A quick primer on hypocalcemia in the ED. Hosts: Joseph Offenbacher, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/hypocalcemia.mp3 Download 4 Comments Tags: calcium, Critical Care, Endocrine Show Notes <img decoding="async" loading="lazy" class="alignnone size-full wp-image-10909" src="https://coreem.net/content/uploads/2022/04/HypoC34.jpg" alt="" width="1297" height="603" srcset="https://i0.wp.com/coreem.net/content/uploads/2022/04/HypoC34.jpg?w=1297&ssl=1 1297w, https://i0.wp.com/coreem.net/content/uploads/2022/04/HypoC34.jpg?resize=300%2C139&ssl=1 300w, https://i0.wp.com/coreem.net/content/uploads/2022/04/HypoC34.jpg?resize=1024%2C476&ssl=1 1024w, https://i0.wp.com/coreem.net/content/uploads/2022/04/HypoC34.jpg?

How and when to reverse anticoagulation in the bleeding EM patient. Hosts: Joe Offenbacher, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/AC_reversal.mp3 Download 3 Comments Tags: Anticoagulation, Critical Care, Resuscitation Show Notes Coagulation Cascade:   Algorithm for Anticoagulated Bleeding Patient in the ED:   <img decoding="async" loading="lazy" class="alignnone size-full wp-image-10797" src="https://coreem.net/content/uploads/2022/02/Reversal-Strat.jpeg" alt="" width="1920" height="750" srcset="https://i0.wp.com/coreem.net/content/uploads/2022/02/Reversal-Strat.jpeg?w=1920&ssl=1 1920w, https://i0.wp.com/coreem.net/content/uploads/2022/02/Reversal-Strat.jpeg?resize=300%2C117&ssl=1 300w, https://i0.wp.com/coreem.

A primer on this airway/ ID/ ENT emergency. Hosts: Joe Offenbacher MD, A Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/ludwigs_2.mp3 Download 2 Comments Tags: Airway, ENT, Infectious Diseases Show Notes

A quick overview of pneumothorax for the EM physician: the what, why, diagnosis, and treatment. Hosts: Joe Offenbacher, MD Audrey Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumothorax_CoreEM_podcast.mp3 Download One Comment Tags: #pneumothorax #FOAMed Show Notes Shownotes: CoreEM Pulmonary Ultrasound Post <img decoding="async" loading="lazy" class="alignnone size-large wp-image-10651" src="https://coreem.net/content/uploads/2021/10/Screen-Shot-2021-10-29-at-3.07.01-PM-1024x780.png" alt="" width="1024" height="780" srcset="ht...

An interesting back story on this must-not-miss EKG finding in the ED! Hosts: Joseph Offenbacher, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/CoreEM_Wellens.mp3 Download One Comment Tags: #FOAMed, #wellens, Cardiology, EKG, STEMI Show Notes Hosts: Joe Offenbacher MD, Audrey Bree Tse MD EKG Findings in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481. Table 1 in de Zwaan C,

We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage. Hosts: Mark Iscoe, MD Brian Gilberti, MD Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/SAH.mp3 Download One Comment Tags: Critical Care, Neurology, Subarachnoid Hemorrhage Show Notes Non-contrast head CT showing SAH (Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 22770)   Hunt-Hess grade and mortality (from Lantigua et al.

We discuss the (F)utility(?) of ED Utox screens with our very own Dr. Phil DiSalvo. Hosts: Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Urine_Drug_Screen_final.mp3 Download Leave a Comment Tags: Toxicology Show Notes Special Thanks To: Dr. Philip DiSalvo, MD Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue New York City Poison Control Center   References: Christian MR, et al. Do rapid comprehensive urine drug screens change clinical management in children? Clin Toxicol (Phila). 2017;57:977-980.

EM management of the rare but potentially complicated precipitous vaginal breech delivery. Hosts: Audrey Bree Tse, MD Masashi Rotte, MD MPH https://media.blubrry.com/coreem/content.blubrry.com/coreem/Breesashi_Breech_CoreEM.mp3 Download One Comment Tags: Obstetrics, Precipitous Deliveries, Pregnancy Show Notes Frank Breech Presentation: Complete Breech Presentation: <img decoding="async" loading="lazy" class="aligncenter wp-image-10019" src="https://coreem.net/content/uploads/2020/07/Screen-Shot-2020-07-23-at-9.43.32-PM.png" alt="" width="310" height="341" srcset="https://i0.wp.com/coreem.net/content/uploads/2020/07/Screen-Shot-2020-07-23-at-9.43.32-PM.png?w=918&ssl=1 918w, https://i0.wp.com/coreem.

The speech given by Dr. Goldfrank at the 2020 NYU / Bellevue Emergency Medicine Graduation Ceremony https://media.blubrry.com/coreem/content.blubrry.com/coreem/Goldfrank_Graduation_Speech_2020.mp3 Download Leave a Comment Tags: Graduation. Goldfrank Show Notes Graduation 2020 Lewis R. Goldfrank, MD June 17, 2020 WELCOME TO THE GRADUATES Congratulations to a wonderful group of physicians. It is a pleasure to recognize your great accomplishments in the presence of your friends, families, loved ones and the residents and faculty who have learned so much from and with you. I would first like to recognize those of you who are members of the Gold Humanism Honor Society. There are a remarkable number of awardees in our graduating class of 2020. CLASS OF 2020 Joe Bennett (R) Max Berger (R) Ashley Miller (R) Leigh Nesheiwat (S) Kristen Ng (R) Emily Unks (S) AND Arie Francis (R) Nisha Narayanan (S) FUTURE PGY-4 Elena Dimiceli (S) Kamini Doobay (S) Mark Iscoe (R) FUTURE PGY-3 Stasha O’Callaghan (S) Nicholus Warstadt (S) FUTURE PGY-1 Aaron Bola (S) Alison (Ali) Graebner (S) Aron Siegelson (S) Melissa Socarras (S) Sarah Spiegel (S) Thomas Sullivan (S) Christy Williams (S) GOLD HUMANISM CORE VALUES Integrity, Excellence, Compassion, Altruism, Respect, Empathy, Service These are the values you want as a doctor for yourself or a loved one, to have outstanding listening skills with patients to be at your side during a medical emergency, to have exceptional interest in service to the community,

An overview and management tips of hemoptysis in the ED. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hemoptysis.mp3 Download One Comment Tags: Critical Care, Pulmonary Show Notes OVERVIEW: Definition: expectoration/ coughing of blood originating from tracheobronchial tree Sources: Bronchial arteries (90%): under systemic circulatory pressure to supply supporting structures of the lung → heavier bleeding Pulmonary arteries (5%): under low pressure to supply alveoli → milder bleeding Nonbronchial arteries (5%): intercostal arteries, coronary arteries, thoracic/ upper/ inferior phrenic arteries Quantification: Mild: Massive defined anywhere from >300mL-1L/ 24hr Mortality: 38% for massive (>500mL/ 24hr) vs 4.5% for nonmassive Etiology (in adults):

We go over the recent updates in the workup and management of pneumonia. Hosts: Brian Gilberti, MD Audrey Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumonia_Updates.mp3 Download Leave a Comment Tags: Infectious Diseases, Pulmonary Show Notes 2007 Infectious Diseases Society of America/American Thoracic Society Criteria for Defining Severe Community-acquired Pneumonia Validated definition includes either one major criterion or three or more minor criteria Minor criteria Respiratory rate > 30 breaths/min PaO2/FIO2 ratio Multilobar infiltrates Confusion/disorientation Uremia (blood urea nitrogen level > 20 mg/dl) Leukopenia* (white blood cell count , 4,000 cells/ml) Thrombocytopenia (platelet count , 100,000/ml) Hypothermia (core temperature , 368 C) Hypotension requiring aggressive fluid resuscitation Major criteria Septic shock with need for vasopressors Respiratory failure requiring mechanical ventilation A special thanks to our Infectious Diseases Editor: Angelica Cifuentes Kottkamp, MD Infectious Diseases & Immunology NYU School of Medicine Read More

Diagnosing and managing one of our critical diagnoses - posterior stroke. Hosts: Mukul Ramakrishnan, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/final_posterior_stroke_podcast_post_edit.mp3 Download 2 Comments Tags: Neurology, Posterior Stroke Show Notes See Dr. Newman-Toker demonstrate the HINTS exam here Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10   Read More

We discuss one of the most complex problems we face – Homelessness Hosts: Kelly Doran, MD Audrey Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Homelessness.mp3 Download One Comment Tags: Social Emergency Medicine Show Notes Special Thanks To: Dr. Kelly Doran, MD MHS Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue ___________________________ References: Doran, K.M.  Commentary: How Can Emergency Departments Help End Homelessness?  A Challenge to Social Emergency Medicine. Ann Emerg Med. 2019;74:S41-S44. Doran, K.M., Raven, M.C. Homelessness and Emergency Medicine: Where Do We Go From Here? Acad Emerg Med. 2018;25:598-600. Salhi, B.A., et al. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med. 2018;25:577-93. U.S. Department of Housing and Urban Development, Annual Homeless Assessment Report to Congress. Available at: https://www.hudexchange.info/resource/5783/2018-ahar-part-1-pit-estimates-of-homelessness-in-the-us/ U.S. Interagency Council on Homelessness. Home, Together Federal Strategic Plan to Prevent and End Homelessness. <a href="https://www.usich.gov/resources/uploads/asset_library/Home-Together-Federal-Strategic-Plan-to-Prevent-and-End-Homeless...

We go into one of the more complex injuries – blunt neck trauma. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blunt_Neck_Injuries.mp3 Download One Comment Tags: Trauma Show Notes Overview Blunt neck trauma comprises 5% of all neck trauma Mortality due to loss of airway more so than hemorrhage Mechanism MVCs with cervical hyperextension, flexion, rotation during rapid deceleration, direct impact   Strangulation: hanging, choking, clothesline injury (see section on strangulation in this chapter) Direct blows: assault, sports, falls Initial Management/Primary Survey Airway Evaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromise Early aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema Assume a difficult airway  Breathing Supplemental oxygen

We dissect one of the most common injuries we see in the ER -- ankle sprains Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Ankle_Sprains.mp3 Download 3 Comments Tags: Orthopedics Show Notes Background Among most common injuries evaluated in ED A sprain is an injury to 1 or more ligaments about the ankle joint Highest rate among teenagers and young adults Higher incidence among women than men Almost a half are sustained during sports Greatest risk factor is a history of prior ankle sprain Anatomy Bone: Distal tibia and fibula over the talus → constitutes the ankle mortise Aside from malleoli, ligament complexes hold joint together Medial deltoid ligament Lateral ligament complex Anterior talofibular ligament Most commonly injured Weakest 85% of all ankle sprains  Posterior talofibular ligament Calcaneofibular ligament Syndesmosis Mechanism of Injury

An overview of Vaping Associated Lung Injury (VALI) Hosts: Audrey Bree Tse, MD Larissa Laskowski, DO Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vaping_Associated_Lung_Injury.mp3 Download 2 Comments Tags: Pulmonary, Toxicology Show Notes Why this matters As of Oct 15, vaping has been associated with acute lung injury in over 1400 people 33 deaths have been confirmed in 24 states 70+% of those with VALI are young men A large number of patients are requiring ICU/ intubation/ ECMO 4 main ingredients in solvent +/- Flavor additives +/- Nicotine or THC (Tetrahydrocannabinol) Propylene Glycol (PG) Vegetable Glycerin (VG) CDC definition of VALI (Vaping Associated Lung Injury) Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset AND <span style="font-weight:...

An overview of septic arthritis. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Arthritis.mp3 Download One Comment Tags: Infectious Diseases, Orthopedics Show Notes Episode Produced by Audrey Bree Tse, MD Background Bacteria enters the joint by hematogenous spread due to absence of basement membrane in synovial space from invasive procedures, contiguous infection (e.g. osteomyelitis, cellulitis), or direct inoculation (e.g. plant thorns, nails) WBCs migrate into joint → acute inflammatory process → synovial hyperplasia, prevents new cartilage from forming, pressure necrosis on surrounding joint, purulent effusion Why do we care?  irreversible loss of function in up to 10% & mortality rate as high as 11% Cartilage destruction can occur in a matter of hours Complications include bacteremia, sepsis, and endocarditis Etiology Risk factors: extremes of age, RA, DJD, IVDA, endocarditis, GC, immunosuppression, trauma, or prosthesis Organisms:  Staph: stap...

A look at the most common type of seizures in the young pediatric population. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Febrile_Seizures.mp3 Download Leave a Comment Tags: Pediatrics Show Notes Background The most common type of seizure in children under 5 years of age Occur in 2-5% of children In children with a fever, aged 6 months to 5 years of age, and without a CNS infection Risk Factors 4 times more likely to have a febrile seizure if parent had one Also increase in risk if siblings or nieces / nephews had one Common associated infections Human Herpesvirus 6 Human Herpesvirus 7 Influenza A & B Simple Febrile Seizure Generalized tonic-clonic activity lasting less than 15 minutes in a child 6 months to 5 years of age Complex Febrile Seizure Lasts longer than 15 minutes, occurs in a child outside of this age range, are focal, or that recur within a 24-hour period. Diagnostics / Workup Gather thorough history and perform thorough physical exam Most cases will not require labs, imaging or EEG If e/o meningitis, perform LP AAP suggests considering LP in: Children 6-12 months who are not immunized for H flu type B or strep pneumo Children who had been on antibiotics For complex seizures, clinician may have a lower threshold for obtaining labs Hyponatremia is more common in this group than in the general population. LPs are more commonly done by providers, but these are low yield with one study showing bacterial meningitis being diagnosed in just 0.

A review for the emergency physician of this common tick-borne illness. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Lyme_Disease.mp3 Download Leave a Comment Tags: Infectious Diseases Show Notes Episode Produced by Audrey Bree Tse, MD 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

An in depth review of this notorious parasite. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD 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: <img aria-describedby="caption-attachment-8759" decoding="async" loading="lazy" class="wp-image-8759" src="https://coreem.net/content/uploads/2019/07/Screen-Shot-2019-07-15-at-9.30.40-AM-666x1024.png" alt="" width="417" height="641" srcset="https://i0.wp.com/coreem.net/content/uploads/2019/07/Screen-Shot-2019-07-15-at-9.30.40-AM.png?resize=666%2C1024&ssl=1 666w, https://i0.wp.com/coreem.net/content/uploads/2019/07/Screen-Shot-2019-07-15-at-9.30.40-AM.png?resize=195%2C300&ssl=1 195w, https://i0.wp.com/coreem.net/content/uploads/2019/07/Screen-Shot-2019-07-15-at-9.30.40-AM.png?resize=768%2C1181&ssl=1 768w, https://i0.wp.com/coreem.

A look at this common and controversial topic. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD 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,

A look at foot fractures – which can be splinted and which may need the OR. Hosts: Audrey Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Foot_Fractures.mp3 Download Leave a Comment Tags: Orthopedics Show Notes Episode Produced by Audrey Bree Tse, MD 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 <img decoding="async" loading="lazy" class="aligncenter wp-image-8609 size-full" src="https://coreem.net/content/uploads/2019/06/fractures-of-the-proximal-5th-metatarsal.jpg" alt="" width="1024" height="1024" srcset="https://i0.wp.com/coreem.net/content/uploads/2019/06/fractures-of-the-proximal-5th-metatarsal.jpg?w=1024&ssl=1 1024w, https://i0.wp.com/coreem.net/content/uploads/2019/06/fractures-of-the-proximal-5th-metatarsal.jpg?resize=150%2C150&ssl=1 150w, https://i0.wp.com/coreem.net/content/uploads/2019/06/fractures-of-the-proximal-5th-metatarsal.jpg?

A discussion with Drs. McNamara and Leifer on the essentials and beyond of debriefing Hosts: Brian Gilberti, MD Audrey Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Debriefing.mp3 Download One 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

A look at one of the most common and potentially concerning upper respiratory infections in children. Host: Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Croup.mp3 Download One 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

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 Episode Produced by Audrey Bree Tse, MD 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 = TEN = >30% TBSA SJS/ TEN Overlap = 10-30% TBSA Incidence is estimated at around 9 per 1 million people in the US Mortality is 10% for SJS and 30-50% for TEN Mainly 2/2 sepsis and end organ dysfunction. SJS can occur even without a precipitating medication Infection can set it off especially in patients with risk factors including HIV, lupus, underlying malignancy, and genetic factors SATAN for the most common drugs Sulfa, Allopurinol, Tetracyclines, Anticonvulsants, and NSAIDS Anti-epileptics include carbamazepine, lamictal, phenobarb, and phenytoin Can have a curious course Hypersensitivity reaction can develop while taking medication, or even one to four weeks after exposure In pediatric population, mycoplasma pneumonia and herpes simplex have been identified as precipitating infections Patients often have a prodrome 1-3 days prior to the skin lesions appearing

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

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 Episode Produced by Audrey Bree Tse, MD    

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. (<a href="https://www.ncbi.nlm.nih.

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

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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

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 t...

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

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

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 One 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 <span style="color: #000000; font-fa...

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,

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 <img aria-describedby="caption-attachment-7311" decoding="async" loading="lazy" class="size-full wp-image-7311" src="https://coreem.net/content/uploads/2018/05/Stroke-Workflow-2018-Final.png" alt="" width="2560" height="1441" srcset="https://i0.wp.com/coreem.net/content/uploads/2018/05/Stroke-Workflow-2018-Final.png?w=2560&ssl=1 2560w, https://i0.wp.com/coreem.

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 One 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

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 <img aria-describedby="caption-attachment-7115" decoding="async" loading="lazy" class="size-full wp-image-7115" src="https://co...

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: <span...

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! <img aria-describedby="caption-attachment-7050" decoding="async" loading="lazy" class="size-full wp-image-7050" src="https://coreem.net/content/uploads/2018/04/Hard-Signs-in-Penetrating-Neck-Injury-Sperry-2013.png" alt="" width="814" height="392" srcset="https://i0.wp.com/coreem.net/content/uploads/2018/04/Hard-Signs-in-Penetrating-Neck-Injury-Sperry-2013.png?w=814&ssl=1 814w, https://i0.wp.com/coreem.

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

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

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,

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: <a href="https://emcrit.

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

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.

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

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

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

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 One 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 3 with a maximal sensitivity of 72.2%, and specificity of 100% TLC1500 cells/mm3 correlated wi...

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: <a href="http://w...

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

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: <a href...

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

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 Bac...

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 <a href="https://coreem.

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

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

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: Id...

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. Infographic <img decoding="async" loading="lazy" class="aligncenter wp-image-10146" src="https://coreem.net/content/uploads/2017/12/Infectious-Flexor-Tenosynovitis-1024x1024.png" alt="" width="700" height="700" srcset="https://i0.wp.com/coreem.

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

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: <span...

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

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...

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

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.

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 Stu...

Part II of II on gallbladder disorders finishing up with acute cholangitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_118_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder, Gastroenterology, General Surgery, GI Show Notes Take Home Points Cholangitis is an acute bacterial infection of the bile ducts resulting from common bile duct obstruction and is potentially life-threatening (mortality 5-10%, acute bacterial infection of the bile ducts Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic. Look for RUQ tenderness with peritoneal signs and fever A normal ultrasound does not rule out acute cholangitis Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery) Read More Radiopaedia: Acute cholangitis Core EM: Cholangitis Read More

Part I of II on gallbladder pathology starting with cholecystitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_117_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder, Gastroenterology, General Surgery, GI Show Notes Take Home Points Acute cholecystitis is an inflammation of the gallbladder and is a clinical diagnosis. Imaging can be helpful but US and CT can both have false negatives. Lab tests are insensitive and non-specific and, as such, they can neither rule in or rule out the diagnosis. Treatment focuses on fluid resuscitation when indicated, supportive care, antibiotics and surgical consultation for cholecystectomy Although uncommon, be aware that patients can develop gangrene, necrosis and perforation as well as frank sepsis and require aggressive resuscitation Read More Core EM: Acute Cholecystitis Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205. Leschka S et al. Chapter 5.1: Acute abdominal pain: diagnostic strategies In: Schwartz DT: Emergency Radiology: C...

This podcast discusses the presentation and management of button battery ingestions in kids. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_116_0_Final_Cut.m4a Download One Comment Tags: Button Battery, GI, Pediatrics Show Notes NBIH Button Battery Ingestion Algorithm <img aria-describedby="caption-attachment-5971" decoding="async" loading="lazy" class=" wp-image-5971" src="https://coreem.net/content/uploads/2017/08/Button-Battery-XR-scielo.br_.jpg" alt="" width="836" height="392" srcset="https://i0.wp.com/coreem.net/content/uploads/2017/08/Button-Battery-XR-scielo.br_.jpg?w=3313&ssl=1 3313w, https://i0.wp.com/coreem.net/content/uploads/2017/08/Button-Battery-XR-scielo.br_.jpg?resize=300%2C141&ssl=1 300w, https://i0.wp.com/coreem.net/content/uploads/2017/08/Button-Battery-XR-scielo.br_.

This week we sit down with toxicologist Meghan Spyres to talk about Wernicke's Encephalopathy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_115_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Abuse, Thiamine, Toxicology, Wernicke's Encephalopathy Show Notes Take Home Points Consider the diagnosis in all patients with nutritional deficiencies, not just alcoholics. Look for ophthalmoplegia, ataxia and confusion in patients that have risk factors for thiamine deficiency. Don’t think that it can’t be Wernicke’s because the triad isn’t complete; any two of the components (dietary deficiency, oculomotor abnormalities, cerebellar dysfunction or altered mental status) makes the diagnosis. Treat Wernicke’s with an initial dose of 500 mg of thiamine IV and admit for continued parenteral therapy. Read More LITFL: Thiamine Deficiency EMRAP: Remember to Take Your Vitamins ALiEM: Mythbusting the Banana Bag Read More

This week we discuss the initial approach to assessment of the alcohol intoxicated patient. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_114_0_Final_Cut.m4a Download One Comment Tags: Alcohol Intoxication, Chronic Alcoholism, Wernicke's Encephalopathy Show Notes Take Home Points Chronic drinkers and even just acutely intoxicated patients are at risk of many medical emergencies including life threatening trauma, infections, metabolic derangements and tox exposures.  Don’t dismiss them as “just drunk” Undress these patients and perform a thorough head to toe examination, focusing on looking for e/o trauma and infection.  Get as much history as you can and be sure to ask about their drinking habits and etoh w/d hx to risk stratify them in your brain Always check FS glucose and replete glucose as needed.  Consider giving your chronic intoxicated patients thiamine injections semi-regularly to prevent WE, and look for e/o the triad in your patients as it can be easily overlooked and deadly if missed! Read More EM Docs: EM@3AM Alcohol Intoxication EM Updates: <...

This podcast takes a deep dive into the presentation, diagnosis and management of preeclampsia and eclampsia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_113_0_Final_Cut.m4a Download Leave a Comment Tags: Eclampsia, Hypertensive Disorders of Pregnancy, Obstetrics, Preeclampsia Show Notes Take Home Points Suspect preeclampsia in any pregnant women presenting with epigastric/RUQ pain, severe or persistent headache, visual disturbances, nausea or vomiting, shortness of breath, increased edema or weight gain Evaluate for preeclampsia by looking at the blood pressure, urine for protein and obtaining a panel to evaluate for HELLP syndrome Severe preeclampsia and eclampsia are treated with bolus and infusion of MgSO4 Emergency delivery is the “cure” for preeclampsia and eclampsia. Consult obstetrics early for an evaluation for delivery Don’t forget to consider preeclampsia and eclampsia in the immediate postpartum period Read More Core EM: Preeclampsia and Eclampsia LITFL: ...

This week we discuss the presentation and management of herpes zoster. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_112_0_Final_Cut.m4a Download Leave a Comment Tags: Infectious Diseases, Varicella Show Notes Take Home Points Classically, herpes zoster will present with rash and pain in a dermatomal distribution Immunocompromised patients are at greater risk for significant complications of zoster, including visceral dissemination and zoster ophthalmicus Appropriate therapy includes antiviral therapy within 72 hours of onset of symptoms and analgesia for acute neuritis Disseminated zoster and zoster ophthalmicus threatening sight should be treated with IV antivirals Read More Emergency Medicine Ireland: Tasty Morsels of EM 073: FRCEM Varicella Life in the Fast Lane: Herpes zoster ophthalmicus Core EM: Herpes Zoster Read More

This week we discuss the presentation and management of native US snake bites with Dr. Meghan Spyres https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_111_0_Final_Cut.m4a Download Leave a Comment Tags: Rattlesnakes, Snake Bites, Snake Envenomation, Toxicology, Vipers Show Notes Read More ALiEM: Envenomations: Initial Management of Common US Snakebites Read More

This week we dive into some advanced topics in RSI including patient positioning and pre-intubation resuscitation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_110_0_Final_Cut.m4a Download One Comment Show Notes Take Home Points Bed up head elevated position for intubation may reduce intubation related complications. Patients who are hypotensive or at risk of hypotension should be aggressively resuscitation prior to intubation with fluids and liberal use of pressors Shock patients would be intubated with decreased induction agent dose, preferably ketamine, and increased paralytic dose. Bed-Up-Head-Elevated Positioning Show Notes EMCrit: Podcast 104 – Laryngosocpe as a Murger Weapon (LAMW) Series – Hemodynamic Kills Life in the Fastlane: Intubation, hypotension and shock Core EM: <a href="https://coreem.

This week we discuss some quick pearls from our conference covering an array of renal and GU pathologies. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_109_0_Final_Cut.m4a Download Leave a Comment Tags: GU, Renal, Urology Show Notes Read More Core EM: Testicular Torsion Core EM: Podcast Episode 92.0 – Dialysis Emergencies Al Sacchetti: ED Repair of Bleeding Dialysis Shunt EM: RAP: Episode 107 – Dialysis Emergencies EMBlog Mayo Clinic: How to Stop a Post-Dialysis Site Bleeding emDocs: Managing Fistula Complications in the Emergency Department References Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID: <a href="https://www.ncbi.nlm.nih.

Should we intubate patients in cardiac arrest? We discuss this topic and some basics of running a good arrest. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_108_0_Final_Cut.m4a Download Leave a Comment Tags: Advanced Airway Management, Cardiac Arrest, Critical Care, Resuscitation Show Notes Take Home Points Intra-arrest intubation does not appear to improve outcomes. For most patients, support with BVM, or possibly an LMA, is adequate. Instead of securing an advanced airway, focus on the two things that clearly make a difference in outcomes – good compressions and defibirillation Good compressions should be fast and hard and you must minimize interruptions in compressions to minimize interruptions in perfusion Don’t forget that a great resuscitation requires great preparation. Take whatever time you have to discuss with your team and assign roles. Read More Rebel EM: In-hospital Cardiac Arrest – The First 15 Minues Core EM: Proper Defibrillator Pad Placement + Dual Sequential Defibrillation

Prompted by the recent CAMEO trial publication on icatibant, we dive into angioedema with a focus on airway management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_107_0_Final_Cut.m4a Download Leave a Comment Tags: ACE Inhibitors, Allergy/Immunology, Angioedema, Icatibant Show Notes Take Home Points Airway management is paramount, expect a challenging intubation and consider controlling the airway early When controlling the airway, consider an awake approach and fiberoptics if available. Always be prepared for the can’t intubate, can’t oxygenate scenario with a double set up. If the patient has urticaria and pruritus, the process is likely histamine mediated and will respond to typical anaphylaxis treatment Finally, observe the patient for progression of swelling and don’t forget to stop the inciting medication Read More Core EM: Angioedema EMCrit: Podcast 145 – Awake Intubation Lecture from SMACC ERCast: Angioedema REBEL EM: <a href="htt...

This week we drop into some of the nitty gritty on PSA including preparation and patient assessment as well as discuss some common pitfalls. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_106_0_Final_Cut.m4a Download Leave a Comment Tags: Pitfalls, Procedural Sedation, PSA Show Notes Take Home Points Always perform a full pre-PSA evaluation including an airway assessment. Time of last meal shouldn’t delay your sedation based on the best available evidence. Always do a complete setup including consideration of different agents, dosage calculations, preparation of airway equipment and reversal agents. PSA serious adverse events are rare but you still must be prepared for them. Careful agent selection and dosing can help prevent issues but, know your outs. If apnea develops, do some basic maneuvers before you reach for the BVM or laryngoscope. Remember OOPS as in “oops, my patient went apneic.” Oxygen on, pull the mandible forward and sit the patient up. This fixes most issues Show Notes Core EM: Procedural Sedation and Analgesia Resources EM Updates:<a href="http://emupdates.

This week we dissect a JAMA article on the whether it's necessary to add TMP-SMX to cephalexin in the treatment of uncomplicated cellulitis https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_105_0_Final_Cut.m4a Download Leave a Comment Tags: Cellulitis, IDSA, Infectious Diseases, MRSA Show Notes SSTI Flow Diagram (Stevens 2014) EM Lit of Note: Double Coverage, Cellulitis Edition Pharm ER Tox Guy: Uncomplicated Cellulitis? Consider Strep-Only Coverage Core EM: Cellulitis Stevens DL et al. Practice guidelines for the diagnosis and managem...

This week we dive into the various common agents used in procedural sedation and analgesia in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_104_0_Final_Cut.m4a Download 2 Comments Tags: Anesthesia, Critical Care, Procedural Sedation, PSA Show Notes Show Notes Core EM : Parenteral Benzodiazepines Core EM: Procedural Sedation and Analgesia Resources EM Updates: Ketamine Brain Continuum First 10 EM: Managing laryngospasm in the emergency department Read More

This week we talk about priapism focusing on emergency department management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_103_0_Final_Cut.m4a Download One Comment Tags: GU, Priapism, Urology Show Notes Read More Dr. Mutara Jubara: Ultrasound Guided Dorsal Penile Nerve Block McCollough M, Sharieff GQ: Genitourinary and Renal Tract Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 174: p 2205-2223. Davis JE, Silverman MA. Urologic Procedures; in Roberts JR: Roberts and Hedges’ Clinical Procedures in Emergency Medicine, ed 6. 2014, (Ch) 55: p 1113-1154 Govier FE et al. Oral terbutaline for the treatment of priapism. J Urol 1994;151: 878-9. PMID: 8126815 Priyadarshi S. Oral terbutaline in the management of pharmaco...

This week we welcome Andy Little onto the show to discuss the modified Valsalva maneuver for breaking SVT. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_102_0-AVNRT_Final_Cut.m4a Download Leave a Comment Tags: Adenosine, AVNRT, Cardiology, SVT, Tachydysrhythmia Show Notes Read More Rebel EM: The REVERT Trial – A Modified Valsalva Maneuver to Convert SVT SGEM: This is a SVT and I’m Gonna Revert It Using a Modified Valsalva Manoeuvre Appelboam A et al. Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias (REVERT): A Randomised Controlled Trial. Lancet 2015. PMID: 26314489 Read More

This week we dive into some of the initial considerations in the resuscitation of major burn patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_101_0_Final_Cut.m4a Download Leave a Comment Tags: Carbon Monoxide, Cyanide, Major Burns, Trauma Show Notes Take Home Points Be prepared to intubate early, the patency of the airway can decline quickly and without warning. If there is any concern for burns to face/neck or smoke inhalation, consider taking control of the airway early. Review the rule of 9s and the parkland formula to direct your large volume fluid resus.  Remember the parkland formula directs you to use 4 mL x %TBSA x weight (kg).  Half in the first 8 hours and the second half over the next 16 hours.  Given the large volume here it’s probably best to use LR or another balanced solution. Do a thorough trauma eval to make sure you don’t miss any other injuries and be sure to watch for developing compartment syndrome And last, consider the need to treat for CO and/or cyanide poisoning.  Poor cardiac function, cardiac arrest or a high lactate can be clues to cyanide poisoning and just start 100% O2 while you wait for a co-ox, since CO tox is pretty likely. <img aria-describedby="caption-attachment-5397" decoding="async" loading="lazy" class="size-full wp-image-5397" src="https://coreem.net/content/uploads/2017/05/Rule-of-9s.

It's been 2 years and 100 podcasts. Jenny and Swami take a minute to talk about the Core EM project and our future directions. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_100_0_Final_Cut.m4a Download One Comment Read More

This week we discuss 3 articles recently reviewed in our conference - LOV-ED study, Validation of Step-By-Step and Therapeutic Hypothermia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_99_0_Final_Cut.m4a Download Leave a Comment Tags: ARDS, Cardiac Arrest, Lung Protective Ventilation, Mechanical Ventilation, OHCA, Step-By-Step Protocol, Therapeutic Hypothermia, TTM Show Notes Take Home Points The step-by-step approach to managing febrile infants is a reliable decision instrument to identify patients at low risk for invasive bacterial infections. Caution in the group of patients 22-28 days of age. The LOV-ED study shows an association between employing a lung-protective ventilation strategy in the ED and decreased complications from mechanical ventilation. Best available evidence says that we should embrace this approach in the ED. Cooling to 33 degrees is no better than cooling to 36 degrees. However, shooting 36 degrees is more difficult than we may have thought. We have to continue to be vigilant about maintaining patients in the target temperature range and avoiding fever. <img aria-describedby="caption-attachment-5306" decoding="async" loading="lazy" class="size-full wp-image-5306" src="https:/...

This week we delve into the argument for cardioversion in recent-onset AF as well as the logistics of getting it done. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_98_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation, Atrial Flutter, Cardiology, Cardioversion Show Notes Read More Core EM: Podcast 64.0 – Rate Control in AF Core EM: Recent Onset Atrial Fibrillation Core EM: 30-Day Outcomes After Aggressive AF Management in the ED The SGEM: SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol References Nuito I et al. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA 2014; 312(6): 647-9. PMID: 25117135 Stiell IG et al. Association of the Ottawa aggressive protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation and flutter. Can J Emerg Med 2010; 12(3): 181-91. PMID: <a href="https://www.ncbi.nlm.nih.

This week we discuss the rare but life-threatening methemoglobinemia with a focus on recognition and use of the antidote. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_97_0_Final_Cut.m4a Download 2 Comments Tags: Methemoglobin, Toxicology Show Notes Take Home Points MetHb –emia occurs as a results of various medications including amyl nitrite, dapsone, nitroprusside, phenazopyridine, sodium nitrite and topical anesthetics like benzocaine Patients will present with cyanosis, short of breath, fatigue, dizziness, weakness and ultimately CNS depression and death at higher concentrations. If you have a cyanotic/hypoxic patient that does not respond to supplemental oxygen, be concerned for MetHb and send a co-oximetry panel. If the level is 25% or the patient is symptomatic, you will treat with the antidote methylene blue given as a bolus of 1-2 mg/kg over 5 minutes And as always, make sure to call your local poison center to get your toxicologists involved. They can help with dosing, and they are also an important player of the public health component in cases such as these, to make sure this is an isolated incident and we don’t have a repeat of the 11 blue men situation. Price DP. Chapter 127. Methemoglobin Inducers. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies,

This week we do a brief review on recognizing CO monoxide poisoning and expertly managing it. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_96_0_Final_Cut.m4a Download Leave a Comment Tags: CO, Inhaled Toxins, Toxicology Show Notes Take Home Points CO poisoning happens most often from common are accidental exposures from faulty home heaters, camp stoves and indoor use of gas powered generators, structure fires and intentional exposure like in suicide attempts. Patients with a mild exposure will present with symptoms like headache, nausea, vomiting, dizziness, vision blurring, palpitations, confusion or myalgias.  More severe exposures may produce Altered mental status. seizures, coma, dysrythmias, myocardial ischemia, metabolic acidosis, syncope and vital sign abnormalities including hypotension and, eventually, cardiac arrest. To help distinguish the vague symptoms of a patient who may have chronic exposure ask about things like whether symptoms improve in different environments or whether they have sick pets, as human viral illness generally don’t affect our dogs and cats. If you’re concerned about CO send a co-ox panel.  City dwellers may have a baseline carboxyhemoglobin of 1-2% and smokers around 6-10% but others should really have no carboxyhemoglobin. Treatment is supplemental O2 which can be stopped when symptoms improve.  For severe symptoms and for pregnant patients, consider hyperbarics to prevent long term sequelae and to protect the fetus.

This week we discuss the identification, prevention and treatment of local anesthetic systemic toxicity. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_95_0_Final_Cut.m4a Download 6 Comments Tags: Antidote, Bupivicaine, Intralipid, Lidocaine, Toxicology Show Notes LITFL: Local Anesthetic Toxicity Wiki EM: Local Anesthetic Systemic Toxicity References: Schwartz DR, Kaufman B. Local Anesthetics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Neal JM et al, American Society of Regional Anesthesia and Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med 2012;37:16–8. PMID: 22189574 Cao D et al. Intravenous lipid emulsion in the emergency department: a systematic review. J Emerg Med 2015; 48(3): 387-97. PMID: <a href="https://www.ncbi.nlm.nih.

This week we talk about mammal bites - dogs, cats and humans - with a focus on wound closure, antibiotics and rabies prophylaxis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_94_0_Final_Cut.m4a Download Leave a Comment Tags: Infectious Diseases, Mammal Bites, Rabies Show Notes EM:RAP: Animal Bites – A Short Board Review EM:RAP: Episode 107 Mammalian Bites Rebel EM: Medical Myths in the Management of Dog Bites CDC: Rabies Info References Chen E et al. Primary Closure of Mammalian Bites. Acad EM 2000; 7(2): 157- 162. PMID: 10691074 Paschos NK et al. Primary closure versus non-closure of dog bite wounds. A radomised controlled trial. Injury 2014 45(1): 237-40. PMID: 23916901 Medeiros IM, Saconato H. Antibiotic prophylaxis for mammalian bite (Review). Cochrane Database of Systematic Reviews 2008 (3); PMID: <a href="https://www.ncbi.nlm.

This week we cover a workshop from our conference on CNS infections focusing on meningitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_93_0_Final_Cut.m4a Download 3 Comments Tags: Bacterial Meningitis, CNS Infections, Infectious Diseases, Meningitis, Neurology Show Notes CSF Analysis (LITFL) EM Lyceum: Viral Meningitis “Answers” EM RAP: Meningitis LITFL: Bacterial Meningitis<...

This week we discuss some of the many dialysis-related emergencies we frequently see in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_92_0_Final_Cut.m4a Download One Comment Tags: Dialysis, ESRD, Nephrology Show Notes Take Home Points On any dialysis patient, make sure to do a good assessment of their access site.  If it’s a fistula, assess for a thrill, for any warmth/induration/erythema and make sure they have distal sensation and perfusion.  If it’s a catheter, evaluate for any signs of infection—so warmth, erythema or discharge. Bleeding is a big concern. If the patient is bleeding from their access, start with direct pressure to the bleeding site, then move on to topical thrombotic agents and if needed throw a figure 8 stitch with a 5-0 proline on a non-cutting needle. Peritoneal dialysis patients are at risk for bacterial peritonitis.  In a PD patient that appears infected, get a peritoneal fluid sample and start antibiotics Dialysis patients are susceptible to dialysis disequilibrium syndrome which can present as altered mental status, focal neurological deficits or even frank coma or seizures after dialysis.  Make sure to consider a broad differential in these patients and start with a solute load such as an amp or two of D50 while start...

This week we discuss a recent article in Annals of EM on contrast induced nephropathy and whether the phenomena is real or dogma. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_91_0_Final_Cut.m4a Download Leave a Comment Tags: AKI, CIN, Contrast Induced Nephropathy, Journal Update Show Notes ACR Table on CIN – FOAMCast FOAMCast: Episode 65 – Contrast Induced Nephropathy and Genitourinary Trauma REBEL EM: Contrast Induced Nephropahty: Fact or Myth Core EM: Acute Kidney Injury is not Associated with IV Contrast Use in the ED EM Lit of Note: <a href="http://www.emlitofnote.com/?

This week we dive into acute rhinosinusitis focusing on diagnosis and discussing the absence of utility for antibiotics in most patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_90_0_Final_Cut.m4a Download Leave a Comment Tags: ENT, Rhinosinusitis, Sinusitis, URI Show Notes Take Home Points Sinusitis is a clinical diagnosis. Patients typically present with purulent nasal discharge and facial pain or other URI symptoms. The vast majority of patients with acute rhino sinusitis will be viral in nature and will not benefit from antibiotics Patients with prolonged symptoms, more than 7-10 days, without improvement or continued fevers past 2-3 days should be considered for antibiotic treatment as should those who are immunocompromised. Show Notes Melio FR, Berge LR. Upper Respiratory Tract Infections, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 75: p 965-79. The NNT: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults The NNT: Antib...

This week we discuss the ED management of anterior and posterior epistaxis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_89_0_Final_Cut.m4a Download 3 Comments Tags: ENT, Epistaxis, Nose Bleeds, TXA Show Notes Take Home Points The first step is managing epistaxis is solid pressure.  This means holding a tight pinch just distal to the nasal bones and hold, without peaking, for at least 5 minutes.  This will stop a good deal of the bleeding. If you need to do more, start by soaking gauze in either oxymetazoline or epinephrine, mix in some lidocaine to help with anesthesia, pack the nare with that and add on some compression.  Hope fully this stops the bleeding enough that you can see a good bleeder and perform cautery. Third line of treatment would be to try some soaked gauze, but this time with TXA. Can’t hurt to try! And then last resort is of course packing. Here make sure the patient is anesthetized with some lidocaine, lubricate the packing well and apply horizonally, no vertically as we are often tempted. <img aria-describedby="caption-attachment-4775" decoding="async" loading="lazy" class="size-full wp-image-4775" src="https://coreem.

This week, we review a simplified approach to determining the rhythm on an EKG with a tachydysrhythmia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_88_0_Final_Cut.m4a Download One Comment Tags: Atrial Fibrillation, AVNRT, SVT, Tachycardias, Tachydysrhythias, Ventricular Tachycardia Show Notes Take Home Points When looking at a tachy rhythm that isn’t sinus tach, quickly differentiate by determining if the QRS complexes is narrow or wide and then determine if the rhythm is regular or irregular. This approach quickly drops the rhythm into 1 of 4 boxes and makes rhythm determination much easier Each of those 4 categories has a small set of rhythms included. Narrow and irregular – AF, Aflutter with variable block or MFAT. Narrow and regular – SVT or Aflutter. Wide and irregular – Torsades, VF, AF with aberrancy or a BBB. Wide and regular – VTach, SVT with aberrancy or SVT with a BBB. If you see wide and regular, the top 3 diagnoses are VT, VT and VT. Assuming VT and treating for that will almost never send you astray Read More EM: RAP: Episode 84 – Tachycardia Core EM: <a href="https://coreem.

This week we discuss two recent journal articles - the POKER trial and the ketorlac analgesic ceiling https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_87_0_Final_Cut.m4a Download Leave a Comment Tags: Ketamine, Ketofol, ketorlac, POKER, Propofol, PSA Show Notes Take Home Points The POKER trial examined the difference between propofol and ketofol when it comes to adverse respiratory events.  They found no significant difference between the groups.  Given the increased risk of medication errors using two medication instead of one, you may want to avoid the mixture. Ketorolac has an analgesic ceiling effect lower than you may have thought.  When comparing IV doses of 10mg, 15mg and 30mg they found no difference in analgesic effect.  Given the risks of side effects may increase with higher doses, you may want to stick to the lower 10mg dose. RebelEM: The POKER Trial: Go All in on Ketofol? St. Emlyn’s: JC: Is Ketofol with the ...

Do patients with 1st trimester bleeding need to get anti-D immunoglobulin if they're Rh negative? We dive into the topic this week. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_86_0_Final_Cut.m4a Download Leave a Comment Tags: Early Pregnancy, Obstetrics, RhoGam, Vaginal Bleeding Show Notes Take Home Points An Rh negative woman can become alloimmunized to Rh antigen if exposed to blood from an Rh positive fetus. Theoretically, this alloimmunization can occur even in early pregnancy While anti-D immune globulin has clearly been shown to be beneficial in preventing alloimmunization in 2nd and 3rd trimester pregnancy, there is no evidence supporting use specifically in the 1st trimester Despite the absence of evidence, RhoGam administration has become routine in many places. At this time, it’s advisable to follow local practice patterns regarding which patients should be given RhoGam. References ACOG Practice Bulletin. Prevention of Rh D Alloimmunization. Int J Gynaecol Obstet 1999; 66(1): 63-70. PMID: 10458556 Recommendations reaffirmed in 2016 Hahn SA et al. Clinical Policy: Critical Issues in the Initial Ealuation and Management of Patients Presenting to the Emergenc...

This week we discuss three common complications of delivery: cord prolapse, nuchal cord and shoulder dystocia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_85_0_Final_Cut.m4a Download Leave a Comment Tags: Cord Prolapse, Nuchal Cord, Obstetrics, Shoulder Dystocia Show Notes Take Home Points If you have a patient with a cord prolapse, elevate the presenting part to take pressure off the cord, place the patient in trendelenburg and fill the bladder. Then, redline it to the OR for a c-section. Nuchal cord is common but likely not too dangerous. Just gently unwrap the umbilical cord and the fetus should be just fine Shoulder dystocia isn’t common but it’s a true emergency as the fetus can suffer severe hypoxia or death. You’ve got a bout 5 minutes to deliver. Immediately call for help from OB, place a foley catheter to drain the bladder and place the mom’s legs so that her knees are pressed into her chest. This helps to open up the pelvis and give more room for the shoulder to be delivered. If that doesn’t work, you can try the wood’s screw maneuver or place the mom on all 4s. If you’ve got an OR ready, pushing the head back in is also an option but only if you have an OR available Read More Core EM: Shoulder Dystocia

This week we look at TBI and discuss some of the pitfalls and pearls in early management of traumatic ICH. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_84_0_Final_Cut.m4a Download 2 Comments Tags: Head Injury, Hyperosmolar Therapy, ICH, Resuscitation, RSI, TBI, Trauma Show Notes Take Home Points If you get a heads up from EMS on an incoming trauma, take the lead time you get to clearly delineate everyone’s roles to help ensure the resuscitation runs smoothly. In the severe TBI patient, the key is in preventing secondary injury to the brain. We do this by guarding against hypoxia, hypercarbia, hypotension and aspiration. Max your pre-ox, get the ETT in quickly to prevent oxygenation and ventilation issues and keep the head up if possible Hypotension is rarely seen in isolated head trauma. If the patient is or becomes hypotensive, reassess for any sources of hemorrhagic shock that may have been missed and consider whether the meds you gave may have caused the problem. Hypertension is much more common and despite extensive research, we haven’t shown that dropping the patient to normal levels is beneficial. Keeping the SBP If the patient’s ICP spikes or your concerned about herniation, administer mannitol or hypertonic saline and get your neurosurgeon to the bedside since the patient is gonna need decompression

This week we discuss a bit about back pain and specifically, lumbar radiculopathy with a focus on causes and red flags. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_83_0_Final_Cut.m4a Download One Comment Tags: Back Pain, Low Back Pain, Musculoskeletal, Steroids Show Notes Read More St. Emlyn’s: Back to Basics: Back Pain in the ED Edlow JA. Managing nontraumatic acute back pain. Ann Emerg Med 2015; 66: 148-53. PMID: 25578887 Goldberg H et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA 2015; 313 (19): 1915-23. PMID: 25988461 Friedman BW et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 2015; 314 (15): 1572-80. PMID: 26501533 Read More

This week we discuss the ED management of seizures focusing on treatment and workup particularly of a 1st seizure episode. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_82_0_Final_Cut.m4a Download Leave a Comment Tags: Neurology, Seizure, Status Epilepticus Show Notes Take Home Points Get a detailed history to tease out whether the patient had a seizure or a syncopal event. Regardless, get an EKG on 1st time seizures in case it was actually syncope. BZDs are first line therapy for seizure termination. If you don’t have IV access, go with 10 mg of midazolam or 2-4 mg of lorazepam IM Always review the 5 main categories for causes of seizures in order to make sure you’re not missing anything. Those categories once again are vital sign abnormalities, CNS infections, toxic/metabolic issues, CNS space occupying lesions including masses and bleeds and finally epilepsy. In patients with a first time seizure without a particular cause and return to baseline neurologic status, there’s unlikely to be any benefit to a NCHCT or to starting an AED. Scheduling close follow up with a neurologist is very reasonable. The key is to do a thorough examination and make sure you’re not missing a subtle abnormality. Finally, in status epilepticus hit the patient with 2-3 hefty doses of BZDs and if the seizure is still ong...

This week, the podcast features a talk on Visualization given at the All NYC EM conference in October 2016. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_81_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, Human Factors, Performance Psychology, Sports Psychology Show Notes Read More EMCrit: EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria Read More

This week we feature a short primer on penetrating chest trauma focusing on circulation first over airway and breathing. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_80_0_Final_Cut.m4a Download Leave a Comment Tags: ED Thoracotomy, EFAST, Resuscitative Thoracotomy, Trauma, Ultrasound Show Notes Take Home Points Don’t rush to the airway. In most situations, you have some time so resuscitate before you intubate. Give blood products and get the BP up a bit to give yourself a little better physiologic situation in which to intubate. Start your massive transfusion immediately if the patient is shocked. There’s always a delay in getting products but the earlier you start, the shorter the delay. Include US in your primary survey. Your E-FAST should start with the cardiac window, then go to the lungs and then, finally, the abdomen. This order focuses on finding pathology you can fix immediately. If the patient is shocked and peri-arrest or recently lost vitals, open the chest and look for a fixable injury. Start with opening the pericardium to relieve tamponade, identify and repair cardiac wounds and cross clamp the aorta. Read More Larry Mellick: <a href="...

This week we discuss facial trauma and the disasters it can cause to your airway management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_79_0_Final_Cut.m4a Download 2 Comments Tags: Airway, Cricothyroidotomy, RSI, Trauma Show Notes Take Home Points In a patient with significant head and neck trauma, EACH step of the airway management can be more difficulty. BVM may be hard, LMA may be hard, RSI may be hard, so don’t be afraid to ask for help early. Decide whether the patient has an actual obstruction of their airway. If they are obstructed above the larynx, don’t bother with your usual airway maneuvers, go directly to the surgical airway. When you do attempt RSI, have double suction and multiple airway techniques set up. This is the time to have your friend standing at your side, scalpel in hand and ready to move directly down the difficult airway algorithm if trouble arises. Finally, consider keeping the patient awake and preserving their own respiratory drive as it may give you more time to secure the airway. Read more LITFL: Facial Trauma LITFL: <a href="http://lifeinthefastlane.

This week we discuss the OXYGEN-ICU trial exploring the effect of excess oxygen on ICU mortality. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_78_0_Final_Cut.m4a Download Leave a Comment Tags: Critical Care, ICU, OXYGEN-ICU Study Show Notes Read More The Bottom Line: Normal Oxygen Versus Hyperoxia in the Intensive Care Unit (ICU) (OXYGEN-ICU) ScanCrit: Avoid the Oxygen Reflex REBEL EM: July 2015 REBEL Cast References Giradis M et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 316(15):1583-1589. 2016. PMID: 27706466 Meyhoff CS et al. PROXI Trial Group. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009; 302(14):1543-1550. PMID: <a href="https://www.ncbi.nlm.nih.

This week the podcast features a talk Jenny Beck-Esmay gave at the 11th All NYC EM Conference entitled "Give TXA Now!" https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_77_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, CRASH-2, Massive Transfusion Protocol, MATTERS, Trauma, TXA Show Notes Take Home Points Giving TXA provides a significant mortality benefit to the any trauma patient requiring massive transfusion with an NNT = 7 for mortality TXA must be given early. Give within 1 hour of injury if possible but the benefit remains up to 3 hours out TXA administration: 1 gram as a bolus followed by 1 gram over the next 8 hours Show Notes Intensive Care Network: Karim Brohi on TXA in Trauma EMCrit: Podcast 67 – Tranexamic Acid (TXA) Core EM: CRASH-2 Tranexamic Acid in Major Trauma References CRASH-2 trial collaborators. Effects of tanexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a ransomised placebo-controlled trial.

This week we discuss Lisfranc injuries with a focus on a diagnostic pathway and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_76_0_Final_Cut.m4a Download Leave a Comment Tags: Lisfranc Fracture, Lisfranc Injury, Orthopedics, Trauma Show Notes Take Home Points A Lisfranc injury is a midfoot injury that results in displacement of one or more of the metatarsal bones from tarsus.  XR will show widening of the space between the 1st and 2nd metatarsals. Getting contralateral XR may help you identify this. Even if you don’t see that widening on the XR, the patient could still have a Lisfranc injury. If they cannot walk due to pain, get a weight bearing XR or CT scan to look further. Once the injury is identified, the patient must be strict non-weightbearing. Place them in a posterior splint and get orthopedics involved either in the ED or for prompt follow up as the patient will probably need surgery. <img aria-describedby="caption-attachment-4236" decoding="async" loading="lazy" class="size-full wp-image-4236" src="https://coreem.net/content/uploads/2016/11/Foot-Skeleton-Superior-View-Google-Images.

This week we do a little spaced repetition on adrenal insufficiency and then discuss fluid responsiveness and resuscitation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_75_0_Final_Cut.m4a Download Leave a Comment Tags: Adrenal Insufficiency, Critical Care, Fluid Responsiveness, Fluid Resuscitation, Sepsis, Septic Shock Show Notes Read More Marik PE. Fluid responsiveness and the six guiding principles of fluid resuscitation. Crit Care Med 2016. PMID: 26571187 LITFL: Adrenal Insufficiency EMCrit: Podcast 64 – Assessing Fluid Responsiveness with Dr. Paul Marik Core EM: Adrenal Crisis Core EM: Episode 15.0 – Adrenal Crisis References

This week we review some pearls in the diagnosis and management of acid reflux. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_74_0_GERD_Final_Cut.m4a Download Leave a Comment Tags: Acid Reflux, Gastrointestinal, GERD, GI Show Notes Take Home Points GERD pain can mimic or co-exist with the more deadly causes of chest pain.  Be sure to consider all the serious causes of chest pain, get an EKG and maybe a chest XR while you go about symptom management. Respond to a treatment doesn’t prove a diagnosis.  GERD pain may get better with nitro and ACS pain may get better with a GI cocktail.  Keep an open mind while seeing these patients. Standard treatment for GERD includes an antacid and H2 blocker and maybe a PPI.  Keep in mind that a PPI takes a while to work, so be sure to give something faster acting in the ED And last, for these patients, take those few extra minutes for some counseling on lifestyle modifications.  All medications come with side effects, so be sure to address things like diet, smoking and weight loss while you have a captive audience.

This week we dive into the controversies surrounding the PESIT study looking at the prevalence of PE in admitted patients with syncope https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_73_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiovascular, Journal Club, PE, Pulmonary, Pulmonary Embolism, Syncope Show Notes Read More EMLit of Note: The Impending Pulmonary Embolism Apocolypse St. Emlyn’s: JC – Prevelance of PE in Patients with Syncope EM Nerd (EMCrit): The Case of the Incidental Bystander Pulm CCM: PESIT Investigators: The Incidence of PE in Those Hospitalized Following First Syncope References Hutchinson BD et al. Overdiagnosis of pulmonary embolism by pulmonary CT angiography.

This week we discuss upper GI bleeding pearls from a workshop we did in our weekly conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_72_0-UGIB_Final_Cut.m4a Download Leave a Comment Tags: Aortoenteric Fistula, Gastric Ulcer, Gastrointestinal, GI, UGIB, Variceal Bleeding Show Notes Take Home Points Respect the UGIB. These patients can bleed a lot. Even if they’re not actively hemorrhagic in front of you, realize that they can open up at any time and decompensate Get your consultants on board early. A skilled endoscopist is your friend as they can get control of bleeding. Don’t forget IR for TIPS in variceal bleeds and general surgery in bleeding ulcers. Activate your massive transfusion protocol if the patient is unstable and give the patient PRBCs, FFP and platelets as indicated. Reverse any anticoagulants as well. Give all patients with confirmed or suspected variceal bleeding antibiotics – typically, ceftriaxone. This intervention saves lives and decreases morbidity. Read More LITFL: EBM Upper GI Haemorrhage

This week we feature a lecture from Anand Swaminathan at our weekly conference on the ED management of acute pulmonary edema https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_71_0_Final_Cut.m4a Download 9 Comments Tags: Acute Decompensated Heart Failure, Acute Pulmonary Edema, ADHF, APE, Cardiovascular Show Notes Read More Core EM: Acute Pulmonary Edema EMCrit: Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema REBEL EM: Morphine Kills in Acute Decompensated Heart Failure emDocs: <a href="http://www.

This week we discuss the rare, but life-threatening baclofen withdrawal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_70_0_Final_Cut.m4a Download Leave a Comment Tags: Baclofen, Critical Care, Toxicology, Withdrawal Syndromes Show Notes Take Home Points Baclofen withdrawal is a rare complication of intrathecal baclofen pumps. It’s presentation mimics sepsis and alcohol withdrawal and is characterized by hemodynamic instability, hyperthermia, increased spasticity, confusion, altered mental status and seizures. Patients can develop rhabdo from the spasticity and, eventually, can develop multi system organ dysfunction. Treating baclofen withdrawal with oral baclofen is unlikely to work even at large oral doses because only a tiny amount gets into the CSF where it needs to act for withdrawal to be treated Baclofen withdrawal can be emergently treated with increasing benzodiazepine doses, propofol infusions and baclofen administered via a lumbar puncture. Ultimately, these patients all need consultation with either neurosurgery or interventional pain management to interrogate the device and surgically correct the issue. Read more EM: RAP November 2015: Lin Sessions Intrathecal P...

This week we discuss why we use antibiotics in COPD exacerbations and whether we should continue to do so. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_69_0_Final_Cut.m4a Download Leave a Comment Tags: Antibiotics, COPD, COPD Exacerbation, Pulmonary Show Notes Take Home Points Most COPD exacerbations are caused by infectious etiologies. While these can be viral, there’s also a decent chance it was caused by an overgrowth of bacteria that chronically colonize these patients. Strong evidence from systematic reviews demonstrates that antibiotic use reduces in-hospital mortality and decreases treatment failure The GOLD group recommends antibiotics be given to patients who have increased dyspnea, increased sputum volume and increased sputum purulence or require non-invasive or invasive ventilation for their exacerbation. Finally, a short course of antibiotics – either ampicillin, doxycycline or azithromycin is adequate for management. Read More GOLD Reports: Diagnosis, Management and Prevention 2016 Berg RMG, Plovsing RR. The hardships of being a Sith Lord: implications of the biopsychosocial model in a space opera. Adv Physiol Educ 2016; 40: 234-6.

This week we discuss the workup and management of hiccups in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_68_0_Final_Cut.mp3 Download One Comment Tags: Hiccups, Singultus Show Notes Take Home Points Hiccups, or singultus, are caused by a reflex arc involving the vagus nerve, CNS and phrenic nerve.  If you remember the path of these nerves, you can remember that possible bad pathologies that could cause a patient to present with prolonged hiccups. Physical maneuvers are the first line for solving the hiccups.  Try things that will interrupt respiration or stimulate the vagus nerve.  We like the modified valsalva in which the patient blows on a syringe, because it’s pretty easy to get the patient to do. Last, medication options for hiccups include antipsychotics, anticonvulsants, muscle relaxers and dopamine agonist.  Generally, we start with chlorpromazine 25-50 mg PO or IM. Read More Steger M et al.  Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther 2015; 42(9):1037-50. PMID 26307025 Read More

This week we review pearls from our Grand Rounds from George Willis, MD talking about feedback. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_67_0_Final_Cut.m4a Download Leave a Comment Tags: Resident Education Show Notes Read More St. Emlyn’s: #TTCNYC Resources for Feedback Talk Read More

This week, we discuss Boerhaave syndrome focusing on making the diagnosis and managing the patient. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_66_0_Final_Cut.m4a Download One Comment Tags: Chest Pain, Pulmonary Show Notes Take Home Points Keep esophageal rupture on your differential for deadly causes of chest, epigastric or back pain.  We don’t see it often, but it’s a real thing.  Boerhaave Syndrome is the spontaneous rupture of the esophagus that is caused by a sudden increase in intraesophageal pressure, as seen in forceful vomiting.  So, if the patient presents with the right symptoms and any vomiting in their history, keep this diagnosis in mind.  Other causes you might see, though less common, are childbirth, seizure, prolonged coughing or laughing, or weightlifting. ED management is essentially ABCs and broad spectrum antibiotics, and maybe even antifungals. As soon as you make this diagnosis, get you CT surgeon on board as the length of time to definitive treatment is directly related to mortality. Read More Radiopaedia: Boerhaave Syndrome LITFL: <a href="http://lifeinthefastlane.

This week we discuss the diagnosis and management of pericarditis with a focus on not missing the hidden STEMI. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_65_0_Final_Cut.m4a Download Leave a Comment Tags: ACS, Cardiology, Cardiovascular, Colchicine, Pericarditis, STEMI Show Notes Read More ECG Case of the Week (Amal Mattu): Acute STEMI vs. Pericarditis Part 1 + Part 2 REBEL EM: Colchicine for Treatment of Pericarditis SOCMOB: Pericarditis: Treatment and Diagnosis Pocket Card FOAMcast: Episode 54 – The Pericardium Core EM: Pericarditis <img aria-describedby="caption-att...

This week we discuss an age-old debate: Calcium Channel Blockers or Beta Blockers for rate control in atrial fibrillation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_64_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation, Beta Blocker, Calcium Channel Blocker, Cardiology, Rate Control Show Notes CoreEM: Recent Onset Atrial Fibrillation ALiEM: Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers? ALiEM: Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED Fromm C, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015 Apr 22. PMID 25913166 <a href="https://coreem.

This week we discuss a recent article looking at the relevance of d/c glucose levels to patient revisits and subsequent hospitalization https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_63_0_Final_Cut.m4a Download Leave a Comment Show Notes Driver BE et al. Discharge glucose is not associated with short-term adverse outcomes in emergency department patients with moderate to severe hyperglycemia. Ann Emerg Med 2016. PMID: 27353284 Read More

This week we discuss the ED management of cardiac arrest with VFib and pulseless VTach. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_62_0_Final_Cut.m4a Download One Comment Tags: Cardiac Arrest, Dual Defibrillation, OHCA, Ventricular Dysrhythmias, Ventricular Fibrillation, Ventricular Tachycardia Show Notes Take Home Points In cardiac arrest, the most important interventions are to deliver electricity quickly when it’s indicated and to administer good high-quality compressions with minimal interruptions to maximize your compression fraction. Medications like epinephrine and amiodarone have never been shown to improve good neurologic outcomes in the ACLS recommended doses. Don’t focus on them. Consider pre-charging your defibrillator to minimize pauses in CPR and maximize your chance for ROSC Finally, remember that as Emergency Physicians, we are specialists in the resuscitation of cardiac arrests. ACLS is just a starting point. Push your understanding of taking care of these patients so you can deliver the best care possible Additional Reading Core EM: <a href="https://coreem.

This week we discuss the presentation and treatment of hypokalemia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_61_0_Final_Cut.m4a Download Leave a Comment Show Notes Take Home Points Hypokalemia has a wide variety of presentations ranging from generalized weakness, to paralysis, to cardiac arrhythmia or cardiac arrest. When you discover hypokalemia, be sure to check and EKG. Think about underlying causes of hypokalemia, because it is rarely a solo event. Treat with oral potassium supplementation of 40-60 orally every 4-6 hours for mild hypokalemia and 10-20 mEq/hour IV for severe or symptomatic hypokalemia. Additional Reading LITFL: Hypokalemia LITFL: Hypokalemic Periodic Paralysis Core EM: Hypokalemia Read More

This week we discuss how to aggressively resuscitate patients with DKA as well as dispelling some dogmatic teachings on the topic. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_60_0_Final_Cut.m4a Download Leave a Comment Tags: Cerebral Edema, DKA, Hypokalemia, Insulin, Resuscitation Show Notes Take Home Points DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis. Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5 The insulin bolus isn’t necessary and appears to cause more episodes of hypokalemia. Just start insulin as an infusion at 0.14 units/kg Be vigilant about cerebral edema. Any change or deterioration in mental status should prompt treatment and evaluation. Mannitol in the euvolemic, normotensive patient and 3% hypertonic saline in the hypotensive/hypovolemic patient Finally, don’t forge to always hunt down the underlying cause of the DKA. Infection and non-compliance is the most common so liberally administer broad spectrum antibiotics if you’ve got even a hint of infection brewing

This week we discuss the recognition, diagnosis and treatment of severe decompensated hyperthyroidism or thyroid storm. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_59_0_Final_Cut.m4a Download Leave a Comment Tags: Thyroid Diseases, Thyroid Storm Show Notes Take Home Points Decompensated hyperthyroidism is a rare, life-threatening condition.  It can develop in patients with long-standing untreated hyperthyroidism and is often precipitated by another event such as an infection, surgery, or trauma. Patients present with tachycardia, fever, altered mental status and GI symptoms.  Keep thyroid storm in mind if a patient has a history of hyperthyroidism or if things just aren’t making sense with your patient, you can’t find a fever source, they have fever and new afib, things like that. You’re going to use a clinical scoring tool like the Burch-Wartofsky scoring system to make the diagnosis. Treatment is three-fold. First treat the peripheral effects with propranolol.  Then prevent further synthesis of thyroid hormone with PTU and corticosteroids.  And last prevent the further release of thyroid hormone with iodine.  Be sure to hold off on giving the iodine until at least 1 hour after the patient receives PTU to avoid worsening the hyperthyroid...

This week we discuss severe hyponatremia - presentation and treatment. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_58_0_Final_Cut.m4a Download Leave a Comment Tags: Electrolytes, Hypertonic Saline, Hyponatremia Show Notes EM Cases: Podcast 60: Emergency Management of Hyponatremia References Adrogue HJ, Maidas NE. Hyponatremia. NEJM 2000; 342(21): 1581-9. PMID: 10824078 Moritz ML, Ayus JC. 100 cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metab Brain Dis 2010; 25: 91-6. PMID: 20221678 Read More

This week we discuss the role of phenobarbital in the management of severe alcohol withdrawal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_57_0_Final_Cut.m4a Download One Comment Tags: Alcohol Withdrawal, Phenobarbital, Toxicology Show Notes References Riggan MA et al. Regarding “Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study.” J Emerg Med 2016; 50 (6): 895-8. PMID: 27221017 Rosenson J et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study. J Emerg Med 2013; 44(3): 592-8. PMID: 2299978 Read More

This week we discuss pearls from a talk from Reuben Strayer on sedation of the agitated patient focusing on patient and staff safety. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_56_0_Final_Cut.m4a Download 3 Comments Tags: Agitation, Droperidol, Excited Delirium, Haloperidol, Lorazepam, Midazolam Show Notes <img decoding="async" loading="lazy" class="size-full wp-image-3495 aligncenter" src="https://coreem.net/content/uploads/2016/07/Strayer-Summary-Slide.png" alt="Strayer Summary Slide" width="912" height="679" srcset="https://i0.wp.com/coreem.net/content/uploads/2016/07/Strayer-Summary-Slide.png?w=912&ssl=1 912w, https://i0.wp.com/coreem.net/content/uploads/2016/07/Strayer-Summary-Slide.png?resize=300%2C223&ssl=1 300w, https://i0.wp.com/coreem.

This week we dive into the PATCH trial investigating the role of platelet transfusions in patients with spontaneous ICH on antiplatelet meds https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_55_0_Final_Cut.m4a Download Leave a Comment Tags: Intracerebral Hemorrhage, PATCH Trial, Platelets Show Notes Read More REBEL EM: The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage? St. Emlyn’s: JC – Platelets for Intracranial Haemorrhage EM Lit of Note: Put the Platelets Away in ICH References

This week we discuss some of the critical issues in preparation, preoxygenation and positioning in RSI. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_54_0_Final_Cut.m4a Download Leave a Comment Tags: 7 Ps, High-flow Nasal Cannula, Intubation, Preoxygenation, RSI Show Notes Read More EM Updates: Intubation Checklist Core EM: Episode 4.0 – Perimortem C-section, Procedural Sedation and Airway Pearls Core EM: Episode 6.0 – Airway Workshops Sales JC et al. The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med 2013; 20(1): 71-8. PMID: 23574475 <img aria-describedby="caption-attachment-3464" decoding="async" loading="lazy" class="size-full wp-image-3464" src="https://coreem.net/content/uploads/2016/06/Screen-Shot-2016-06-28-at-1.22.52-PM.png" alt="LEMON Mnemonic Device" width="1011" height="473" srcset="https://i0.wp.

This week we discuss a recent study published in the NEJM on low-dose tPA vs standard-dose in acute ischemic stroke. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_53_0_Final_Cut.m4a Download Leave a Comment Tags: Alteplast, CVA, Ischemic Stroke, The ENCHANTED Trial, tPA Show Notes Read More Anderson CS et al. Low-dose versus standard-dose intravenous alteplase in acute ischemic stroke. NEJM 2016. PMID: 27161018 EMNerd: The Case of the Non-Inferior Inferiority Continues REBEL EM: The ENCHANTED Trial: Is Low-Dose the Right Dose for Intravenous tPA in Acute Ischemic Stroke? EMCrit: Podcast 116 – the tPA for Ischemic Stroke Debate EMNerd: A Secondary Examination of the Adventure of the Cardboard Box SMART EM: <a href="https://itunes.apple.com/us/podcast/smart-em/id512413488?

This week we review anaphylaxis, the importance of epinephrine/adrenaline and how to use it properly. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_52_0_Final_Cut.m4a Download One Comment Tags: Allergic Reactions, Allergy, Anaphylaxis, Epinephrine Show Notes Anaphylaxis Definition Read More Tran TP, Muelleman RL: Allergy, Hypersensitivity, Angioedema, and Anaphylaxis, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 119: p 1543-1560. YouTube: Epinephrine Auto-Injector Use The SGEM: #57: Should I Stay or Should I Go (Biphasic Anaphylac...

This week we dive into a recent article on pain control in renal colic and how it affects our management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_51_0_Final_Cut.m4a Download Leave a Comment Tags: Analgesia, Kidney Stones, Renal Colic, Urology Show Notes Read More Core EM: Optimal First Line Analgesia in Ureteric Colic ALiEM: Top 10 reasons NOT to order a CT scan for suspected renal colic REBEL EM: Does Use of Tamsulosin in Renal Colic Facilitate Stone Passage Core EM: Medical Expulsive Therapy (MET) in Renal Colic Wang RC. Managing Urolithiasis. Ann Emerg Med 2015 PMID: 26616536 References Pathan SA et al. Delivering safe and effective analgesia for management of renal colic in the emerg...

This week we look at the rarely used, but potentially life-saving, procedure of gastric lavage. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_50_0_Final_Cut.m4a Download Leave a Comment Tags: Gastric Emptying, Gastric Lavage, Toxicology Show Notes Gastric Lavage Indications (Goldfrank’s Toxicologic Emergencies Ch 7) <img aria-describedby="caption-attachment-3242" decoding="async" loading="lazy" class="size-full wp-image-3242" src="https://coreem.net/content/uploads/2016/05/Gastric-Lavage-Risk-Assessment.png" alt="Gastric Lavage Risk Assessment (Goldfrank's Toxicologic Emergencies Ch 7)" width="1022" height="590" srcset="https://i0.wp.com/coreem.net/content/uploads/2016/05/Gastric-Lavage-Risk-Assessment.png?w=1022&ssl=1 1022w, https://i0.wp.com/coreem.net/content/uploads/2016/05/Gastric-Lavage-Risk-Assessment.

This week we take a look at alcohol withdrawal with a focus on recognition and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_49_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Withdrawal, Ativan, Benzodiazipines, Delirium Tremens, Ethanol, Thaimine, Valium Show Notes Yip L. Chapter 77. Ethanol. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e. New York, NY: McGraw-Hill; 2011. EmCrit Podcast: Delirium Tremens Life in the Fast Lane: Alcohol Withdrawal The Poison Review: CPC: alcohol withdrawal with delirium tremens and a significant missed diagnosis EM Updates: Avoid Alcohol Withdrawal Admissions MDCalc: <a href="http://www.

This week we delve into the anticholinergic toxidrome with a focus on management and the use of physostigmine. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_48_0_Final_Cut.m4a Download Leave a Comment Tags: Anticholinergic, Diphenhydramine, Physostigmine, TCA, Toxicology Show Notes Howland M. Antidotes in Depth (A12): Physostigmine Salicylate. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e . New York, NY: McGraw-Hill; 2011. Velez LI, Feng SY: Anticholinergics, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 150: p 1970-5. Anticholinergic Infographic ...

This week we review mandible dislocations and reduction approahces focusing on the new "syringe" technique. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_47_0_Final_Cut.m4a Download Leave a Comment Tags: Mandible Dislocation, Oral Surgery, Syringe Technique Show Notes Read More ALiEM: Tick of the Trade: Extra-oral reduction technique of anterior mandible dislocation Gorchynski J et al.  The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibulardislocations in the emergency department.  J Emerg Med. 2014; 47(6):676-81. PMID 25278137   <img aria-describedby="caption-attachment-3121" decoding="async" loading="lazy" class="size-full wp-image-3121" src="https://coreem.net/content/uploads/2016/04/Syringe-Technique-Step-1.png" alt="Syringe Technique Step 1" width="598" height="557" srcset="https://i0.wp.com/coreem.net/content/uploads/2016/04/Syringe-Technique-Step-1.png?w=598&ssl=1 598w, https://i0.wp.com/coreem.net/content/uploads/2016/04/Syringe-Technique-Step-1.png?resize=300%2C279&ssl=1 300w" sizes="(max-width: 598px) 100vw,

This week, the podcast features a full length talk from our Grand Rounds series. This talk was given by Ilene Claudius on pediatric SOB https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_46_0_Final_Cut.m4a Download Leave a Comment Tags: Asthma, Atropine, Bronchiolitis, Croup, Magnesium, RSI Show Notes Irazuzta JE et al. High-dose magnesium sulfate infusion for severe asthma in the emergency department: efficacy study. Crit Care Med 2016; 17: e29-e33. PMID: 26649938 Read More

This week we review a number of controversial topics in SSTI management with a focus on the role of antibiotics in abscess management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_45_0_Final_Cut.m4a Download Leave a Comment Tags: Abscess, Cellulitis, Controversy, I+D, Irrigation, TMP-SMX Show Notes Core EM: Predictors of failed outpatient cellulitis treatment EM Nerd: The Case of the Pragmatic Wound REBEL EM: Trimethoprim-sulfamethoxazole for uncomplicated skin abscesses EM Lyceum: Abscess, “Answers” References Peterson D et al. Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients with Uncomplicated Cellulitis. Acad Emerg Med 2014; 21: 526-31. PMID: 24842503

This week we touch on some pearls and pitfalls on diagnosis and management of tick borne illnesses. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_44_0_Final_Cut.m4a Download One Comment Tags: Babesiosis, Ehrlichiosis, Lyme Disease, RMSF, Rocky Mountain Spotted Fever, Tick Show Notes CDC: Ticks CDC: Tick Borne Illnesses of the United States Read More

This week we review delayed ICH in patients with head trauma on blood thinners and discuss the role of repeat imaging and admission. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_43_0_Final_Cut.m4a Download 2 Comments Tags: Clopidogrel, Delayed Intracranial Hemorrhage, Head Trauma, Plavix, Warfarin Show Notes Nishijima DK et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and perjury warfarin or clopidogrel use. Ann Emerge Med 2012; 59(6): 460-8. PMID: 22626015 Menditto VG et al. Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 2012; 59(6): 451-5. PMID: 22244878 Miller J et al. Delayed intracranial hemorrhage in the anticoagulated patient: a systematic review. J Trauma Acute Care Surg 2015; 79: 310-3. PMID: 26218702 Read More

This week we review how to ventilate the intubated asthmatic patient. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_42_0_Final_Cut.m4a Download One Comment Tags: Asthma, Crashing Asthmatic, Permissive Hypercapnea, Ventilation Show Notes REBEL EM: The Crashing Asthmatic EMCrit: Podcast 15 – The Severe Asthmatic EMCrit: Dominating the Vent: Part I + Part II Read More

This week we look at herpetic infections of the eye and skin focusing on diagnosis and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_41_0_Final_Cut.m4a Download One Comment Tags: Herpes, Herpetic Keratitis, Shingles, Zoster Show Notes Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev 2010. PMID: 21154352 American Academy of Ophthalmology: Herpes Simplex Virus Keratitis Treatment Guideline Read More

This week we delve into dental emergencies from infections to trauma as well as discussing dental anesthesia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_40_0_Final_Cut.m4a Download Leave a Comment Tags: Dental Caries, Dental Emergencies, Dental Trauma, Dentoalveolar Abscess Show Notes Taming the SRU: Regional Anesthesia of the Face & Mouth ALiEM: Paucis Verbis: Dental trauma ALiEM Paucis Verbis: Dental infections ALiEM Tricks of the Trade: Dental Avulsion and Subluxation EB Medicine: Fixing Faces Pain Painlessly: Facial Anesthesia in Emergency Medicine Core EM: Tongue Blade Test The Dental Box Instructional Videos Read More

This podcast reviews highlights from a grand rounds talk given by Michael Bond on Killer back pain. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_39_0_Final_Cut.m4a Download Leave a Comment Tags: AAA, Back Pain, Epidural Abscess, Vertebral Osteomyelitis Show Notes Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med 2015; 66: 148-53. PMID: 25578887 <img decoding="async" loading="lazy" class="size-full wp-image-2799 aligncenter" src="https://coreem.net/content/uploads/2016/02/Screen-Shot-2016-02-03-at-8.29.13-PM.png" alt="Screen Shot 2016-02-03 at 8.29.13 PM" width="747" height="493" srcset="https://i0.wp.com/coreem.net/content/uploads/2016/02/Screen-Shot-2016-02-03-at-8.29.13-PM.png?w=747&ssl=1 747w, https://i0.wp.com/coreem.net/content/uploads/2016/02/Screen-Shot-2016-02-03-at-8.29.13-PM.png?resize=300%2C198&ssl=1 300w, https://i0.wp.com/coreem.

This week we discuss everyone's favorite infectious diseases: Gonorrhea and Chlamydia https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_38_0_Final_Cut.m4a Download Leave a Comment Tags: Chlamydia, Gonorrhea, PID, STD, STI Show Notes The SGEM: SGEM #104: Let’s Talk About Sex Baby, Let’s Talk About STDs ALiEM: Is the Pelvic Exam in the Emergency Department Useful? HQMedEd: Blind Swab vs Speculum-Assisted Endocervical Swab EM Lyceum: PID Answers Exposed: Why is Gonorrhea Called the Clap? CDC: Expedited Partner Therapy CDC: Sexually Transmitted Diseases...

This week we discuss ovarian pathology focusing on ovarian torsion and tubo-ovarian abscess. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_37_0_Final_Cut.m4a Download Leave a Comment Tags: gynecology, Ovarian Torsion, TOA, tubo-ovarian abscess Show Notes Pediatric EM Morsels: Ovarian Torsion EM Lyceum: Ovarian Torsion Beigi, R.H. (2015). Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Beigi, R.H. (2015). Management and complications of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Hart, D, Lipsky, A. Acute Pelvic Pain in Women. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 266-272. Lee D, Swaminathan A. Sensitivity of Ultrasound for the Diagnosis of Tubo-Ovarian Abscess: A Case Report and Literature Review. J Emerg Med. 2011 vol 40 (2): 170-5. PMID: 20466506 Tibbles, CD. Selected Gynecologic Disorders. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 1355-1362. Read More

This week's podcast delves into cervical spine injuries and the findings found on CT imaging of the cervical spine. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_36_0_Final_Cut.m4a Download Leave a Comment Tags: Cervical Spine, Fracture, Trauma Show Notes Core EM: C-Spine Injuries + CT Interpretation Schwartz DT. Section 5. Cervical Spine. In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008. http://accessemergencymedicine.mhmedical.com/ (via NYU Health Sciences Library) Read More

This week we discuss an article on door to balloon time and focus on the EPs role in patients who present with ST elevations on their EKG. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_35_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiology, Door to Balloon Time, Resuscitation, STEMI Show Notes Fanari Z et al. Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential risks and role of quality improvement. Mayo Clin Proc 2015. PMID: 26549506 REBEL EM: December 2015: All Cardiology REBELCast Read More

This week, we cover the physiologic changes in pregnancy and how they affect trauma management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_34_0_Final_Cut.m4a Download Leave a Comment Tags: Perimortem C-section, Pregnancy, Trauma Show Notes EMCrit: Peri-Mortem C-Section emDocs.net: Resuscitation of the Pregnant Trauma Patient – Pearls and Pitfalls Core EM: Peri-Mortem C-Secton Core EM: Podcast 4.0 <img aria-describedby="caption-attachment-2659" decoding="async" loading="lazy" class="size-full wp-image-2659" src="https://coreem.net/content/uploads/2016/01/Meds-in-Pregnancy-Table.png" alt="Medications in Pregnancy" width="533" height="398" srcset="https://i0.wp.com/coreem.net/content/uploads/2016/01/Meds-in-Pregnancy-Table.png?w=533&ssl=1 533w, https://i0.wp.com/coreem.net/content/uploads/2016/01/Meds-in-Pregnancy-Table.png?resize=300%2C224&ssl=1 300w" sizes="(max-width: 533px) 100vw,

This week, we review the management of post-partum hemorrhage focusing on identifying the cause, resuscitation and directed medical therapy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_33_0_Final_Cut.m4a Download Leave a Comment Tags: Post-partum hemorrhage, Pregnancy Show Notes Core EM: Shoulder Dystocia Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82. PMID: 24360351 Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82. <img aria-describedby="caption-attachment-2670" decoding="async" loading="lazy" class="size-full wp-image-2670" src="https://coreem.net/content/uploads/2016/01/Drugs-for-the-Management-of-Uterine-Atony-Roberts-Hedges.png" alt="Drugs for the Management of Uterine Atony - Roberts + Hedges" width="1093" height="458" srcset="https://i0.wp.com/coreem.net/content/uploads/2016/01/Drugs-for-the-Management-of-Uterine-Atony-Roberts-Hedges.png?w=1093&ssl=1 1093w, https://i0.wp.com/coreem.net/content/uploads/2016/01/Drugs-for-the-Management-of-Uterine-Atony-Roberts-Hedges.png?resize=300%2C126&ssl=1 300w, https://i0.wp.com/coreem.net/content/uploads/2016/01/Drugs-for-the-Management-of-Uterine-Atony-Roberts-...

This is part I of a 2 part series on C-spine CT scans. In part 1, we discuss the basic ins and outs of reading the C-spine CT. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_32_0_Final_Cut.m4a Download Leave a Comment Tags: Cervical Spine, CT Scan Show Notes Core EM: The ABCs of Reading C-Spine CTs Read More

This podcast is a recorded lecture from our conference on why Rocuronium should be the go to drug for RSI in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_31_0_Final_Cut.m4a Download 2 Comments Tags: Airway, Rocuronium, RSI, Succinycholine Show Notes Sydney HEMS Sux Contraindications Read More: Strayer RJ. Rocuronium versus succinylcholine: Cochrane synopsis reconsidered. Ann Emerg Med 2011; 58(2): 217-8 Strayer RJ. Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 345-6. Mallon WK et al. Response to Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 346-7. Strayer RJ. (2010, January 14). Screencast: Rocuronium vs. Succinylcholine in 8 minutes. Retrieved from http://emupdates.com/2010/01/14/rocuronium-vs-succinylcholine/...

This episode delves into pediatric c-spine injuries focusing on the question of who needs imaging? https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_30_0_Final_Cut.m4a Download Tags: Cervical Spine, NEXUS C-spine, Pediatrics Show Notes Leonard JC et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med 2011; 58(2): 145-55. PMID: 21035905 ERCast: Pediatric C-spine Clearnace PECARN Decision Rule <img aria-describedby="caption-attachment-2588" decoding="async" loading="lazy" class="size-full wp-image-2588" src="https://coreem.net/content/uploads/2015/12/PECARN-Paramater-Definitions.png" alt="PECARN Paramater Definitions" width="743" height="528" srcset="https://i0.wp.com/coreem.net/content/uploads/2015/12/PECARN-Paramater-Definitions.png?w=743&ssl=1 743w, https://i0.wp.com/coreem.net/content/uploads/2015/12/PECARN-Paramater-Definitions.png?

This week we discuss the work up for dementia and delirium as well as a bit on ischemic CVA management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_29_0_Final_Cut.m4a Download Leave a Comment Tags: CVA, Delirium, Dementia, Stroke, tPA Show Notes SAEM Geriatric Guidelines (includes screening tools for delirium): GEMCast: Diagnosing and Managing Delirium in Older Adults Gioia, LC et al. Blood pressure management in acute intracerebral hemorrhage: current evidence and ongoing controversies. Curr Opin Crit Care. 2015; 21(2):99-106. PMID: 25689125 Miller J et al. Management of hypertension in stroke. Ann Emerg Med. 2014; 64(3): 248-55. PMID: 24731431 EM Nerd: A Truncated Summation of the Adventure of the Cardboard Box Ed in the ED WDYS: Talking about tPA – Expert and Community Commentary   Read More

This week we review some of the different aspects used in assessment of the suicidal patient who presents to the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_28_0_Final_Cut.m4a Download Leave a Comment Tags: Depression, Suicide Assessment Show Notes ERCast: Suicide Risk ERCast: Is My Patient Suicidal Columbia Suicide Severity Rating Scale Read More

Are you ready for endovascular therapy in ischemic CVA? We discuss some of the ins and outs focusing on the MR CLEAN trial. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_27_0_Final_Cut.m4a Download Leave a Comment Tags: CVA, Ischemic Stroke, MR CLEAN Show Notes Montori VM et al. Randomized trials stopped early for benefit: a systematic review. JAMA 2005; 294(17): 2203-9. PMID: 16264162 EMCrit: Podcast 116 – the tPA for Ischemic Stroke Debate EM Nerd: A Truncated Summation of the Adventure of the Cardboard Box (Reviews the major endovascular treatment studies) Read More

This week's podcast is a full length recording of Ashley Shreves' Grand Rounds talk at Bellevue Hospital on dying in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_26_0_Final_Cut.m4a Download Leave a Comment Tags: Palliative Care Show Notes All NYC EM Podcast: Ashley Shreves – Pathway to a Peaceful Death Read More

Emergent placement of a temporary TV pacer is a life-saving procedure. We review the procedure along with some pearls along the way. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_25_0_TV_Pacemakers_Final_Cut.m4a Download Leave a Comment Tags: Transvenous Pacemaker Show Notes Bessman ES: Emergency Cardiac Pacing, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 15:p 277-300. Read More: EM Updates: Electromechanical Dissociation LITFL: Temporary Transvenous Cardiac Pacing <img aria-describedby="caption-attachment-2312" decoding="async" loading="lazy" class="size-full wp-image-2312" src="https://coreem.net/content/uploads/2015/10/TV-Pacemaker-Equipment-Roberts-and-Hedges.png" alt="Robert's + Hedges - TV Pacemaker Equipment" width="480" height="358" srcset="https://i0.wp.com/coreem.net/content/uploads/2015/10/TV-Pacemaker-Equipment-Roberts-and-Hedges.png?w=480&ssl=1 480w, https://i0.wp.com/coreem.net/content/uploads/2015/10/TV-Pacemaker-Equipment-Roberts-and-...

This podcast is a brief discussion on hepatic encephalopathy: How it presents, the utility of ammonia levels and what else to look out for. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_24_0_Final_Cut.m4a Download Leave a Comment Tags: Ammonia, AMS, Hepatic Encephalopathy Read More

This week we review small bowel obstruction presentation, diagnosis and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_19_0_Final_Cut.m4a Download Leave a Comment Tags: Large Bowel Obstruction, SBO Show Notes 5 Minute Sono: Small Bowel Obstruction EM Lyceum: GI Imaging FOAMCast: Episode 23 – SBO and Mesenteric Ischemia Read More

This week we'll discuss some common causes of abdominal pain that originate in extra-abdominal pathology. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_22_0_Abdominal_Pain_Final_Cut.m4a Download Leave a Comment Tags: Abdominal Pain Show Notes Life in the Fast Lane: Metabolic Causes of Abdominal Pain Read More

This week podcast focuses on esophageal food impaction and pearls + pitfalls in the diagnosis of peds appendicitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_21_0_Final.m4a Download Leave a Comment Tags: Appendicitis, Food Impaction, Pediatrics Show Notes REBEL Cast: November 2015: All Vascular Access Episode Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855 Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002; 37(6): 877-81. PMID: 12037754 Ross MJ et al. Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound. Acad Emerg Med 2015; 21(5): 538-42. PMID: 24842505

On this podcast we review some background on AVNRT and focus on Emergency Department management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_20_0_Final.m4a Download 2 Comments Tags: AVNRT, PSVT, REVERT Trial, Tachydysrhythmias Show Notes AVNRT with Aberrancy vs. VT REBEL EM: SVT with Aberrancy Versus VT Amal Mattu’s ECG Case of the Week: August 26th, 2013 Valsalva Maneuver ALiEM: Tricks of the Trade: Valsalva Maneuver By Using a 10cc Syringe St. Emlyn’s: JC The REVERT Trial Adenosine in AVNRT Larry Mellick: Treating SVT with Adensoine ALiEM: Trick of the Trade: Combining Adenosine with the Flush Verapamil in AVNRT RAGE Podcast: <a href="http://ragepodcast.

Bonus Podcast - Grand Rounds from 9/23/15 featuring Brian Freeze MD on Numeracy. Lecture is part of the Chief Resident Incubator Program https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_19_1_Numeracy_Final.m4a Download Leave a Comment Tags: Chief Resident Incubator, Numeracy, Statistics Read More

Pearls and take home messages from our weekly conference. This week, we review talks on influenza and pediatric foreign body aspiration. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_19_0_Final.m4a Download Leave a Comment Tags: Aspiration, Foreign Body, Influenza, Oseltamivir, Tamfiflu Show Notes Influenza Populations at High Risk for Severe Influenza – IDSA ALiEM: Neuraminidase Inhibitors for Influenza – The Truth, The Whole Truth, and Nothing But the Truth. Finally. EM Lit of Note: <a href="http://www.emlitofnote.

This bonus podcast is from our Grand Rounds series. Here, Jeremy Faust gives a great talk on the role of Music in Medicine. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_18_1-Music_in_Medicine_feat_Jeremy_Faust_.m4a Download Leave a Comment Tags: Grand Rounds, Music Show Notes References Platz, F. and Kopiez, R., “When the first impression counts: Music performers, audience, and the evaluation of stage entrance behavior”, Musicae Scientiae 17, No. 2 (2013), pp. 167-197 Acad Emerg Med. 2012 Oct;19(10):1166-72. Epub 2012 Oct 4. Predictors of parent satisfaction in pediatric laceration repair. Lowe DA, Monuteaux MC, Ziniel S, Stack AM. Proc Natl Acad Sci U S A. 2013 Sep 3;110(36):14580-5. Epub 2013 Aug 19. Sight over sound in the judgment of music performance. Tsay CJ. Med Educ. 2013 Aug;47(8):842-50.  Music lessons: revealing medicine’s learning culture through a comparison with that of music. Watling C, Driessen E, van der Vleuten CP, Vanstone M, Lingard L. The New Yorker. October 3, 2011. Personal Best. Top athletes and singers have coaches. Should you? Atul Gawande. ANZ J Surg. 2013 Jun;83(6):477-80. Epub 2013 Apr 26. Improving the impact of didactic resident training with online spaced education. Gyorki DE, Shaw T, Nicholson J, Baker C, Pitcher M, Skandarajah A, Segelov E, Mann GB. Psychol Sci Public Interest. 2013 Jan;14(1):4-58. Improving Students’ Learning With Effective Learning Techniques: Promising Directions From Cognitive and Educational Psychology. Dunlosky J, Rawson KA, Marsh EJ,

This week we discuss some information on influenza testing in the ED and management of epistaxis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_18_0_Final_Version.m4a Download Leave a Comment Tags: Epistaxis, Influenza Show Notes Show Notes EMCrit: Dominating the Vent I http://emcrit.org/lectures/vent-part-1/ EMCrit: Dominating the Vent II http://emcrit.org/podcasts/vent-part-2/ ALiEM: Neuraminidase Inhibitors for Influenza – The Truth, The Whole Truth, and Nothing But the Truth. Finally. EM Lit of Note: Remember, Tamflu is Still Junk. EM Lit of Note: Which Review of Tamflu Data do You Believe? Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013; 31: 1389-92. PMID: 23911102 Derkay CS et al. Posterior nasal packing.

Pearls from our weekly conference discussing severe asthma and COPD exacerbations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_17_0_Final.m4a Download 4 Comments Tags: Asthma, BPAP, COPD, NIPPV, Respiratory Show Notes Shownotes EMCrit: Delayed Sequence Intubation REBEL EM: The Crashing Asthmatic EM:RAP: The Rule of 2s Abdo WF, Heunks LM. Oxygen-induced hypercapnia in COPD: myths and facts. Critical Care 16(5):323. PMID: 23106947 Read More

Pearls from our conference discussing apparent life-threatening events (ALTE). https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_16_Final.m4a Download Leave a Comment Tags: ALTE, Pediatrics Show Notes Shownotes Mittal MK et al. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012; 28(7): 599-605. PMID: 22743742 Kaji AH et al. Apparent life-threatening event: multi center prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med 2013; 61(4): 379-87. PMID: 23026786 Read More

Pearls from a core content talk on adrenal emergencies, a journal update looking at D-dimer in aortic dissection and some acid/base cases. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_15_0_Final.m4a Download Leave a Comment Tags: Acid Base, Adrenal Gland, Adrenal Insufficiency, Aortic Dissection, Congenital Adrenal Hyperplasia, D-dimer Show Notes Shownotes Asha SE, Miers JW. A systematic review and meta-analysis of D-dimer as a rule-out test for suspected acute aortic dissection. Ann Emerg Med 2015. PMID: 25805111 Dierks DB et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med 2015; 65: 32-42. PMID: 25529153 Acid-Base Cases   Quick questions & answers: For acute respiratory acidosis or alkalosis, how much does the pH change for every 10mm change of PCO2? What is the Winter’s formula? For stable chronic respiratory acidosis, for every 10 mm increase in PCO2, how much should the pH decrease by? For each of the following cases, please analyze the acid-base status (i.e. anion gap metabolic acidosis, respiratory alkalosis,

This is a full length recording of Mike Stone's Grand Rounds at Bellevue Hospital on Ultrasound Guided Nerve Blocks for Regional Anesthesia https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_14_0_Grand_Rounds_Stone_Nerve_Blocks_Final.m4a Download Leave a Comment Tags: Nerve Blocks, Ultrasound Show Notes Regional Anesthesia Resources The Ultrasound Podcast: Nerve Blocks Archive ASAHQ: Standards for Basic Anesthetic Monitoring Cook County Regional: Chapter on Local Anesthetics Anesthesiology News: Nerve Injury After Peripheral Nerve Block <img aria-describedby="caption-attachment-1883" decoding="async" loading="lazy" class="size-full wp-image-1883" src="https://coreem.net/content/uploads/2015/08/Template-for-Peripheral-Nerve-Blocks.jpg" alt="Template for Peripheral Nerve Blocks" width="600" height="1016" srcset="https://i0.wp.com/coreem.

Lily Abrukin (Chief Resident) and Swami discuss the care of a critically ill patient with DKA. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_13_0_Final.m4a Download 5 Comments Tags: DKA, Hyperkalemia Show Notes Diabetic Ketoacidosis LITFL: EBM Diabetic Ketoacidosis emDocs: Myths in DKA Management REBEL EM: Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis? Hyperkalemia LITFL: Hyperkalaemia Core EM: Hyperkalemia Core EM: Podcast 7.0 Intubation in Severe Metabolic Acidosis EMCrit: Podcast 3 – Laryngoscope as a Murder Weapon Series – Ventilatory Kills – Intubating the Patient with Severe Metabolic Acidosis

This week we discuss some of the dangers of blood transfusions and pearls from our procedure workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_12_Final.m4a Download Leave a Comment Tags: Blood Transfusions, Cricothyroidotomy, Lateral Canthotomy, Tube Thoracostomy Show Notes Cricothyrotomy Resources EMCrit: EMCrit Wee – Mind Blowing Cricothyrotomy Video ACEP Now: Tips and Tricks for Performing Cricothyrotomy Tube Thoracostomy University of Maryland EM: Tube Thoracostomy Lateral Canthotomy Resources Rowh AD et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med 2015. 48(3):325-330. PMID: 25524455 Larry Mellick: Emergency Lateral Canthotomy and Cantholysis

This is a full length talk from our Grand Rounds series featuring Andy Sloas of the PEM ED Podcast on Infant Emergencies. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_11_1_Final.m4a Download Leave a Comment Tags: Pediatric Resuscitation Show Notes ACEP: THE MISFITS THE MISFITS – Sick Kids Mnemonic Read More

Pearls from our weekly resident conference - discussion of PE risk stratification and TEE in cardiac arrest https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_11_0_Final.m4a Download Leave a Comment Tags: Cardiac Arrest, Pulmonary Embolism, TEE Show Notes Ultrasound in Cardiac Arrest Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation 2008; 78: 135-40. PMID: 18486300 Ultrasound Podcast: Ultrasound guided CPR Part 1. How we’re doing it wrong. Ultrasound Podcast: Ultrasound guided CPR Part 2. TEE & US = New pulse check Read More

Pearls from a core content talk on aortic dissection, syncope workshop and journal update on ATLS. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_10.m4a Download 2 Comments Tags: Aortic Dissection, ATLS, Cardiovascular, Syncope Show Notes Resources Aortic Dissection Hagan PG et al. The international registry of acute aortic dissection (IRAD): New insights into an old disease. JAMA 2000; 283: 897-903. PMID: 10685714 Rosman HS et al. Quality of history taking in patients with aortic dissection. Chest 1998; 114(3): 793-5. PMID: 9743168 All NYC EM Podcast: Rob Rogers – Aortic Dissection Syncope EM Lyceum: Syncope, Answers Amal Mattu: ECG Weekly Steve Smith: Dr. Smith’s ECG Blog Journal Update – ATLS Wiles MD. ATLS: Archaic Trauma Life Support? Anaes 2015; 70: 893-906. PMID: 26152249 Read More

Full length Grand Rounds recording from Sergey Motov's talk - "The Evolution of Pain Management in the ED: From Poppy Seeds to Ketamine https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_9_1_Final_Version.m4a Download Leave a Comment Tags: Ketamine, Opioid Free ED, Pain Management Show Notes Pain Free ED Site ACEP Now: Non-Opioid Pain Medications to Consider for Emergency Department Patients EMCrit: Opiate-Free ED with Sergey Motov Read More

Pearls, pitfalls and take home points from the NYU/Bellevue EM Residency weekly conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_9_0_Final.m4a Download Leave a Comment Tags: Pediatric Cardiology, Pericardial Tamponade Show Notes Vaillancourt S. et al. Repeated Emergency Department Visits Among ChildrenAdmitted With Meningitis or Septicemia: A Population-Based Study. Ann Emerg Med 2015; 65(6): 625-631. PMID: 25458981 EMCrit: Rapid Ultrasound for Shock and Hypotension – the RUSH Exam. Verma V et al. The utility of routine admission chest X-ray films on patient care. Eur J Intern Med 2011; 22(3): 286-8. PMID: 21570649 EMCrit: Opiate-Free ED with Sergey Motov Read More

Recapping pearls from our weekly conference. This week, we discussed pearls on chest pain. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_Episode_8.m4a Download Leave a Comment Tags: ACS, Chest Pain Show Notes How to Build a Great Talk The Teaching Course Podcast: How to Build a Talk – Part I The Teaching Course Podcast: How to Build a Talk – Part II Chest Pain Workshop Core EM: Chief Complaint – Chest Pain REBEL EM: Is it time to start using the HEART pathway in the Emergency Department? EMCast November 2014: Low Risk Chest Pain Backus BE et al. Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department. Curr Card Rev 2011; 7: 2-8. PMC: 3131711 Mahler SA et al. The HEART Pathway Randomized Trial Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge.

This week we discuss the management of hyperkalemia + a journal update on beta blockers vs Ca channel blockers in AF https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_7_Final.m4a Download Leave a Comment Tags: Atrial Fibrillation, Hyperkalemia Show Notes Core EM: Hyperkalemia REBEL EM: Is Kayexalate Useful in the Treatment of Hyperkalemia in the Emergency Department? Core EM: Diltiazem vs. Metoprolol for Rate Control in Atrial Fibrillation Read More

Pearls and take home points from our challenging airway workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_6_Finial.m4a Download Leave a Comment Tags: Airway, Challenging Airway, DSI Show Notes Highlighted Resources EMCrit: Podcast 40 – Delayed Sequence Intubation (DSI) EMCrit Wee: Mind Blowing Cricothrotomy Video EP Monthly: NO DESAT! EMCrit: Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer EMUpdates: Optimize the Head During Laryngoscopy Read More

Podcast 5.0 features pearls from Howie Mell's Grand Rounds talk "48 Tweets on 24 Topics" https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_5.m4a Download Leave a Comment Tags: Grand Rounds, Howie Mell Show Notes Ovarian Hyperstimulatoin Syndrome (OHSS) Braude P, Rowell P. ABC of subfertility – Assisted conception III – problems with assisted conception. BMJ 2003; 327: 920-923. PMC: 218823 Backboards ACEP Clinical Policy Statement: EMS Management of Patients with Potential Spinal Injury EM Cases: Episode 66 Backboard and Collar Nightmares from the Emergency Medicine Update Confernce. Tranexamic Acid (TXA) HIPPO EM: “Stop the Bleeding!” – TXA in Prehospital Care The Skeptics Guide to EM: SGEM#80: CRASH-2 (Classic Paper) INSERT LINK TO OUR CRASH 2 REVIEW Nasal Oxygen During Efforts Securing a Tube (NO DESAT) EP Monthly: NO DESAT! Read More

Episode 4.0 features pearls on perimortem C-sections, procedural sedation and an interview with Reuben Strayer on Airway Nightmares https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_4_0_Final_Version.m4a Download Leave a Comment Tags: Airway, Perimortem C-section, Procedural Sedation, RSI Show Notes Perimortem C-Section Links EMCrit: Perimortem C-Section Procedural Sedation Links EM Updates: Emergency Department Procedural Sedation Checklist V2 EM Updates: The Procedural Sedation Screencast Trilogy EMCrit: Procedural Sedation Resources Airway Nightmares EM Updates: Direct vs. Video Laryngoscopy in 10 Minutes   Read More

Episode 3.0 covers a variety of topics from our ID workshops and Disaster Management Grand Rounds https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_3_0-ID_Workshops_Disaster-Final.mp3 Download Leave a Comment Tags: Blast Injuries, Disaster Management, Infectious Diseases, Pneumonia, Skin and Soft Tissue Infections Show Notes General ID Workshop Take Home Points Know your local antibiogram. This is the best way to tailor your management to your patient. Search for recent old cultures from your patients and order antibiotics based on this information. Skin + Soft Tissue Take Home Points Antibiotics aren’t required for most simple abscesses. I+D and if no overlying cellulitis, no antibiotics needed. Not all abscesses need packing. If they’re small and on the extremeties, it’s reasonable to leave them unpacked. Not all patients need MRSA coverage for cellulitis. Most cellulitis without abscess is strep. Necrotizing Fasciitis can be tough to pick up. The LRINEC scoring system is one method to help. Most patients will be toxic but look for pain that’s out of proportion to the examination. Relevant Links AliEM – The Not-So-Sick Health-Care Associated Pneumonia Patient: New Treatment Strategy

This podcast highlights pearls, pitfalls and take home points from our conference on ID emergencies as well as a sepsis update for 2015 https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_Episode_2.mp3 Download Leave a Comment Tags: Ebola, Endocarditis, Infectious Diseases, Myocarditis, Sepsis Show Notes SIRS Criteria Read More REBELCast: Sepsis Care in 2015 References Tattevin P et al. Does this patient have Ebola virus disease? Intensive Care Med 2014; 40(11): 1738-41. PMID: 25183574 Rivers E et al. Early goal-directed therapy in the treatment o...

This talk was given by Jay Lemery in May 2015 when he came out from Denver for Grand Rounds. Jay is an associate professor of EM at Denver Health as well as the past president of the Wilderness Medicine Society. This talk is about what Wilderness Medicine is in 2015. "Wilderness Medicine is about providing care in austere environments." https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_1_1.mp3 Download Leave a Comment Tags: Wilderness Medicine Read More

This podcast highlights pearls and take home points from Chris McStay's grand rounds talk on Electrical and Lightning Injuries from our Wilderness Medicine Grand Rounds on May 6th, 2015. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core-EM-Podcast-1_0-Final.mp3 Download One Comment Tags: Electrical Injuries, Lightning Injuries, Wilderness Medicine Read More

Episode 0.0: Intro to the Core EM Podcast. Every Monday we'll release a podcast featuring pearls, pitfalls and critical take home messages from our weekly resident conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core-EM-Podcast-0_0-Intro-Final.mp3 Download 2 Comments Tags: Introduction Read More