EMGuidewire's Podcast: Recent Episodes
EMGuideWire Team - From Carolinas Medical Center Emergency Medicine Residen
Join the faculty and residents of Carolinas Emergency Medicine Residency Program, one of the oldest programs in the country, as they explore some of the Core Concepts of Emergency Medicine as well as many of the niche environments of this important arena of specialty care.
Join the EMGuidewire crew as Dr. Diurba and Dr. Folk reflect upon their residency experience and the initiation of the Intern Nuggets episodes while, of course, discussing some important tips and tricks they learned along the way.
Join the team from EMGuidewire from CMC Emergency Medicine Residency for another Intern Nuggets! In this episode, Drs. Crow and Lim discuss some tips on how they have approached the first half of their intern years as well as review management of Atrial Fibrillation and Atrial Flutter.
Join the crew from Carolinas Medical Center Emergency Medicine (@CMCEM) and EMGuidewire (@EMGuidewire) as they introduce a new group of interns as they discuss some of the first lessons they have learned about Agitation Management in the ED.
Join the EMGuidewire team from Carolinas Medical Center's Emergency Medicine Residency Program as Drs. Calienes Cerpa and Bissell gather together to discuss another great case filled with learning points. In this episode, they review myositis in a pediatric patient.
Join the EMGuideWire team from Carolinas Medical Center, Emergency Medicine Residency, as Drs. Calienes and Bissell discuss Heart Blocks.
Join the crew from Carolinas Medical Center's Emergency Medicine Residency and EMGuidewire as they discuss some interesting cases with Drs. Sofiya Diurba and Destiny Folk. This episode deals with a complex, critically ill adult who has septic pulmonary emboli.
Join the crew of EMGuidewire and the Residents and Faculty at Carolinas Medical Center Emergency Medicine Residency as they learn along with Drs. Sofiya Diurba and Destiny Folk. In this episode, Drs. Folk and Diurba will discuss an educational Pediatric Case that involves some critical decisions!
Join the EMGuidewire team from Carolinas Medical Center's Emergency Medicine Residency Program as Drs. Bissell and Calienes Cerpa discuss some more important topics in their Intern Nuggets series. In this episode, they address some important Self Care issues that all interns (and likely everyone) need to consider. They also discuss the possible components in those very popular "migraine cocktails."
Join Drs. Diurba and Folk and the EMGuidewire team from @CMCEM as they begin an important conversation regarding Resident and Physician Wellness. If we exercise our bodies to remain physically healthy, shouldn't we exercise our emotional selves as well? Perhaps some proactive counseling sessions can be good for us all.
Join Drs. Diurba and Folk and the EMGuidewire team from @CMCEM as they begin an important conversation regarding Resident and Physician Wellness. If we exercise our bodies to remain physically healthy, shouldn't we exercise our emotional selves as well? Perhaps some proactive counseling sessions can be good for us all.
Join the EMGuideWire's team as they celebrate the beginning of the new academic year by introducing us to two new interns who will be taking over the Intern Nuggets! Drs. Calienes and Dr. Bissell take over the task of discussing interesting cases that they have encountered during the start of their careers. This episode finds them wrestling with a challenging case of palpitations and anxious feelings.
Join the EMGuideWire's team as they celebrate the beginning of the new academic year by introducing us to two new interns who will be taking over the Intern Nuggets! Drs. Calienes and Dr. Bissell take over the task of discussing interesting cases that they have encountered during the start of their careers. This episode finds them wrestling with a challenging case of palpitations and anxious feelings.
Join the EMGuidewire team and Drs. Allen and Fox from Carolinas Medical Center as they discuss tips for Mitigating Anxiety and Pain in the Pediatric patient. This episode is published in concert with EMSC Innovation and Improvement Center.
The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
Join the EMGuidewire team from Carolinas Emergency Medicine Residency as Drs. Diurba and Folk discuss their favorite learning points from this year's SAEM scientific assembly conference.
Join Drs. Diurba and Folk, stellar Carolinas Medical Center Emergency Medicine Interns, and the EMGuidewire team as they discuss various reversal options for the numerous anticoagulants that exist today.
Join Drs. Folk and Diurba, Emergency Medicine Interns enjoying their training at Carolinas Medical Center, as they discuss a case of Altered Mental Status with the EMGuidewire Team!
Join Drs. Folk and Diurba, Emergency Medicine Interns enjoying their training at Carolinas Medical Center, as they discuss Beer Potomania and Hyponatremia with the EMGuidewire Team!
Join the EMGuidewire team as Drs. Folk and Diurba explore another episode of INTERN NUGGETS! In this episode, they discuss an approach to the medically complex patient as well as giving and receiving feedback. They also explore the extremely important topic of burnout and ways to avoid it.
Join the team from EMGuideWire from Carolinas Medical Center as Dr. Clare Gunn gets to chat with Dr. Pendell Meyers about the challenges of relying on the STEMI paradigm and what other factors to consider when evaluating patients for Occlusive Myocardial Infarctions (OMI).
Join the @EMGuideWire team from @CMCEM as they learn from former Chief Resident, Dr. Rushnell, how to manage the complex condition of Tension Pneumoperitoneum.
Join the EMGuideWire team from the CMC EM Residency Program as we welcome back Dr. Rushnell, prior CMC EM Chief Resident, to discuss the challenging topic of Pediatric DVT and PE.
Join the EMGuideWire Team from Carolinas Medical Center (@CMCEM) and Dr. Mark Kastner and Dr. Matthew Cravens in the Chief's Corner as they discuss the presentation and diagnosis of the challenging diagnosis of Guillain–Barré Syndrome.
Join the crew from EMGuidewire as they are joined, once again, by Drs. Diurba and Folk for their unique perspectives from an intern's point of view. This month's Intern Nugget will cover sign-out and transition of care tips as well as some learning point on pediatric dehydration management and BRUE.
Join the EMGuideWire Team as they welcome back Dr. Chelsea Rushnell, prior Chief Resident at CMC Emergency Residency, to discuss the management of the anticoagulated trauma patient. Perhaps just flooding individuals with FFP is not the best strategy. Dr. Rushnell will review the evidence for the use of 4 Factor PCC.
Join the EMGuideWire team from CMC EM residency as they hear a fresh perspective... from newly minted residency Interns, Drs. Destiny Folk and Sofiya Diurba.
For this Intern Nugget, they address:
1) Imposter Syndrome and how to overcome it.
2) Complex Regional Pain Syndrome and how to manage it.
3) Analgesia options in the ED
Join the EMGuidewire team at Carolinas Medical Center Emergency Medicine program as they discuss important topics. This week, Drs. Cravens and Kastner discuss Penetrating Cardiac Injury (PCI):
-The diagnosis of PCI is made in the trauma bay with repeat cardiac ultrasound exams and chest x-ray. If suspicion remains high despite inconclusive imaging, operative subxiphoid pericardial window is the definitive diagnostic modality.
-Large pericardial injury, especially from ballistic injuries, can result in PCI without positive pericardial fluid on FAST, if the blood is draining into the hemithorax. This would result in hemothorax, but not always with high enough drainage to mandate operative intervention if PCI is not kept with high index of suspicion.
-ED management of PCI is stabilization until the patient can be managed in the OR with sternotomy and external cardiac repair. In the pulseless patient with recent arrest, ED thoracotomy is indicated, provided operating room intervention is available immediately following. Unstable patients with a pulse need immediate operative intervention; if FAST is positive for pericardial fluid, ED pericardiocentesis should be considered as a temporizing measure in these patients, especially if transfer is needed for OR intervention.
Join the EMGuideWire Team from CMC EM group as they explore the initial thoughts and management of a patient who presents with severe Diabetic Ketoacidosis (DKA). For this episode, Drs. Claire Milam and Travis Barlock explore the initial considerations and practical management tips.
Definitions of severity of DKA:
Mild
-
- pH: 7.25-7.3
- CO2: 15-18 mEq/L
- Anion Gap: > 10 mEq/L
- Mental Status: Alert
- Blood Glucose: >250 mg/dl
- Urine and Serum Ketones: Positive
Moderate
-
- pH: 7.0-7.24
- CO2: 10-15 mEq/L
- Anion Gap: >12 mEq/L
- Mental Status: Alert to Drowsy
- Blood Glucose: >250 mg/dl
- Urine and Serum Ketones: Positive
Severe
-
- pH: < 7.0
- CO2: < 10 mEq/L
- Anion Gap: > 12 mEq/L
- Mental Status: Stuporous to Comatose
- Blood Glucose: >250 mg/dl
- Urine and Serum Ketones: Positive
Join the Drs. Ray and Barlock from the EMGuideWire team as the discuss the initial assessment and evaluation of some ocular complaints with specific attention to pathology of the Posterior Eye.
SHOWNOTES:
Key PointsAlways get visual acuity for any eye complaint Swinging flashlight test can help with your diagnosis
Dilate the eyes for optimal fundoscopic exam
Optic neuritis -> give IV steroids
Use U/S to look for papilledema along with optic nerve sheath diameter
Find the optic nerve when evaluating retinal detachment vs vitreous hemorrhage
CRAO= “stroke of the eye”
CRVO= “DVT of the eye”
Optic NeuritisOnset: Acute
Pain: With EOMI, can be painless
Visual Acuity: Decreased
Laterality: Usually unilateral, can be bilateral
Classic presentation: Young female (15-45) with acute vision loss
Exam: + APD
Associations: MS, infection (lyme, herpes, syphilis), autoimmune, methanol, DM
Treatment: IV steroids
Papilledema
Onset: Subacute to chronic
Pain: Headache
Visual Acuity: Normal initially
Laterality: Bilateral
Classic presentation: Headache, N/V, transient vision loss
Exam: Optic disc swelling
Treatment: treat underlying cause
Retinal Detachment
Onset: Sudden
Pain: No
Visual Acuity: Impaired
Laterality: Unilateral
Classic presentation: Sudden, painless, with flashes, or a curtain over the visual field
Exam: +/- mild APD
Management: Ophtho consult, minimize activity, treat underlying cause, surgical options available
Central Retinal Artery OcclusionOnset: Sudden
Pain: No
Visual Acuity: Impaired
Laterality: Unilateral
Classic presentation: Sudden, painless vision loss in vasculopathy
Exam: + APD
Associations: carotid vascular disease, pediatric blood disorders (SCD, leukemia)
Management: Ophtho consult, restore blood flow
Central Retinal Vein OcclusionOnset: Acute
Pain: No
Visual Acuity: Impaired
Laterality: Unilateral
Classic presentation: Sudden blurry or distorted vision in hypercoagulable patient
Exam: + APD
Associations: OCPs, HTN, DM, vasculitis
Management: Ophtho consult
Join the EMGuidewire team as Drs. Serven and Blackwell discuss the management of the patient presenting with Severe Status Asthmaticus in the Emergency Department. Don't forget to review the basic concepts that were published earlier... this time the focus is on the critically ill patient.
Join the EMGuidewire Team as they address how to prepare for the arrival of a trauma patient in your Emergency Department. Drs. Serven and Blackwell from Carolinas Medical Center Emergency Medicine Residency Program will give us some insight and pearls on how to manage the potential chaos.
Join the EMGuideWire team as Drs. Serven and Shreve are joined by Dr. Trigonis to discuss simple strategies to make sure your room is set up and you are prepared for performing an emergent intubation on your patients in the Emergency Department.
Shownotes - Once through start to finish:
- Set up suction
- Set up pre-oxygenation (nasal cannula, NRB, BVM as backup)
- Choose a tube + back up tube
- Lube the tube, check the tube
- Choose a stylet
- Set up video and DL
- Ask nurse for meds (nicely)
- Check hemodynamics
- Acknowledge preoxygenation
- Positioning
- Give meds
- Wait for paralytic medications to work
- Tube ‘em
- Call out your tube positioning
- Leave the blade in place until tube placement assured
- Confirm with color change, EtO2, bilateral breath sounds
- Wait for RT to secure the tube
- Call for post-intubation meds
- Check CXR for position
Join Drs. Alyssa Thomas and Victoria Serven from Carolinas Medical Center Emergency Medicine Residency Program and the EMGuideWire Team as they discuss how they initially evaluate and manage the patient who present with acute pulmonary edema and hypertension.
Join the EMGuideWire team as they explore the use of Point-of-Care Ultrasound for the evaluation of patients with possible COVID-19 infection. Dr. Patrick Lam, from the Carolinas Medical Center Department of Emergency Medicine Department Division of Ultrasound, will guide us on the techniques and pro-tips for this application.
Join EMGuideWire team as they listen in to EM Residency Conference at Carolinas Medical Center (in Charlotte, NC) and learn from Emily MacNeill, MD as she discusses "What Happens When a Disease Management System Crashes into a Public Health Crisis."
Join the EMGuideWire team as they learn from one of the world's foremost experts in neurologic emergencies, Dr. Andrew Asimos. This episode will address the Neurologic Manifestations and Complications of the COVID-19 Infection.
Join the EMGuideWire team as they listen to Dr. Geib discuss how to recognize and manage Hydroxychloroquine toxicity, which may become more prevalent during the current COVID-19 pandemic.
Join the EMGuideWire team as they learn from Critical Care fellow, Dr. Russell Trigonis while he addresses the important aspects of managing ARDS in patients with COVID-19 infections.
OB Trauma Core Concepts
- Physiologic changes of pregnancy: physiologic anemia, decreased SVR, increased HR, increased RR, and pelvic vessel engorgement
- Traumatic complications: placental abruption, preterm labor (PTL), uterine rupture, and pelvic fx
- Abruption triad = abd pain, large for dates uterus, vaginal bleeding
- Perform cervical check to eval for PTL
- Obtain Type and Screen and KB test
- Give Rhogam if mom is Rh neg. 50 mcg if <12 wks, 300mcg if > 12 wks
- Check fetal HR after E-FAST, nml is 120-160
-Travis Barlock
Join the EMGuideWire Crew from CMC EM Residency Program as they discuss Ludwig's Angina and the management Priorities!!!
BACKGROUND
- Angina = “Strangling”
- Bilateral infection of submental, submandibular, and sublingual spaces
-
70-85% of cases arise from odontogenic source
- Periapical abscesses of mandibular molars
- Piercings (frenulum)
- URI more common cause in children
-
Source of infection often polymicrobial
- Most commonly viridans; also Staphylococcus and Bacteroides species
- Patients usually 20-60 years-old; more common in males1
- Mortality in treated Ludwig’s Angina = 8%7
- ***Airway compromise = leading cause of death8
Who Is At Risk?
- Diabetes mellitus
- Chronic alcohol abuse
- IVDA
- HIV/AIDS
- Malnutrition
- Poor oral hygiene
- Smokers
Anatomy & Pathophysiology
- Mylohyoid subdivides submandibular space:
- Sublingual space
- Submaxillary (submylohyoid) space
- Infection extends posteriorly and superiorly, elevating tongue against hypopharynx
- If left untreated, can extend inferiorly to retropharyngeal space and into superior mediastinum3
Clinical Signs & Symptoms
- Dysphagia
- Odynophagia
- Trismus
- Edema of upper midline neck and floor of mouth
- Raised tongue
- "Woody" or brawny texture to floor of mouth with visible swelling and erythema
Late Findings
- Drooling
- Tongue protrusion
- Trismus
- Dysphonia
- Cyanosis
- Acute laryngospasm
- Stridor
- Patients may demonstrate signs of systemic toxicity → fever, tachycardia, and hypotension
How Do I Make the Diagnosis?
- Clinically!
- Consider CT head/neck
- Can help evaluate extent of infection if clinical situation persists
- CBC
- Chemistry
- Lactate
- Blood Cultures
Management
- Emergent ENT/OMFS consult for I&D in OR and extraction of dentition if source is dental abscess
- Airway Management
- Intubation will be VERY difficult due to trismus and posterior pharyngeal extension
- Ideal situation = awake fiberoptic intubation in OR
- ALWAYS have a surgical airway ready as your back up plan
- Blind insertion devices (e.g. intubating LMA) are NOT recommended
Management - Antibiotics
- Must cover typical polymicrobial oral flora
- Immunocompetent
- 3rd-generation Cephalosporin + (Clindamycin or Metronidazole)
- Ampicillin/Sulbactam
- Penicillin G + Metronidazole
- Clindamycin (allergic to penicillin)
-
Immunocompromised → *Need MRSA and GNR coverage!3
- Cefepime + Metronidazole
- Meropenem
- Piperacillin-tazobactam
- Add Vancomycin if concern for MRSA risk factors
-
Steroids
- Dexamethasone 10 mg IV
- Thought to chemically decompress for airway protection and increase antibiotic penetration6
- Nebulized epinephrine
- Resuscitation and pain control
- Dexamethasone 10 mg IV
Complications
- Intracranial infections (e.g. CST, brain abscess)
- IJ thrombophlebitis (Lemirre’s Syndrome)
- Mediastinitis
- Mandibular osteomyelitis
- Empyema
Pearls
Three characteristics of Ludwig’s angina can be remembered as the 3 Fs:
- Feared
- Often Fatal
- Rarely Fluctuant
- ABCs—Sit upright
- Early notification of ENT/OMFS and anesthesia to facilitate definitive airway management
- Arrange for the patient to be admitted to ICU
Priorities!!!
- Secure the airway EARLY!
- Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway
- Prevent the development of septic shock and multi-organ failure — give antibiotics early
References
- Lin HW, O’Neil A, Cunningham MJ. Ludwig’s Angina in the Pediatric Population. Clin Pediatr (Phila) 2009;48:583-7.
- Baez-Pravia, Orville V. et al. “Should We Consider IgG Hypogammaglobulinemia a Risk Factor for Severe Complications of Ludwig Angina?: A Case Report and Review of the Literature.” Medicine. 2017;96(47):e8708.
- Pandey M, Kaur M, Sanwal M, Jain A, Sinha SK. Ludwig’s Angina in children anesthesiologist’s nightmare: Case series and review of literature. J Anaesthesiol Clin Pharmacol. 2017 Jul-Sep;33(3):406-409.
- Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig’s Angina Ann Maxillofac Surg. 2015 Jul-Dec;5(2):168-73.
- Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110: 1051, 2001.
- Saifeldeen K, R Evans. Ludwig’s Angina. Emerg Med J 2004; 21: 242-243
- Nanda N, Zalzal HG, Borah Gl. Negative-Pressure Wound Therapy for Ludwig’s Angina: A Case Series.Plast Reconstr Surg Glob Open2017 Nov 7;5(11):e1561.
- Pak S, Cha D, Meyer C, Dee C, Fershko A.Ludwig’s Angina. Cureus. 2017 Aug 21;9(8):e1588.
Join the EMGuideWire team as they discuss Superior Vena Cava Syndrome!
Shownotes:
Definition:
- Any condition leading to obstruction of blood flow through the SVC
Pathophysiology:
- Pathology in adjacent anatomy (lung, lymph node, thymus, mediastinum) or within the SVC itself obstructs venous return to the right atrium. As the SVC is compressed, venous collaterals form alternative pathways returning blood to the right atrium which can dilate over several weeks. As a result, upper body venous pressure increases, which in extreme cases lead to airway congestion and venous cerebrovascular congestion and edema. Hemomdynamic compromise is most often by direct compression of the heart, not from SVC obstruction.
Risk factors:
- Indwelling device through the SVC (Central line, dialysis catheter, pacemaker)
- Lung cancer
- Lymphoma
- Thymoma
Presentation:
- Signs – plethoric appearance, dilated neck and chest veins, swollen face/neck/chest
- Symptoms – congestive symptoms (head fullness, swelling), cardiopulmonary symptoms (chest pain, dyspnea, stridor, hoarseness), and neurologic symptoms (headache, confusion, obtundation, visual disturbances)
Work-up:
- Is the patient unstalbe? Do they have severe SVC?
- If yes, secure airway, support breathing, support circulation
- Consult vascular/cardiothoracic surgery
- If patient is stable, then:
- Confirm diagnosis and evaluate for malignant obstruction
- CBC, CMP, PT/INR, CXR, CT chest w/contrast
- Does the patient have a malignant obstruction or thrombosis?
- Yes -> consult heme/onc and admit
- No -> observe in ED
- Confirm diagnosis and evaluate for malignant obstruction
References:
García Mónaco R, Bertoni H, Pallota G, et al. Use of self-expanding vascular endoprostheses in superior vena cava syndrome. Eur J Cardiothorac Surg 2003; 24:208.
Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore) 2006; 85:37.
Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior vena caval obstruction. Is it a medical emergency? Am J Med 1981; 70:1169.
Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356:1862.
October was Domestic Violence month and in an effort to help highlight this very important topic, join Drs. Salzman, Dragoo, and Richardson from Carolinas Emergency Medicine Residency while they discuss the very important presentation of Strangulation. This is not a mere gesture of power, it may be our last opportunity to save this patient's life!
Pearls
- Strangulation victims are 750% more likely to become a homicide victim.
- Strangulation is not choking. Call it what it is.
- External exam findings are often not present and do not rule out internal injury.
- History is key. Look for neck pain, dizziness, vision/hearing changes, dysphagia, and SOB.
- Most common internal injury is hyoid fracture.
- Suspect strangulation? Get CTA neck. Neuro findings? Get non-con CT head + MRI brain.
Summarized by Travis Barlock, MD PGY-1
Join the EMGuideWire crew as they discuss some tips and pearls on how to skillfully run a medical resuscitation.
Pearls
- Preparation is everything. Get your staff, and get your stuff!
- Call out names, be redundant, and say what you are thinking out loud.
- Don’t go for the tube! Supraglottic airways are quicker and safer!
- High quality compressions are life saving.
- V-tach and V-fib are usually ischemic. PEA is usually non-cardiac.
- PEA? Is it Wide or Narrow? Narrow - think procedural. Wide - think chemical.
- Ultrasound is your friend. RV strain, pericardial tamponade, and pneumothorax can all be quickly found!
- Wide complex (but not V-tach) is hyperkalemia until proven otherwise. Provide Calcium Chloride (not gluconate).
Summarized by Travis Barlock, MD PGY-1
The EMGuideWire Team is visited by a prior crew member, Russell Trigonis, MD! Join them as they discuss how the patient diagnosed with Sepsis in your ED has their care continued in the ICU!
Pearls
- Start pressors with IVF (30-40cc/kg). NE at 7mcg/min peripherally can always be stopped, but better earlier than later.
- Increase NE until at 20mcg/min, if still hypotensive, then add a 2nd pressor like Vasopressin at 0.03units/min and 100mg Hydrocortisone Q8h.
- Start antibiotics early and identify source. CXR, US lungs/abd, UA, CT abd should all be considered.
- Procalcitonin is helpful for stopping abx. Doesn’t change ED treatment.
- Don’t order Vitamin C or thiamine in ED.
-Travis Barlock, MD
It it the end of Sepsis Awareness Month, but there is a BONUS Monday (Sept. 30th), so why not a BONUS episode! Join the EMGuideWire Team as they explore the challenges the children bring to this clinical condition. Let's review Pediatric Sepsis!
Pearls:
- Screening should be age adjusted. Identify severe sepsis. Treat w/early antibiotics, balanced fluid administration, and EPI if needed.
- SIRS in children must be age-adjusted. HR & RR > 2 standard deviations of nml; WBC age adjusted.
- Screen: high risk medical history + vital sign abnormalities (age based SIRS) require check of cap refill, mental status, and general appearance followed by a physician assessment.
- Identify: Severe sepsis = sepsis + organ dysfunction (CV/resp/neuro/renal/hepatic dysfunction). Order a lactate, CBC, CMP, and blood cultures, and consider CXR and UA. CRP is helpful for inpatient team.
- Higher lactate has higher mortality and is associated with septic shock.
- Treat: Start 20cc/kg bolus LR and reassess. Those with heart disease can’t take anymore fluids after this, so only add pressors if needed. Continue to 40cc/kg and up to 60cc/kg total bolus prior to pressors for other patients.
- If still hypotensive, start 0.1 mcg/kg/min of EPI (peripheral or IO).
- Early antibiotics saves lives.
- LR is better than NS.
Summarized by: Travis Barlock, MD PGY-1
References:
-
Emrath ET, Fortenberry JD, Travers C, McCracken CE, Hebbar KB. Resuscitation With Balanced Fluids Is Associated With Improved Survival in Pediatric Severe Sepsis. Critical Care Medicine. 2017 Jul;45(7):1177-1183
-
Ventura et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Critical Care Medicine. 2015; 43(11):2292-302
Join the EMGuideWire Crew as they continue to explore the High Yield management points for Sepsis!
This week's Episode's Pearls:
- Early fluids save lives. Give 40cc/kg bolus in first 3 hours. But don’t fluid overload the patient!
- U/S the heart and lungs: A plethoric IVC, immobile mitral valve, and B lines on the lungs should urge you to be more cautious with fluids.
- Goal in all patients is to establish an adequate MAP ASAP! Fluids + Vasopressors!
- Vasopressor titration algorithm: First low dose NE (10mcg/min); if still in shock, initiate vasopressin (0.04 units/min); do not wait on providing vasopressin if EPI is readily available (establish MAP ASAP!).
- Initiate vasopressors early with fluids! NE can be initiated peripherally, so don’t wait for a central line!
- Only consider dopamine for absolute bradycardia.
- Methylene blue is a last resort consideration.
- Vasopressors are commonly needed at high doses (i.e., 1mcg/kg/min EPI).
- Hydrocortisone 50-100mg for patients with septic SHOCK, not sepsis alone.
Summarized by: Travis Barlock, MD PGY-1
References:
- Farkas J. PulmCrit- Epinephrine challenge in sepsis: An empiric approach to catecholamines. EMCrit Project. https://emcrit.org/pulmcrit/epi/. Published August 21, 2018. Accessed September 17, 2019.
- Dellinger RP, Levy MM, Rhodes A, et al. 2017. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2016. Critical Care Medicine. 44(3):486-552.
Join the EMGuideWire crew once again for this month's series on Sepsis in honor of Sepsis Awareness month. Episode 3 will cover antibiotic use and selection.
Antibiotics for Sepsis
- Take a history and perform a chart biopsy first! Consider past infections, bug susceptibilities, healthcare acquired vs. community acquired infection, foreign travel, and comorbidities.
- Always check local antibiogram and prior culture results.
- Septic shock - Start broad spectrum antibiotics within 1 hour.
- Stable patient - find the source! UA, CXR, and a good skin exam are fast and can help guide antibiotic choice. Remember some patients need surgical management!
- Antibiotic choice in septic shock.
-
- 1st agent - Piperacillin/Tazobactam (covers GP/GN + Pseudo)
- 2nd agent - Choose based on patient characteristics
-
- Ceftriaxone - simple community acquired infections.
- Vancomycin - covers MRSA.
- Meropenem - use for patients with a hx of ESBL.
- Flagyl + cefepime/meropenem - Use for intra-abdominal infections.
- Clindamycin - Useful for skin infections (toxin suppression).
- Cefazolin - IV line infections, endocarditis, soft tissue infections w/o MRSA (covers MSSA, GAS, GBS).
Summarized by: Travis Barlock, MD PGY-1
References:
- Alam N et al. 2018. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet. Respiratory Medicine. 6(1): 40-50.
- Dellinger RP, Levy MM, Rhodes A, et al. 2017. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2016. Critical Care Medicine. 44(3):486-552.
Sepsis Awareness Month continues! Join the EMGuideWire Team as they dive into the issues of Fluid selection for resuscitation.
1) Fluids are not all created equal. Use balanced fluids for large volume resuscitation.
2) Lactated Ringers is likely the best choice available in the ED. Plasmalyte is also a good option, if you have it.
3) You can start low dose vasopressors peripherally if you need to, rather than continuing to flood patients with fluids for hypotension.
Join the EMGuideWire Team,from Carolinas Emergency Medicine Residency Program in Charlotte, NC, as they explore the critical core concepts on the important topic of Sepsis. In this first episode, the team will discuss the definitions of Sepsis.
Pearls:
- Sepsis is a dysregulated systemic inflammatory response to infection causing intravascular inflammation, tissue ischemia, cytopathic injury, and dysregulated apoptosis.
- SIRS terminology is now outdated. Current terminology is “Sepsis” (SIRS, suspected source, end organ damage) and “Septic Shock.”
- Septic shock: SBP <90 or MAP <65 despite fluids; or if lactate is >2 after fluids.
- qSOFA = RR > 22, AMS, SBP < 100; 2-3 points = poor outcomes.
- Epidemiology: 164,000 cases annually. Bacterial etiology most common. Mortality for sepsis and septic shock is 10 and 40% respectively.
Summarized by Travis Barlock, MD PGY-1
References:
- Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. New England Journal of Medicine 2003; 348:1546.
- Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:762.
Join the EMGuideWire Team, from Carolinas Emergency Medicine Residency Program in Charlotte, NC, as they explore the critical core concepts on the important topic of Sepsis. Over the course of September, Sepsis Awareness Month, the group will cover a variety of high-yield points to help make us all better at recognizing, evaluating, and managing Sepsis. This is the Intro to the month. Follow us every week for more information... and maybe even get a Bonus 5th episode as a reward!
Join the EMGuideWire team from Carolinas Medical Center Emergency Medicine Residency Program as they discuss the challenging condition of thyrotoxicosis and thyroid storm! From evaluation to management, this critical state requires our respect and attention!
Join the EMGuideWire crew as they explore the various skin and soft tissue infections that are commonly encountered and considered in the Emergency Department. While some may be minor, like furuncles, others can be life-threatening, like necrotizing fasciitis.
Join the EMGuideWire Team as they explore the Basic Principles that must be considered when managing a pediatric airway. Knowledge of the anatomic and physiologic differences that exist between adults and children is paramount! Assuming that all pediatric airways are going to be "difficult" may help keep us prepared.
Join the EMGuideWire Team as they discuss some of the tips for having a successful and safe Sign-Out in the ED. Hear from recent graduates from the Carolinas Medical Center Emergency Medicine Program as they discuss their perspectives on Transition of Care in the ED.
Join the EMGuideWire Team as they are joined by two Pediatric EM experts (Drs. Simone Lawson and Pat Morgan) to discuss the very important and challenging topic of Pediatric Non-Accidental Trauma (NAT). Let's discover ways to remain help pick up on the subtle and sentinel cases to help protect our most vulnerable patients.
Join Dr. Driscoll from the EMGuideWire crew as he enters the Sports Medicine Corner once again. Today, he covers some of the issues with athlete cardiac screening and sudden cardiac death in athletes.
Join the EMGuideWire Team as they discuss the evaluation and management of Myasthenia Gravis and a Myasthenic Crisis! Learn about the means to assess a patient's ability to maintain her/his own airway.
Join the EMGuidewire team from CMC EM program as they discuss a potentially critical condition, HyperKalemia. Review the important HyperKalemia EKG Changes and be ready to take action!
Join the Ped EM Fellows from Carolinas Medical Center and the EMGuideWire as they discuss the seemingly simple issue of Pediatric Urinary Tract Infections. Who needs to be test and how do we do so? Let's review this less than simple topic.
Join Drs. Trigonis and Murray from the EMGuideWire team as they discuss use and selection of Vasopressors in the ED.
Join the EMGuideWire Team, from the CMC EM program, as they enter the TOXIDome once again to wrestle with Aspirin (ASA) Toxicity!
The patient is agitated and combative and a danger to everyone in the ED. What do you give? Haloperidol and lorazepam? Maybe there are better choices. Join the EMGuideWire crew as they enter the TOXIDome to discuss a better approach to the management of the Agitated Patient.
Join the EMGuideWire team as they enter the TOXIDome once again and review Toxidromes with Dr. Kopec!
Join the EMGuideWire team as they introduce a new Toxicology Series. Enter the TOXIDome with them as they wrestle with Tylenol Toxicity and discuss when and why to use NAC!
Join the EMGuideWire Team as they discuss a simple approach to the very complex and complicated patients with a Left Ventricular Assist Device (LVAD). "LVAD" is for "Look & Listen, Ventricle, Anticoagulation, and Driveline."
Join the EMGuideWire Team as they discuss the current core concepts of imaging and management of patients with findings concerning for Ischemic CVA (stroke). The EMGuideWire crew is joined by world renowned Emergency Neurology expert, Dr. Andrew Asimos!
Join Drs. Richardson and Potter as they ReBake a Morsel of Pediatric Emergency Medicine. It is Flu Season in the Northern Hemisphere. Let's review some Morsels on Pediatric Flu!
Join Drs. Nicholena Richardson and Jennifer Potter from the EMGuidewire Team as they review and REBAKE previous Ped EM Morsels (www.pedemmorsels.com). In this episode, they discuss three important potential causes of chest pain in the pediatric patient.
Join Dr. Driscoll from the EMGuideWire team as he discusses the very important topic of exertion related heat illness. The Sports Medicine Corner can be helpful for everyone who cares for our patients who may overexert themselves. Know how to stay cool when they get too hot!
Join the EMGuideWire crew as they review Pericarditis evaluation and management in the ED. Are those ST segments more concerning for ischemia? Are steroids helpful? These questions and more will be answered!
Join the EMGuideWire Team as they discuss some basic concepts to help you make decisions about initial ventilator settings after intubation.
Join Dr. Jeremy Driscoll and his Sports Medicine Corner as the EMGuideWire addresses LisFranc Fracture. Know how to evaluate and manage this important foot injury!
Join Dr. Jeremy Driscoll of the EMGuideWire Team for this episode of his Sports Medicine Corner.In this episode, Dr. Driscoll covers Patellar Dislocation!
Join the EMGuideWire team as they discuss the basics of successful procedural sedation. Explore the various medication options that can keep our patients comfortable.
Join the Dr. Kathryn Kopec as she joins the EMGuideWire team to discuss how the Toxicologist approaches the patient who has a potential exposure to an intoxicant. Review your basic evaluation and treatment options and learn how to recognize those all important toxidromes!
Join the EMGuideWire Team as they discuss the evaluation and management of Peritonsillar Abscess (PTA) in adults and children.
Join the EMGuideWire team as they discuss some of the subtle and severe presentations of Lupus, a condition that can affect every organ system, in your ED.
Join the EMGuideWire Team and Dr. Jeremy Driscoll as he covers the evaluation and management of Knee Dislocations.
Join Dr. Driscoll and the EMGuidewire Team in this episode of Sports Medicine Corner. This episode will discuss evaluation and management of Clavicle Fracture.
Join Dr. Driscoll and the EMGuidewire Team in this episode of Sports Medicine Corner. This episode will discuss evaluation and management of Biceps Tendon Rupture.
Join the Dr. Jeremy Driscoll as he discusses Achilles Tendon Injury in this episode of the EMGuideWire's Sports Medicine Corner.
Join the EMGuidewire Team as they introduce a new series, the Sports Medicine Corner. This episode will cover a common finger injury, the Mallet Finger.
Join the EMGuideWire team as they discuss the core concepts of this critical procedure that can be extremely challenging. Learn the basic steps and some expert tips to help make your next Nasotracheal Intubation go as smoothly as possible.
Join the EMGuideWire Team as they discuss some of the common and some of the easily missed traumatic injuries that can involve the lower extremities. Know how to be aware of them and learn how to initially manage them.
Join the EMGuideWire Team as we discuss Pain Management issues and options in our Emergency Departments. EM physicians Sergey Motov and Chris Griggs discuss concepts that may help alleviate not only the patients' pain, but also the challenges physicians face in today's environment.
Join the EMGuideWire Team as they review some of the important medications in your typical "Code Cart." Know the important details about these medications that will enable you to use them most effectively!
Join the EMGuideWire team as they discuss the common, and sometimes frustrating, complaint of Pediatric Nasal Foreign Body. What are some of the approaches to help alleviate the problem?
Join the EMGuideWire team as they review the Core Concepts that will help you manage the challenging cases of Hyperemesis Gravidarum. From initial evaluation to medications, what can we do to help our pregnant patients with this condition feel better? Let's find out.
Join the Pediatric Emergency Medicine Fellows and the EMGuideWire crew as they discuss the challenges of fluid resuscitation in pediatric patients with diabetic ketoacidosis (DKA). What does the most recent literature say we should do?
Join the EMGuideWire team as they tackle the tough core concepts of how to manage the patients with simple and critical Upper Gastrointestinal Bleeds. Know what medicines are imperative to start and what ones may be discussed with your consultants.
Join the EMGuideWire Team as they explore the basic issues with managing patients with the dreaded Hepatorenal Syndrome. Do you use Albumin? Do you use Pressors? Do you use Both? A little understanding of the pathophysiology will help us answer those questions.
Join the crew from EMGuideWire as they review a clinically useful approach to and management of PEA. Dr. Laszlo Littmann will, once again, be our guide on this Cardiology Core Concepts tour.
Join the EM GuideWire team as they complete the journey through management of Wide Complex Tachycardia with Dr. Laszlo Littmann with the 3rd installment. This time, you'll treat the unstable and critically ill patient.
Join the EMGuideWire team as they explore the painful, and personal, aspects of Acute Urinary Retention. Learn what issues must be considered and some strategies to help you manage the patient with acute urinary retention in your Emergency Department.
Join the EMGuideWire crew as they learn from the master, Dr. Laszlo Littmann, how to interpret patients' rhythm strips to discern whether there is VTach, SVT, or even artifacts.
Join the EMGuideWire crew at CMC in Charlotte, NC as they take on the complex and scary topic of Irregular Wide Complex Tachycardia in Part 2 of the 3 part series on the approach to Wide Complex Tachycardia. Dr. Laszlo Littmann's expert advice, once again, saves the day!
Join the EMGuideWire crew as they discuss how to manage the dying asthma patient. Dr. David Pearson will help guide the team through the management of these severely ill patients while helping to anticipate the pitfalls and, hopefully, avoiding them.
Join the EM GuideWire team as they discuss some simple strategies to manage increased intracranial pressure (ICP). From intubation to administration of hypertonic saline, the group will discuss the basic steps to help your most critical patients.
Wide Complex Tachycardia will grab everyone's attention. Let's join the crew from EMGuideWire and Dr. Littmann to review a simplified approach to evaluation and management of Wide Complex Tachycardia!
Aside from making your fingers blue, Methylene Blue is a very useful dye that know how and when to use in the Emergency Department! Join the EM GuideWire Team as they explore this potentially life saving medication!
A Fib is the most common arrhythmia that is encountered in the ED. Knowing how to manage it when it is causing problems is important! Join the EM GuideWire Team as they discuss a-fib with RVR management with esteemed Cardiologist (and friend of us in the ED), Dr. Laszlo Littmann.
Hypertension may be a medical emergency, but many time EM physicians are faced with the patient with asymptomatic hypertension. Join the EM GuideWire Team as it address with issue and helps us all know how to appropriately evaluate and manage these situations.
Hyperkalemia can present subtly or as a critical condition. Join the EM GuideWire Team as they discuss how to address the issues of Hyperkalemia and manage it successfully!
Swollen lips, tongue, and throat... Oh My! The EM GuideWire team will cover the Core Concepts on how to quickly assess and manage these complicated emergencies involving angioedema.
Hypothermia can be a challenging environmental emergency condition and presents with a wide range of symptoms. The EM GuideWire Team will review the Core Concepts of hypothermia in this informative and educational podcast.
Preoxygenation is not just a step included in the process of Rapid Sequence Intubation, it is critical! The EM GuideWire team takes a quick look on how to optimize the preoxygenation process and what techniques can be applied most practically in the ED.
The agitated patient can be very challenging to evaluate in the ED. This episode of EMGuideWire's Core Concepts will address options to help evaluate these patients while keeping the patient and the staff safe.