July 30, 2019
A review for the emergency physician of this common disease that can take many forms. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Lyme_Disease.mp3 Download Leave a Comment Tags: Infectious Diseases Show Notes Background * Most common tick-born illness in North America * Endemic in Northeast, Upper Midwest, northwest California * 80% to 90% in summer months Pathophysiology * Ixodes tick (deer tick) has a 3-stage life cycle (larvae, nymph, adult) & takes 1 blood meal per stage * Deer tick feeds on an infected wild animal (infected with spirochete Borrelia burgodrferi) then bites humans * On humans, they typically move until they encounter resistance (e.g. hairline, waistband, elastic, skin fold).  It takes 24-48 hrs for B. Burgdorferi to move from the tick to the host * Pathogenesis: organism induced local inflammation, cytokine release, autoimmunity * No person to person transmission Clinical Presentation Stage 1: Early * Symptom onset few days to a month after tick bite * Erythema migrans rash: bulls eye rash seen in more than 90% of patients with Lyme disease (Irregular expanding annular lesion(s)) * Regional adenopathy, intermittent fevers, headache, myalgias, arthralgia, fatigue, malaise Stage 2: disseminated/ secondary * Days to weeks after tick bite * Intermittent fluctuating sx that eventually resolve * Triad of aseptic meningitis, cranial neuritis, and radiculoneuritis: bell palsy most common * Cardiac symptoms: tachycardia, bradycardia, AV block, myopericarditis Stage 3: tertiary/ late * Symptoms occur >1 year after tick bite * Acrodermatitis chronic atrophicans: Atrophic lesions on extensor surfaces of extremities (resembles scleroderma) * Monoarthritis, oligoarthritis (knee > shoulder > elbow) * GI: Hepatitis, RUQ pain * Ocular: keratitis, uveitis, iritis, optic neuritis * Neurological: Chronic axonal polyneuropathy or encephalopathy Chronic Lyme disease (versus well-accepted Lyme disease sequelae): * Continuation of symptoms after antibiotics * Current recommendation for management is supportive care only Pediatric considerations: * More likely to be febrile than adults * Facial palsy accompanied by aseptic meningitis in 1/3 * Untreated kids can develop keratitis * Excellent prognosis if appropriately treated History * Travel, camping, woods, playing under leaves or in wood piles * Living in endemic area (Northeastern area: Maine to Virginia; upper Midwestern: Wisconsin, Minnesota; Northwest California) * Endemic in Northern Europe and Eastern Asia as well * History of tick bite (- 30-50% of patients recall tick bite)
July 15, 2019
An in depth review of this notorious parasite. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Malaria.mp3 Download Leave a Comment Tags: Infectious Diseases Show Notes Background * In 2017, there were 219 million cases and 435,000 people deaths from malaria * Five species: Falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. * Falciparum, Vivax and Knowlesi can be fatal * History of recent travel to Africa (69% of cases in US), particularly to west-Africa should raise suspicion for malaria Clinical Manifestations * Average incubation period for Falciparum is 12 days * 95% will develop symptoms within 1 month * Clinical findings with high likelihood ratios include periodic fevers, jaundice, splenomegaly, pallor. * Can also have vomiting, headache, chills, abdominal pain, cough, and diarrhea * Severe malaria has a mortality of 5% to 30%, even with therapy * Diagnostic criteria for severe malaria: Ashley 2018 * Most common manifestations of severe malaria affect the brain, lungs, and kidneys * Patients with cerebral malaria can present encephalopathic or comatose, some severe enough to exhibit extensor posturing, or seizures * Can have acute lung injury with a quarter of these patients progressing to ARDS * Can have AKI from ATN and resultant acidosis * Labs may be unremarkable but watch for anemia and thrombocytopenia * Hgb
July 1, 2019
A look at this common and controversial topic. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Otitis_Media.mp3 Download Leave a Comment Tags: Pediatrics Show Notes Background: * The most common infection seen in pediatrics and the most common reason these kids receive antibiotics * The release of the PCV (pneumococcal conjugate vaccine), or Prevnar vaccine, has made a big difference since its release in 2000 (Marom 2014) * This, along with more stringent criteria for what we are calling AOM, has led to a significant decrease in the number of cases seen since then * 29% reduction in AOM caused by all pneumococcal serotypes among children who received PCV7 before 24 months of age * The peak incidence is between 6 and 18 months of age * Risk factors: winter season, genetic predisposition, day care, low socioeconomic status, males, reduced duration of or no breast feeding, and exposure to tobacco smoke. * The predominant organisms: Streptococcus pneumoniae, non-typable Haemophilus influenzae (NTHi), and Moraxella catarrhalis. * Prevalence rates of infections due to Streptococcus pneumoniae are declining due to widespread use of the Prevnar vaccine while the proportion of Moraxella and NTHi infection increases with NTHi now the most common causative bacterium * Strep pneumo is associated with more severe illness, like worse fevers, otalgia and also increased incidence of complications like mastoiditis. Diagnosis * The diagnosis of acute otitis media is a clinical one without a gold standard in the ED (tympanocentesis) * Ear pain (+LR 3.0-7.3), or in the preverbal child, ear-tugging or rubbing is going to be the most common symptom but far from universally present in children. Parents may also report fevers, excessive crying, decreased activity, and difficulty sleeping. * Challenging especially in the younger patient, whose symptoms may be non-specific and exam is difficult * Important to keep in mind that otitis media with effusion, which does not require antibiotics, can masquerade as AOM AAP: Diagnosis of Acute Otitis Media (2013)* * In 2013, the AAP came out with a paper to help guide the diagnosis of AOM * Moderate-Severe bulging of the tympanic membrane or new-onset otorrhea not due to acute otitis externa (grade B) * The presence of bulging is a specific sign and will help us distinguish between AOM and OME, the latter has opacification of the tympanic membrane or air-fluid level without bulging (Shaikh 2012, with algorithm) * Bulging of the TM is the most important feature and one systematic review found that its presence had an adjusted LR of 51 (Rothman 2003) * Classic triad is bulging along with impaired mobility and redness or cloudiness of TM
June 17, 2019
A look at foot fractures – which can be splinted and which may need to go to the OR. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Foot_Fractures.mp3 Download Leave a Comment Tags: Orthopedics Show Notes Background: * Why do we care about Jones fractures? * Propensity for poor healing due to watershed area of blood supply * Fifth metatarsal fractures account for 68% of metatarsal fractures in adults * Proximal 5th metatarsal fractures are divided into 3 zones (93% zone 1, 4% zone 2, 3% zone 3) * Zone 1 (pseudo-Jones): * Tuberosity avulsion fracture * Typically avulsion type injuries due to acute episode of forefoot supination with plantar flexion * Typical fracture pattern is transverse to slightly oblique * Zone 2 (Jones fracture): * Fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal * Typically acute episode of large adduction force applied to forefoot with the ankle plantar flexed * Zone 3: * Proximal diaphyseal stress fracture * Typically results from a fatigue or stress mechanism Clinical Presentation: * History of acute or repetitive trauma to forefoot * Fracture type / pattern closely related to injury location * Foot often swollen, ecchymotic, very tender to fifth metatarsal +/- crepitus, inability to hear weight Diagnosis: * Clinical exam: * Evaluate skin integrity * Check neurovascular status * Evaluate toes/ feet/ ankles/ tib fib/ knees/ hips, involved tendon function, associated adjacent structures (Achilles, ankle ROM/ function, etc) * 3 XR views: lateral, anteroposterior, 45* oblique *  Acute stress fractures are typically not detected on the standard 3 views; therefore, repeat XRs 10-14d after onset of sx (may see radiolucent reabsorption gap around fracture) * For more complex mid foot trauma, consider CT to r/o Lisfranc Treatment: * Consider classification of fracture, patient demographics & activity level when deciding on treatment * Tertiary care centers that have access to Orthopedics/Podiatry services * Consider consultation for “true” Jones fractures, as some cases may be operatively managed acutely and/or for expedited follow-up to be arranged * If working in community/rural locations: other than patients that present with “open” injuries, concerns for compartment syndrome (almost never), and “high-end”/professional athletes, there are generally no other circumstances that would require expedited transfer to a tertiary care center for immediate further evaluation. * Less favorable outcomes associated with certain patient factors: female gender, DM, obesity
June 3, 2019
A discussion with Dr. McNamara and Dr. Leifer on the essentials and beyond of debriefing https://media.blubrry.com/coreem/content.blubrry.com/coreem/Debriefing.mp3 Download Leave a Comment Tags: Resuscitation, Simulation Show Notes TAKE HOME POINTS * Debriefing after a clinical case in the ED is a way to have an interprofessional, reflective conversation with a focus on improving for the next patient.  We can debrief routine cases, challenging cases, or even cases that go well. * Follow a structure when leading a debrief. * The prebrief sets ground rules and informs the team that the debrief is optional and will only take 3-5 minutes. * Introduce names and roles * Then give a one-liner about what happened in the case, followed by a plus/ delta: address  what went well and why, then how to improve * Finally, wrap up with take home points * Pitfalls to watch out for in clinical debriefing include: * Avoid siloing or alienating any learners.  Learn from all your colleagues on your team- it’s less about medicine and more about interprofessional and systems issues * Don’t pick on individual performance.  It’s not about shaming- it’s about improving patient care * Avoid “guess what I’m thinking” questions; ask real questions * Proceed with caution in order to dampen or avoid psychological trauma and second victim syndrome.  The learner may ask “was this my fault?”; we never want a learner to feel this way.  Ask, what systems supported or did not support you today?  Talk about what happened.  Avoid shame and blame. * Have the right values and do it for the right reasons. ADDITIONAL TOOLS PEARLS Debriefing Tool INFO Model: GUESTS Dr. Shannon McNamara completed residency in Emergency Medicine at Temple University hospital and fellowship in Medical Simulation at Mount Sinai St. Lukes-Roosevelt. She now is the Director of the Simulation Division in the NYU Department of Emergency Medicine. She's thrilled to have somehow made a career out of teaching people to talk about their feelings using big computers shaped like people. Dr. Jessica Leifer attended NYU for medical school and completed her residency training in emergency medicine at Mount Sinai St. Luke’s-Roosevelt. She completed a fellowship in medical simulation at the Mount Sinai Hospital. She is now simulation faculty in the NYU department of Emergency Medicine. Her academic interests include using simulation for patient safety, operations, and improving teamwork. Read Mor...
May 20, 2019
A look at one of the most common and potentially concerning upper respiratory infections in children. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Croup.mp3 Download Leave a Comment Tags: Airway, Infectious Diseases, Pediatrics Show Notes Background * Croup is a viral infection starts in the nasal and pharyngeal mucosa but spreads to the larynx and trachea * Subglottic narrowing from inflammation * Dynamic obstruction * Barking cough * Inspiratory stridor * Causes: * Parainfluenza virus (most common) * Rhinovirus * Enterovirus * RSV * Rarely: Influenza, Measles * Age range: 6 months to 36 months * Seasonal component with high prevalence in fall and early winter * Differential * Bacterial tracheitis * Acute epiglottitis * Inhaled FB * Retropharyngeal abscess * Anaphylaxis Presentation & Diagnosis * Classically a prodrome of nonspecific symptoms for 1-3 days with low grade fevers, congestion, runny nose. * Symptoms reach peak severity on the 4th day * “Steeple sign” on Xray (subglottic narrowing) present in only 50% of patients with croup * Assess air entry, skin color, level of consciousness, for tachypnea, if there are retractions / nasal flaring (if present at rest or with agitation) & coughing * “Westley Croup Score” (https://www.mdcalc.com/westley-croup-score) * Chest wall retractions * Stridor * Cyanosis * Level of consciousness * Air entry Management * Mild Croup * Occasional barking cough, but no stridor at rest and mild to no retractions * Tx: Single dose of dex * Has been shown to improve severity and duration of symptoms * Route is not particularly important, whether it’s PO, IV or IM * Chosen route should aim to minimize agitation in the patient that might worsen their condition * May be managed at with supportive care * Humidifiers (NB: there isn’t good evidence supporting the use of humidifiers) * Antipyretics * PO fluids * Moderate Group * May have stridor at rest, mild-moderate retractions but no AMS and will not be in distress. * Tx: Dex + Racemic Epinephrine * Racemic epinpehrine will start to work in about 10 minutes * Effects last for more than an hour * Severe group * Receives the same initial therapy as the moderate group with dex and race epi * Pts with worrisome signs: stridor at rest,
May 6, 2019
A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/SJS.mp3 Download Leave a Comment Tags: Critical Care, Dermatology Show Notes * Rash with dysuria should raise concern for SJS with associated urethritis * Dysuria present in a majority of cases * SJS is a mucocutaneous reaction caused by Type IV hypersensitivity * Cytotoxic t-lymphocytes apoptose keratinocytes → blistering, bullae formation, and sloughing of the detached skin * Disease spectrum * SJS = 30% TBSA * SJS/ TEN Overlap = 10-30% TBSA * Incidence is estimated at around 9 per 1 million people in the US * Mortality is 10% for SJS and 30-50% for TEN * Mainly 2/2 sepsis and end organ dysfunction. * SJS can occur even without a precipitating medication * Infection can set it off especially in patients with risk factors including HIV, lupus, underlying malignancy, and genetic factors * SATAN for the most common drugs * Sulfa, Allopurinol, Tetracyclines, Anticonvulsants, and NSAIDS * Anti-epileptics include carbamazepine, lamictal, phenobarb, and phenytoin * Can have a curious course * Hypersensitivity reaction can develop while taking medication, or even one to four weeks after exposure * In pediatric population, mycoplasma pneumonia and herpes simplex have been identified as precipitating infections * Patients often have a prodrome 1-3 days prior to the skin lesions appearing * May complain of fever, myalgias, headaches, URI symptoms, and malaise * Rash may be the sole complaint * Starts as dark purple or erythematous lesions with purpuric centers that progress to bullae * Skin surrounding the lesions detaches from the dermis with just light pressure (Nikolsky Sign) * Up to 95% of patients will have mucous membrane lesions * ~85% will have conjunctival lesions * Symptoms: Burning or itching eyes, a cough or sore throat, pain with eating, pain with urinating or defecating Source: JAMA Dermatol. 2017 * Differential Diagnosis: SSSS, autoimmune bullous diseases, bullous fixed drug eruption, erythema multiforme, thermal burns, phototoxic reactions, and TSS * SJS is a clinical diagnosis * Basic workup: CBC, chemistry panel, LFTs, and a UA * Treatment * Supportive care * IV fluid repletion guided by TBSA affected,
April 22, 2019
A look at the opioid epidemic and what ED providers can do to combat this formidable foe. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Opioid_Epidemic.mp3 Download Leave a Comment Tags: Opioid Dependence, Opioid Free ED Show Notes * Consider alternatives to opiates for acute pain * NSAIDs * Subdissociative ketamine * Nerve blocks * Curb misuse and diversion through prescribing a short supply and perform I-STOP checks * Narcan is not just for acute overdose treatment by EMS or within the ED anymore * We can equip patients, family members and friends with Narcan kits prior to discharge * In New York state, can prescribe Narcan to patients with near fatal overdoses or who screen positive for an opioid use disorder * Intranasal formulation is cheaper and more commonly prescribed than IM * Buprenorphine induction can be done in the ED for patients in active withdrawal, as calculated by the COWS score. * MDcalc calculator: https://www.mdcalc.com/cows-score-opiate-withdrawal * Providers do not need an X-waiver to give a dose of Buprenorphine in the ED for 3 days * Home induction can be considered for patients not actively withdrawing but would like to enter medication assisted treatment * Some considerations: * Contraindicated in patients with severe liver dysfunction and with hypersensitivity reaction to drug * Oversedation can occur with concurrent use of benzodiazepines and alcohol * Will precipitate withdrawal if concurrently using full opioid agonists * Longitudinal care has to be established for patients started on Buprenorphine * SAMHSA’s Buprenorphine practitioner locator site: https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator * Buprenorphine Induction Pamphlet Read More
April 8, 2019
In this episode, we discuss the recent measles outbreak and how ED providers can best prepare to treat this almost vanquished foe. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Measles_Final_Cut.mp3 Download One Comment Tags: Infectious Diseases, Pediatrics Show Notes       References: CDC Measles for Health Care Providers.  https://www.cdc.gov/measles/hcp/index.html#lab. Gladwin M, Trattler B.  Orthomyxo and Paramyxoviridae.  In: Clinical Microbiology Made Ridiculously Simple.  4th ed.  Miami, FL: MedMaster, Inc; 2009: 240-243. Hussey G, Klein M.  A Randomized, Controlled Trial of Vitamin A in Children with Severe Measles.  N Engl J Med.  1990; 323: 160-164.doi: 10.1056/NEJM199007193230304. Nir, Sarah Mailin and Gold, Michael.  “An Outbreak Spreads Fear: Of Measles, of Ultra-Orthodox Jews, of Anti-Semitism.”  New York Times [New York City] 03/29/2019. https://www.nytimes.com/2019/03/29/nyregion/measles-jewish-community.html A massive thanks to: Shweta Iyer, MD: NYU Langone 3rd year Pediatric Emergency Medicine Fellow. Jennifer Lighter, MD: Assistant Professor of Pediatric Infectious Diseases, NYU School of Medicine. Michael Mojica, MD: Associate Professor of Pediatric Emergency Medicine, NYU Langone Medical Center. Michael Phillips, MD: Chief Hospital Epidemiologist, NYU Langone Medical Center. Read More
March 22, 2019
In this episode, we discuss acute decompensated heart failure and how to best manage these dyspneic patients in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_ADHF.mp3 Download Leave a Comment Tags: Cardiology, Respiratory Show Notes * Features that increase the probability of heart failure. (Wang 2005) * B-lines seen in pulmonary edema. * Positioning of ultrasound probe in BLUE protocol. (Lichtenstein 2008) Read More
March 8, 2019
In this episode, we discuss Boxer's fractures and how to best manage them in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Boxer_s_Fracture_eq.m4a Download One Comment Tags: Orthopedics, Trauma Podcast Video https://youtu.be/UreET5eLHas Show Notes Background: * 40% of all hand fractures * A metacarpal fracture can occur at any point along the bone (head, neck, shaft, or base) * “Boxer’s” fractures classically at neck * Most common mechanism: direct axial load with a clenched fist * Most common metacarpal injured is the 5th * A majority of these injuries are isolated injuries, closed and stable Examination: * Ensure that this is an isolated injury * May note a loss of knuckle contour or shortening * A thorough evaluation of the skin is important * Patients may also have fight bites and require irrigation and antibiotics * Tender along the dorsum of the affected metacarpal * Evaluate the range of motion as the commonly seen shortening results in extension lag * For every 2 mm of shortening there is going to be a 7 degree decrease in ability to extend the joint * Check rotational alignment of digits with the MCP and PIP at 50% flexion. * Partially clench their fist and ensure that the axis of each digit converges near the scaphoid pole / mid wrist * Deformity is often seen due to the imbalance of volar and dorsal forces * Dorsal angulation * AP, lateral and oblique views should be obtained on XR * The degree of angulation is estimated with the lateral view * NB: Normal angle between the metacarpal head and neck is 15 degrees Management: * Most may be splinted with an ulnar gutter splint * Must be closed, not significantly angulated, and not malrotated * When splinting, place the wrist in slight extension, MCP (knuckles) at 90 degrees and the DIP and PIP in a relaxed, slightly flexed position * A closed reduction is indicated if there is significant angulation * “20, 30, 40” rule * If angulation is more than: * 20 in the middle finger metacarpal * 30 in the ring finger metacarpal * 40 in the pinky finger metacarpal * Analgesia with a hematoma block or ulnar nerve block * Reduction technique: https://www.aliem.com/2013/01/trick-of-trade-reducing-metacarpal/ Referral: * May have mild deformity or decreased functionality...
August 13, 2018
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_157_0_Final_Cut.m4a Download 5 Comments Read More
July 30, 2018
This week we dive into a recent article highlighting a major update in the treatment of community acquired pneumonia (CAP) https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_156_0_Final_Cut.m4a Download Leave a Comment Tags: CAP, Macrolides, Pulmonary Show Notes Read More REBEL EM: Update in Community Acquired Pneumonia (CAP) Treatment - Macrolide Resistance Moran GJ, Talan, DA; Pneumonia, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 76: p 978-89. Haran JP et al. Macrolide resistance in cases of community-acquired bacterial pneumonia in the emergency department. J Emerg Med 2018. PMID: 29789175 Mandell LA et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27–72. PMID: 17278083 Arnold FW et al. A worldwide perspective of atypical pathogens in community-acquired pneumonia. AmJ Respir Crit Care Med 2007;175:1086–93. PMID: 17332485 Read More
July 23, 2018
This week we discuss three recent articles looking at esmolol in refractory VF, c-spine clearance and antibiotics after abscess drainage https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_155_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiac Arrest, Cervical Spine, Esmolol, I+D, Infectious Diseases, Journal Club, MRSA, Refractory VF, Trauma Show Notes Read More REBEL EM: Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses Bryan Hayes at ALiEM: Sulfamethoxazole-Trimethoprim for Skin and Soft Tissue Infections: 1 or 2 Tablets BID? The SGEM: SGEM#164: Cuts Like a Knife Core EM: Antibiotics in the Treatment of Smaller Abscesses EM Nerd: The Case of the Pragmatic Wound REBEL EM: Refractory ventricular fibrillation Resus.ME: Esmolol for Refractory VF Read More
July 16, 2018
This week we review femoral shaft fractures with a focus on assessment and analgesia https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_154_0_Final_Cut.m4a Download Leave a Comment Tags: Femoral Nerve Blocks, Orthopedics Show Notes Read More Orthobullets Femoral Shaft Fracture Rosen’s Emergency Medicine Concepts and Clinical Practice(link) Tintinalli’s Emergency Medicine(link) Femoral Nerve Block video (link) Read More
July 9, 2018
More amazing pearls from our Bellevue morning report series. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_153_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Intoxication, Discitis, ESRD, Necrotizing Fasciitis Show Notes Read More Core EM: Spinal Epidural Abscess REBEL EM: Cauda Equina Syndrome Radiopaedia: Discitis LITFL: Necrotizing Fasciitis REBEL Cast: Episode 50 - Intoxicated Patients Can Equal Badness Read More
July 2, 2018
This week, we discuss penetrating neck trauma and some pearls and pitfalls in management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_152_0_Final_Cut.m4a Download Leave a Comment Tags: Neck Trauma, Trauma Show Notes REBEL EM: Penetrating Neck Injuries Zone 1 Zone 2 Zone 3 Anatomic Landmarks Clavicle/Sternum to Cricoid Cartilage Cricoid Cartilage to the Angle of the Mandible Superior to the Angle of the Mandible Anatomic Structures in Zone Proximal Common Carotid Artery Carotid Artery Vertebral Artery Subclavian Artery Vertebral Artery Distal Carotid Artery Vertebral Artery Jugular Vein Distal Jugular Vein Lung Apices Pharynx Salivary and Parotid Glands Trachea Trachea Cranial Nerves IX - XII Thyroid Esophagus Spinal Cord Esophagus Larynx Thoracic Duct Vagus Nerve Spinal Cord Recurrent Laryngeal Nerve Spinal Cord Hard + Soft Signs of Major Aerodigestive or Neurovascular Injury Hard Signs Soft Signs Airway Compromise Hemoptysis Expanding or Pulsatile Hematoma Oropharyngeal Blood Active, Brisk Bleeding Dyspnea Hemorrhagic Shock Dysphagia Hematemesis Dysphonia Neurologic Deficit Nonexpanding Hematoma Massive Subcutaneous Emphysema Chest Tube Air Leak Air Bubbling Through Wound Subcutaneous or Mediastinal Air
June 25, 2018
This week we discuss the difficult to diagnose and high morbidity cauda equina syndrome. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_151_0_Final_Cut.m4a Download Leave a Comment Tags: Back Pain, Cauda Equina Show Notes Take Home Points Cauda equina syndrome is a rare emergency with devastating consequences Early recognition is paramount as the presence of bladder dysfunction portends bad functional outcomes The presence of bilateral lower extremity weakness or sensory changes should alert clinicians to the diagnosis. Saddle anesthesia (or change in sensation) and any bladder/bowel changes in function should also raise suspicion for the disorder MRI is the diagnostic modality of choice though CT myelogram can be performed if necessary Prompt surgical consultation is mandatory for all patients with cauda equina syndrome regardless of symptoms at presentation Read More EM Cases: Best Case Ever 11: Cauda Equina Syndrome OrthoBullets: Cauda Equina Syndrome Radiopaedia: Cauda Equina Syndrome Perron AD, Huff JS: Spinal Cord Disorders, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 106: p 1419-30. References Lavy C et al. Cauda Equina Syndrome. BMJ 2009; 338: PMID: 19336488 Todd NV. Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurg 2005;19:301-6 PMID: 16455534 Read More
June 18, 2018
This week we review some recent publications on steroids in pharyngitis and the VAN assessment in stroke. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_150_0_Final_Cut.m4a Download Leave a Comment Tags: Pharyngitis, Steroids, VAN Assessment Show Notes Read More The SGEM: SGEM #203: Let Me Clear My Sore Throat with a Corticosteroid Core EM: Corticosteroids in Pharyngitis - Systematic Review + Meta-Analysis REBEL EM: Does it Take a VAN to Identify Emergency Large Vessel Occlusion (EVLO) in Ischemic Stroke? REBEL EM: Stroke Workflow in 2018 Stroke Workflow 2017 (REBEL EM) References Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials BMJ 2017; 358 :j3887. PMID: 28931508 Teleb MS et al. Stroke vision, aphasia, neglect (VAN) assessment - a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. J Neurointervent Surg 2017; 9(2): 122-6. PMID: 26891627 Read More
June 11, 2018
This week the podcast features a lecture from Dr. Frosso Admakos - Assistant Residency Director at Metropolitan Hospital in NYC https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_149_0_Final_Cut.m4a Download Leave a Comment Tags: All NYC EM, Pediatrics, Trauma Show Notes Take Home Points While peds traumas and severe traumas are uncommon, stay cool and collected - you’ve run many resuscitations in the past and resuscitating a kid is no different. You’ve got this When it comes to access, think 1, 2 IO. 2 shots at a peripheral line and if you don’t get it, go to IO Tachycardia should be assumed to be compensated shock until proven otherwise. Don’t write tachycardia off as anxiety Failed airway approach - place an 18 gauge catheter into the neck - hopefully through the cricothyroid membrane and bag through that. If you still have difficult getting an airway from above, consider a retrograde intubation over a wire Read More University of Maryland EM: Retrograde Intubation Read More
June 4, 2018
This episode reviews the highlights from the recent ACEP clinical policy on acute VTE management in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_148_0_Final_Cut.m4a Download Leave a Comment Tags: Deep Venous Thrombosis, DVT, PE, Pulmonary Embolism, VTE Show Notes Take Home Points The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing. Age-adjusted D-dimers are ready for use and it doesn’t matter if your assay uses FEU (cutoff 500) or DDU (cutoff 250). For FEU use an upper limit of 10 X age and for DDU use an upper limit of 5 X age. For now, subsegmental PEs should continue to routinely be anticoagulated even in the absence of a DVT. Keep an eye out for more research on this area. Although outpatient management of select PE patients (using sPESI or Hestia criteria) may be standard practice, the evidence wasn’t strong enough for ACEP to give it’s support Patients with DVT can be started on a NOAC and discharged from the ED sPESI Tool (MDCalc.com) PERC Decision Tool (MDCalc.com) Read More REBEL EM: ACEP Clinical Policy on Acute VTE 2018 Core EM: PE Rule-Out Criteria RCT Core EM: Age-Adjusted D-dimer (Using D-dimer Units) Core EM: Age Adjusted D-dimer in PE - The ADJUST-PE Trial REBEL EM: Is It PROER to PERC It Up References ACEP Clinical Policies Subcommittee. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71(5): e59-109. PMID: 29681319 Jaconelli T, Eragat M, Crane S. Can an age-adjusted D-dimer level be adopted in managing venous thromboembolism in the emergency department? A retrospective cohort study. European journal of emergency medicine : official journal of the Eur Soc Emerg Med. 2017. PMID: 28079562 Freund Y et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA 2018; 319(6): 559-66.
May 28, 2018
This episode reviews the identification and management of patients with salicylate toxicity. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_147_0_Final_Cut.m4a Download 4 Comments Tags: Aspirin, Salicylate, Toxicology Show Notes Take Home Points Always consider salicylate toxicity: In patients with tachypnea, hyperpnea, AMS and clear lungs In the presence of an anion gap metabolic acidosis with a respiratory alkalosis Treat salicylate toxicity by alkalinizing the blood and urine to increase excretion Avoid intubation until absolutely necessary. If you do have to intubate, minimize apneic time and consider awake intubation and nake sure your ventilator settings match the patient’s necessary high minute ventilation Think about chronic salicylate toxicity in unexplained altered mental status, tachypnea or metabolic acidosis in elderly Know indications for hemodialysis in salicylate toxic patients Read More REBEL EM: Salicylate Toxicity LITFL: Salicylates Wiki EM: Salicylate Toxicity Rebel EM: Acute Salicylate Toxicity, Mechanical Ventilation, and Hemodialysis * Mosier JM et al. The Physiologically Difficult Airway. The western journal of emergency medicine. 16(7):1109-17. 2015. PMID: 26759664 Read More
May 21, 2018
More pearls from our fantastic morning report series at Bellevue. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_146_0_Final_Cut.m4a Download Leave a Comment Tags: Endocarditis, Ludwig's Angina, Penetrating Neck Trauma Show Notes Take Home Points In patients with neck pain, consider Ludwig’s angina particularly if they have any swelling, fever, truisms or respiratory difficulty. Consider early airway management and get your consultants involved early for operative management Endocarditis is a tricky diagnosis and will often be subtle. Any patient with a prosthetic valve and a fever has endocarditis until proven otherwise. Suspect it in any patient with fever and a murmur, get lots of cultures and remember that TEE is the gold standard but, TTE is highly specific Finally, penetrating neck trauma. Patients with hard signs - airway compromise, ongoing brisk bleeding, an expanding/pulsatile hematoma, neurologic compromise, shock or hematemesis should go directly to the OR and don’t probe the wounds! Hard Signs in Penetrating Neck Injury (Sperry 2013) Management Algorithm for Penetrating Neck Injury (Sperry 2013) Read More LITFL: Ludwig’s Angina Core EM: Infective Endocarditis EM Cases: Endocarditis and Blood Culture Interpretation Sperry JL et al. Western Trauma Association Critical Decisions in Trauma: Penetrating Neck Trauma. J Trauma Acute Care Surg 2013; 75(6): 936-41. PMID: 24256663 [OPEN ACCESS] Read More
May 14, 2018
This week we discuss some pearls from the 14th All NYC EM Conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_145_0_Final_Cut.m4a Download Leave a Comment Tags: Documentation, Major Trauma, Massive Transfusion Protocol Show Notes All NYC EM Conference Read More Core EM: Episode 77.0 - Give TXA Now! Read More
May 7, 2018
This week we dive into rhinosinusitis exploring the recommendations of who needs antibiotics and who doesn't. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_144_0_Final_Cut.m4a Download Leave a Comment Tags: Acute Bacterial Sinusitis, ENT, Sinusitis Show Notes Take Home Points Acute rhinosinusitis is a clinical diagnosis The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement. Read More Core EM: Acute Rhinosinusitis TheNNT.com: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults TheNNT.com: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Read More
April 30, 2018
This week we review the presentation, examination and diagnosis of testicular torsion. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_143_0_Final_Cut.m4a Download Leave a Comment Tags: Acute Scrotal Pain, Torsion, Urology Show Notes Take Home Points Consider the diagnosis of testicular torsion in all patients with acute testicular pain Testicular torsion is a surgical emergency that requires immediate urologic consultation to increase the rate of tissue salvage. History, physical examination and ultrasound are all flawed in making the diagnosis. The gold standard is surgical exploration Consider manual detorsion in patients where consultation will be delayed Show Notes Core EM: Testicular Torsion Ben-Israel T et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28:786-789. Sidler D et al. A 25-year review of the acute scrotum in children. S Afr Med J. 1997;87(12) 1696-8. PMID: Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID: Ban KM, Easter JS: Selected Urologic Problems; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 99: p 1326-1356. Read More
April 23, 2018
This week we discuss more pearls from our morning report conference on APE, SAH and caustic ingestions. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_142_0_Final_Cut.m4a Download Leave a Comment Tags: APE, Cardiology, Caustic Ingestions, CHF, SAH, SCAPE, Subarachnoid Hemorrhage, Toxicology Show Notes Take Home Points In patients with APE, give high-dose nitro to decrease after load and preload quickly. 400-500 mcg/min for the first 4-5 minutes is my standard approach Consider DSI to facilitate pre-oxygenation. Ketamine is your go to drug here A NCHCT performed within 6 hours of symptom onset is extremely sensitive for ruling out SAH but, nothing is 100%. If you’ve got a high-risk patient, you should still consider LP Patients with caustic ingestions can have rapidly deteriorating airways. Prepare early and be ready to take over the airway at a moments notice Read More Core EM: Acute Pulmonary Edema EMCrit: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) EMCrit: Delayed Sequence Intubation Core EM: Setting Up Non-Invasive Ventilation The SGEM: Thunderstruck (Subarachnoid Hemorrhage) Friedman BW. Managing Migraine. Ann Emerg Med 2017; 69(2): 202-7. PMID: 27510942 Read More
April 16, 2018
This week we discuss some recent publications relevant to EM: ADRENAL, Idarucizumab and Time to Furosemide. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_141_0_Final_Cut.m4a Download Leave a Comment Tags: ADRENAL, CHF, Corticosteroids, Furosemide, Idarucizumab, Journal Club, Journal Update, Sepsis Show Notes Read More Core EM: Idarucizumab for Reversal of Dabigitran Core EM: Idarucizumab for Reversal of Dabigitran II First10EM: Idarucizumab: Plenty of Optimism, Not Enough Science EM Lit of Note: The Door-to-Lasix Quality Measure EMS MED: When It’s More Complicated Than A Tweet: Door-To-Furosemide And EMS REBEL EM: Door to Furosemide (D2F) in Acute CHF . . . Really? emDocs.net: Furosemide in the Treatment of Acute Pulmonary Edema Core EM: Door-to-Furosemide Time References Pollack et al. Idarucizumab for dabigitran reversal - full cohort analysis. NEJM 2017; 377(5): 431-41. PMID: 28693366 Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized with Acute Heart Failure J Am Coll Cardiol 2017; 69(25): 3042-51. PMID: 28641794 Read More
April 9, 2018
This week we discuss the disutility of orthostatic vital signs as a diagnostic tool in patients with suspected volume loss. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_140_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiology, Orthostatic Hypotension Show Notes Summary: Based on the limited available evidence, it’s unlikely orthostatic vital sign measurement can be used to determine which patients have volume loss and which do not. The baseline prevalence of orthostatic vital signs is common and patients will not always develop orthostatic vital signs in response to volume loss. Therefore, there will both be patients who are orthostatic by numbers without volume loss and there will be patients with volume loss who are not orthostatic by numbers. Symptoms, with the exception of inability to stand to have orthostatics performed, are not useful either. Bottom Line: Based on the low overall sensitivity of orthostatic vital sign measurements, they should not be used to influence clinical decision making. Read More REBEL EM: Orthostatic Hypotension in Volume Depletion References: Skinner JE et al. Orthostatic heart rate and blood pressure in adolescents: reference ranges. J Child Neuro 2010; 25(10): 1210-5. PMID: 20197269 Stewart JM. Transient orthostatic hypotension is common in adolescents. J Pediatr 2002; 140: 418-24. PMID: 12006955 Ooi WL et al. Patterns of orthostatic blood pressure change and the clinical correlates in a frail, elderly population. JAMA 1997; 277: 1299-1304. PMID: 9109468 Aronow WS et al. Prevalence of postural hypotension in elderly patients in a long-term health care facility. Am J Cardiology 1988; 62(4): 336-7. PMID: 3135742 Witting MD et al. Defining the positive tilt test: a study of healthy adults with moderate acute blood loss. Ann Emerg Med 1994; 23(6): 1320-3. PMID: 8198307 McGee S et al. The rational clinical examination. Is this patient hypovolemic. JAMA 1999; 281(11): 1022-9. PMID: 10086438 Johnson DR et al. Dehydration and orthostatic vital signs in women with hyper emesis gravidarum. Acad Emerg Med 1995; 2(8): 692-7. PMID: 7584747 Read More
April 2, 2018
This week we welcome back Andy Little from Doctors Hospital in Columbus, Ohio to chat about ear foreign body removal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_139_0_Final_Cut.m4a Download Leave a Comment Tags: ENT, Foreign Body Show Notes Read More DiMuzio J, Deschler, DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol. 2002; 23(4):473-5. PMID: 12170148 Leffler S et al. Chemical immobilization and killing of intra-aural roaches: an in-vitro comparative study. Ann Emerg Med. 1993; 22(12):1795-8. PMID: 8239097 ALiEM: Trick of the Trade: Ear Foreign Body Removal with Modified Suction Setup Read More
March 26, 2018
This week we review pearls from the EEMCrit conference back in January 2018. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_138_0_Final_Cut.m4a Download Leave a Comment Tags: BRASH, Hyperkalemia, TTP, Ventricular Tachycardia, VTach Show Notes Show Notes Core EM: Procainamide vs Amiodarone in Stable Wide QRS Tachydysrhythmias (PROCAMIO) PulmCrit: Myth-Buesting: Lactated Ringers is Safe in Hyperkalemia, and Is Superior to NS PulmCrit: BRASH Syndrome Read More
March 19, 2018
This podcast discusses an 8 step process for building better presentations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_137_0_Final_Cut.m4a Download One Comment Show Notes Resources: P Cubed Presentations Presentation Zen Presentation Zen: Simple Ideas on Presentation Design and Delivery Keynotable Read More
March 12, 2018
This week we discuss some pearls and pitfalls when caring for HIV+ patients in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_136_0_Final_Cut.m4a Download Leave a Comment Tags: AIDS, HIV, Infectious Diseases, PCP, TB, Tuberculosis Show Notes HIV Associated Infections Based on CD4 Count (cooperhealth.org) Total Lymphocyte Count  = (% lymphocytes x WBC count)/100 TLC 1200 cells/mm3 correlated with CD4 count of < 200 cells/mm3 with a maximal sensitivity of 72.2%, and specificity of 100% TLC1500 cells/mm3 correlated with CD4 count of 200 – 499 cells/mm3 with a maximal sensitivity of 96.7% and specificity of 100% TLC 1900 cells/mm3 correlated with CD4 count of ≥ 500 cells/mm3 with a maximal sensitivity of 98.5% and specificity of 100% Show Notes REBEL EM: REBEL Cast Episode 1 - Total Lymphocyte Count as a Surrogate Marker for CD4 Count LITFL: HIV and AIDS References Obirikorang C et al. Total Lymphocyte Count as a Surrogate Marker for CD4 Count in Resource-Limited. BMC Infectious Diseases Journal 2012; 12 (128): 1 - 5. PMID: 22676809 Read More
March 5, 2018
This podcast reviews how clinicians should think about patients who's shock isn't responding to our typical management options. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_135_0_Final_Cut.m4a Download One Comment Tags: Critical Care, Resuscitation, Shock, Vasopressors Show Notes Read More Core EM: Occult Causes of Non-Response to Vasopressors Emergency Medicine Updates: Hypotension: Differential Diagnosis EMCrit: Steroids in Septic Shock - PRE-ADRENAL The Bottom Line: Steroids in Sepsis EMCrit: RUSH Exam Read More
February 26, 2018
More pearls from our fantastic morning report series. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_134_0_Final_Cut.m4a Download 2 Comments Tags: ALL, Altered Mental Status, Hyperleukocytosis, Hyponatremia, Leukostasis Show Notes Take Home Points 1. When seeing patients with AMS, think of the 5 broad categories of pathologies - VS abnormalities, toxic-metabolic, infectious causes, CNS abnormalities and, lastly as a diagnosis of exclusion - psychiatric issues 2. In kids with AMS, think of zebra diagnoses and toxic ingestions and remember that primary psychosis is rare 3. Patients with ALL are susceptible to developing hyperleukocytosis. If the WBC is > 100K, think about getting hematology on the line to initiate chemo induction and leukopheresis 4. Always think about electrolyte disorders, particularly hypoNa in patients with global AMS. Remember to treat severe hypoNa w/ hypertonic saline and, to correct slowly as to avoid ODS Read More LITFL: HSV Encephalitis EM Cases: Episode 60 - Emergency Management of Hyponatremia Core EM: Severe Hyponatremia Core EM: Episode 58: Hyponatremia Read More
February 19, 2018
This week we dive in to the initial trauma assessment. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_133_0_Final_Cut.m4a Download Leave a Comment Tags: ABCDEs, Trauma Show Notes Take Home Points * Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures * Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team * Complete the primary survey (ABCDEs) and address immediate life threats * Round out your assessment with a good medical history and remember to complete a comprehensive head-to-toe exam Read More Shlamovitz GZ, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007;50(1):25-33, 33.e1. PMID: 17391807 ER Cast: Gunshot to the Groin with Kenji Inaba EM:RAP: Do We Still Need The C-Collar? YouTube: Death of the Dinosaur: Debunking Trauma Myths by Dr. S.V. Mahadevan REBEL EM: Is ATLS wrong about palpable blood pressure estimates? Life in the Fast Lane: Digital rectal exam (DRE) in trauma Read More
February 12, 2018
This week we dive into the rare but potentially fatal, and difficult to diagnose, air embolism. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_132_0_Final_Cut.m4a Download 2 Comments Tags: Air Embolism, Central Lines, Hyperbaric Oxygen Show Notes Take Home Points Air embolism is a rare but potentially fatal complication of central line placement and some surgical procedures and of course of as the result of barotrauma. Recognizing the signs and symptoms of air embolism can be tricky because it will look like any other ischemic process.  Consider air embolism if you have a patient that rapidly decompensates after placement of a central line, the most likely culprit for those of us in the ED. Treatment should focus on supportive cares.  Give supplemental O2, IV fluids and hemodynamic support and consider hyperbarics and cardiopulmonary bypass for the super sick patient. Show Notes Core EM: Air Embolism Blanc et al. Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation. Intensive Care Med. 2002; 28(5): 559-63. PMID 12029402 Read More
February 5, 2018
This week we explore the presentation, diagnosis and management of SBP. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_131_0_Final_Cut.m4a Download Leave a Comment Tags: Gastroenterology, Infectious Diseases, SBP Show Notes Take Home Points SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL) Read More Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205. REBEL EM: Spontaneous Bacterial Peritonitis EMRAP: C3 Live Paracentesis Video LITFL: Spontaneous Bacterial Peritonitis SinaiEM: SBP Pearls REBEL EM: Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)? Core EM: Episode 123.0 - Paracentesis Journal Update Read More
January 29, 2018
Another set of high-yield pearls coming out of our morning report conferences. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_130_0_Final_Cut.m4a Download Leave a Comment Tags: Babesiosis, Carbon Monoxide, Doxycycline, Myasthenia Gravis, Tick-Borne Illnesses Show Notes Take Home Points Non-specific viral syndromes are usually just that, a viral syndrome but, be cautious as a number of more serious ailments can present similarly. This includes tick borne illnesses, acute HIV and carbon monoxide Doxycycline is safe in kids. The dental staining seen with tetracycline is specific to that drug, not the class. If doxy is the best drug for the disease, use it. Lots of meds can lead to a myasthenia gravis exacerbation. Carefully review meds before prescribing for interactions Read More CDC: Research on Doxycycline and Tooth Staining Core EM: Episode 96.0 - Carbon Monoxide Poisoning Sinai EM: Succinycholine in Myasthenia Gravis Read More
January 22, 2018
We welcome Meghan Spyres back to the podcast to discuss toxic alcohol ingestion diagnosis and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_129_0_Final_Cut.m4a Download Leave a Comment Tags: Ethylene Glycol, Fomepizole, Methanol, Toxic Alcohols, Toxicology Show Notes Take Home Points * Suspect a toxic alcohol in any patient with a large osmol gap or a large anion gap metabolic acidosis and consider treating these patients empirically. * Fomepizole is the critical antidote for toxic alcohol ingestions but, patients are likely going to require dialysis as well. * Call your local poison control center if you suspect a toxic alcohol ingestion to help guide management. Read More LITFL: Toxic Alcohol Ingestion ER Cast: Mind the Gap: Anion Gap Acidosis FOAMCast: Episode 43 - Alcohols Read More
January 15, 2018
This week, we sit down with Billy Goldberg - senior faculty at NYU/Bellevue, to discuss some nuances of hip dislocation management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_128_0_Final_Cut.m4a Download Leave a Comment Tags: Orthopedics, Trauma Show Notes Read More Core EM: Hip Dislocation OrthoBullets: Hip Dislocation EMin5: Hip Dislocation Read More
January 8, 2018
This week we talk about the subacute headache and the dangerous, can't miss diagnoses of cerebral venous thrombosis and IIH https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_127_0_Final_Cut.m4a Download Leave a Comment Tags: Cerebral Venous Sinus Thrombosis, Headache, Neurology Show Notes Take Home Points Keep IIH and CVST on the differential for patient’s coming in with a subacute headache, particularly if they have visual or neuro symptoms. Consider an ocular ultrasound! It’s quick, shockingly easy to do, and can help point you toward a diagnosis you may have otherwise overlooked.  I have made it my practice now to include a quick look in the physical exam of my patients with a concerning sounding headache or a headache with neurologic symptoms.  Consider IIH particularly in an overweight female of child bearing age with a subacute headache, but remember patients outside that demographic can have IIH as well. Consider CVST in a patient with a thrombophilic process like cancer, pregnancy or the use of OCPs or androgens or in a patient with a recent facial infection like sinusitis or cellulitis. Read More WikEM: Idiopathic Intracranial Hypertension WikEM: Ocular Ultrasound Sinai EM Ultrasound - Pseutotumor Cerebri Read More
December 18, 2017
This week we discuss the uncommon but must make diagnosis of flexor tenosynovitis https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_126_0_Final_Cut.m4a Download Leave a Comment Tags: Hand, Kanavel Signs, Orthopedics, Soft Tissue Infections Show Notes Take Home Points Think about flexor tenosynovitis in a patient with atraumatic finger pain.  They may have any combination of these signs: Tenderness along the course of the flexor tendon Symmetrical swelling of the finger - often called the sausage digit Pain on passive extension of the finger and Patient holds the finger in a flex position at rest for increased comfort Give antibiotics to cover staph, strep and possibly gram negatives. Get your surgeon to see the patient, while we can get the antibiotics started, these patients need admission and may require surgical intervention. Read More Mailhot T, Lyn ET: Hand; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 50: p 534-571 OrthoBullets: Pyogenic Flexor Tenosynovitis Ped EMMorsels: Flexor Tenosynovitis Read More
December 11, 2017
This week we discuss some critical pearls and teaching points from our morning report conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_125_0_Final_Cut.m4a Download One Comment Tags: Fluoroquinolones, Pneumonia, Spleen Show Notes FOAMCast: Episode 17 - The Spleen! Read More
December 4, 2017
This week we discuss a quick case leading into the management of MALA. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_124_0_Final_Cut.m4a Download 2 Comments Tags: Metformin, Toxicology Show Notes Take Home Points In patients with shortness of breath and clear lungs, consider metabolic acidosis with respiratory alkalis as a potential cause Suspect MALA in any patient on metformin who presents with abdominal pain, nausea and vomiting and/or AMS Patients with MALA will have a low pH, a high-anion gap metabolic acidosis and high lactate levels Call your tox consultant to assist with management which will focus on fluid resuscitation with isotonic bicarbonate and dialysis Read More Bosse GM. Antidiabetics and Hypoglycemics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Accessed October 31, 2017 LITFL: Metformin-Associated Lactic Acidosis LITFL: Metformin The Poison Review: 6 Pearls About Metformin and Lactic Acidosis Read More
November 27, 2017
This week we dive into a recent journal article questioning whether we should tap all ascites. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_123_0_Final_Cut.m4a Download Leave a Comment Tags: Albumin, Cirrhosis, Paracentesis, SBP, Spontaneous Bacterial Peritonitis Show Notes Take Home Points SBP is a difficult diagnosis to make clinically. While patients may have the triad of fever, abdominal pain and increasing ascites, they are far more likely to only have 1 or 2 of these symptoms In patients admitted to the hospital with ascites, consider performing a diagnostic paracentesis on all patients as limited literature shows an association with decreased mortality and, the procedure is simple and low risk Once you get the fluid, focus on the cell count: WBC > 500 or PMN > 250 should prompt treatment with a 3rd generation cephalosporin and albumin infusion Gaetano et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. Journal of Gastroenterology and Hepatology 2016. PMID: 26642977 Read More EMRAP: C3 Live Paracentesis Video LITFL: Spontaneous Bacterial Peritonitis SinaiEM: SBP Pearls REBEL EM: Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)? Approach to the Diagnosis and Treatment of SBP (University of Washington) Read More
November 20, 2017
This week we discuss the tibio-femoral knee dislocation focusing on identification of the dangerous complications. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_122_0_Final_Cut.m4a Download Leave a Comment Tags: Knee Dislocation, Orthopedics, Popliteal Artery Show Notes Take Home Points Up to 50% of true knee dislocations will spontaneously reduce prior to arrival. Be suspicious of a dislocation in any patient who describes the joint moving out of place or if they have significant swelling, joint effusion or ecchymosis despite normal X-rays In all patients with suspected dislocation, perform a neurovascular exam immediately as popliteal artery injury is common. If they’ve got an absent DP or PT pulse, reduce immediately and get a CT angiogram as quickly as possible to assess for popliteal injuries If distal pulses are intact, you can either do ABIs and if normal, observe and repeat them or get a CTA. If the ABI is abnormal or the patient had an absent or decreased pulse at any point, get the CTA Read More OrthoBullets: Knee Dislocation Radiopaedia: Knee Dislocation EM: RAP: Obese Patient and Knee Dislocations Core EM: True Knee and Patellar Dislocations Read More
November 13, 2017
This week we dive into the diagnosis and management of pancreatitis in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_121_0_Final_Cut.m4a Download Leave a Comment Tags: Gastroenterology, GI, Pancreatitis Show Notes Ranson's Criteria for Pancreatitis-Associated Mortality (Rosen's) Take Home Points Pancreatitis is diagnosed by a combination of clinical features (epigastric pain with radiation to back, nausea/vomiting etc) and diagnostic tests (lipsae 3x normal, CT scan) A RUQ US should be performed looking for gallstones as this finding significantly alters management The focus of management is on supportive care. IV fluids, while central to therapy, should be given judiciously and titrated to end organ perfusion Patients will mild pancreatitis who are tolerating oral intake and can reliably follow up, can be discharged home Read More Hemphill RR, Santen SA: Disorders of the Pancreas; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 91: p 1205-1226 PulmCrit: The Myth of Large-Volume Resuscitation in Acute Pancreatitis PulmCrit: Hypertriglyceridemic Pancreatitis: Can We Defuse the Bomb? Read More
November 6, 2017
This week we discuss common bites, stings and envenomations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_120_0_Final_Cut.m4a Download Leave a Comment Tags: Bee Sting, Black Widow, Brown Recluse Spider, Hymenoptera Show Notes Take Home Points The most common bites and stings you will see are by bees and ants.  These can present as a local reaction, toxic reaction, anaphylaxis or delayed reaction.  For all of these, treat with local wound care and epinephrine for any systemic symptoms. The brown recluse spider is found in the Midwest and presents as local pain and swelling but carries the risk of a necrotic ulcer The black widow spider is found all around the US and presents with either localized or generalized muscle cramping, localized sweating and potentially tachycardia and hypertension.  Treatment is symptom management with analgesics and benzos. The bark scorpion usually presents with localized pain and swelling, but particularly in children, may present with a serious systemic presentation including jerking muscle movements, cranial nerve dysfunction, hypersalivation, ataxia and opsoclonus, which is the rapid, involuntary movement of the eyes in all directions. Treatment is supportive cares, but remember to call your poison center to ask about antivenin. Read More WikEM: Brown Recluse Spider Bite WikEM: Black Widdow Spider Bite WikEM: Hymenoptera Stings Read More
October 30, 2017
This week we review 4 articles discussed in our conference in the last month. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_119_0_Final_Cut.m4a Download Leave a Comment Tags: ACS, AMI, Cardiac Arrest, Cardiology, Oxygen, Pediatrics, POCUS, Syncope Show Notes Take Home Points Tachycardia in peds patients at discharge was associated with more revisits but not with more critical interventions. If your workup is reassuring, isolated tachycardia in and of itself shouldn’t change your disposition. Supplemental O2 is not necessary in the management of AMI patients with an O2 sat > 90% and, may be harmful Until further study and prospective validation has been performed, we’re not going to recommend embracing the Canadian decision instrument on predicting dysrhythmias after a syncopal event. Finally, our agreement on what cardiac standstill is isn’t great. We need a unified definition going forward to teach our trainees and for the purposes of research. Read More Core EM: ED POCUS in OHCA - The REASON Study ALiEM: Management of Syncope EM Nerd: The Case of the Liberated Radicals ScanCrit: O2 Not Needed in Myocardial Infarction Core EM: Predicting Dysrhythmia after Syncope Gaspari R et al. Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital  and in-ED Cardiac Arrest. Resuscitation 2016; 109: 33 – 39. PMID: 27693280 References Wilson PM et al. Is Tachycardia at Discharge from the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study.Ann Emerg Med. 2017. PMID: 28238501 Hofmann R et al. Oxygen Therapy in Suspected Acute Myocardial Infarction. NEJM 2017. PMID: 28844200 Thiruganasambandamoorthy V  et al. Predicting short-term risk of arrhythmia among patients with syncope: the Canadian syncope arrhythmia risk score. Acad Emerg Med 2017. PMID: 28791782 Hu K et al. Variability in Interpretation of Cardiac Standstill Among Physician Sonograph...
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