity and mortality in those patients.

Jeff: That’s right. The 2017-2018 vaccine was only 40% effective, but this still translates to 40% less severe cases and a subsequent decrease in hospitalizations and death.

Nachi: But before we get into actual hospitalization, treatment, and preventing death, let’s talk about the differential. We’re not just focusing on influenza here, but any influenza like illness, since they can be hard to distinguish. The CDC defines “influenza-like illness” as a temperature > 100 F, plus cough or sore throat, in the absence of a known cause other than influenza.

false https://podcast.show/emplify/episode/39023198/ 39023198 http://www.blubrry.com/emplify/episode/39023198/ EB Medicine Thu, 01 Nov 2018 05:00:00 -0400

Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re back with our old routine – no special guests.

Nachi: Don’t sound so sad about it! Jeremy was great last month, and he’s definitely paved the way for more special guests in upcoming episodes.

Jeff: You’re right. But this month’s episode is special in its own way - we’ll be tackling Electrical Injuries in the emergency department - from low and high voltage injuries to the more extreme and rare lightning related injuries.

Nachi: And this is obviously not something we see that often, so listen up for some easy to remember high yield points to help you when you get an electrical injury in the ED. And pay particular attention to the , which, as always, signals the answer to one of our CME questions.

Jeff: I hate to digress so early and drop a cliché, “let’s start with a case…” but we, just a month ago, had a lightning strike induced cardiac arrest in Pittsburgh, so this hits really close to home. Thankfully, that gentleman was successfully resuscitated despite no bystander CPR, and if you listen carefully, we hope to arm you with the tools to do so similarly.

Nachi: This month’s print issue was authored by Dr. Gentges and Dr. Schieche from the Oklahoma University School of Community Medicine. It was peer reviewed by Dr. O’Keefe and Dr. Silverberg from Florida State University College of Medicine and Kings County Hospital, respectively.

Jeff: And unlike past issues covering more common pathologies, like, say, sepsis, this month’s team reviewed much more literature than just the past 10 years. In total, they pulled references from 1966 until 2018. Their search yielded 477 articles, which was narrowed to 88 after initial review.

Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Thankfully, fatalities are declining, with just 565 in 2015. On average, between 25 and 50 of the yearly fatalities can be attributed to lightning strikes.

Jeff: Interestingly, most of the decrease in fatalities is due to improvements in occupational protections and not due so much to changes in healthcare.

Nachi: That is interesting and great to hear for workers. Also, worth noting is the trimodal distribution of patients with electrical injuries: with young children being affected by household currents, adolescent males engaging in high risk behaviors, and adult males with occupational exposures and hazards.

Jeff: Electrical injuries and snake bites – leave it to us men to excel at all the wrong things… Anyway, before we get into the medicine, we unfortunately need to cover some basic physics. I know, it might seem painful, but it’s necessary. There are a couple of terms we need to define to help us understand the pathologies we’ll be discussing. Those terms are: current, amperes, voltage, and resistance.

Nachi: So, the current is the total amount of electrons moving down a gradient over time, and it’s measured in amperes.

Jeff: Voltage, on the other hand, is the potential difference between the top and bottom of a gradient. The current is directly proportional to the voltage. It can be alternating, AC, or direct, DC.

Nachi: Resistance is the obstruction of electrical flow and it is inversely proportional to the current. Think of Ohm’s Law here. Voltage = current x resistance.

Jeff: Damage to the tissues from electricity is largely due to thermal injury, which depends on the tissue resistance, voltage, amperage, type of circuit, and the duration of contact.

Nachi: That brings us to an interesting concept – the let-go threshold. Since electrical injuries are often due to grasping an electric source, this can induce tetanic muscle contractions and therefore the inability to let go, thus increasing the duration of contact and extent of injury.

Jeff: Definitely adding insult to injury right there. With respect to the tissue resistance, that amount varies widely depending on the type of tissue. Dry skin has high resistance, far greater than wet or lacerated skin. And the skin’s resistance breaks down as it absorbs more energy. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat have the highest resistance. In between nerve and bone or fat, we have blood and vascular tissue, which have low resistance, and muscle and the viscera which have a slightly higher resistance.

Nachi: Understanding the resistances will help you anticipate the types of injuries you are treating, since current will tend to follow the path of least resistance. In high resistance tissues, most of the energy is lost as heat, causing coagulation necrosis. These concepts also explain why you may have deeper injuries beyond what can be visualized on the surface.

Jeff: And not only does the resistance play a role, but so too does the amount and type of current. AC, which is often found in standard home and office settings, but can also be found in high voltage transmission lines, usually affects the electrically sensitive tissues like nerve and muscle. DC has a higher let-go threshold and does not cause as much sensation. It also requires more amperage to cause v-fib. DC is often found in batteries, car and computer electrical systems, some high voltage transmission lines, and capacitors.

Nachi: Voltage has a twofold effect on tissues. The first mechanism is through electroporation, which is direct damage to cell membranes by high voltage. The second is by overcoming the resistance of body tissues and intervening objects such as clothes or water. You’re probably familiar with this concept when you see high voltages arcing through the air without direct contact with the actual electrical source, leading to diffuse burns.

Jeff: As voltage increases, the resistance of dry skin is -- not surprisingly -- reduced, leading to worse injuries.

Nachi: And for this reason, the US Department of Energy has set 600 Volts as the cutoff for low vs high voltage electrical exposure.

Jeff: It is absolutely critical that we also mention and then re-mention throughout this episode, that those with electrical injuries often have multisystem injuries due to not only the thermal injury, electrical damage to electrically sensitive tissue, but also mechanical trauma. Injuries are not uncommon both from forceful pulling away from the source or a subsequent fall if one occurs.

Nachi: That’s a great point which we’ll return to soon, as it plays an important role in destination selection. But before we get there, let’s review the common clinical manifestations of electrical injuries.

Jeff: First up is – the cutaneous injuries. Most electrical injuries present with burns to the skin. Low voltage exposures typically cause superficial burns at the entry and exit sites, whereas high voltage exposures cause larger, deeper burns that may require skin grafting, debridement, and even amputation.

Nachi: High voltage injuries can also travel through the sub-q tissue leading to extensive burns to deep structures despite what appears to be relatively uninjured skin. In addition, high voltage injuries can also result in superficial burns to large areas secondary to flash injury.

Jeff: Electrical injuries can also lead to musculoskeletal injuries via either thermal or mechanical means. Thermal injury can lead to muscle breakdown, rhabdo, myonecrosis, edema, and in worse cases, compartment syndrome. In the bones, it can lead to osteonecrosis and periosteal burns.

Nachi: In terms of mechanical injury – electrical injury often leads to forceful muscular contraction and falls. In 2 retrospective studies, 11% of patients with high voltage exposures also had traumatic injuries.

Jeff: While not nearly as common, the rarer cardiovascular injuries are certainly up there as the most feared. Pay attention to the entry and exit sites, as the pathway of the shock is predictive of the potential for myocardial injury and arrhythmia. Common arrhythmias include AV block, bundle branch blocks, a fib, QT prolongation and even ventricular arrhythmias, including both v-fib and v-tach, both of which typically occur immediately after the injury.

Nachi: There is a school of thought out there that victims of electrical injury can have delayed onset arrhythmias and require prolonged car]]> false https://podcast.show/emplify/episode/38111951/ 38111951 http://www.blubrry.com/emplify/episode/38111951/ EB Medicine Mon, 01 Oct 2018 04:00:00 -0400 Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos.

Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. We have a special  episode for you this month… We’ve brought Dr. Jeremy Rose, one of the peer reviewers, and a sepsis expert, on with us to talk through the content this month.

Jeremy: Dr. Jeremy Rose here. Thanks for having me in on this conversation.  I’m always happy to talk about this topic because it’s clearly important.  There’s a great deal of confusion around sepsis and I hope that in the next couple minutes we can clarify things in a way that really help your average front line doc trying to get it right.

Nachi: So Dr. Rose, before we get started, tell us a bit about your background and your interest in sepsis…

Jeremy: I’m the Assistant Medical Director and Sepsis Chair at Mount Sinai Beth Israel in Manhattan.  For those listening, my hospital probably looks a little bit like yours.  We’re busy, interesting, and just a little rough around the edges.  We like it that way.  More importantly, though, we mirror the national averages regarding sepsis.  Roughly half of in-hospital mortality is associated with septic  in some fashion.  Pretty incredible when you think about it.  Half.

Jeff:  Sepsis chair... clearly this is an important topic if it warrants it’s own chair at a major hospital in NYC. But getting back to the article this month. This month’s issue was authored by Faheem Guirgis, Laurent Page Black, and Elizabeth DeVos of the University of Florida, Department of Emergency Medicine.

Nachi: And it was peer reviewed by Michael Allison, Assistant Director of the Adult ICU at Saint Agnes Hospital, and Jeremy Rose and Eric Steinberg of Mount Sinai Beth Israel.

Jeff: So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis?  It seems that every month or so we have a new guideline, bundle, definition, or whatever… I think it’s best to start with the basics -  At its core, sepsis is a dysregulated response to infection that can be life-threatening.

Nachi: Right and it’s the combined inflammatory with immunosuppressive features of sepsis that lead to the devastating organ dysfunction and even death. Optimal management of septic patients has been a source of intense research, stemming from the landmark study by Rivers in 2001. Jeremy, can you give us a little historical context there?

Jeremy: Rivers was a real pioneer.  He found a 16% mortality reduction with randomization to an early aggressive care bundle.  Amazing work.  That being said, many components of that bundle have since been disregarded.  For example, Manny Rivers would measure CVP in all of his patients, something we rarely do.

Nachi: Not to cut you off and steal your thunder there, but we’ll get to the most recent updates in management shortly. Let’s first talk definitions and terminology, and specifically, diagnosis, which is definitely a big elephant in the room. As Jeff mentioned a few minutes ago, diagnostic criteria have undergone so so so many changes.

Jeff: Yes it has! 1991 marked the first standardized definition.  Then in 2001, sepsis-2 was introduced.  In 2014, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine started a task force, and by 2016, updated definitions were out again! Sepsis-3!! A lot of this came after the realization that SIRS was just too broad and was overly sensitive and non-specific. Jeremy, why don’t you take us through Sepsis 3.

Jeremy: So just to back up a little and frame this:

Here’s the fundamental problem:  As we likes to say, “there’s no troponin for sepsis.”  And if you look at our patients, we tend not to miss the hypotensive, tachycardic, febrile patient.  We know they’re septic.  But how do we find the ones who don’t look as sick.  Frequently elderly, possibly with normal-ish vitals and no fever.  Those can be a lot harder to spot, but they may indeed be septic.  Also, for research purposes we have to have a common definition, so Sepsis 3 came up with something called the SOFA score.

The problem with the SOFA score is that its difficult to perform in the ED.  It has parameters like bilirubin that often aren’t available when we want to screen out very sick patients.  Fortunately there is the abridged version qSOFA, which identifies non-icu patients who are at high risk of inpatient mortality.

So here it is, and if you get one thing from this episode, this is it:

There are ONLY 3 criteria to the qSOFA.  3 Criteria. RR > 22; AMS; SBP <= 100. That’s it. If you have two of these criteria, you are up to 14 times more likely to die of sepsis during a hospital admission. That’s pretty profound; these patients are very sick.  This is meant to replace SIRS.  It also captures  a much sicker population than the patients included in the Medicare definition.

Jeff: So why do you think these parameters turn out to be so useful?

Jeremy:  Drilling down into these criteria you can see the pathophysiology at work. Obviously, SBP < 100 means sick.  Interestingly, an elevated RR also turns out to be prognostic, because you’re seeing the compensation for an underlying acidosis.  WHen you see a patient breathing quickly, it’s either from a primary respiratory problem or them trying to relieve an underlying acidosis. The caveat here is that you have to check it. At our hospital in southern Manhattan, patients tend to breathe around 16.  At our hospital in northern Manhattan they like to breath around 18. It’s probably because the air is thinner.  Seriously though, you have to actually measure RR for this to work. Temp is not in QSOFA but we should be checking that too. And I mean checking it by putting something that measures temperature inside the patient. We’ve looked at the forehead and tympanic thermometers and in real world conditions, they tend to underestimate by a degree or more. Think about that. A patient with a headache and a temperature of 99.5 is a very different patient than one with a temp of 100.5.  Make sure you measure temperature.

Nachi: Very true and these two patients can definitely go down very different management pathways! Rounding out our discussion on sepsis-3. We should note that severe sepsis is now a term of the past under Sepsis-3. And sepsis-3 redefined septic shock as “hypotension not responsive to fluid resuscitation” with the added requirement of vasopressors to maintain a MAP greater than or equal to 65 and with a lactate > 2. So quite a few changes!

Jeff: And Jeremy, sticky topic coming up here. Center for Medicare and Medicaid Services (or CMS) quality measures - They haven’t really caught on to and adapted to Sepsis-3 yet, have they?

Jeremy:  The CMS mandate is based on the presence of SIRS criteria. Sepsis 3 is based on SOFA.  This is definitely confusing.  Part of the challenge in discussing this topic is separating out the QI guidelines from what is actually relevant to patient care based on the latest evidence-based medicine.

Nachi: That seems fair.  We’re really going to put you in an uncomfortable spot for a second and push you here Jeremy. Do you have any insight into why CMS isn’t interested in following the mountains of research that have led to sepsis-3? Is there a reason they are sticking to their current criteria?

Jeremy:  I think some of it is the slow pace of bureaucracy and the time that it takes to develop a consensus on management.  Even if we can agree on who is septic, it’s really hard, if not impossible to link the care to a pay-for-performance metric which is what CMS ultimately would like to see.  That’s not how Sepsis-3, or for that matter, SIRS, was designed to be used.  You’re trying to take a tool which was originally designed for research and mold them into a tool used for pay for performance.

Nachi: What a struggle. The CMS metrics are slightly different from the 2001 sepsis guidelines also. Take a look at Table 2 of the article for a quick comparison of sepsis-3, 2001 sepsis, and cms side-by-side. And for those on twitter, we’ll be sure to tweet this table out too for your review.

Jeff: With so many different scores and definitions, I think that adequately sets the stage for the challenge this month’s authors faced coming up with real evidenced based guidelines.

Nachi: Oh absolutely.  And to make matters worse - this is a HUGE problem. We’re talking up to 850,000 ED visits annually in the US, and 19 million cases worldwide. Compounding this, sepsis results in death in approximately 1 out of 4 cases. Not only is it lethal, it is also very costly -- 17 billion dollars per year in the US alone!

Jeff: And don’t forget importantly the 30-day hospital readmission rate. Sepsis is coming in at a higher readmission rate and cost per admission than acute MI, CHF, COPD, and PNA.

Nachi: Let’s speak briefly on the etiology and pathophysiology of sepsis: we all know that sepsis is due to local infections that then become systemic. Previously, it was believed that the bacterial infection itself was the cause of the clinical syndrome of sepsis. However, we now know now that the syndrome of sepsis is due to the inflammatory and immunosuppressive mediators that were triggered by the infection. Normal immune regulatory safeguards fail and this leads to the syndrome. And interestingly, several studies have shown that critically ill septic patients experience reactivations of specific viruses that were previously limited to patients with severe immunosuppression.

Jeff: Definitely something to look out for in your criticall...]]> false https://podcast.show/emplify/episode/36567760/ 36567760 http://www.blubrry.com/emplify/episode/36567760/ EB Medicine Sat, 01 Sep 2018 05:00:00 -0400 Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the September 2018 issue of Emergency Medicine Practice - Emergency Department Management of North American Snake envenomations.

Nachi: Although this isn’t something we encountered too frequently – it does seem like I’ve been hearing more about snake bites in the recent months.

Jeff: I actually flew someone just the other day because the local ED ran out of CroFab after an envenomation in Western PA.

Nachi: Yeah, this is definitely more than “just a boards topic,” and it’s really important to know about in those rare circumstances. In terms of incidence, there are actually about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species.

Jeff:  That’s a good teaser, so let’s start by recognizing this month’s team – the two authors, Dr. Sheikh, a medical toxicologist, and Patrick Leffers, a pharmD, and emergency medicine and clinical toxicology fellow. Both are at the University of Florida Jacksonville, and they reviewed a total of 120 articles from 2006-2017, in addition to reviews from both Cochrane and Dare.

Nachi: And don’t forget our peer reviewers this month, Dr. Daniel Sessions, a medical toxicologist working at the South Texas Poison Center, and our very own editor-in-chief, Dr. Andy Jagoda, who is also Chair of the Department of Emergency Medicine at Mount Sinai in New York City.

Jeff: What a team! But, let’s get back to the snakes. As some background, from 2006-2015 there were almost 66,000 reported snake exposures and 31 deaths from snake envenomation in the US.  Of course, this number likely underestimates the true total.

Nachi: And there are two key subfamilies of venomous snakes to be aware of – the Crotalinae – or pit vipers – which includes rattlesnakes, copperheads, and water moccasins; and the Elapidae – of which you really only need to know about the coral snake.

Jeff:  And while those are the only two NATIVE snake subfamilies to be acutely aware of, don’t forget that exotic snakes, which are shockingly popular pets -- they can also cause significant morbidity and mortality.

Nachi:  Oh, and one other quick note before we get into the epidemiology – most of the recommendations this month come from expert opinion, as high quality RCTs are obviously difficult.  In addition, many of the studies were based in other countries, where the snakes, the anti-venoms and their availability, and the general healthcare systems are different from those that most of us work in.

Jeff:  Unless we have listeners abroad? Do we have listeners in other countries?

Nachi: Oh we definitely do... but we are going to be a bit biased towards US envenomation today. In any case, venomous snake bites occur most frequently in men aged 18 to 49 during warmer months with provoked bites occurring more frequently in the upper extremities and unprovoked bites in the lower extremities.

Jeff:  In one study of poison center data from the last decade, nearly half of all victims of snake bites were victims of unknown type snakes.  However, of those that were known, copperheads were the most common, while rattlesnakes caused the most fatalities – 19 of 31 in this dataset.

Nachi:  In a separate study of snake bites in the early 2000s, 32% of exposures were from venomous snakes and 59% of those resulted in admission. That’s remarkably high.

Jeff:  Snake bite severity depends on several key factors: the amount of venom, the composition of the venom, the body size of the bite victim, the victim's clothing, the size of the bite, comorbid conditions, and the timing and quality of medical care the victim receives.

Nachi:  To be a bit more specific - First, the amount of venom will depend on the species of snake, with variations even occurring within the same species.  Secondly, while there is a correlation between rattlesnake size and bite severity, there is much more at play.  Some snakes can even vary the amount of venom based on threat risk – with defensive bites having different profiles than bites to strike prey.

Jeff: I found it pretty interesting that  an estimated 10-25% of pit viper bites are considered dry bites, that is, ones in which no venom is released.

Nachi:  Right, this is just one reason why all victims shouldn’t immediately get anti-venom, but we’ll get there.

Jeff:  We definitely will.  As we already stated – venom composition varies greatly.  Pit vipers produce a predominantly hemotoxic venom.  Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis.  Neurotoxicity is rare and is usually due to inter-breeding between species.

Nachi:  While rattlesnake bites are associated with higher morbidity and mortality, the more common copperhead bites typically only cause local tissue effects.  More serious systemic findings such as coagulopathy and respiratory failure have been reported though.

Jeff:  So that’s a solid background to get us started.  Let’s talk about the individual snakes.  Why don’t you start with the crotalinae family – aka the pit vipers.

Nachi:  Sure – the crotalinae includes rattlesnakes, cottonmouths (also known as water moccasins), and copperheads.  These make up the vast majority of reports to the poison centers.  They can be identified by their heat sensing pits located behind their nostrils (hence pit vipers).  As a general rule, you can also identify the venomous snakes by their triangular or spade-like head, elliptical pupils, and hollow retractable fangs.

Jeff:  wait, so you want me to walk up to the snake and ask to see if their fangs retract… yea, no thanks.

Nachi: Haha, of course not, I’m just giving you some of the general principles here. In contrast, non-venomous pit vipers have rounded heads, round pupils, a double row of vertical scales, and they lack fangs.

Jeff: In terms of location, rattlesnakes are found in all states but Hawaii, and cottonmouths and copperheads are distributed mostly throughout the southern and southeastern states, with copperheads also extending further north, even into Massachusetts.

Nachi: Moving on to the Elapidae –  there are 3 species of coral snakes, only two of which you need to know about, Micrurus fulvius fulvius or the eastern coral snake and Micrurus tener or the Texas coral snake.  Of the two, the eastern or Micrurus fulvius fulvius produces more potent venom.

Jeff:  As you may have guessed by their names, the eastern coral snake is found in the southeastern united states, specifically, east of the Mississippi -- whereas the Texas coral snake lives west of the Mississippi.

Nachi:  Venomous North American coral snakes can be recognized by the red and yellow bands around their bodies whereas their nonvenomous counterparts can be recognized by their characteristic black band between the red and yellow bands. I’m sure you’ve heard the popular mnemonic for this… Red touch yellow kill a fellow, red touch black, venom lack.

Jeff:  I have heard that one, and it’s not a bad mnemonic. Just remember that this is more of a guideline than a rule, as it doesn’t always hold true.

Nachi: Coral snakes also tend to chew rather than bite thanks to their short, fixed, hollow fangs.  Locally, bites can lead to muscle destruction thanks to a certain myotoxin.  Systemic signs of infection include nausea, vomiting, abdominal pain, and dizziness. 

Jeff: The venom also contains a neurotoxin which can lead to diplopia, difficulty swallowing and speaking and generalized weakness.

Nachi: Complicating matters even further, the onset of these symptoms may be delayed for many hours.

Jeff:  Alright, so I think that about wraps up the background.  Let’s move on to the meat and potatoes of this article, starting with the differential.

Nachi:  For differential this month, we are really focusing on differentiating a venomous snake from a non-venomous one.

Jeff: Oh yeah, this is where you want us to ask the snake if it can retract its fangs, right?

Nachi: Ha very funny – Although the type of snake may be obvious if the patient...]]> false https://podcast.show/emplify/episode/35911851/ 35911851 http://www.blubrry.com/emplify/episode/35911851/ EB Medicine Wed, 01 Aug 2018 08:00:00 -0400 Show Notes

Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos.

Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice.

Nachi: This month’s topic is one that Jeff has significant personal experience with from his college days. We’re reviewing Cannabinoids -- and emerging evidence in their use and abuse.

Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes?

Nachi: Sometimes…

Jeff: This month’s issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York.

Nachi: We’re going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready.

Jeff: As you’re listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you’re not driving while listening, be sure to jot down these answers and get your CME credit when we’re going through this issue..

Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US.

Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available.

Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure.

Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia.

Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance.

Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses.

Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising.

Jeff: Let’s get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described.

Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found in the greatest quantities. The neuropsychiatric and addictive properties of cannabis are due primarily to the delta-9-THC.

Jeff: THC and other cannabis derivatives work through the endocannabinoid system and other neuroregulators. The endogenous cannabinoid system has 4 components: (1) endogenous endocannabinoids, (2) receptors, (3) degradation enzymes, and (4) transport mechanisms.

Nachi: There are two endogenous endocannabinoids to know about: anandamide (AEA) and 2-arachidonoyl-glycerol.

Jeff: Cannabinoid receptors are broadly dispersed through the central nervous system, and to a lesser degree, also to other organ systems.

Nachi: Because CB receptors are concentrated within the central nervous system, they exert the majority of their effects on the neuropsychiatric systems. And   -- yes that’s a double ding -- the cannabinoid 1 (or CB1) receptor is most responsible for cannabis-induced neuropsychiatric effects.

Jeff: Interestingly, the anti-emetic effects and possible palliative properties of cannabis derivatives are thought to be secondary to the inhibitory effects on serotonin receptors and the excitatory effects on the transient receptor potential vanilloid 1 (or TRPV1).  More on TRPV1 later...

Nachi: So far we have been talking about cannabinoids from the cannabis plant, but with cannabis being illegal in many states, there has been a growing emergence of synthetic cannabinoids. Synthetics were initially developed in the 1980s largely for research purposes.

Jeff: Because the current DEA controlled substances schedule designations are based on original chemical names, synthetics have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designation as well as routine urine drug screening tests.

Nachi: You may be familiar with some of the street names for synthetics -- like spice, K2, scooby snacks, black mamba, kush, and kronic. These can often be purchased over the internet or through specialty smoke shops.

Jeff: Scooby Snacks, what a fantastic name, mooovingggg on… Synthetic cannabinoids often have greater affinity for the CB1 receptor than naturally occurring cannabinoids -- and synthetics can produce 100 times the effect. As a result, the presenting symptoms with synthetic intoxication can be difficult to differentiate from crystal meth or bath salt abuse.

Nachi: Manufacturers sometimes use solvents and other contaminants. Clusters of toxic ingestions and deaths have occurred. Emergency clinicians need to be aware of this and should report suspicious events immediately.

Jeff: For more on synthetic intoxications in the ED, be sure to take a look at the recent May 2018 issue of Pediatric Emergency Medicine Practice on Synthetic Drug Intoxication in Children if you haven’t already read it. Also, just a quick FYI - If you’re not a current subscriber to Pediatric Emergency Medicine Practice, we’re giving away a free copy of the issue specifically for our listeners. Just head over to ebmedicine.net/drugs for the PDF of the issue.

Nachi: A free issue for our listeners, that’s nice! Let’s move on to a discussion about current indications for cannabinoids. So, there is no clear consensus on these indications, but there is some research of varying quality that supports the treatment of some chronically debilitating diseases with cannabinoids.

Jeff: A systematic review and meta-analysis from 2015 found low-quality evidence to support cannabis therapy for appetite suppression in HIV and aids patients; moderate-quality evidence for treatment of chronic pain and spasticity; and also moderate quality evidence for some chronic debilitating diseases.

Nachi: While talking about evidence-based medicine here, another review by the National Academies of Science, Engineering, and Medicine on possible associations between cannabis and cancers arising in the lungs, head, and neck, or testicles -- showed no statistically significant associations exist.

Jeff: So in case that wasn’t clear - the overall evidence to support cannabis therapy, in general, is weak. Also, be aware that there are various formulations of cannabis that allow for different routes of administration. We’re talking oils, tinctures, teas, extracts, edibles like candies and baked goods, parenteral formulations, eye solutions, intranasal, sublingual, transmucosal, tablets, sprays, skin patches, topical creams, rectal suppositories, and capsules -- just to name, a few.

Nachi: A few! That seems pretty complete to me. Basically, any way you can imagine, it seems like a route of administration has been explored. But of importance, these formulations have different absorption times -- as you might expect. The shortest duration to peak plasma levels of delta-9-THC is through the inhalation route, which can produce effects within 3 minutes. On the longer end, rectal cannabis administration can take up to 8 hours to reach peak plasma concentrations.

Jeff: Let’s talk about some of the clinical findings and systemic effects associated with cannabis use. First up is the link between cannabis use and stroke or TIA. Cannabis users wh...]]> false https://podcast.show/emplify/episode/35213943/ 35213943 http://www.blubrry.com/emplify/episode/35213943/ EB Medicine Sun, 01 Jul 2018 10:18:24 -0400 Join Jeff, a former firefighter, and Nachi, a former mathematician, as they take you through the July 2018 issue of Emergency Medicine Practice: Emergency department management of dyspnea in the dying patient

Most Important References

17. Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest. 1986;89(2):234-236. (Prospective; 1754 patients)34. Lunney JR, Lynn J, Foley DJ, et al. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387-2392. (Prospective cohort; 4190 patients)40. Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476-2482. (Cross-sectional survey; 1122 patients/families/providers)41. Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want “everything.” Ann Intern Med. 2009;151(5):345-349. (Review)63. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer. 2009;17(4):367-377. (Nonrandomized trial; 46 patients)66. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. 2010;376(9743):784-793. (Double-blind randomized controlled trial; 239 patients)68. Galbraith S, Fagan P, Perkins P, et al. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage. 2010;39(5):831-838. (Randomized controlled crossover trial; 50 patients)]]> false https://foamed.ebmedicine.net/podcast/episode-17-managing-shoulder-injuries-in-the-emergency-department-fracture-dislocation-and-overuse/ 86604250 http://www.blubrry.com/emplify/episode/86604250/ EB Medicine Fri, 01 Jun 2018 08:00:00 -0400 false https://foamed.ebmedicine.net/podcast/episode-16-recognizing-and-managing-emerging-infectious-diseases-in-the-emergency-department/ 86604249 http://www.blubrry.com/emplify/episode/86604249/ EB Medicine Tue, 01 May 2018 08:00:00 -0400 false https://foamed.ebmedicine.net/podcast/episode-15-jaundice-in-the-emergency-department-meeting-the-challenges-of-diagnosis-and-treatment/ 86604248 http://www.blubrry.com/emplify/episode/86604248/ EB Medicine Sun, 01 Apr 2018 08:00:00 -0400 false https://podcast.show/emplify/episode/31829404/ 31829404 http://www.blubrry.com/emplify/episode/31829404/ EB Medicine Thu, 01 Mar 2018 07:58:19 -0500 When treating patients who have suffered injury in a fire, managing their airway is as critical as treating their burns.

Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the March 2018 issue of Emergency Medicine Practice: Emergency Department Management of Smoke Inhalation Injuries in Adults.

This month’s issue was authored by Dr. Otterness and Dr. Ahn of the Stony Brook School of Medicine. It was also reviewed by a toxicology duo of Dr. Manini of The Icahn School of Medicine at Mount Sinai and Dr. Nelson of Rutgers New Jersey Medical School.

]]> false https://podcast.show/emplify/episode/31057940/ 31057940 http://www.blubrry.com/emplify/episode/31057940/ EB Medicine Thu, 01 Feb 2018 11:11:00 -0500 Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. We’ll be taking you through the February 2018 issue of Emergency Medicine Practice: Emergency Department Management of Patients with Thermal Burns.
]]> false https://foamed.ebmedicine.net/podcast/episode-12-managing-patients-with-oncologic-complications-in-the-emergency-department/ 86604245 http://www.blubrry.com/emplify/episode/86604245/ EB Medicine Mon, 01 Jan 2018 18:35:56 -0500 false 11 http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559 29373302 http://www.blubrry.com/emplify/episode/29373302/ EB Medicine Fri, 01 Dec 2017 07:31:00 -0500 Lower-extremity dislocations are less common in the emergency department (ED) than shoulder and elbow dislocations, and emergency clinicians’ experience with evaluation and reduction techniques is often limited. Nonetheless, these dislocations can be serious because of their association with vascular injury. This episode discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle.

This episode of EB Medicine's EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month's corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Caylyne Arnold, Dr. Zane Fayos, Dr. David Bruner, and Dr. Dylan Arnold. It was peer reviewed by Dr. Melissa Leber and Dr. Christopher Tainter.

Link to article: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559

]]> 0:27:28 false Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department 11 full https://podcast.show/emplify/episode/28574075/ 28574075 http://www.blubrry.com/emplify/episode/28574075/ EB Medicine Wed, 01 Nov 2017 00:00:00 -0400 Because of the chronic relapsing nature of inflammatory bowel disease (IBD), emergency clinicians frequently manage patients with acute flares and complications. IBD patients present with an often-broad range of nonspecific signs and symptoms, and it is essential to differentiate a mild flare from a life-threatening intra-abdominal process. Recognizing extraintestinal manifestations and the presence of infection are critical. This episode reviews the literature on management of IBD flares in the emergency department, including laboratory testing, imaging, and identification of surgical emergencies, emphasizing the importance of coordination of care with specialists on treatment plans and offering patients resources for ongoing support

This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Michael Burg and Dr. Steven Riccoboni. It was peer reviewed by Dr. Andrew Lee and Dr. Chad Roline.

Links and Resouces:

http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559 - Management of Inflammatory Bowel Disease Flares in the Emergency

]]> false https://podcast.show/emplify/episode/27681931/ 27681931 http://www.blubrry.com/emplify/episode/27681931/ EB Medicine Sun, 01 Oct 2017 14:15:05 -0400 COPD has huge economic and human burdens in the US. In fact, in 2010, two studies estimated that COPD exacted a direct and indirect cost of somewhere between $36 and $50 billion dollars in the US. With respect to the ED – in 2011, there were more than 1.7 million ED visits for COPD-related problems, with nearly 1/5th requiring hospitalization.

 

This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by a strong team from the University of Maryland: Drs. Van Holden, Donald Slack, Michael McCurdy, and Nirav Shah. It was peer reviewed by Dr. Gabriel Wardi of the University of California San Diego and Dr. Geralda Xavier of Kings County Hospital in New York City.

Links and Resouces:

http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=557 - Diagnosis and Management of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

]]> 0:29:15 false https://foamed.ebmedicine.net/podcast/episode-8-recognizing-and-managing-adrenal-disorders-in-the-emergency-department/ 86604241 http://www.blubrry.com/emplify/episode/86604241/ EB Medicine Fri, 01 Sep 2017 00:00:00 -0400 false https://foamed.ebmedicine.net/podcast/episode-7-emergency-management-of-renal-and-genitourinary-trauma-best-practices-update/ 86604240 http://www.blubrry.com/emplify/episode/86604240/ EB Medicine Tue, 01 Aug 2017 06:00:00 -0400 false https://foamed.ebmedicine.net/podcast/episode-6-identifying-emergency-department-patients-with-chest-pain-who-are-at-low-risk-for-acute-coronary-syndromes/ 86604239 http://www.blubrry.com/emplify/episode/86604239/ EB Medicine Sat, 01 Jul 2017 07:00:00 -0400 false https://foamed.ebmedicine.net/podcast/episode-5-dental-emergencies-management-strategies-that-improve-outcomes-trauma-cme/ 86604238 http://www.blubrry.com/emplify/episode/86604238/ EB Medicine Thu, 01 Jun 2017 01:00:00 -0400 false https://podcast.show/emplify/episode/23179760/ 23179760 http://www.blubrry.com/emplify/episode/23179760/ EB Medicine Mon, 01 May 2017 02:00:00 -0400 0:27:01 false https://foamed.ebmedicine.net/podcast/episode-3-maxillofacial-trauma-in-the-emergency-department/ 86604236 http://www.blubrry.com/emplify/episode/86604236/ EB Medicine Fri, 31 Mar 2017 20:30:00 -0400 false https://foamed.ebmedicine.net/podcast/episode-2-sedative-hypnotic-drug-withdrawal-syndrome-recognition-and-treatment/ 86604235 http://www.blubrry.com/emplify/episode/86604235/ EB Medicine Tue, 14 Mar 2017 23:30:00 -0400 false https://foamed.ebmedicine.net/podcast/episode-1-optimizing-survival-outcomes-for-adult-patients-with-nontraumatic-cardiac-arrest/ 86604234 http://www.blubrry.com/emplify/episode/86604234/ EB Medicine Tue, 14 Feb 2017 00:00:00 -0500 false https://foamed.ebmedicine.net/podcast/pilot-episode-transient-global-amnesia/ 86604233 http://www.blubrry.com/emplify/episode/86604233/ EB Medicine Mon, 30 Jan 2017 07:42:21 -0500 false