Core EM Podcast

This week we dissect a JAMA article on the whether it's necessary to add TMP-SMX to cephalexin in the treatment of uncomplicated cellulitis https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_105_0_Final_Cut.m4a Download Leave a Comment Tags: Cellulitis, IDSA, Infectious Diseases, MRSA Show Notes [caption id="attachment_5536" align="aligncenter" width="857"] SSTI Flow Diagram (Stevens 2014)[/caption]

EM Lit of Note: Double Coverage, Cellulitis Edition

Pharm ER Tox Guy: Uncomplicated Cellulitis? Consider Strep-Only Coverage

Core EM: Cellulitis

Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis 2014; 59(2): e10-52. PMID: 24973422

This week we dive into the various common agents used in procedural sedation and analgesia in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_104_0_Final_Cut.m4a Download 2 Comments Tags: Anesthesia, Critical Care, Procedural Sedation, PSA Show Notes

Show Notes

Core EM : Parenteral Benzodiazepines

Core EM: Procedural Sedation and Analgesia Resources

EM Updates: Ketamine Brain Continuum

First 10 EM: Managing laryngospasm in the emergency department

This week we talk about priapism focusing on emergency department management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_103_0_Final_Cut.m4a Download One Comment Tags: GU, Priapism, Urology Show Notes

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Dr. Mutara Jubara: Ultrasound Guided Dorsal Penile Nerve Block

McCollough M, Sharieff GQ: Genitourinary and Renal Tract Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 174: p 2205-2223.

Davis JE, Silverman MA. Urologic Procedures; in Roberts JR: Roberts and Hedges’ Clinical Procedures in Emergency Medicine, ed 6. 2014, (Ch) 55: p 1113-1154

Govier FE et al. Oral terbutaline for the treatment of priapism. J Urol 1994;151: 878-9. PMID: 8126815

Priyadarshi S. Oral terbutaline in the management of pharmacologically induced prolonged erection. Int J Impot Res. 2004;16:424-426. PMID: 14999218

This week we welcome Andy Little onto the show to discuss the modified Valsalva maneuver for breaking SVT. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_102_0-AVNRT_Final_Cut.m4a Download Leave a Comment Tags: Adenosine, AVNRT, Cardiology, SVT, Tachydysrhythmia Show Notes

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Rebel EM: The REVERT Trial - A Modified Valsalva Maneuver to Convert SVT

SGEM: This is a SVT and I’m Gonna Revert It Using a Modified Valsalva Manoeuvre

Appelboam A et al. Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias (REVERT): A Randomised Controlled Trial. Lancet 2015. PMID: 26314489

This week we dive into some of the initial considerations in the resuscitation of major burn patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_101_0_Final_Cut.m4a Download Leave a Comment Tags: Carbon Monoxide, Cyanide, Major Burns, Trauma Show Notes

Take Home Points

• Be prepared to intubate early, the patency of the airway can decline quickly and without warning. If there is any concern for burns to face/neck or smoke inhalation, consider taking control of the airway early.
• Review the rule of 9s and the parkland formula to direct your large volume fluid resus.  Remember the parkland formula directs you to use 4 mL x %TBSA x weight (kg).  Half in the first 8 hours and the second half over the next 16 hours.  Given the large volume here it’s probably best to use LR or another balanced solution.
• Do a thorough trauma eval to make sure you don’t miss any other injuries and be sure to watch for developing compartment syndrome
• And last, consider the need to treat for CO and/or cyanide poisoning.  Poor cardiac function, cardiac arrest or a high lactate can be clues to cyanide poisoning and just start 100% O2 while you wait for a co-ox, since CO tox is pretty likely.

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It's been 2 years and 100 podcasts. Jenny and Swami take a minute to talk about the Core EM project and our future directions. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_100_0_Final_Cut.m4a Download One Comment
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This week we discuss 3 articles recently reviewed in our conference - LOV-ED study, Validation of Step-By-Step and Therapeutic Hypothermia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_99_0_Final_Cut.m4a Download Leave a Comment Tags: ARDS, Cardiac Arrest, Lung Protective Ventilation, Mechanical Ventilation, OHCA, Step-By-Step Protocol, Therapeutic Hypothermia, TTM Show Notes Take Home Points

1. The step-by-step approach to managing febrile infants is a reliable decision instrument to identify patients at low risk for invasive bacterial infections. Caution in the group of patients 22-28 days of age.
2. The LOV-ED study shows an association between employing a lung-protective ventilation strategy in the ED and decreased complications from mechanical ventilation. Best available evidence says that we should embrace this approach in the ED.
3. Cooling to 33 degrees is no better than cooling to 36 degrees. However, shooting 36 degrees is more difficult than we may have thought. We have to continue to be vigilant about maintaining patients in the target temperature range and avoiding fever.

This week we delve into the argument for cardioversion in recent-onset AF as well as the logistics of getting it done. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_98_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation, Atrial Flutter, Cardiology, Cardioversion Show Notes

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Core EM: Podcast 64.0 - Rate Control in AF

Core EM: Recent Onset Atrial Fibrillation

Core EM: 30-Day Outcomes After Aggressive AF Management in the ED

The SGEM: SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol

References

Nuito I et al. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA 2014; 312(6): 647-9. PMID: 25117135

Stiell IG et al. Association of the Ottawa aggressive protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation and flutter. Can J Emerg Med 2010; 12(3): 181-91. PMID: 20522282

This week we discuss the rare but life-threatening methemoglobinemia with a focus on recognition and use of the antidote. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_97_0_Final_Cut.m4a Download 2 Comments Tags: Methemoglobin, Toxicology Show Notes

Take Home Points

• MetHb –emia occurs as a results of various medications including amyl nitrite, dapsone, nitroprusside, phenazopyridine, sodium nitrite and topical anesthetics like benzocaine
• Patients will present with cyanosis, short of breath, fatigue, dizziness, weakness and ultimately CNS depression and death at higher concentrations.
• If you have a cyanotic/hypoxic patient that does not respond to supplemental oxygen, be concerned for MetHb and send a co-oximetry panel.
• If the level is <25% and the patient is asymptomatic you can observe, but if the level is >25% or the patient is symptomatic, you will treat with the antidote methylene blue given as a bolus of 1-2 mg/kg over 5 minutes
• And as always, make sure to call your local poison center to get your toxicologists involved. They can help with dosing, and they are also an important player of the public health component in cases such as these, to make sure this is an isolated incident and we don’t have a repeat of the 11 blue men situation.

Price DP. Chapter 127. Methemoglobin Inducers. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e New York, NY: McGraw-Hill; 2011. Accessed April 19, 2017.

This week we do a brief review on recognizing CO monoxide poisoning and expertly managing it. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_96_0_Final_Cut.m4a Download Leave a Comment Tags: CO, Inhaled Toxins, Toxicology Show Notes

Take Home Points

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