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    Core EM – Emergency Medicine Podcast

    Core EM Emergency Medicine Podcast

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    Copyright: © Core EM

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    Latest Episodes:
    Episode 77.0 – Give TXA Now! Dec 19, 2016
    Show notes

    This week the podcast features a talk Jenny Beck-Esmay gave at the 11th All NYC EM Conference entitled "Give TXA Now!"

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_77_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, CRASH-2, Massive Transfusion Protocol, MATTERS, Trauma, TXA

    Show Notes

    Take Home Points

    1. Giving TXA provides a significant mortality benefit to the any trauma patient requiring massive transfusion with an NNT = 7 for mortality
    2. TXA must be given early. Give within 1 hour of injury if possible but the benefit remains up to 3 hours out
    3. TXA administration: 1 gram as a bolus followed by 1 gram over the next 8 hours

    Show Notes

    Intensive Care Network: Karim Brohi on TXA in Trauma

    EMCrit: Podcast 67 – Tranexamic Acid (TXA)

    Core EM: CRASH-2 Tranexamic Acid in Major Trauma

    References

    CRASH-2 trial collaborators. Effects of tanexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a ransomised placebo-controlled trial. Lancet 2010; 376: 23-32. PMID: 20554319

    Guerriero C et al. Cost-effectiveness analysis of administering tranexamic acid to bleeding trauma patients using evidence from the CRASH-2 trial. PLoS One 2011; 6(5): e18987. PMID: 21559279

    Ker K et al. Avoidable mortality from giving tranexamic acid to bleeding trauma patients: an estimation based on WHO mortality data, a systematic literature review and data from the CRASH-2 trial. BMC Emerg Med 2012; 12:3. PMID: 22380715

    Morrison JJ et al. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) Study. Arch Surg 2012; 147 (2): 113-9. PMID: 22006852


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    Episode 76.0 – The Lisfranc Injury Dec 12, 2016
    Show notes

    This week we discuss Lisfranc injuries with a focus on a diagnostic pathway and management.

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_76_0_Final_Cut.m4a Download Leave a Comment Tags: Lisfranc Fracture, Lisfranc Injury, Orthopedics, Trauma

    Show Notes

    Take Home Points

    1. A Lisfranc injury is a midfoot injury that results in displacement of one or more of the metatarsal bones from tarsus.
    2. XR will show widening of the space between the 1st and 2nd metatarsals. Getting contralateral XR may help you identify this.
    3. Even if you don’t see that widening on the XR, the patient could still have a Lisfranc injury. If they cannot walk due to pain, get a weight bearing XR or CT scan to look further.
    4. Once the injury is identified, the patient must be strict non-weightbearing. Place them in a posterior splint and get orthopedics involved either in the ED or for prompt follow up as the patient will probably need surgery.
    Foot Bones (Google Images)

    Foot Bones (Google Images)

    Normal Foot X-ray Series (Case courtesy of Dr Andrew Dixon, Radiopaedia.org. From the case rID: 36688)

    Normal Foot X-ray Series (Case courtesy of Dr Andrew Dixon, Radiopaedia.org. From the case rID: 36688)

    Lisfranc Injury AP X-ray (Radiopaedia Image #1: Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. From the case rID: 10919)

    Lisfranc Injury AP X-ray (Radiopaedia Image #1: Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. From the case rID: 10919)

    Divergent Lisfranc Injury

    Divergent Lisfranc Injury

    Read More

    LITFL: Eponymous Fractures

    Radiopaedia: Lisfranc Injury

    Core EM: Compartment Syndrome


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    Episode 75.0 – Fluid Responsiveness + Resuscitation Dec 05, 2016
    Show notes

    This week we do a little spaced repetition on adrenal insufficiency and then discuss fluid responsiveness and resuscitation.

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_75_0_Final_Cut.m4a Download Leave a Comment Tags: Adrenal Insufficiency, Critical Care, Fluid Responsiveness, Fluid Resuscitation, Sepsis, Septic Shock

    Show Notes

    Read More

    Marik PE. Fluid responsiveness and the six guiding principles of fluid resuscitation. Crit Care Med 2016. PMID: 26571187

    LITFL: Adrenal Insufficiency

    EMCrit: Podcast 64 – Assessing Fluid Responsiveness with Dr. Paul Marik

    Core EM: Adrenal Crisis

    Core EM: Episode 15.0 – Adrenal Crisis

    References

    Cavallaro F et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systemic review and meta-analysis of clinical studies. Intensive Care Med. 2010:36(9):1475-83. PMID: 20502865.

    Cecconi M et al. Fluid challenges in intensive care: the FENICE study: A global inception cohort study. Intensive Care Med. 2015:41(9):1529-37. PMID: 26162676.

    Landesberg G et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J. 2012:33(7):895-903. PMID: 21911341.

    Lee CV et al. Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound. J Crit Care. 2016:31(1):96-100. PMID: 26475100.

    Marik PE. Noninvasive cardiac output monitors: a state-of the-art review. Cardiothorac Vasc Anesth. 2013:27(1):121-34. PMID: 22609340.


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    Episode 74.0 – Gastroesophogeal Reflux (GERD) Nov 28, 2016
    Show notes

    This week we review some pearls in the diagnosis and management of acid reflux.

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_74_0_GERD_Final_Cut.m4a Download Leave a Comment Tags: Acid Reflux, Gastrointestinal, GERD, GI

    Show Notes

    Take Home Points

    1. GERD pain can mimic or co-exist with the more deadly causes of chest pain. Be sure to consider all the serious causes of chest pain, get an EKG and maybe a chest XR while you go about symptom management.
    2. Respond to a treatment doesn’t prove a diagnosis. GERD pain may get better with nitro and ACS pain may get better with a GI cocktail. Keep an open mind while seeing these patients.
    3. Standard treatment for GERD includes an antacid and H2 blocker and maybe a PPI. Keep in mind that a PPI takes a while to work, so be sure to give something faster acting in the ED
    4. And last, for these patients, take those few extra minutes for some counseling on lifestyle modifications. All medications come with side effects, so be sure to address things like diet, smoking and weight loss while you have a captive audience.

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    Episode 73.0 – PE in Syncope Study Nov 21, 2016
    Show notes

    This week we dive into the controversies surrounding the PESIT study looking at the prevalence of PE in admitted patients with syncope

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_73_0_Final_Cut.m4a Download Leave a Comment Tags: Cardiovascular, Journal Club, PE, Pulmonary, Pulmonary Embolism, Syncope

    Show Notes

    Read More

    EMLit of Note: The Impending Pulmonary Embolism Apocolypse

    St. Emlyn’s: JC – Prevelance of PE in Patients with Syncope

    EM Nerd (EMCrit): The Case of the Incidental Bystander

    Pulm CCM: PESIT Investigators: The Incidence of PE in Those Hospitalized Following First Syncope

    References

    Hutchinson BD et al. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. Am J Rad 2015; 205(2):271-7. PMID: 26204274


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    Episode 72.0 – Upper GI Bleeding Nov 14, 2016
    Show notes

    This week we discuss upper GI bleeding pearls from a workshop we did in our weekly conference.

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_72_0-UGIB_Final_Cut.m4a Download Leave a Comment Tags: Aortoenteric Fistula, Gastric Ulcer, Gastrointestinal, GI, UGIB, Variceal Bleeding

    Show Notes

    Take Home Points

    1. Respect the UGIB. These patients can bleed a lot. Even if they’re not actively hemorrhagic in front of you, realize that they can open up at any time and decompensate
    2. Get your consultants on board early. A skilled endoscopist is your friend as they can get control of bleeding. Don’t forget IR for TIPS in variceal bleeds and general surgery in bleeding ulcers.
    3. Activate your massive transfusion protocol if the patient is unstable and give the patient PRBCs, FFP and platelets as indicated. Reverse any anticoagulants as well.
    4. Give all patients with confirmed or suspected variceal bleeding antibiotics – typically, ceftriaxone. This intervention saves lives and decreases morbidity.

    Read More

    LITFL: EBM Upper GI Haemorrhage

    EMCrit: Episode 5: Upper GI Bleed Guidelines

    EMCrit: Intubating the Critical GI Bleeder

    The NNT: Prophylactic Antibiotics for Cirrhotics with Upper GI Bleed

    The NNT: Somatostatin Analogues (Octreotide) for Acute Variceal Bleeding

    EMRAP HD: Placement of a Blakemore Tube for Bleeding Varices


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    Episode 71.0 – Acute Pulmonary Edema Nov 07, 2016
    Show notes

    This week we feature a lecture from Anand Swaminathan at our weekly conference on the ED management of acute pulmonary edema

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_71_0_Final_Cut.m4a Download 9 Comments Tags: Acute Decompensated Heart Failure, Acute Pulmonary Edema, ADHF, APE, Cardiovascular

    Show Notes

    screen-shot-2016-09-28-at-2-40-06-pm

    Read More

    Core EM: Acute Pulmonary Edema

    EMCrit: Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema

    REBEL EM: Morphine Kills in Acute Decompensated Heart Failure

    emDocs: Furosemide in the Treatment of Acute Pulmonary Edema


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    Episode 70.0 – Baclofen Withdrawal Oct 31, 2016
    Show notes

    This week we discuss the rare, but life-threatening baclofen withdrawal.

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_70_0_Final_Cut.m4a Download Leave a Comment Tags: Baclofen, Critical Care, Toxicology, Withdrawal Syndromes

    Show Notes

    Take Home Points

    1. Baclofen withdrawal is a rare complication of intrathecal baclofen pumps. It’s presentation mimics sepsis and alcohol withdrawal and is characterized by hemodynamic instability, hyperthermia, increased spasticity, confusion, altered mental status and seizures. Patients can develop rhabdo from the spasticity and, eventually, can develop multi system organ dysfunction.
    2. Treating baclofen withdrawal with oral baclofen is unlikely to work even at large oral doses because only a tiny amount gets into the CSF where it needs to act for withdrawal to be treated
    3. Baclofen withdrawal can be emergently treated with increasing benzodiazepine doses, propofol infusions and baclofen administered via a lumbar puncture. Ultimately, these patients all need consultation with either neurosurgery or interventional pain management to interrogate the device and surgically correct the issue.

    Read more

    EM: RAP November 2015: Lin Sessions Intrathecal Pumps

    REBEL EM: Baclofen Withdrawal

    Chidester S, Smith S. Baclofen pump complications. The NYS Poison Centers Toxicology Letter 2011; 16(4): 1-12. Link

    Ross J et al. Acute Intrathecal Baclofen Withdrawal: A Brief Review of Treatment Options. Neurocrit Care. 2011;14(1):103-108. PMID: 20717751

    Stetkarova I et al. Procedure- and device-related complications of intrathecal baclofen administration for management of adult muscle hypertonia: a review. Neurorehabil Neural Repair. 2010;24(7):609-619. PMID: 20233964

    Shirley KW et al. Intrathecal baclofen overdose and withdrawal. Pediatr Emerg Care. 2006;22(4):258-261. PMID: 16651918


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    Episode 69.0 – Antibiotics in COPD Exacerbations Oct 24, 2016
    Show notes

    This week we discuss why we use antibiotics in COPD exacerbations and whether we should continue to do so.

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_69_0_Final_Cut.m4a Download Leave a Comment Tags: Antibiotics, COPD, COPD Exacerbation, Pulmonary

    Show Notes

    Take Home Points

    1. Most COPD exacerbations are caused by infectious etiologies. While these can be viral, there’s also a decent chance it was caused by an overgrowth of bacteria that chronically colonize these patients.
    2. Strong evidence from systematic reviews demonstrates that antibiotic use reduces in-hospital mortality and decreases treatment failure
    3. The GOLD group recommends antibiotics be given to patients who have increased dyspnea, increased sputum volume and increased sputum purulence or require non-invasive or invasive ventilation for their exacerbation.
    4. Finally, a short course of antibiotics – either ampicillin, doxycycline or azithromycin is adequate for management.

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    GOLD Reports: Diagnosis, Management and Prevention 2016

    Berg RMG, Plovsing RR. The hardships of being a Sith Lord: implications of the biopsychosocial model in a space opera. Adv Physiol Educ 2016; 40: 234-6. PMID: 27105743

    Johannes M et al. Antibiotics in Addition to Systemic Corticosteroids for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Resp Crit Care Med 2010; 181(2): 150-7. PMID: 19875685

    Quon BS et al. Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis. Chest 2008; 133:756-66. PMID: 18321904

    Ram FS et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006:CD004403 PMID: 16625602

    Rothberg MB et al. Antibiotic Therapy and Treatment Failure in Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. JAMA 2010; 303(20): 2035-2042 PMID: 20501925

    Vollenweider DJ et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012: CD010257 PMID: 23235687

    The Podcasting Course


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    Episode 68.0 – Hiccups Oct 17, 2016
    Show notes

    This week we discuss the workup and management of hiccups in the ED

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_68_0_Final_Cut.mp3 Download One Comment Tags: Hiccups, Singultus

    Show Notes

    Take Home Points

    1. Hiccups, or singultus, are caused by a reflex arc involving the vagus nerve, CNS and phrenic nerve. If you remember the path of these nerves, you can remember that possible bad pathologies that could cause a patient to present with prolonged hiccups.
    2. Physical maneuvers are the first line for solving the hiccups. Try things that will interrupt respiration or stimulate the vagus nerve. We like the modified valsalva in which the patient blows on a syringe, because it’s pretty easy to get the patient to do.
    3. Last, medication options for hiccups include antipsychotics, anticonvulsants, muscle relaxers and dopamine agonist. Generally, we start with chlorpromazine 25-50 mg PO or IM.

    Read More

    Steger M et al. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther 2015; 42(9):1037-50. PMID 26307025


    Read More
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