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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the October 2025 Emergency Medicine Practice article, Emergency Department Evaluation and Management of Patients With Adrenal Insufficiency

Introduction

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

Article Overview

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

Clinical Context & Epidemiology

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

Pathophysiology

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

Differential Diagnosis

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

Prehospital Care

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

Emergency Department Evaluation

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

Physical Examination

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

Diagnostic Workup

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

Treatment

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

Special Populations

Pregnancy considerations
Septic shock and adrenal crisis

Common Pitfalls & Takeaways

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

ClosingSummary and final thoughts

Reminders for further reading and CME
Farewell and next episode teaser

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In this episode, Sam Ashoo, MD interviews Evan Dvorin, MD about the dangers of short term steroid use.

Background & Regional Differences

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

Inappropriate Steroid Use

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

Risks and Side Effects of Short-Term Steroid Use

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

Patient Communication & Shared Decision-Making

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

Impact of Provider Education & Quality Metrics

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

Special Populations & Scenarios

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

Medical-Legal Considerations

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

Alternatives & Symptom Management

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

Resources

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

Conclusion

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

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

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

Topic Introduction

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

Why Status Epilepticus Matters

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

Guidelines and Evidence

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

Classification and Diagnosis

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

Etiology and Workup

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

Prehospital and ED Management

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

Diagnostics

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

Treatment Approach

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

Special Populations

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

Risk Management Pitfalls

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

Clinical Pathway

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

Conclusion

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

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In this episode, Sam Ashoo, MD interviews Ali Chaudhary, MD about the benefits of working Locum Tenens in Emergency Medicine.

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

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

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In this episode, Sam Ashoo, MD interviews Lauren Black, MD about the August 2025 Emergency Medicine Practice article, Updates and Controversies in the Early Management of Sepsis and Septic Shock

00:00 Introduction and Welcome

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

01:56 Sepsis Statistics and Impact

04:16 Understanding Sepsis Definitions

09:56 Screening Tools for Sepsis

13:57 Pre-Hospital Sepsis Recognition

19:33 Clinical Examination and Diagnostics

24:03 The Role of Lactate and Procalcitonin

27:40 Clinical Gestalt and Imaging in Diagnosis

29:21 CMS Bundle Requirements and Updates

34:02 Fluid Type Preferences in Sepsis

36:49 Antibiotic Timing and Selection

43:43 Vasopressors and Steroids in Sepsis Management

50:18 Special Populations and Future Directions

53:44 Conclusion and Resources

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In this episode, Sam Ashoo, MD interviews Christina Shenvi, MD, PhD, MBA about ways to manage your day and keep distraction at bay.

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

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the July 2025 Emergency Medicine Practice article, Emergency Department Management of Status Epilepticus in Pediatric Patients

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

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

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

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

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

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

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

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

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

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

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

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Special Offer - EB Medicine is 26 years old! Get 26% off all purchases at ebmedicine.net!In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the June 2025 Emergency Medicine Practice article, Emergency Department Management of Patients With Thyroid Emergencies

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the May 2025 Emergency Medicine Practice article, Emergency Department Management of Patients With Complications of Chronic Neurologic Disease: Parkinson Disease, Myasthenia Gravis, and Multiple Sclerosis

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

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

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

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In this episode, Sam Ashoo, MD interviews Rob Orman, MD about ways to manage the trauma inflicted by the ER.

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

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the April 2025 Emergency Medicine Practice article, Sodium Disorders in the Emergency Department: A Review of Hypernatremia and Hyponatremia

Hypernatremia (High Sodium Levels)

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

Hyponatremia (Low Sodium Levels)

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

Treatment Guidelines and Strategies

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

Special Considerations

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

Five Things That Will Change Your Practice

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

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In this episode, Sam Ashoo, MD interviews Patrick O'Malley MD about his career in emergency medicine, The Laceration Course, and the power of connection with our patients.

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

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the March 2025 Emergency Medicine Practice article, Emergency Department Management of Knee Pain

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

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In this episode, Sam Ashoo, MD interviews Ashley Weisman, MD about her career in rural emergency medicine, and the February 2025 Emergency Medicine Practice article, Management of Traumatic Intracranial Hemorrhage in the Emergency Department

Interview with Dr. Ashley Wiseman

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

Practicing Skills in Rural Medicine

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

Advocacy for Rural Emergency Medicine

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

Focus on Traumatic Intracranial Hemorrhage (ICH)

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

Conclusion

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

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

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

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

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In this episode, Sam Ashoo, MD interviews Erin D'Agostino, MD about the February 2025 Emergency Medicine Practice article, Management of Traumatic Intracranial Hemorrhage in the Emergency Department

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the January 2025 Emergency Medicine Practice article, Alkali Exposure: An Evidence-Based Approach to Diagnosis and Treatment

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

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In this episode, Sam Ashoo, MD interviews Nicholas Stark, MD, MBA & Zaid Altawil, MD about the Emergency Medicine Innovation Collaborative

Discussion on EMIC
Overview of the collaborative
Background and formation during the pandemic in late 2021
Growth of EMIC
Expansion from three members to over 500
Focus areas: Education, mentorship, opportunity
Achievements of EMIC
Examples of innovations and initiatives born from EMIC
Pitch event at ACEP annual conference and other engagements
Importance of Physicians in Innovation
Internal and external factors
Benefits of physicians leading innovation efforts in healthcare
Opportunities for Collaboration
Engaging with healthcare startups and companies
Expanding collaborations and growing the network
EMIC Fellowship
Ideal candidates
Application process and benefits
Success stories and projects undertaken
Long-Term Vision for EMIC
Goals for future growth and expansion
Bridging gaps between industry and physicians for better patient care
Membership Details
How to join EMIC
Benefits of membership

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the December 2024 Emergency Medicine Practice article, Diagnosis and Management of Acute Mesenteric Ischemia in the Emergency Department

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the November 2024 Emergency Medicine Practice article, Emergency Department Management of Patients With Low Back Pain: A Review of Current Evidence

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the October 2024 Pediatric Emergency Medicine Practice article, Emergency Department Management of Acute Scrotal Pain in Pediatric Patients

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

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In this special episode Sam Ashoo, MD interviews Ryan Johnson, Pharm. D. who shares strategies to address the recent IV fluid shortage caused by Hurricane Helene.

00:00 Introduction and Episode Overview

01:10 Meet Ryan Johnson: Clinical Pharmacist

02:06 Role of Clinical Pharmacists in Emergency Medicine

05:03 IV Fluid Shortage: Causes and Impact

05:56 Institutional Strategies to Mitigate IV Fluid Shortages

14:52 Provider-Level Solutions for Fluid Conservation

22:11 Pharmacy and Nursing Staff Roles in Fluid Management

26:34 Advanced Measures and Federal Guidelines

34:40 Conclusion and Final Thoughts

Resources mentioned in the podcast:

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

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In this episode, Dr. Julia Draper shares her firsthand account of managing a crisis during a hurricane in Asheville, North Carolina. As the area faced unprecedented flooding, Dr. Draper describes the challenges faced at Mission Hospital, including loss of power and water. She details the innovative solutions the hospital implemented and highlights the tireless efforts of staff during a natural disaster of this magnitude.

00:00 Introduction to Dr. Julia Draper

01:03 Experiencing the Hurricane

03:19 Immediate Aftermath and Hospital Challenges

11:22 Dealing with Water and Supply Shortages

20:48 Community and External Support

24:10 Ongoing Efforts and Future Plans

27:51 Conclusion and Final Thoughts

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In this special episode, Sam Ashoo MD and Rob Orman MD discuss the concept of Maladaptive Perfectionism and its application to emergency medicine.

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

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the September 2024 Emergency Medicine Practice article, Elder Abuse and Neglect: Making the Diagnosis and Devising a Treatment Plan in the Emergency Department Introduction and Announcements Elder Abuse and Neglect: An Overview Risk Factors and Reporting Pre-Hospital and Emergency Department Considerations Screening Tools and Physical Examination Documentation and Disposition Cultural Considerations and Future Directions Conclusion and ResourcesSuspected Elder Abuse should be reported to one of these organizations:ADULT PROTECTIVE SERVICES - Living at homeLONG-TERM CARE OMBUDSMAN - Living in a long term care facility

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the September 2024 Emergency Medicine Practice article, Elder Abuse and Neglect: Making the Diagnosis and Devising a Treatment Plan in the Emergency Department

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

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

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

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In this episode, Sam Ashoo, MD interviews social media marketing expert Adam Goodcoff, DO, Founder and CEO of MedFluencers.

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the August 2024 Emergency Medicine Practice article, Emergency Department Management of Patients With Sickle Cell Disease

Epidemiology

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

Pathophysiology

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

Clinical Management

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

Advanced Treatment Options

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

Special Populations

Pregnant Patients with Sickle Cell Disease
Increased Risks and Complication Management

View Details

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the July 2024 Emergency Medicine Practice article, Emergency Department Management of Patients With Complications of Dialysis

Overview of Dialysis Complications

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

Disaster Preparedness

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

Pre-Hospital Care

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

Treatments

Risk Management PitfallsCommon Pitfalls to Avoid

Conclusion

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In this episode, Tracey Davidoff, MD and Joe Toscano, MD discuss the June 2024Evidence-Based Urgent Care article, HIV in the Urgent Care Setting: Treatment and Prevention

Introduction to HIV in Urgent Care
HIV Treatment and Prevention Overview
Epidemiology and Pathophysiology of HIV
Clinical Presentation and Differential Diagnosis
Urgent Care Evaluation and Screening
Pre-Exposure and Post-Exposure Prophylaxis
Testing and Diagnosis of HIV
Treatment Guidelines and Medication Management
Special Situations and Cutting-Edge Treatments
Key Points and Clinical Pearls
Conclusion and Final Thoughts

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD interview Corey Hazekamp, MD, MS, one of authors of the June 2024 Emergency Medicine Practice article, Managing Emergency Department Patients With Opioid Use DisorderCurrent State of Opioid EpidemicOverview of overdose deaths and trends.Data and statistics about opioid overdose mortality rates.Three Waves of Opioid Overdose Deaths in the U.S.Opioid Classifications and Urine Drug TestingTypes of opioids: synthetic, semi-synthetic, and natural.Urine drug testing limitations and false positives/negatives.Practical use and research on co-ingestionsEmergency Medical Services (EMS) and Pre-Hospital CareImportance of ABCs in acute opioid overdose cases.Naloxone usage trends and an empirical approach.Anecdotal insights on changing naloxone administration dosages.Clinical Management in the Emergency DepartmentBuprenorphine InitiationProtocols for initiating buprenorphine in ED settings.Assessment using the Clinical Opiate Withdrawal Scale (COWS).Safe dosing procedures for buprenorphine.Withdrawal and Overdose CareLaboratory testing recommendations.Capnography and VBG in overdose management.The role of end-tidal CO2 monitoring and respirations.Methadone vs. Buprenorphine ConsiderationsMethadone to buprenorphine transition protocols.Personal testimonials and clinical experiences in managing overdoses and withdrawal symptoms.Patient Discharge and Follow-upPreparation of discharge prescriptions.Referral to addiction medicine clinics and resources.Educating patients on continued treatment and harm reduction.

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD interview Corey Hazekamp, MD, MS, one of authors of the June 2024 Emergency Medicine Practice article, Managing Emergency Department Patients With Opioid Use Disorder

Current State of Opioid Epidemic

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

Opioid Classifications and Urine Drug Testing

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

Emergency Medical Services (EMS) and Pre-Hospital Care

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

Clinical Management in the Emergency Department

Buprenorphine Initiation

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

Withdrawal and Overdose Care

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

Methadone vs. Buprenorphine Considerations

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

Patient Discharge and Follow-upPreparation of discharge prescriptions.

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

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In this episode, Sam Ashoo, MD interviews Rob Orman, MD, founder of Orman Physician Coaching, about routine examination of our careers in emergency medicine.

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD interview Reuben J. Strayer, MD, author of the May 2024 Emergency Medicine Practice article, Current Concepts in Ketamine Therapy in the Emergency Department

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

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In this episode, Sam Ashoo, MD interviews Ashley A. Foster, MD, Bijan Ketabchi, MD, MPH and Jennifer A. Hoffmann, MD, MS on the March 2024 Pediatric Emergency Medicine Practice article, Evaluation and Management of Suicidal Ideation and Self-Harm in Children in the Emergency Department

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the April 2024 Pediatric Emergency Medicine Practice article, Brief Resolved Unexplained Events: Practical Evaluation and Management in the Emergency Department

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

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In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the March 2024 Emergency Medicine Practice article, Emergency Department Evaluation and Management of Constipation

Prevalence and Impact

Understanding the Causes

Medications That Can Cause Constipation

Dealing with Fecal Impaction

Understanding Stercoral Colitis

Pre-Hospital Care

ED History and Physical Exam

Diagnostic Studies and Imaging

X-Ray
CT Scans
Advanced Testing

Treatment Options for Constipation

Enemas
Osmotic Laxatives and Stool Softeners

Special Considerations: Pregnant, Pediatric, and Hospice Patients

Prescription Medications for Constipation

Clinical Pathway for Constipation Management

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In this episode, Sam Ashoo, MD interviews Paul Aronson, MD, MHS, one of the authors of the February 2024 Pediatric Emergency Medicine Practice article, Febrile Infants Aged ≤60 Days: Evaluation and Management in the Emergency Department

Guideline Changes

Pathophysiology

Etiology and Definitions

Prehospital Care

ED History and Physical

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

Lumbar Puncture

Viral Testing

Urinalysis

Shared Decision Making

Disposition

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In this episode, Sam Ashoo, MD, and T.R. Eckler MD interview Nick Harrison, MD and Daniel Brenner, MD, two of the authors of the February 2024 Emergency Medicine Practice article, Emergency Department Management of Patients With Right Heart Failure

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

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In this episode, Sam Ashoo, MD, interviews Vasisht Srinivasan, MD, FACEP one of the authors of the December 2023 Emergency Medicine Practice EXTRA article, Emergency Department Management of Stroke in Pregnant and Postpartum Patients

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

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2024 Pediatric Emergency Medicine Practice article, Management of Pediatric Urinary Tract Infections in the Emergency Department, and the January 2024 Evidence Based Urgent Care article on Pediatric Community-Acquired Pneumonia: Diagnosis and Management in the Urgent Care Setting.

UTIEpidemiology and Nomenclature

Prehospital Care

ED History and Physical Exam

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

Urinalysis

Clean Catch Protocol
Catheterization
Suprapubic Aspiration

Blood Cultures and CSF

Biomarkers (CRP and ESR)

Treatment

Community Acquired PneumoniaDistinguishing Viral vs Bacterial Pneumonia

Imaging

Antibiotic Treatment

Vaccination

Steroids

Atypical Presentations

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

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2023 Pediatric Emergency Medicine Practice article, Management of Pediatric Toxic Ingestions in the Emergency Department.

Need help now? Call the Poison Help Line at: 1‑800‑222‑1222Epidemiology

Prehospital Care

ED History and Physical Exam

Diagnostic Studies

Labs
EKG
Imaging
Urine Toxicology Testing

Treatment

Hemodialysis
Activated Charcoal
Whole Bowel Irrigation
Gastric Lavage
Ipecac

Drug Specific Therapies

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

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

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the November 2023 Pediatric Emergency Medicine Practice article, Pediatric Diabetes: Management of Acute Complications in the Emergency Department and some of the highlights from the other EB Medicine articles published in November.

Epidemiology

Differential diagnosis

Prehospital care

ED history and physical exam

Diagnostic studies

Point of care testing
Labs
Imaging

Treatment

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

Complications

Cerebral edema
Intubation

Insulin pumps

Disposition

Summary

Highlights

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

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

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the October 2023 Pediatric Emergency Medicine Practice article, Substance Use in Adolescents: Recognition and Management in the Emergency Department and the October 2023 Emergency Medicine Practice article, Evidence-Based Emergency Department Management of Migraine and Other Primary Headaches

Substance Use In Adolescents

Epidemiology

Risk Factors

Differential Diagnosis

Prehospital Care

ED History and Physical Exam

Urine Drug Screen

Treatment

Marijuana
Alcohol
Methaphetamines
MDMA
Cocaine
Opioids

Disposition

Migraine and Other Primary Headaches

Epidemiology

Cluster Headaches

Medication Overuse Headache

Nerve Blocks

Greater Occipital
Sphenopalatine Ganglion

Pregnant Patients

Disposition

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

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the September 2023Emergency Medicine Practice article, Emergency Department Management of Patients With Rectal Bleeding

Etiology/pathophysiology

Risk factors

Differential diagnosis

Prehospital care

ED history and physical exam

Diagnostic studies

Laboratory testing
Imaging studies

Treatment

Transfusion
Coagulation reversal
Embolization

Special Populations

Pediatrics
Pregnant patients
Elderly patients

Scoring systems

Disposition

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

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, interview Al Sacchetti, MD, about the August 2023 Emergency Medicine Practice article, Evidence-Based Management of Pulmonary Embolism in the Emergency Department

Etiology/pathophysiology

Risk factors

Differential diagnosis

Prehospital care

ED history and physical exam

Diagnostic scoring systems

Pregnant patients

Diagnostic studies

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

Treatment

IV fluids
Anticoagulation
Vasopressors
Thrombolytics
Thrombectomy
ECMO

Disposition

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

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2023 Emergency Medicine Practice article, Diagnosing and Treating Pericarditis and Myocarditis in the Emergency Department

Epidemiology

Nomenclature

Etiology

Differential diagnosis

Prehospital care

ED history and physical

Diagnostics

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

Treatment

Special populations

COVID-19
Athletes
MIS-C

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the June 2023 Emergency Medicine Practice article, Hypertensive Emergencies: Guidelines and Best Practice Recommendations

Epidemiology

Etiology

Differential diagnosis

Prehospital care

History and physical

Diagnostics

Treatment

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

Controversies

Arterial line placement
Beta blockers and cocaine

Risk management caveats

Summary

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the May 2023Emergency Medicine Practice article on Emergency Department Management of Gastrointestinal Foreign Body Ingestion

Epidemiology

Etiology - types of ingestions

Anatomy - common locations by age

Food impaction
Sharp objects
Button batteries
Magnets
Colorectal foreign bodies

Prehospital care

History and Physical

Imaging

Expectant management

Endoscopic removal

Non-endoscopic techniques

Body Packing

Glucagon

Gastric button batteries

Summary

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In this episode, Sam Ashoo, MD, talks with Rob Orman, MD, founder of Orman Physician Coaching, about longevity in emergency medicine.

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

More at Orman Physician Coaching

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Announcements:

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

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

Epidemiology

Pathophysiology

Populations at Risk

Complications

Intracranial hemorrhage
Aneurysms
Heart block

Prehospital Care

ED History and Examination

Imaging

Antibiotic Therapy

Surgical Treatment

Special Populations

Summary

View Details

Announcements:

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

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

—

History

Point-of-care testing

I/O lines

Presentation, differential, and treatment of:

Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia
Hypocalcemia
Hypercalcemia
Hypomagnesemia
Hypophosphatemia

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Announcements:

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

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

DEA-X Waiver Repeal:

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

Opioids in Children and Adolescents:

Introduction

Epidemiology and Statistics

Medication safety at home

Escalation of pain meds at home

Naloxone prescriptions

Medications in children

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

Opioids and sedation

Regional anesthesia

Chronic pain

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Announcements:

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

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

Intro

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

Criteria

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

Pathophysiology

Epidemiology

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

Prehospital Care

Give epi, H1 blockers
Mainstay = recognition

ED Care

Airway
Epinephrine
Decontamination
H1 and H2 blockers
Corticosteroids
Biphasic reactions
Glucagon

Special Cases

Alpha-gal
Scombroid
Kounis syndrome

View Details

Announcements:

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

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

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

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

Definitions

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

Etiology

Neonate
Central line and VP shunts
Asplenia
Immunocompromised children

Differential Diagnosis

Prehospital Care

ED Evaluation

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

Diagnostics

Labs
Imaging

Treatment

IV/IO placement
Fluid boluses
Antibiotics
Pressors
Airway management

Special Populations

Febrile neutropenia
Newborns with septic shock

Controversies

Fluid volume
Fluid type
Antibiotic timing
Corticosteroids

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2022 Evidence-Based Urgent Care article on Influenza in Urgent Care.

Epidemiology

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

Outbreaks

Transmission

Classification

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

Pathophysiology

Transmission
Incubation
Secondary infection
H3N2

Vaccines

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

Differential Diagnosis

Complications

Testing

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

Treatment

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

Billing and Coding

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In this episode, Sam Ashoo, MD, interviews Prayag Mehta, MD, and Nikola Milanko, MD, two of the authors of the October 2022 Emergency Medicine Practice article on Angioedema in the Emergency Department

Pathophysiology: Non-pitting edema of respiratory or GI tract

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

Histamine Mediated

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

Bradykinin Mediated

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

Table 1 Differential Diagnosis

Prehospital Care

Protect airway
Epi, steroids, antihistamines
Avoid CPAP

ED History

Figure 2: Distinguishing characteristics of histamine vs bradykinin mediated

ED Exam

Importance of repetitive exams
Airway examination
Laryngoscopy?

Diagnostics

Figure 6: Flow diagram of ED workup
Labs
Imaging

Treatment

Airway: Intubation
Medication

Special Populations

Pediatric
Pregnant/lactating patients

Controversies

Disposition

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In this episode, Sam Ashoo, MD, interviews Ami Shah, MD, MPH, and Don Walker, MD, about eye injuries in the pediatric population.

Why ocular injuries? Why did you pick this topic?

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

Injury zones and terminology

Differential Diagnosis

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

Prehospital Care

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

ED Evaluation

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

Treatment

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

Special Populations

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

Controversies and Cutting Edge

Ketamine
Tetanus
NSAIDs, topical?
Topical anesthetics
Visual acuity apps

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In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Rob Orman, MD, founder of Orman Physician Coaching, about career disillusionment.

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

More at Orman Physician Coaching.

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In this episode, Sam Ashoo, MD interviews Rawad Rayes, MD and Eva Tovar Hirashima, MD, MPH – two of the authors of the August 2022 PEMP article on Pediatric Firearm Injuries to the Extremity: Management in the Emergency Department.

Episode Outline:

How common are pediatric firearm injuries?

What is the most common location of these injuries?

Is there much literature published on this topic?

Epidemiology

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

Terminology: For those unfamiliar with firearms (table 1)

Ballistics: Mechanisms of damage.

Pre-hospital care

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

ED Evaluation

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

Controversies

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

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In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Andrew Phillips, MD, founder of EM Coach, about artificial intelligence and emergency medicine education.

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

EM Coach - what is it?

Artificial Intelligence -

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

How and where to access EM Coach

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In this episode, Sam Ashoo, MD interviews Lela Bachrach, MD, MS, Larissa Truschel, MD, MPH, and Makini Chisolm-Straker, MD, MPH - the authors of the July 2022 PEMP article on Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to human trafficking.

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

EMplify - Sept 2022

Episode Outline:

Differential Diagnosis

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

EMS/Prehospital Care

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

ED Evaluation

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

Diagnostic Studies

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

Treatment

Medical
Beyond medicines: Local services, national hotline

Special Populations

Diagnosis: What to chart?

National Human Trafficking Hotline

1-888-373-7888https://humantraffickinghotline.org/

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In this episode of EMplify: Conversation – Sam Ashoo, MD, and TR Eckler, MD, speak with John Roberts, MD, MPH, about his work with the International Medical Corps and his efforts in Ukraine.

Topics include:

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

Links

MC Website

IMC Jobs

Roster Positions

Roster position - MD

Roster position - Nurse

Roster position - Nurse Practitioner

Roster position - Midwife

Disaster Medicine

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

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In this episode, Sam Ashoo, MD interviews Adam Siegel, MD and Stephanie Costa, MD - the authors of the August 2022 EMP article on Managing Acute Cardiac Valvular Emergencies in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to valvular emergencies.

Managing Acute Cardiac Valvular Emergencies in the Emergency Department

EMplify - August 2022

Episode Outline:

Why Valvular disease?
How common is it?
How often do we see it in the ED?
Which valves are we talking about?
Aortic Valve Disease
Types and causes
Mitral Valve Disease
Types and causes
Tricuspid and Pulmonic Disease
Differential Diagnosis
acute coronary syndromes (ACS)
pulmonary embolism
tamponade
chronic obstructive pulmonary disease (COPD)
pneumonia
pneumothorax
Prehospital Care
Evaluation of chest pain
History
Shock
ED Evaluation
History
Aortic Stenosis
Aortic Regurgitation
Mitral Stenosis
Mitral Regurgitation
Physical exam findings
Diagnostic Testing
Labs
ECG
CXR
Bedside US
Formal ECHO
Treatment
Special Populations
Prosthetic valves
Pregnant patients

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In this episode of EMplify, Sam Ashoo, MD reviews recent updates on the following topics:

COVID-19

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

Monkeypox

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

Medication Shortages

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

988 Crisis Line

Baby Formula Shortage

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In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss meningococcal meningitis and the recent outbreak in Florida.

Topics discussed include:

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

Further Reading

Current WHO Outbreak TrackerCDC Monkeypox ReferenceJohns Hopkins Monkeypox Reference

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This is the second episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.

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

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

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

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

Thanks for being a listener.

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In this episode, Sam Ashoo, MD interviews Kyle Howarth, MD and Joby Thoppil, MD, PhD - two of the authors of the May, 2022 EMP article on Cellulitis and Skin and Soft Tissue Infections. Listen to the discussion to hear more about the emergency department management of cellulitis and necrotizing skin infections.

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

EMplify – May 2022

Episode Outline:

Why cellulitis/skin infections?
Terminology

Erysipelas vs cellulitis vs fasciitis Purulent cellulitis

Most common pathogens
Special situations
Necrotizing infection classification system – is this helpful in the ED, and if so, why?
Differential – unilateral vs bilateral presentation
Prehospital care
ED evaluation

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

Diagnostics

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

Labs

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

11. Treatment

NSTI antibiotics Abscesses

12. Special populations

IV drug users Diabetic patients Immunocompromised patients

13. Wound irrigation and loop drainage

Disposition

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The first episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.

This episode is a conversation between Dr. T.R. Eckler and Dr. Sam Ashoo about the recently passed federal Dr. Lorna Breen Legislation and its significance on the field of Emergency Medicine.

Take the listener survey:

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

More on the Dr. Lorna Breen Legislation here.

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Episode 68 -- Emergency Department Management of Adults With Infectious Meningitis and Encephalitis – An Interview with Dr. Andrew Hogan

EMplify -- April 2022

Interview with the Author: Andrew N. Hogan, MD

1.Meningitis vs encephalitis

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

2.Bacterial meningitis

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

3.Viral meningitis

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

4.Viral encephalitis

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

5.Fungal infections

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

6.Prehospital care:

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

7.ED evaluation: History

8.ED evaluation: Physical exam

9.Diagnostics: CSF

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

10.Serum labs

What is helpful? Serum PCR Serum cryptococcal antigen

11.Imaging

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

12.Treatment

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

13.Special populations

Autoimmune disease Lacking childhood vaccines Healthcare associated infections

14.Cutting edge

15.Disposition

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Episode 67 – Managing Postpartum Complications in the Emergency Department – An Interview with Dr. Nicole Yuzuk, Dr. Joseph Bove, and Dr. Riddhi DesaiEMplify – March 2022Interview with the Authors: Nicole Yuzuk, DO, Joseph Bove, DO, and Riddhi Desai, DOEpisode Outline:1.Why is this an important topic in EM? 2.Hemorrhage etiologies and definition3.Headache etiologies, both common and the more dangerous (ICH)4.Fever and infectionMastitisEndometritis5.Preeclampsia/eclampsia Definition, diagnosis, risk factors (Table 1)6.HELLP syndromeDefinition, diagnosis (Table 2)7.Peripartum cardiomyopathyTime of onset, how to make the diagnosis, risks (Table 3)8.Prehospital careIV fluidsTXAAMS evaluationChest painFever/hypotension 9.ED evaluation History (what kind of things should we remember to ask?) Physical exam (what should we be paying attention to?) 10.Diagnostic studiesHemorrhage (exam, vitals, labs, US)Headache (labs, imaging – what type?)Fever and infection (labs, imaging – US or CT, antibiotics)Cardiopulmonary complaints (labs, imaging, ECG)11.TreatmentHemorrhage Headache (CVT)Infection (mastitis, endometritis, wound Infection)Preeclampsia, eclampsia, HELLP, seizuresCardiomyopathy12.What about breastfeeding mothers? 13.Controversies and cutting edgeEndovascular therapyThromboelastography

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Episode 66 – Acute Asthma Exacerbations – An Interview with Dr. Steven Hochman and Dr. Brandon SomwaruEMplify – February 2022Emergency Department Management of Acute Asthma ExacerbationsInterview with the authors: Steven M. Hochman, MD, and Brandon Somwaru, DO Episode Outline:EpidemiologyRisk factors for death from asthma (Table 1)Triggers for asthma attacksVariants of asthma (Table 2)Differential diagnosis (Table 3)Can PE be a trigger for an acute asthma attack? Prehospital careED care: history (what should we ask?)ED care: physical exam (what are we looking for?)Classifying mild/moderate/severe asthma Lab studiesPOCUS (Table 5 and Figure 3)Peak expiratory flowETCO2 capnography and capnometryChest x-rayTreatment (Table 6)MedicationsOxygenSABA vs LABAWhat about MDIs?Continuous nebs?AnticholinergicsSteroids (IV, oral, inhaled; prednisone vs dexamethasone)Magnesium sulfateEpinephrineTerbutalineKetamineNIPPVIntubation pearls and pitfalls (Table 8)Special populationsPediatrics PregnancyCOVID-19 Controversies and cutting edgeBiologicsFractional exhaled nitric oxideHeliox High flow nasal cannulaDelayed sequence intubationECMODisposition

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Diagnosis and Management of Acute Joint Pain in the Emergency DepartmentInterview with author: Rachel Sullivan, MDWhy joint pain ?Differential Diagnosis Mono vs Poly Articular Presentation? Figure 1Infectious, degenerative, autoimmune, crystal deposition, reactive, traumaticSeptic Arthritis-Bimodal incidence RisksSeptic arthritis is polyarticular in 15% to 20% of cases, and in these cases, the mortality is highGonococcal Highest riskCommonly affected jointsSymptomatic or asymptomatic infection Lyme ArthritisViral - Zika, chikungunya, human parvovirus B19, hepatitisDegenerative osteoarthritis AutoimmuneGoutCPPDPrehospital ED History - table 2, table 4ED exam Labs - do we need them? ImagingArthrocentesis - Table 5TreatmentSpecial PopulationsProstheses Immunocompromised HIVClinical Pathway

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EMplify - December 2021

Announcements:

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

Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management Interview with author: Anthony Hackett, MD

Thoracic Aortic Syndromes

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

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EMplify - November 2021

Announcements:

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

Emergency Department Management of Rib Fractures

Author: Patrick Maher, MD

Episode Outline:

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

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EMplify - October 2021

Announcements:

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

Emergency Dept. Management of Cervical Spine Injuries

Authors:

Geoffrey Jara-Alamonte, MD

Chandni Pawar, MD

Epidemiology

Anatomy (Figure 2 +3)

Spinal Cord Injury Injury (Table1)

Primary
Secondary

Differential Diagnosis

Prehospital Care - selective immobilization

ED evaluations

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

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EMplify - October 2021

Announcements:

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

Emergency Dept. Management of Cervical Spine Injuries

Authors:

Geoffrey Jara-Alamonte, MD

Chandni Pawar, MD

Epidemiology

Anatomy (Figure 2 +3)

Spinal Cord Injury Injury (Table1)

PrimarySecondary

Differential Diagnosis

Prehospital Care - selective immobilization

ED evaluations

HistoryPhysical Exam (Table 6)ImagingVascular Injury - Modified Denver Criteria (table 9)TreatmentSpecial PopulationsPediatrics

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EMplify - September 2021 Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !! Also, this month use code SB25 and get a $25 Starbucks gift card when you subscribe at ebmedicine.net !

Abnormal Uterine Bleeding in the Emergency Department Authors: Tazeen Abbas, MD Abbas Husain, MD, FACEP

Physiology review Terminology Differentiating Causes: PALM-COEIN

Structural: Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia Non-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise specified Other causes: thyroid disease, hyperprolactinemia, stress, weight loss and anorexia, heavy exercise

Age Based Differential

12-18

Immaturity of the hypothalamic-pituitary- ovarian axis Sexually transmitted infections Coagulopathies, and bleeding disorders (von Willibrand disease)

19-39

polyps fibroids malignancy PCOS

Age 40 and older

endometrial atrophy malignancy

History Physical Exam Diagnostic Studies Treatment

Unstable Stable

Special Cases

DOACs Prepubescent girls genital injuries

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EMplify - August 2021 Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !!

August 2021 Pediatric Emergency Medicine Practice

Less Lethal Law Enforcement Weapons Authors: Jessica Osterman, MD , Cara Buchanan, MD

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

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

Differential Diagnosis Prehospital Care Trauma Informed Care Conductive Electrical Weapons - Taser Chemical Irritants- Pepper Spray, Tear Gas K9 Injuries Kinetic Impact Projectiles- Rubber Bullets, Beanbags, Sting Balls/Grenades

Sounds: Police Siren https://freesound.org/people/MultiMax2121/sounds/156869/ Ambulance https://freesound.org/people/sofialomba/sounds/469413/ Angry Man https://freesound.org/people/ebcrosby/sounds/334439/ Taser https://freesound.org/people/The_Chemical_Workshop/sounds/403252/ Taser https://freesound.org/people/Greub/sounds/402636 Coughs https://freesound.org/people/freesound/sounds/25301/ Dog Bark https://freesound.org/people/ivolipa/sounds/337101/ Grenade https://freesound.org/people/superfreq/sounds/268101/

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EMplify - July 2021 Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !!

HIV- An Interview With Dr. Daniel Egan

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

Why HIV?

2018 , 1,2 million people living with HIV, almost 40k new infections People living with HIV visit the ED 3 x per year on average HIV infected patients accounted for 6 in 1000 ED visits in 2017 New Transmission of HIV, Figure 1

What does acute infection look like ? What about chronic infection ?The chronic phase can last 10 years or more and be asymptomatic. Are people with HIV more likely to develop: CAD, COPD, DVT and why?

What if they are on medication for HIV?

Screening in the ED, everyone? Do they have to have symptoms or risks?

What does universal screening mean? What does risk based screening mean?

What are the risk factors? What if I see someone on PrEP who is in the ED for an unrelated complaint? History

Ask about cd4 and viral load and last test Ask about he of opportunistic infections Ask about medication side effects What else?

Exam Labs - rapid testing, 4th gen, viral load and cd4, etc Imaging Treatment

Table 1 Highly effective and reduces transmission

Medication side effects (we don’t have to dwell on each Med and side effect and just reference the charts) hep B virus deactivation System Based Disease

Heart Failure and CAD PCP (role of LDH) TB COPD Renal Disease - stones , radiolucent Neurologic- CVA, cryptococcal meningitis, toxo, progressive multi focal leukoencephalopathy, HAND GI - diarrhea causes, c diff, hep C Heme- cytopenia Endocrine - metabolic syndrome Musculoskeletal Psychiatric table 3 Derm

Special Circumstances

PEP PrEP

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EMplify - June 2021 Announcements:

The Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this summer !!

Syncope- An Interview With Dr. James Morris See the EB Medicine Article @ https://www.ebmedicine.net/topics/cardiovascular/syncope

Why syncope? Prevalence, hospitalizations, etc. Etiology: figure 1 is fantastic. Physiologic basis of syncope Neurally mediated Orthostatic - are we still doing orthostatic vitals in the ED? Cardiac

Differentiating syncope from seizure Features that point to seizure Urinary incontinence Number of jerks Age?

Prehospital care is all about details What did bystanders see? What do paramedics see? Any trauma? Any neuro deficits ? Glucose ECG

ED History - table 4 History of similar Prodrome Associated symptoms (chest pain, neuro symptoms, etc) Falls Pre-syncope ?

ED exam Vitals, vitals, vitals Orthostatic vitals ? Carotid sinus massage, why this? Do we do in the ED?

ECG Brugada, blocks, VT, ST changes, etc

Labs BNP, delta bnp ? Trop Lactic acid Pregnancy test CBC lutes Bun/Cr

Echo - any role in the ED? CT Head PE- get this on everyone ? Is it high prevalence?

Risk stratification tools- the bad and the worse Table 7, amazing Controversies Admitting the elderly Orthostatic vitals (we discussed already)

Disposition

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EMplify - May 2021 Announcements:

Atrial Fibrillation : An Approach To Diagnosis And Management In The Emergency Department - An Interview with Dr Brian Millman Epidemiology Causes Prehospital treatment - careful with causes of the A Fib. ED Evaluation

History - beware the causes Physical ECG Labs Imaging Echocardiography

Treatment Rate control

Calcium channel blockers Beta blockers Esmolol Magnesium

Rhythm control

Amiodarone Procainamide Cardioversion

Watch and Wait Anticoagulation Disoposition

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EMplify - April 2021 Announcements

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

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

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

Why this topic?

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

Pathophysiology:

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

ED Evaluation:

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

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EMplify - March 2021 Management of Acute Urinary Retention in the Emergency Department

An algorithmic approach to urinary retention. Relieve the obstruction

Foley Cudet cather Silicone catheter Suprapubic catheter

Determine the cause -

Structural Medications / Toxicologic Neurologic Infectious

Alpha blockers Antibiotics Slow vs rapid bladder decompression Admit or discharge Phimosis and Paraphimosis

Announcements:

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

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EMplify - February 2021 Community Acquired Pneumonia - An Interview with Dr. Matthew DeLaney, FACEP 1. Pneumonia and nomenclature : healthcare associated vs hospital associated2. COVID-19 and antibiotics3. Bacteriology - Strep is only 10-15% of hospitalized pneumonia, Viral pneumonia is about 20% (pre covid)4. Conditions that predispose to pneumonia

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

Is there a historical or exam item most likely to be indicative of pneumonia?6. How good is a CXR?7. When should I consider a CT if the CXR is normal?8. Procalcitonin9. Blood cultures, sputum cultures, urine antigens- are these helpful?10. CURB-65 vs PSI11. Antibiotics- table 3 major and minor, history of prior infection, and doxy for everyone !12. Duration - 5 days works13. A walk through the pathway

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EMplify January 2021 Evaluation and Management of ST-Segment Elevation Myocardial Infarction in the Emergency Department Authors Marshall Frank, DO, MPH, FACEP Carson Sanders, BS, NRP, CCEMT-P Bryan P. Berry, MD, BCEM, FACEP Topics Epidemiology Pathophysiology Prehospital care Emergency Dept Evaluation

History Physical

Imaging Labs Electrocardiogram

aVR Posterior Leads LBBB Serial ECGs Reciprocal Changes Pericarditis vs STEMI

Treatment

Oxygen Opioids Antiplatelet Agents Nitroglycerin Beta Blockers Reperfusion

PCI Thrombolytics Dysrhythmias

Anticoagulants

Transfers Special Circumstances

Gender Age Cocaine

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

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EMplify December 2020 Rhabdomyolysis: Evidence- Based Management in the Emergency Department Authors: Gi Xiang Lee, MD David Duong MD, MS, FACEP Topics: Evidence Review Biology & Pathophysiology Differential Diagnosis Pre-hospital care Emergency Department Evaluation

History Physical Examination Labs

Treatment Special Populations Disposition Have questions or comments on the podcast? Write us at emplify@ebmedicine.net . Don’t forget about the $50 Amazon card with any order over $300 through 12/31/20. Use code AMAZON20

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EMplify November 2020 An Evidence-Based Approach to Nonoperative Management of Traumatic Hemorrhagic Shock in the Emergency Department Authors: Christopher Pitotti, MD, FACEP Jason David, MD Topics: The Lethal Triad Prehospital Care

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

ED Assessment

Shock Recognition Predictors of Massive Transfusion Imaging

Ultrasound - eFAST CT

Labs

Viscoelastic Clot Testing

Treatment

REBOA- Resuscitative Endovascular Balloon Occlusion of the Aorta CPR Resuscitative Thoracotomy Airway - Intubation Breathing Circulation

Massive Transfusion Crystalloid Blood Products

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

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EMplify October 2020

Management of Deep Vein Thrombosis in the Emergency Department Authors:

Shane R. Sergent, DO, FAAEM, FACOEP, FAWM, RDMS Michael Galuska, MD, FACEP, FAAEM John Ashurst, DO, MSc, FACEP, FACOEP Topics: Epidemiology Causes: • Unprovoked • Provoked Risk Factors Testing • D-dimer • Ultrasound Anticoagulation • Heparins • DOACs • Warfarin • Other Special Populations • Malignancy • Pregnancy • Elderly • Distal Calf DVT Have questions or comments on the podcast? Write us at emplify@ebmedicine.net .

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Emergency Care for Transgender and Gender-Diverse Children and Adolescents - An Interview With Dr. Hannah Janeway and Dr. Clinton Coil This issue of Pediatric Emergency Medicine Practice is available at no cost here: https://www.ebmedicine.net/topics/ethics/trasnsgender-gender-diverse-children

Topics:

What is the difference between gender and sexual orientation? What are some of the terms we may encounter (current or retired)? How does a lack of knowledge / competency regarding care for transgender and gender diverse (TGD) youth create barriers to effective care? Or negatively affect the quality of care these patients receive? What is the best way to approach a transgender patient in the ER? There are a number of ways transgender patient may alter their appearance. Why are these methods relevant (complications) and how do I ask about them?

Tucking Packing Binding

What medical gender-affirming therapies are currently available? And what complications can they cause?

Pubertal suppression Feminizing or masculinizing hormones Contraception

Is gender-affirming surgery used in this population ? What types (chest, genital) ? STI’s and Pregnancy are still considerations, correct? What are some of the problems that transgender youth have an increased risk of?

Substance abuse Suicide Self harm Anxiety Depression Eating disorders Physicians and sexual violence Family rejection Homelessness Food insecurity Poverty

What are some helpful resources if I want to learn more?

UCSF Center for Excellence for Transgender Health (https://prevention.ucsf.edu/transhealth) PFLAG (https://pflag.org/)

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

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EMplify September 2020 – Infective Endocarditis

Topics:

Definition and new classification methods. Changes in at-risk patients in the U.S. History and Examination Imaging

Chest Xray Trans-throacic Echocardiography (TTE) Trans-esophagel Echocardiography (TEE) CT Angiography MRI

Bacteriology Antibiotics Summary

Write us at emplify@ebmedicine.net

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EMplify August 2020 – Racism In Medicine with Dr. Maurice Selby, Assistant Professor, Emergency Medicine, Emory School of Medicine Host- Health In Harlem radio show (WHCR 90.3 FM)and podcast

Topics:

History of racism in medicine

Niggerology Experimentation on Women Pain thresholds, endurance to harsh environments, food and water

Institutional Review Boards (IRBs) and their role in racism Non-compliant patients Believing your patient Poor outcomes in medicine due to racial bias Bereaving families Racism among physicians and providers

Micro agressions What it’s like to experience racism as a physician.

Next steps.

Leave us a voicemail at 678-336-8466, ext 128 Write us at emplify@ebmedicine.net

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EMplify July 2020 – Ventilator Management Of Adult Patients with Dr. Ryan Pedigo, Part 2 Topics:

ARDS COVD-19

Lung Compliance Prone Positioning

Metabolic Derangements

DKA

Capnography and Waveform Analysis

Leave us a voicemail at 678-336-8466, ext 128 Write us at emplify@ebmedicine.net

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EMplify July 2020 – Ventilator Management Of Adult Patients with Dr. Ryan Pedigo, Part 1 Topics:

Ventilator Modes

Volume Assist vs Pressure Support

Tidal Volumes

Tidal Volume Measurement Tables

Inspiratory / Expiratory Ration FiO2: How much oxygen do we need? COPD Patients

Permissive Hypercapnia Volume vs Respiratory Rate Adjustments

Asthma Patients

Respiratory Rate Adjustments

Leave us a voicemail at 678-336-8466, ext 128 Write us at emplify@ebmedicine.net

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EMplify June 2020 Multi-system Inflammatory Syndrome in Children (MIS-C) with COVID-19: An Interview with Dr. Ilene Claudius and Dr. Mohsen Saidinejad.

What is it and when did we discover it as an entity? Have either of you treated anyone with the disease? Discussion of different cohorts of patients with MIS-C. Definition of MIS-C. Shock: cardiogenic and distributive shock presentations. Fever, is 4 days required? Discussion of where in the COVID-19 illness MIS-C occurs. Is clinical shock a requirement? Screening criteria (labs) and the Children’s Hospital Of Philadelphia pathway. What is available as treatment?

A discussion of IVIG Steroids Cytokine blockers Remdesivir

Why IVIG? Complications of the disease. Why are there more cases in New York? How has MIS-C changed your practice of testing children? Is there utility in testing for COVID-19 infection or antibodies in these cases?

Resources:EB Medicine Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians EB Medicine COVID-19: The Impact on Pediatric Emergency Care Children’s Hospital of Philadelphia Clinical Pathway for MIS-C. Have questions or comments on the podcast? Leave us a voicemail at 678-336-8466, ext 128 or write us at emplify@ebmedicine.net .

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EMplify June 2020 Rural Emergency Medicine and COVID-19: An Interview with Dr. Harry Wingate and Dr. Ken Gramyk.

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

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

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You may be accustomed to hearing me speak about COVID-19. Yes, the crisis appears to be improving, and yes much remains unknown and still to be told. But today, even in the midst of pandemic, there is another, different crisis gripping our country. Racism.

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

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

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

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

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

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

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

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

Leave us a voicemail at 678-336-8466, ext 128 Write us at emplify@ebmedicine.net

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

EBMedicine Live Webinars: Thursday, June 4th - Life-threatening Headaches + current considerations due to COVID-19 Wednesday, June 17th – A New Timing-and-Triggers Approach to Diagnosing Causes of Acute Dizziness Click the link to register: https://www.crowdcast.io/e/20200606/register

Leave us a voicemail at 678-336-8466, ext 128 Write us at emplify@ebmedicine.net

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EMplify May 2020- Mt Sinai COVID-19 Protocols - Dr. Legome Contact us: emplify@ebmedicine.net 1-678-336-8466, ext. 128 Emergency Department COVID Management Protocols: One Institution’s Experience and Lessons Learned

Laboratory Testing and Imaging Disposition/admission Criteria Cardiac Arrest Protocol Medication Treatment Guidelines

Anticoagulation Protocol

Intubation Protocol Nonaerosolized Asthma Protocol Acute Dyspnea/Palliative Care Treatment

Death Management Talking Points

COVID-19 Smart Phrases / Discharge Plan for Likely COVID-19 Patients Guidelines for Prone Positioning of Nonintubated Patients Critical Care for ED COVID-19 Patients

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EMplify April 2020 – Colby Redfield, MD

COVID-19 Topics: 1.Triage Tent Implementation (02:35) 2.Telemedicine – In the tent, in the department, and in follow up. (08:45) 3. PPE (16:30)

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

EMS (22:44)

Crew Safety Criteria for transport Viral filters Handoff to the ED

Helpful Links: 1. Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians https://www.ebmedicine.net/topics/infectious-disease/COVID-19 2. Reusable Facemasks and COVID-19 https://adminem.com/reusable-facemasks-and-covid-19/ 3. University of Florida Halyard H600 masks https://anest.ufl.edu/clinical-divisions/mask-alternative/ https://ufhealth.org/news/2020/uf-health-anesthesiology-team-devises-respirator-mask-made-existing-hospital-materials

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Interview with Joe Habboushe, MD, CEO of MDCalc about new COVID-19 tools and his New York City experience.

MDCalc's new COVID-19 resource center: https://www.mdcalc.com/covid-19 EBMedicine's COVID-19 article with recent updates: https://www.ebmedicine.net/topics/infectious-disease/COVID-19 Time Stamps: 00:00- Discussion of new tools for COVID-19: calculators, risk factors and odds ratios, labs, etc. 40:02- Discussion of the New York City COVID-19 crisis.

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COVID-19 Update 03-18-2020 - An interview with Andrea Duca, MD, Emergency Physician in Bergamo, Italy Time Stamps: 01:29 Dr. Andrea Duca introduction. 02:05 What were your shifts like at the start of the epidemic? 04:50 Were you testing patients for CoOVID-19 initially? 05:08 Were the COVID-19 tests completed in-house or sent out to a government lab? 05:35 The arrival of the first cases. Then… and now. 07:03 What percent of your daily volume is due to COVID-19 patients? 08:17 Are COVID-19 patients diverted to a regional facility? 09:13 Are you still testing patients for COVID-19 today? 09:57 What is your current medication protocol? 10:35 Which antivirals are you currently using? 10:54 Hydroxychloroquine 11:14 Do you use non-invasive ventilation? 13:35 What kind of isolation do you use, airborne or droplet? 14:46 Do you put on new PPE as you go room to room? 15:21 What PPE do you currently use? 15:38 When did you create dirty and clean zones in the emergency department? 16:45 Do you have a dirty and clean side in the waiting room? 17:03 What is your annual emergency department volume? Daily volume? 18:04 How many treatment rooms are in your emergency department? 18:38 What percent of patients are admitted? Do you have borders? 19:54 Where do discharged patients go? 20:14 Have you personally been infected? 20:58 Do you test your staff who are ill? What is your protocol for infected staff? 22:46 What percent of the ED staff were sick at any given time? And inpatient nurses? 24:00 How did you deal with so many inpatient nurses being sick? 24:36 What are your surgeons, who cannot operate, currently doing? 25:35 Are you running out of non-invasive ventilation equipment? 26:20 Summary of current workflow for infected staff. 26:36 How do you use ultrasound for COVID-19 patients in the ED? 29:50 What criteria must a patient meet to be discharged? 31:00 EMS and their role in community screening. 32:20 What are you looking for on ultrasound examination? 34.42 What size chest tube are you utilizing for a pneumothorax in a patient with positive pressure ventilation? 26:33 What inpatient location are patients sent to? By what criteria? 37:05 Have you seen any infected pregnant patients or staff? 38:02 Have you seen any infected children? 38:43 Are you still testing patients? How many times are you testing them? 39:21 What psychological support do you have for staff? 42:25 What would you have liked to know early on, that yo

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In this episode of EMplify, Dr. Sam Ashoo interviews Drs. Al Giwa and Akash Desai, the authors of Emergency Medicine Practice’s recent article: Novel Coronavirus COVID-19: An Overview for Emergency Clinicians.

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

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

00:00 Intro 01:01 Why should we care about Coronavirus? 02:22 What is zoonotic transmission? 03:56 SARS and MERS and previous coronaviruses. 04:38 What are typical Coronavirus symptoms? 04:55 What is R0 (R naught)? 06:46 Why is there so much concern about this Coronavirus strain? 10:05 Is there concern that COVID-19 is more lethal? 12:45 What tools do we have to combat pandemics? Containment 14:38 Treatment and vaccines 16:32 Fecal oral transmission 19:01 Airborne and droplet transmission 21:20 Recommendations for the public 22:00 Recommendations for healthcare workers 23:24 Who should get tested? 24:47 How to get patients tested? 25:51 What do you do with a patient you want to be tested? 30:28 Closing

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Acute Gastroenteritis- Author: Dr. Brian Geyer Introduction:

Do both vomiting and diarrhea have to be present? No

1996 AAP guidelines, 2016 ACG guidelines, and 2017 IDSA guidelines all note diarrhea illness but may be vomiting predominant.

Studies use more vague definitions like:

1 episode of vomiting and/or > 3 episodes of diarrhea in 24 hours without known chronic cause like inflammatory bowel disease. Diarrhea is at least 3 unformed stools per day. Acute episode <14 days Persistent episode 14-29 days Chronic diarrhea >29 days

Patients in the ED may present with only some of these symptoms depending their time in course of illness.

Literature Review:

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

Causes:

70% of US cases are estimated to be caused by viruses, norovirus being most common.

o 26% norovirus o 18% rotavirus

Among bacterial causes:

o 5.3% Salmonella, most common o 5.3% Clostridium o 3% Campylobacter o 3% parasitic infections

Large portion, 51%, have no cause identified. (In ED patients) Interestingly, 79% of cases never have a cause identified (not ED specific) In ED patients, only 25% ever have a cause identified, this increases to 49% when a stool sample is obtained. (not ED specific) Food poisoning is responsible for 5% of AGE but results in 30% of deaths. Most commonly:

Salmonella, Clostridium perfringens, and Campylobacter Majority of foodborne illness is still viral, mostly norovirus

E Coli is normal in the gut, but two most common causes are:

Shiga toxin Ecoli (STEC) AKA enterohemorrhagic Ecoli (EHEC) - causes Hemolytic Uremic Syndrome in 5-10% Entertoxigenic Ecoli (ETEC) - causes traveler's diarrhea Both cause self-limited illness.

Alternate Diagnoses:

Appendicitis: In the peds literature, misdiagnosis of appendicitis as AGE leads to 47% absolute increased risk of perforation. Suggestive findings include:

Migration of pain to RLQ RLQ tenderness on exam (initial or repeat) Absence of diarrhea Pain not improved with episodes of diarrhea Negative factors include multiple ill family members, recent international travel, presence of diarrhea (as defined above).

Ciguatera Fish Poisoning

Toxin produced by algae consumed by reef fish like grouper, red snapper, sea bass and Spanish mackerel. Symptoms begin 6-24 hours post ingestion. Fish tastes normal. Patients may develop neurological symptoms like paresthesias, generalized pruritis, and reversal of hot/cold sensation. Symptoms resolve spontaneously, and treatment with mannitol is controversial.

Scombroid Poisoning

Ingesting fish in the Scombroidae family - mackerel, bonito, albacore, and skipjack - that have been stored improperly Bacteria produce histidine decarboxylase which converts histidine to histamine Causes abdominal cramps and diarrhea, and may cause metallic bitter or peppery taste in mouth, and facial flushing within 20-30 min of ingestion Can be confused with allergic reaction Symptoms resolve in 6-8 hours Notification of health dept may prevent others from being infected.

Page 5 Table 1- Distinguishing Factors in the Differential Diagnosis of AGE

History:

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

Physical Exam:

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

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Show Notes Please take our listener survey at https://forms.gle/spMwHJS795Qnfgww7 Diabetic Hyperglycemic Emergencies: A Systematic Approach, by H. Evan Dingle, MD and Corey Slovis, MD, FACP, FACEP, FAAEM, FAEMS American Diabetes Association (ADA) and International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines are reviewed in addition to the references used by each consensus statement. Also, a primary literature review was conducted with particular attention given to prospective studies. Topics reviewed include:

Etiology and pathophysiology of DKA and HHS Precipitating causes Differential diagnosis Diagnostic studies

ECG Lab Imaging

Treatment

IV fluids Insulin therapy Potassium Sodium bicarbonate Phosphate

Pediatrics

IVF changes Insulin changes Cerebral edema

Airway management Euglycemia DKA Thrombosis and anticoagulation.

Time stamps:

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

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Show Notes Please click here and take our listener survey Emergency Department management of Non-St Segment Elevation Myocardial Infarction, by Drs Julianna Jung and Sharon Bord.

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

Guidelines reviewed include those from:

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

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Please click here and take our listener survey Part 1: Definitions

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

STEMI definition from the European Society of cardiology:

ST elevation >1mm in two or more contiguous leads other than V2-V3 ST elevation in V2-V3

2.5mm in med < 40 yrs old 2 mm in men > 40 yrs old 1.5mm in woman, regardless of age.

MACE= Major Adverse Cardiovascular Event: including re-infarction, stroke, dysrhythmia, heart failure, cardiogenic shock, and death. Part 2 : Why do we care?

In-hospital mortality rates are about the same for STEMI and NSTEMI, about 10%. 1-year fatality rate in NSTEMI is more than double that of STEMI, at about 25%

Part 3: Pathophysiology

Type 1 MI (Infarction) is caused by atherosclerotic plaque rupture. Type 2 MI is the "mismatch" due to an imbalance in myocardial oxygen supply and demand. This can be the result of hypotension, tachycardia, sepsis, PE, etc.

Part 4: Pre-hospital care

Prehospital ECGs decrease time to intervention. (PCI) in STEMI Early administration of aspirin decreases mortality and complications of MI (all types). (19), and is safe in the pre-hospital setting (20) - only 45% of get it during EMS transport, so room for improvement here (21)

Part 5: ED evaluation: Some of the interesting highlights History

Diaphoresis Vomiting Radiation of pain to both arms or shoulders Radiation of pain to right shoulder Although teaching has been that women have atypical presentations, a 2016 study did not support it. However, it did find that elderly patients and those with diabetes may present atypically. (dyspnea, fatigue, nausea, or epigastric pain)

Past Medical History

Family and personal history of CAD Other medical diagnoses Tobacco use Illicit substance abuse Age (CAD prevalence in age<40 is 1%, age >80 is 25%) ** HIV - find citing

Grunfeld C, Delaney JA, Wanke C, et al. Preclinical atherosclerosis due to HIV infection: carotid intima-medial thickness measurements from the FRAM study. AIDS (London, England). 2009;23(14):1841–9. [PMC free article] [PubMed] [Google Scholar]
Holloway CJ, Ntusi N, Suttie J, et al. Comprehensive cardiac magnetic resonance imaging and spectroscopy reveal a high burden of myocardial disease in HIV patients. Circulation. 2013;128(8):814–22. [PubMed] [Google Scholar]

** Cancer with hx of radiation to the chest

Exam

Neurological neurologic deficit may point to aortic dissection Friction rub may be heard New murmur associated with papillary muscle rupture.

Diagnostics

Telemetry ECG. Patterns to know… Troponin... you should get it

Scoring systems

Heart Score Grace TIMI

Imaging in the ED

CXR CT angiography, CT PE, CCTA Echocardiography - POC or formal

Part 6: Medications

Oxygen (if sat <90%) Morphine (no) Nitrates Aspirin Antiplatelet agents

PSY12 inhibitors IIb/IIIa inhibitors

Heparins

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Show Notes Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness. This episode reviews risk factors for apnea and severe bronchiolitis; discusses treatments/therapies and provides evidence-based recommendations for the management of pediatric patients with bronchiolitis. Show More v

Pathophysiology

Bronchiolar narrowing and obstruction is caused by:

Increased mucus secretion Cell death and sloughing Peri-bronchiolar lymphocytic infiltrate Submucosal edema

Smooth muscle constriction seems to have a limited role, perhaps explaining the lack of response to bronchodilators. Median duration of illness is 12 days in children <24 months 18% still ill at 3 weeks.2 9% still ill at 4 weeks.2

Etiology

RSV accounts for 50-80% of cases, but rare in children >2 yo.3

Late fall epidemic peaking Nov-March, in the US.4

Human Metapneumovirus (HMPV) accounts for 3-19% 5,6

Similar seasonal variation to RSV.

Parainfluenza, influenza, adenoviruses, coronaviruses, rhinoviruses, and enteroviruses are other causes.4-6 Rhinoviruses have been shown to play a larger role in Asthma.7

Presentation

The American Academy of Pediatrics defines it as any of the following in infants: 1

Rhinitis Tachypnea Wheezing Cough Crackles Use of accessory muscles Nasal flaring

Differential Diagnosis

Emergent Causes

Infection: pneumonia, chlamydia, pertussis Foreign body: aspirated or esophageal Cardiac anomaly: congestive heart failure, vascular ring Allergic reaction Bronchopulmonary dysplasia exacerbation

Non-acute Causes

Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia Gastroesophageal reflux disease Mediastinal mass Cystic fibrosis

Clinical Pearls

Vomiting, wheezing, and coughing associated with feeding; consider GERD. Wheezing associated with position changes; consider tracheomalacia or great vessel anomalies. Wheezing exacerbated by flexion of neck and relieved by neck hyperextension; consider vascular ring. Multiple respiratory tract infections and failure to thrive; consider cystic fibrosis or immunodeficiency. Wheezing with heart murmur, cardiomegaly, cyanosis, exertion or sweating with feeding; consider cardiac disease. Sudden onset of wheezing and choking; consider foreign body.

Risk Factors for Severe Bronchiolitis

Age < 6-12 weeks11-13 Prematurity < 35-37 weeks’ gestation11-13 Underlying respiratory illness such as bronchopulmonary dysplasia1 Significant congenital heart disease; immune deficiency including HIV, organ or bone marrow transplants, or congenital immune deficiencies14,15 Altered mental status (impending respiratory failure) Dehydration due to inability to tolerate oral fluids Ill appearance12 Oxygen saturation level ≤ 90%1 Respiratory rate: > 70 breaths/min or higher than normal rate for patient age1,12 Increased work of breathing: moderate to severe retractions and/or accessory muscle use1 Nasal flaring Grunting

Risk Factors for Apnea

Full-term birth and < 1 month of age16,17 Preterm birth (< 37 weeks’ gestation) and age < 2 months post birth11-13,17 History of apnea of prematurity Emergency department presentation with apnea17 Apnea witnessed by a caregiver17

Diagnostic Testing

Xray

Radiographs increase the likely hood of a physician giving antibiotics, even if the X-ray is negative.18-20 Routine radiography is discouraged, but may be helpful when severe disease requires further evaluation or exclusion of foreign body.

Viral testing is not necessary for the diagnosis but may help when searching for the cause of fever in young infants.

2016 ACEP fever guidelines note that positive viral testing can impact further workup ...

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Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. Nachi: For our regular listeners, you probably noticed a lapse in recent episodes as we pulled away from our usual monthly releases. Jeff: With both of us having increasing demands on our time -- myself with business school and the busiest 21 month old in the world and Nachi with yet another entrepreneurial endeavor on the horizon -- we decided that it would be best to pass the podcast on to another host, so EMplify can continue to create and deliver the high quality materials that you deserve. Nachi: We have obviously really enjoyed creating this podcast and working closely with EB Medicine to produce it. We are deeply appreciative of you, our listeners, and your wonderful feedback and comments over the years. Without you, there would be no point in us working so hard on this. Jeff: And keep the feedback coming as we hand the reins to Dr. Sam Ashoo as the new host of EMplify. Dr. Ashoo is an Emergency Physician based out of Tallahassee Florida with a keen interest in informatics who has been featured on several other podcasts you may have heard. We can’t think of a better person to take over for EMplify. I’m sure you’ll really like him and the content he produces. Well, with that, let’s get started on our final scheduled episode of EMplify! Nachi: As we are just about to see one of the busiest travel days of the year, that would be the Wednesday before Thanksgiving, we thought there would be no better time to discuss the September 2019 issue of EMP: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls. Jeff: This was a fantastic issue, thanks to the hard work by Drs. DeLaney and Greene, both of the University of Alabama Birmingham School of Medicine. Thanks as well to the peer editors, Dr. Knight, and Dr. Hill of the University of Cincinnati. Nachi: And I think you have a bit of a disclosure for this month... Show More v

Jeff: Well, this is a first! Finally at the point in my career where I can announce a disclosure, though it’s more of a potential conflict of interest than an actual disclosure, but certainly still worth noting. I currently spend some of my time working for STAT-MD - which is an airline consultation service run by the Center for Emergency Medicine and UPMC. Though I’m certainly a junior member of the team, in some sense, I’ve responded nearly 500 inflight emergencies over the last two years. Nachi: And this definitely places you are in a particularly nice position to share some information with our listeners this month, and I’ll have some questions scattered throughout the episode for you too. Jeff: Sounds great, so let’s dive in, starting with what I think is the most important point - qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal concerns. Nachi: I couldn’t agree more, so let me reiterate, please trust the evidence. And volunteer to help should you hear the call. We’ll get to this in a bit but there is little medicolegal concern and you owe it to the sick passenger to help. Jeff: So what are the chances you are called - well, they are not particularly high, but certainly not negligible either. In 2019, of the 4 billion passengers expected to fly, there will be an estimated 60,000 medical emergencies. That means there will be about 1 emergency per every 604 flights. Nachi: So, I fly about 4 times a month for work. At 4 times per month, over the next 12 years I can expect about one medical emergency. Already excited! Let’s start with some physiology. Cabin pressurization varies, but is typically equivalent to an altitude of 8000 feet. Jeff: And this has a huge effect, in one study of healthy volunteers, this change in pressure resulted in a 4-10 point decrease in oxygen saturation and a 35 point d...

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Show Notes Dr. Susan Kirelik, a concussion specialist and emergency medicine physician, discusses the key points of concussion diagnosis and management from the perspective of the emergency medicine clinician. The topics covered include:

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

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

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

References McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838- 847. (Consensus statement) Meeuwisse WH, Schneider KJ, Dvorak J, et al. The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport. Br J Sports Med. 2017;51(11):873-876. (Conference summary) Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort study; 42,412 patients) Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. (Prospective cohort study; 3121 patients) Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42(10):2479-2486. (Cross-sectional study; 64 patients) Links to tools and publications mentioned in the podcast: PECARN Pediatric Head Trauma: Official Visual Decision Aid for Clinicians Vestibular/Ocular-Motor Screening (VOMS) for Concussion SCAT5 tool Child SCAT5 tool REAP concussion management (NOTE: this is the new URL for “center4concussion.com,” which is mentioned in the podcast) Tip sheets for educators, parents, and healthcare providers on managing concussion recovery in the classroom

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Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs. Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico. Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology. Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants. Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality. Show More v

Jeff: Fair enough, we’ll take what we can get. Nachi: Well, I’m sure more of those studies are still coming. Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin. Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising. Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism. Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile. Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins. Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S. Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many. Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition. Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis. Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation. Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours,

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Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing. Jeff: Thankfully, this month’s author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month’s evidence-based article. Nachi: And don’t forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let’s dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30. Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go… Show More v

Nachi: Nah! Just some definitions, nothing personal! Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits! Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery. Jeff: Well that’s kind worrisome. Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!! Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled! Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs. Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group. Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures.

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Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v

Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst,

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Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department. Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression? Nachi: That would certainly be all of our listeners! Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval? Show More v

Nachi: Again, just about all of our listeners I’m sure! Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes? Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in. Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University. Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside. Jeff: Quite the team, from a variety of backgrounds. Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt. Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23% Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode. Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable. Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions. Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest. Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks. Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning. Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes. Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD. Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder....

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Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections.

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Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management. Nachi: With no gold standard diagnostic test and with complications ranging from simple ectopic beats to fulminant cardiac failure and death, this isn’t an episode you’ll want to miss. Jeff: Before we begin, let me give a quick shout out to our incredible group of authors from New York -- Dr. Eric Morley, Dr. Bryan English, and Dr. David Cohen of Stony Brook Medicine and Dr. William Paolo, residency program director at SUNY Upstate. I should also mention their peer reviewers Drs. Jennifer Maccagnano and Ashley Norse of the NY institute of technology college of osteopathic medicine and UF Health Jacksonville, respectively. Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST. Jeff: Clearly a large undertaking for a difficult topic to come up with solid evidence based recommendations. Nachi: For sure. Let’s begin with some epidemiology, which is admittedly quite difficult without universally accepted diagnostic criteria. Jeff: As you likely know, despite advances in motor vehicle safety, trauma remains a leading cause of death for young adults. In the US alone, each year, there are about 900,000 cases of cardiac injury secondary to trauma. Most of these occur in the setting of vehicular trauma.

Nachi: And keep in mind, that those injuries don’t occur in isolation as 70-80% of patients with blunt cardiac injury sustain other injuries. This idea of concomitant trauma will be a major theme in today’s episode. Jeff: It certainly will. But before we get there, we have some more definitions to review - cardiac concussion and contusion, both of which were defined in a 1989 study. In this study, cardiac concussion was defined as an elevated CKMB with a normal echo, while a cardiac contusion was defined as an elevated CKMB and abnormal echo. Nachi: Much to my surprise, though, abnormal echo and elevated ck-mb have not been shown to be predictive of adverse outcomes, but conduction abnormalities on ekgs have been predictive of development of serious dysrhythmia Jeff: More on complications in a bit, but first, returning to the idea of concomitant injuries, in one autopsy study of nearly 1600 patients with blunt trauma - cardiac injuries were reported in 11.9% of cases and contributed to the death of 45.2% of those patients. Nachi: Looking more broadly at the data, according to one retrospective review, blunt cardiac injury may carry a mortality of up to 44%. Jeff: That’s scary high, though I guess not terribly surprising, given that we are discussing heart injuries due to major trauma... Nachi: The force may be direct or indirect, involve rapid deceleration, be bidirectional, compressive, concussive, or even involve a combination of these. In general, the right ventricle is the most frequently injured area due to the proximity to the chest wall. Jeff: Perfect, so that's enough background, let’s talk differential. As you likely expected, the differential is broad and includes cardiovascular injuries, pulmonary injuries, and other mediastinal injuries like pneumomediastinum and esophageal injuries. Nachi: Among the most devastating injuries on the differential is cardiac wall rupture, which not surprisingly has an extremely high mortality rate. In terms of location of rupture, both ventricles are far more likely to rupture than the atria with the right atria being more likely to rupture than the left atria. Atrial ruptures are more survivable, whereas complete free wall rupture is nearly universally fatal. Jeff: Septal injuries are also on the ddx. Septal injuries occur immediately,

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Shownotes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re tackling an incredibly important topic - evaluation and management of life threatening headaches in the Emergency Department. Nachi: Fear not, this will not simply be “who needs a head CT episode”; we’ll cover much more than that. Listen closely as this is an important topic, with huge consequences for mismanagement. Jeff: Absolutely. As some quick background - headaches account for 3% of all ED visits in the US, with 90% being benign primary headaches and less than 10% being secondary to other causes like vascular, infectious, or traumatic etiologies. It’s within these later 10% that we are looking for the red flag signs to identify the potentially life-threatening headaches. Nachi: And to do so, Dr. David Zodda and Dr. Amit Gupta, PD and APD at Hackensack University Medical and Trauma Center, and their colleague Dr. Gabrielle Procopio, a PharmD, have done a fantastic job parsing through the literature, which included over 500 abstracts, 89 full text articles, guidelines from ACEP and the American Academy of Neurology, as well as canadian and european neurology guidelines, to summarize the best evidence based recommendations for you all. Jeff: We would be remiss to not also mention Dr. Mert Erogul of Maimonides Medical Center and Dr. Steven Godwin, Chair of Emergency Medicine at the University of Florida College of Medicine. Nachi: Alright, so let’s get started with some definitions and pathophysiology. The international classification of headache disorders 3, or ICHD-3, classifies headaches into primary, secondary, and cranial neuropathies. Jeff: Primary headache disorders include migraine, tension, and cluster headaches. Secondary headaches include those secondary to vascular disorders, traumatic disorders, and disorders in hemostasis. These are the potentially life threatening headaches that can have a mortality has high as 50%. Nachi: And the final category includes cranial neuropathies, such as trigeminal neuralgia. Jeff: And I think we can safely say that that wraps up our discussion in this episode on cranial neuropathies, moving on…. Nachi: Headaches result from traction to or irritation of the meninges and blood vessels, which are the only innervated central nervous system structures. Activation of specific nerve ganglion complexes by neuropeptides like -- substance P and calcitonin gene-related peptide -- are thought to contribute to head pain. Jeff: It is important to note that all headache pain shares common pain pathways, thus response to pain medications does not exclude potential life threatening secondary causes of headache. This led to the ACEP guideline which states just that.. Nachi: I feel like that deserves ding sound as it's a critically important point. To repeat, just because a pain medication relieves a headache, that does not exclude dangerous secondary causes! Jeff: And what are the life threatening headaches? Life-threatening headaches include subarachnoid hemorrhage, cervical Artery Dissection, which includes both vertebral Artery Dissection and carotid artery dissection, cerebral Venous Thrombosis, idiopathic intracranial hypertension, giant cell arteritis, and posterior reversible encephalopathy syndrome, or PRES. Nachi: Slow down for a second and let’s not skip over your favorite section.. Let’s talk pre hospital care for headache patients. Jeff: Good call! Pre-hospital care is fairly straightforward and includes a primary survey, conducting a focused neurologic exam, and assessing for red flag signs, which include focal neurologic deficits, sudden onset headache, new headache in those over 50, neck pain or stiffness, changes in visual Acuity, fever or immunocompromised State, history of malignancy, pregnancy or postpartum status, syncope, and seizure. That’s quite a list.

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

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

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

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

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

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

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

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

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

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

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

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

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

Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jeff: I think that’s enough epidemiology for now. Let’s get started with the basics of the influenza virus. Influenza is spread primarily through direct person-to-person contact via expelled respiratory secretions.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. We have a special episode for you this month… We’ve brought Dr. Jeremy Rose, one of the peer reviewers, and a sepsis expert, on with us to talk through the content this month. Jeremy: Dr. Jeremy Rose here. Thanks for having me in on this conversation. I’m always happy to talk about this topic because it’s clearly important. There’s a great deal of confusion around sepsis and I hope that in the next couple minutes we can clarify things in a way that really help your average front line doc trying to get it right. Nachi: So Dr. Rose, before we get started, tell us a bit about your background and your interest in sepsis… Jeremy: I’m the Assistant Medical Director and Sepsis Chair at Mount Sinai Beth Israel in Manhattan. For those listening, my hospital probably looks a little bit like yours. We’re busy, interesting, and just a little rough around the edges. We like it that way. More importantly, though, we mirror the national averages regarding sepsis. Roughly half of in-hospital mortality is associated with septic in some fashion. Pretty incredible when you think about it. Half. Jeff: Sepsis chair... clearly this is an important topic if it warrants it’s own chair at a major hospital in NYC. But getting back to the article this month. This month’s issue was authored by Faheem Guirgis, Laurent Page Black, and Elizabeth DeVos of the University of Florida, Department of Emergency Medicine. Nachi: And it was peer reviewed by Michael Allison, Assistant Director of the Adult ICU at Saint Agnes Hospital, and Jeremy Rose and Eric Steinberg of Mount Sinai Beth Israel. Jeff: So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis? It seems that every month or so we have a new guideline, bundle, definition, or whatever… I think it’s best to start with the basics - At its core, sepsis is a dysregulated response to infection that can be life-threatening. Nachi: Right and it’s the combined inflammatory with immunosuppressive features of sepsis that lead to the devastating organ dysfunction and even death. Optimal management of septic patients has been a source of intense research, stemming from the landmark study by Rivers in 2001. Jeremy, can you give us a little historical context there? Jeremy: Rivers was a real pioneer. He found a 16% mortality reduction with randomization to an early aggressive care bundle. Amazing work. That being said, many components of that bundle have since been disregarded. For example, Manny Rivers would measure CVP in all of his patients, something we rarely do. Nachi: Not to cut you off and steal your thunder there, but we’ll get to the most recent updates in management shortly. Let’s first talk definitions and terminology, and specifically, diagnosis, which is definitely a big elephant in the room. As Jeff mentioned a few minutes ago, diagnostic criteria have undergone so so so many changes. Jeff: Yes it has! 1991 marked the first standardized definition. Then in 2001, sepsis-2 was introduced. In 2014, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine started a task force, and by 2016, updated definitions were out again! Sepsis-3!! A lot of this came after the realization that SIRS was just too broad and was overly sensitive and non-specific. Jeremy, why don’t you take us through Sepsis 3. Jeremy: So just to back up a little and frame this: Here’s the fundamental problem: As we likes to say, “there’s no troponin for sepsis.” And if you look at our patients, we tend not to miss the hypotensive, tachycardic, febrile patient. We know they’re septic.

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Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the September 2018 issue of Emergency Medicine Practice - Emergency Department Management of North American Snake envenomations. Nachi: Although this isn’t something we encountered too frequently – it does seem like I’ve been hearing more about snake bites in the recent months. Jeff: I actually flew someone just the other day because the local ED ran out of CroFab after an envenomation in Western PA. Nachi: Yeah, this is definitely more than “just a boards topic,” and it’s really important to know about in those rare circumstances. In terms of incidence, there are actually about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species.

Jeff: That’s a good teaser, so let’s start by recognizing this month’s team – the two authors, Dr. Sheikh, a medical toxicologist, and Patrick Leffers, a pharmD, and emergency medicine and clinical toxicology fellow. Both are at the University of Florida Jacksonville, and they reviewed a total of 120 articles from 2006-2017, in addition to reviews from both Cochrane and Dare.

Nachi: And don’t forget our peer reviewers this month, Dr. Daniel Sessions, a medical toxicologist working at the South Texas Poison Center, and our very own editor-in-chief, Dr. Andy Jagoda, who is also Chair of the Department of Emergency Medicine at Mount Sinai in New York City.

Jeff: What a team! But, let’s get back to the snakes. As some background, from 2006-2015 there were almost 66,000 reported snake exposures and 31 deaths from snake envenomation in the US. Of course, this number likely underestimates the true total.

Nachi: And there are two key subfamilies of venomous snakes to be aware of – the Crotalinae – or pit vipers – which includes rattlesnakes, copperheads, and water moccasins; and the Elapidae – of which you really only need to know about the coral snake.

Jeff: And while those are the only two NATIVE snake subfamilies to be acutely aware of, don’t forget that exotic snakes, which are shockingly popular pets -- they can also cause significant morbidity and mortality.

Nachi: Oh, and one other quick note before we get into the epidemiology – most of the recommendations this month come from expert opinion, as high quality RCTs are obviously difficult. In addition, many of the studies were based in other countries, where the snakes, the anti-venoms and their availability, and the general healthcare systems are different from those that most of us work in.

Jeff: Unless we have listeners abroad? Do we have listeners in other countries?

Nachi: Oh we definitely do... but we are going to be a bit biased towards US envenomation today. In any case, venomous snake bites occur most frequently in men aged 18 to 49 during warmer months with provoked bites occurring more frequently in the upper extremities and unprovoked bites in the lower extremities.

Jeff: In one study of poison center data from the last decade, nearly half of all victims of snake bites were victims of unknown type snakes. However, of those that were known, copperheads were the most common, while rattlesnakes caused the most fatalities – 19 of 31 in this dataset.

Nachi: In a separate study of snake bites in the early 2000s, 32% of exposures were from venomous snakes and 59% of those resulted in admission. That’s remarkably high.

Jeff: Snake bite severity depends on several key factors: the amount of venom, the composition of the venom, the body size of the bite victim, the victim's clothing, the size of the bite, comorbid conditions, and the timing and quality of medical care the victim receives.

Nachi: To be a bit more specific - First, the amount of venom will depend on the species of snake, with variations even occurring within the same species. Secondly,

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Show Notes Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice. Nachi: This month’s topic is one that Jeff has significant personal experience with from his college days. We’re reviewing Cannabinoids -- and emerging evidence in their use and abuse. Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes? Nachi: Sometimes… Jeff: This month’s issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. Nachi: We’re going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready. Jeff: As you’re listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you’re not driving while listening, be sure to jot down these answers and get your CME credit when we’re going through this issue.. Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available. Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure. Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance. Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses. Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising. Jeff: Let’s get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described. Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found...

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Join Jeff, a former firefighter, and Nachi, a former mathematician, as they take you through the July 2018 issue of Emergency Medicine Practice: Emergency department management of dyspnea in the dying patient Most Important References 17. Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest. 1986;89(2):234-236. (Prospective; 1754 patients)34. Lunney JR, Lynn J, Foley DJ, et al. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387-2392. (Prospective cohort; 4190 patients)40. Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476-2482. (Cross-sectional survey; 1122 patients/families/providers)41. Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want “everything.” Ann Intern Med. 2009;151(5):345-349. (Review)63. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer. 2009;17(4):367-377. (Nonrandomized trial; 46 patients)66. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. 2010;376(9743):784-793. (Double-blind randomized controlled trial; 239 patients)68. Galbraith S, Fagan P, Perkins P, et al. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage. 2010;39(5):831-838. (Randomized controlled crossover trial; 50 patients)

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Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the June 2018 issue of Emergency Medicine Practice: Managing Shoulder Injuries in the Emergency Department Fracture, Dislocation, and Overuse.

This month, Richard Pescatore, director of clinical research at Crozer-Keystone Health System and clinical assistant professor at the Rowan University School of Osteopathic Medicine, along with Andrew Nyce, vice chairman and associate professor at cooper medical school of Rowan University reviewed just over 100 articles to come up with their evidence-based recommendations.

Their recommendations were then edited by John Munyak of Maimonides and Mark Silverberg of SUNY Downstate and Kings County Hospital.

Most Important References

Ponce BA, Kundukulam JA, Pflugner R, et al. Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg. 2013;22(7):993-999. (Prospective cohort; 49 patients)
Slaven EJ, Mathers J. Differential diagnosis of shoulder and cervical pain: a case report. J Man Manip Ther. 2010;18(4):191-196. (Case report)
Helfen T, Ockert B, Pozder P, et al. Management of prehospital shoulder dislocation: feasibility and need of reduction. Eur J Trauma Emerg Surg. 2016;42(3):357-362. (Retrospective review; 70 patients)
Lenza M, Belloti JC, Andriolo RB, et al. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. 2014(5):CD007121. (Systematic review; 3 trials, 354 patients)
Neer CS, 2nd. Displaced proximal humeral fractures: part I. Classification and evaluation. 1970. Clin Orthop Relat Res. 2006;442:77-82. (Review article)
Sholsberg J, Jackson R. Best evidence topic report. Intra-articular corticosteroid injections in acute rheumatoid monoarthritides. Emerg Med J. 2004;21(2):204. (Systematic review; 1 study, 137 patients)

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Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the May 2018 issue of Emergency Medicine Practice: Recognizing and Managing Emerging Infectious Diseases in the Emergency Department. This month’s issue was authored by Drs. Millan, Thomas-Paulose, and Egan from Mount Sinai St Luke’s and Mount Sinai West in New York city.

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Jaundice is a manifestation of elevated serum bilirubin, and can have many causes, some of which can be life-threatening. Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the April 2018 issue of Emergency Medicine Practice: Jaundice in the Emergency Department: Meeting the Challenges of Diagnosis and Treatment. This month’s issue was authored by Dr. Taylor and Dr. Wheatley both of the Emory School of Medicine. It was peer reviewed by Dr. Chung of the Icahn School of Medicine at Mount Sinai, and Dr. Horan of Our Lady of Lourdes Medical Center.

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When treating patients who have suffered injury in a fire, managing their airway is as critical as treating their burns. Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the March 2018 issue of Emergency Medicine Practice: Emergency Department Management of Smoke Inhalation Injuries in Adults. This month’s issue was authored by Dr. Otterness and Dr. Ahn of the Stony Brook School of Medicine. It was also reviewed by a toxicology duo of Dr. Manini of The Icahn School of Medicine at Mount Sinai and Dr. Nelson of Rutgers New Jersey Medical School.

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Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. We’ll be taking you through the February 2018 issue of Emergency Medicine Practice: Emergency Department Management of Patients with Thermal Burns.

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As the prevalence of cancer continues to increase in the general population and improvements in cancer treatment prolong survival, the incidence of patients presenting to the emergency department with oncologic complications will, similarly, continue to rise. This episode reviews 3 of the more common presentations of oncology patients to the emergency department: metastatic spinal cord compression, tumor lysis syndrome, and febrile neutropenia. Signs and symptoms of these conditions can be varied and nonspecific, and may be related to the malignancy itself or to an adverse effect of the cancer treatment. Timely evidence-based decisions in the emergency department regarding diagnostic testing, medications, and arrangement of disposition and oncology follow-up can significantly improve a cancer patient's quality of life. This episode of EB Medicine's EMplify podcast is hosted by Nachi Gupta, MD, PhD, and Jeff Nusbaum, MD. This month's corresponding full-length journal issue of Emergency Medicine Practice was authored by David Wacker, MD, and Michael McCurdy, MD. It was peer reviewed by Kevin Chase, MD, and Natalie Kreitzer, MD. Link to article: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=564

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Lower-extremity dislocations are less common in the emergency department (ED) than shoulder and elbow dislocations, and emergency clinicians’ experience with evaluation and reduction techniques is often limited. Nonetheless, these dislocations can be serious because of their association with vascular injury. This episode discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle. This episode of EB Medicine's EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month's corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Caylyne Arnold, Dr. Zane Fayos, Dr. David Bruner, and Dr. Dylan Arnold. It was peer reviewed by Dr. Melissa Leber and Dr. Christopher Tainter. Link to article: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559

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Because of the chronic relapsing nature of inflammatory bowel disease (IBD), emergency clinicians frequently manage patients with acute flares and complications. IBD patients present with an often-broad range of nonspecific signs and symptoms, and it is essential to differentiate a mild flare from a life-threatening intra-abdominal process. Recognizing extraintestinal manifestations and the presence of infection are critical. This episode reviews the literature on management of IBD flares in the emergency department, including laboratory testing, imaging, and identification of surgical emergencies, emphasizing the importance of coordination of care with specialists on treatment plans and offering patients resources for ongoing support This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Michael Burg and Dr. Steven Riccoboni. It was peer reviewed by Dr. Andrew Lee and Dr. Chad Roline. Links and Resouces: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559 - Management of Inflammatory Bowel Disease Flares in the Emergency

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COPD has huge economic and human burdens in the US. In fact, in 2010, two studies estimated that COPD exacted a direct and indirect cost of somewhere between $36 and $50 billion dollars in the US. With respect to the ED – in 2011, there were more than 1.7 million ED visits for COPD-related problems, with nearly 1/5th requiring hospitalization. This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by a strong team from the University of Maryland: Drs. Van Holden, Donald Slack, Michael McCurdy, and Nirav Shah. It was peer reviewed by Dr. Gabriel Wardi of the University of California San Diego and Dr. Geralda Xavier of Kings County Hospital in New York City. Links and Resouces: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=557 - Diagnosis and Management of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

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Primary and secondary adrenal insufficiency are underrecognized conditions among emergency department patients, affecting an estimated 10% to 20% of critically ill patients. The signs and symptoms of cortisol deficit can be nonspecific and wide-ranging, and identification and swift treatment with stress-dosing of hydrocortisone is vital to avoid life-threatening adrenal crisis. This episode offers a review of the literature regarding adrenal disorders, from diagnosis to management to disposition.

This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Drs. Cutright, Ducey, and Barthold of the University of Nebraska Medical Center, and it was edited by Dr. Knight of the University of Cincinnati and Dr. Zammit of the University of Rochester. Thank you, team, for your efforts putting this together.

Links and resources: EB Medicine - www.ebmedicine.net Recognizing and Managing Adrenal Disorders in the Emergency Department - http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=550

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For trauma patients in the ED, life- and limb-threatening injuries take priority, but renal and genitourinary injury can have long-term consequences for patients, including chronic kidney disease, erectile dysfunction, incontinence, and other serious problems. This episode offers a review of the literature regarding treatment of renal and GU injuries, from diagnosis to management to disposition.

This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Drs. Bryant and Shewakramani of the University of Cincinnati College of medicine and it was edited by Dr. Bryce of Vanderbilt University Medical Center and Dr. Shaukat of Coney Island Hospital. Thank you, team, for your efforts putting this together.

Links and resources: EB Medicine - www.ebmedicine.net Emergency Management of Renal and Genitourinary Trauma: Best Practices Update - http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=547

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Though a minority of patients presenting to the emergency department with chest pain have acute coronary syndromes, identifying the patients who may be safely discharged and determining whether further testing is needed remains challenging. This topic is of massive importance to emergency physicians and there is a wealth of literature exploring it. Every year, in the US, there are roughly 8 million ED visits for chest pain, and of those, only 13-25% lead to the diagnosis of acute coronary syndromes or ACS.

This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Dr. David Markel, of Tacoma Emergency Care Physicians and was reviewed by Dr. Keith Marill from Mass General and Dr. Andrew Schmidt of the University of Florida College of Medicine.

Links and resources: EB Medicine - www.ebmedicine.net Identifying Emergency Department Patients With Chest Pain who are at Low Risk for Acute Coronary Syndromes - https://tinyurl.com/y848wacl MDCalc - www.mdcalc.com

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This month's episode of EMplify, a podcast corollary to the Emergency Medicine Practice journal, focuses on management strategies that improve dental emergency outcomes. Hosts Jeff Nusbaum, MD, and Nachi Gupta, MD, cover all aspects of the diagnosis and management of this condition, from initial diagnosis and treatment in the emergency department to controversies and cutting-edge strategies. This podcast is based on the full-length review published in the June 2017 issue of Emergency Medicine Practice. In it, author Ryan Pedigo, MD, Director of Undergraduate Medical Education at Harbor-UCLA Medical Center and Assistant Professor of Emergency Medicine at the David Geffen School of Medicine, cover evidence published in more than 700 articles and reviewed recommendations from the International Association for Dental Traumatology and the Cochrane Database.

Topics covered in this episode of EMplify include: Case Presentations Dental Anatomy Pathophysiology Traumatic Dental Emergencies Concussion Subluxation Luxation Avulsion Fracture Ellis classification system Atraumatic dental emergencies Dental Infections Dental Disease Prehospital Care Imaging Nerve blocks Antibiotics Management of tooth trauma Treatment for dental fractures Summary of key points

Links and resources: Tables referenced in this podcast episode - http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=543&seg_id=9020 Dental Emergencies: Management Strategies That Improve Outcomes - https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=532 Clinical Decision Making in Emergency Medicine - http://www.clinicaldecisionmaking.com/

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This month's episode of EMplify, the podcast corollary to the Emergency Medicine Practice journal, focuses on acute decompensated heart failure. Hosts Jeff Nusbaum, MD, and Nachi Gupta, MD, cover all aspects of the acute management of this condition, from initial diagnosis and treatment in the emergency department to novel biomarkers and new and controversial therapies.

The podcast is based on the full-length review published in the May 2017 issue of Emergency Medicine Practice. In it, co-authors Emily Singer Fisher, MD, and Boyd Burns, DO, FACEP, FAAEM, both of the University of Oklahoma School of Community Medicine, cover evidence published in 190 articles, and 10 reviews from the Cochrane database, as well as current guidelines issued by the American Heart Association and the American College of Cardiology Foundation.

Topics covered in this episode of EMplify include

Basics of acute decompensated heart failure Key differences in the pathophysiology of heart failure with reduced ejection fraction and heart failure with preserved ejection fraction Prehospital Care Initial ED Evaluation of acute decompensated heart failure Narrowing down the differential Physical exam best practices Diagnostic Studies Pulmonary ultrasound Cardiac ultrasound Treatment Lab markers Management of acute decompensated heart failure Role of early revascularization New and novel therapies Disposition Summary of the key points

Links and resources: Tables referenced in this podcast episode - https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=541&seg_id=8977 Noninvasive Ventilation For Patients In Acute Respiratory Distress: An Update - https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=532 Clinical Decision Making in Emergency Medicine - http://www.clinicaldecisionmaking.com/

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Welcome back to another episode of EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. This month, we’ll be talking “Maxillofacial Trauma in the Emergency Department.”

This episode’s content was curated by Drs. Devjani Das, MD, RDMS, FACEP, and Lea Salazar, MD. Both of Hofstra Northwell School of Medicine, Northwell Health-Staten Island University Hospital, Staten Island, NY. Don’t miss it!

Topics: Overview on Maxillofacial Trauma Epidemiology of Maxillofacial Trauma Fracture Types: Nasal bone fractures Mandibular fractures Orbital fractures Zygomatic fractures Maxillary fractures or Le Fort fractures Le Fort 1 fractures or horizontal fractures Le fort 2 fractures or pyramidal fractures Le Fort 3 fractures or transverse fractures Frontal bone fractures Prehospital Care Initial ED Evaluation and Management 10 Steps of the Physical Exam Diagnostic Testing, Treatment, and Disposition Imaging Specific to Each Injury Management of Each Injury Special Populations Controversies and Cutting-Edge A Disposition Quick Rundown of the Key Take-Home Points

Links and Resources:

Maxillofacial Trauma: Managing Potentially Dangerous and Disfiguring Complex Injuries - https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=538 Hofstra Northwell School of Medicine - http://medicine.hofstra.edu/ Northwell Health-Staten Island University - https://www.northwell.edu/find-care/locations/staten-island-university-hospital Clinical Decision Making in Emergency Medicine - http://www.clinicaldecisionmaking.com/ EMplify Twitter Account - @ebmedicine Email: emplify@ebmedicine.net

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Welcome back to another episode of EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. This month, we’ll be talking about sedative-hypnotics. Specifically, we’ll be talking about sedative-hypnotic drug withdrawal syndromes, both the recognition of such syndromes and their appropriate treatment.

This episode’s content was curated by Cynthia Santos, MD, of Emory University Hospital and Ruben Olmedo, MD, who is director of the division of toxicology at Mount Sinai Hospital. Don’t miss it!

Topics: Why EB Medicine chose this topic Pathophysiology of sedative-hypnotic drug withdrawal syndromes Specific sedative hypnotic classes Toxicologic syndromes’ differential subcategories Prehospital care Initial ED management Emergency department diagnostic studies Treatment Different classes of medications Controversies Quick rundown of the key take-home points Bonus: Interview with Dr. Cynthia Santos

Links and Resources:

Sedative-Hypnotic Drug Withdrawal Syndrome: Recognition And Treatment - http://bit.ly/2mp4mAR Alcohol Withdrawal Syndrome: Improving Outcomes Through Early Identification And Aggressive Treatment Strategies (Critical Care Issue) - http://bit.ly/2mWN8hp Current Guidelines For The Management Of Acute Alcohol Withdrawal In The Emergency Department - http://bit.ly/2nkBM7H Emory University Hospital - https://www.emoryhealthcare.org/locations/hospitals/emory-university-hospital/ Mount Sinai Hospital - http://www.mountsinai.org/locations/mount-sinai Twitter Account - @ebmedicine 16th Annual Clinical Decision Making in Emergency Medicine - http://clinicaldecisionmaking.com/ Email: emplify@ebmedicine.net

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Welcome to the inaugural episode of EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice journal. For the first episode, we are going to focus on one of the most popular articles from last year, the October 2016 issue, entitled “Optimizing Survival Outcomes For Adult Patients With Nontraumatic Cardiac Arrest.”

We have one huge disclosure about this episode, as we will have for them all. The content was not originally created by us. This issue was authored by Dr. Julianna Jung, MD, FACEP at Johns Hopkins University. Here’s what we will cover:

Topics: Facts about cardiac arrest A quick review of the latest iteration of the AHA guidelines The pathophysiology The differential The common underlying causes Prehospital care Diagnostic imaging Chest compressions and shock Ventilation Medications Post-arrest cooling Tools used to prognosticate When to stop resuscitating Special circumstances Recent controversies and cutting-edge advances

Links and Resources: Link to the post - http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=521 The New England Journal of Medicine - http://www.nejm.org/ Johns Hopkins University - https://www.jhu.edu/ AHA - http://www.heart.org/HEARTORG/ Email: emplify@ebmedicine.net

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Brought to you by EB Medicine, this new emergency medicine podcast will refresh your knowledge on each monthly topic from Emergency Medicine Practice while you're on the go.

EMplify by EB Medicine: Recent Episodes

Sam Ashoo, MD