EMGuidewire's Podcast - TopPodcast.com

Senior Residents' Reflections and Perspectives Apr 16, 2024

Join the EMGuidewire crew as Dr. Diurba and Dr. Folk reflect upon their residency experience and the initiation of the Intern Nuggets episodes while, of course, discussing some important tips and tricks they learned along the way.

Intern Nuggets '24: A-fib and A-flutter Mar 05, 2024

Join the team from EMGuidewire from CMC Emergency Medicine Residency for another Intern Nuggets! In this episode, Drs. Crow and Lim discuss some tips on how they have approached the first half of their intern years as well as review management of Atrial Fibrillation and Atrial Flutter.

Intern Nuggets '23 #1 - Agitation Management Tips Nov 04, 2023

Join the crew from Carolinas Medical Center Emergency Medicine (@CMCEM) and EMGuidewire (@EMGuidewire) as they introduce a new group of interns as they discuss some of the first lessons they have learned about Agitation Management in the ED.

Intern Nuggets #4 2023: Myositis Mar 31, 2023

Join the EMGuidewire team from Carolinas Medical Center's Emergency Medicine Residency Program as Drs. Calienes Cerpa and Bissell gather together to discuss another great case filled with learning points. In this episode, they review myositis in a pediatric patient.

Intern Nuggets #3 2023: Heart Blocks Mar 16, 2023

Join the EMGuideWire team from Carolinas Medical Center, Emergency Medicine Residency, as Drs. Calienes and Bissell discuss Heart Blocks.

Quick Cases with Drs. Diurba and Folk - Septic Pulmonary Emboli Feb 08, 2023

Join the crew from Carolinas Medical Center's Emergency Medicine Residency and EMGuidewire as they discuss some interesting cases with Drs. Sofiya Diurba and Destiny Folk. This episode deals with a complex, critically ill adult who has septic pulmonary emboli.

Quick Cases with Drs. Diurba and Folk - Critical Pediatric Case Feb 07, 2023

Join the crew of EMGuidewire and the Residents and Faculty at Carolinas Medical Center Emergency Medicine Residency as they learn along with Drs. Sofiya Diurba and Destiny Folk. In this episode, Drs. Folk and Diurba will discuss an educational Pediatric Case that involves some critical decisions!

Intern Nuggets 2022 #2 Self Care and Migraine Cocktails Nov 05, 2022

Join the EMGuidewire team from Carolinas Medical Center's Emergency Medicine Residency Program as Drs. Bissell and Calienes Cerpa discuss some more important topics in their Intern Nuggets series. In this episode, they address some important Self Care issues that all interns (and likely everyone) need to consider. They also discuss the possible components in those very popular "migraine cocktails."

Resident Wellness Proactive Counseling Sep 02, 2022

Join Drs. Diurba and Folk and the EMGuidewire team from @CMCEM as they begin an important conversation regarding Resident and Physician Wellness. If we exercise our bodies to remain physically healthy, shouldn't we exercise our emotional selves as well? Perhaps some proactive counseling sessions can be good for us all.

Intern Nuggets 2022 #1 Palpitations Aug 30, 2022

Join the EMGuideWire's team as they celebrate the beginning of the new academic year by introducing us to two new interns who will be taking over the Intern Nuggets! Drs. Calienes and Dr. Bissell take over the task of discussing interesting cases that they have encountered during the start of their careers. This episode finds them wrestling with a challenging case of palpitations and anxious feelings.

Pediatric Pain Management - EMSC Improvement Project Jun 29, 2022

Join the EMGuidewire team and Drs. Allen and Fox from Carolinas Medical Center as they discuss tips for Mitigating Anxiety and Pain in the Pediatric patient. This episode is published in concert with EMSC Innovation and Improvement Center.

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Intern Nuggets #7: SAEM Learning Points Jun 27, 2022

Join the EMGuidewire team from Carolinas Emergency Medicine Residency as Drs. Diurba and Folk discuss their favorite learning points from this year's SAEM scientific assembly conference.

Intern Nuggets #6: Reversal of Anticoagulants Jun 24, 2022

Join Drs. Diurba and Folk, stellar Carolinas Medical Center Emergency Medicine Interns, and the EMGuidewire team as they discuss various reversal options for the numerous anticoagulants that exist today.

Intern Nuggets #5: Altered Mental Status May 10, 2022

Join Drs. Folk and Diurba, Emergency Medicine Interns enjoying their training at Carolinas Medical Center, as they discuss a case of Altered Mental Status with the EMGuidewire Team!

Intern Nuggets #4: Beer Potomania and Hyponatremia Feb 15, 2022

Join Drs. Folk and Diurba, Emergency Medicine Interns enjoying their training at Carolinas Medical Center, as they discuss Beer Potomania and Hyponatremia with the EMGuidewire Team!

Intern Nuggets #3: Approach to Complex Patients and Feedback and Avoiding Burnout Nov 15, 2021

Join the EMGuidewire team as Drs. Folk and Diurba explore another episode of INTERN NUGGETS! In this episode, they discuss an approach to the medically complex patient as well as giving and receiving feedback. They also explore the extremely important topic of burnout and ways to avoid it.

Occlusive Myocardial Infarction Intro Nov 04, 2021

Join the team from EMGuideWire from Carolinas Medical Center as Dr. Clare Gunn gets to chat with Dr. Pendell Meyers about the challenges of relying on the STEMI paradigm and what other factors to consider when evaluating patients for Occlusive Myocardial Infarctions (OMI).

Tension Pneumoperitoneum: More Than Bad Belly Pain Oct 01, 2021

Join the @EMGuideWire team from @CMCEM as they learn from former Chief Resident, Dr. Rushnell, how to manage the complex condition of Tension Pneumoperitoneum.

Pediatric DVT and PE Sep 24, 2021

Join the EMGuideWire team from the CMC EM Residency Program as we welcome back Dr. Rushnell, prior CMC EM Chief Resident, to discuss the challenging topic of Pediatric DVT and PE.

Guillain–Barré Syndrome Sep 03, 2021

Join the EMGuideWire Team from Carolinas Medical Center (@CMCEM) and Dr. Mark Kastner and Dr. Matthew Cravens in the Chief's Corner as they discuss the presentation and diagnosis of the challenging diagnosis of Guillain–Barré Syndrome.

Intern Nuggets #2: Sign-out Tips and Pediatric Dehydration and BRUE Aug 18, 2021

Join the crew from EMGuidewire as they are joined, once again, by Drs. Diurba and Folk for their unique perspectives from an intern's point of view. This month's Intern Nugget will cover sign-out and transition of care tips as well as some learning point on pediatric dehydration management and BRUE.

4 Factor PCC in Trauma Aug 06, 2021

Join the EMGuideWire Team as they welcome back Dr. Chelsea Rushnell, prior Chief Resident at CMC Emergency Residency, to discuss the management of the anticoagulated trauma patient. Perhaps just flooding individuals with FFP is not the best strategy. Dr. Rushnell will review the evidence for the use of 4 Factor PCC.

Intern Nugget #1: Imposter Syndrome, Complex Regional Pain Syndrome, and Analgesia Options Aug 03, 2021

Join the EMGuideWire team from CMC EM residency as they hear a fresh perspective... from newly minted residency Interns, Drs. Destiny Folk and Sofiya Diurba.

For this Intern Nugget, they address:

1) Imposter Syndrome and how to overcome it.

2) Complex Regional Pain Syndrome and how to manage it.

3) Analgesia options in the ED

Penetrating Cardiac Trauma Jul 27, 2021

Join the EMGuidewire team at Carolinas Medical Center Emergency Medicine program as they discuss important topics. This week, Drs. Cravens and Kastner discuss Penetrating Cardiac Injury (PCI):

-The diagnosis of PCI is made in the trauma bay with repeat cardiac ultrasound exams and chest x-ray. If suspicion remains high despite inconclusive imaging, operative subxiphoid pericardial window is the definitive diagnostic modality.

-Large pericardial injury, especially from ballistic injuries, can result in PCI without positive pericardial fluid on FAST, if the blood is draining into the hemithorax. This would result in hemothorax, but not always with high enough drainage to mandate operative intervention if PCI is not kept with high index of suspicion.

-ED management of PCI is stabilization until the patient can be managed in the OR with sternotomy and external cardiac repair. In the pulseless patient with recent arrest, ED thoracotomy is indicated, provided operating room intervention is available immediately following. Unstable patients with a pulse need immediate operative intervention; if FAST is positive for pericardial fluid, ED pericardiocentesis should be considered as a temporizing measure in these patients, especially if transfer is needed for OR intervention.

Diabetic Ketoacidosis Emergent Management Nov 25, 2020

Join the EMGuideWire Team from CMC EM group as they explore the initial thoughts and management of a patient who presents with severe Diabetic Ketoacidosis (DKA). For this episode, Drs. Claire Milam and Travis Barlock explore the initial considerations and practical management tips.

Definitions of severity of DKA:

Mild

- pH: 7.25-7.3
- CO2: 15-18 mEq/L
- Anion Gap: > 10 mEq/L
- Mental Status: Alert
- Blood Glucose: >250 mg/dl
- Urine and Serum Ketones: Positive

Moderate

- pH: 7.0-7.24
- CO2: 10-15 mEq/L
- Anion Gap: >12 mEq/L
- Mental Status: Alert to Drowsy
- Blood Glucose: >250 mg/dl
- Urine and Serum Ketones: Positive

Severe

- pH: < 7.0
- CO2: < 10 mEq/L
- Anion Gap: > 12 mEq/L
- Mental Status: Stuporous to Comatose
- Blood Glucose: >250 mg/dl
- Urine and Serum Ketones: Positive

Posterior Eye Pathology Core Concepts Nov 17, 2020

Join the Drs. Ray and Barlock from the EMGuideWire team as the discuss the initial assessment and evaluation of some ocular complaints with specific attention to pathology of the Posterior Eye.

SHOWNOTES:

Key PointsAlways get visual acuity for any eye complaint Swinging flashlight test can help with your diagnosis Dilate the eyes for optimal fundoscopic exam Optic neuritis -> give IV steroids Use U/S to look for papilledema along with optic nerve sheath diameter Find the optic nerve when evaluating retinal detachment vs vitreous hemorrhage CRAO= “stroke of the eye” CRVO= “DVT of the eye”

Optic NeuritisOnset: Acute Pain: With EOMI, can be painless Visual Acuity: Decreased Laterality: Usually unilateral, can be bilateral Classic presentation: Young female (15-45) with acute vision loss Exam: + APD Associations: MS, infection (lyme, herpes, syphilis), autoimmune, methanol, DM Treatment: IV steroids

Papilledema Onset: Subacute to chronic Pain: Headache Visual Acuity: Normal initially Laterality: Bilateral Classic presentation: Headache, N/V, transient vision loss Exam: Optic disc swelling Treatment: treat underlying cause

Retinal Detachment Onset: Sudden Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden, painless, with flashes, or a curtain over the visual field Exam: +/- mild APD Management: Ophtho consult, minimize activity, treat underlying cause, surgical options available

Central Retinal Artery OcclusionOnset: Sudden Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden, painless vision loss in vasculopathy Exam: + APD Associations: carotid vascular disease, pediatric blood disorders (SCD, leukemia) Management: Ophtho consult, restore blood flow

Central Retinal Vein OcclusionOnset: Acute Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden blurry or distorted vision in hypercoagulable patient Exam: + APD Associations: OCPs, HTN, DM, vasculitis Management: Ophtho consult

Severe Asthma Management in the ED Nov 02, 2020

Join the EMGuidewire team as Drs. Serven and Blackwell discuss the management of the patient presenting with Severe Status Asthmaticus in the Emergency Department. Don't forget to review the basic concepts that were published earlier... this time the focus is on the critically ill patient.

Trauma Assessment Sep 21, 2020

Join the EMGuidewire Team as they address how to prepare for the arrival of a trauma patient in your Emergency Department. Drs. Serven and Blackwell from Carolinas Medical Center Emergency Medicine Residency Program will give us some insight and pearls on how to manage the potential chaos.

Airway Management Preparation Sep 03, 2020

Join the EMGuideWire team as Drs. Serven and Shreve are joined by Dr. Trigonis to discuss simple strategies to make sure your room is set up and you are prepared for performing an emergent intubation on your patients in the Emergency Department.

Shownotes - Once through start to finish:

Set up suction
Set up pre-oxygenation (nasal cannula, NRB, BVM as backup)
Choose a tube + back up tube
Lube the tube, check the tube
Choose a stylet
Set up video and DL
Ask nurse for meds (nicely)
Check hemodynamics
Acknowledge preoxygenation
Positioning
Give meds
Wait for paralytic medications to work
Tube ‘em
Call out your tube positioning
Leave the blade in place until tube placement assured
Confirm with color change, EtO2, bilateral breath sounds
Wait for RT to secure the tube
Call for post-intubation meds
Check CXR for position

Pulmonary Edema and Hypertension Aug 23, 2020

Join Drs. Alyssa Thomas and Victoria Serven from Carolinas Medical Center Emergency Medicine Residency Program and the EMGuideWire Team as they discuss how they initially evaluate and manage the patient who present with acute pulmonary edema and hypertension.

Point of Care Ultrasound for COVID-19 Patients Apr 21, 2020

Join the EMGuideWire team as they explore the use of Point-of-Care Ultrasound for the evaluation of patients with possible COVID-19 infection. Dr. Patrick Lam, from the Carolinas Medical Center Department of Emergency Medicine Department Division of Ultrasound, will guide us on the techniques and pro-tips for this application.

Healthcare Disparities and COVID Pandemic Apr 14, 2020

Join EMGuideWire team as they listen in to EM Residency Conference at Carolinas Medical Center (in Charlotte, NC) and learn from Emily MacNeill, MD as she discusses "What Happens When a Disease Management System Crashes into a Public Health Crisis."

Neurologic Manifestations and Complications of COVID-19 Apr 10, 2020

Join the EMGuideWire team as they learn from one of the world's foremost experts in neurologic emergencies, Dr. Andrew Asimos. This episode will address the Neurologic Manifestations and Complications of the COVID-19 Infection.

Hydroxychloroquine Toxicity Apr 03, 2020

Join the EMGuideWire team as they listen to Dr. Geib discuss how to recognize and manage Hydroxychloroquine toxicity, which may become more prevalent during the current COVID-19 pandemic.

ARDS Management during COVID 19 Apr 03, 2020

Join the EMGuideWire team as they learn from Critical Care fellow, Dr. Russell Trigonis while he addresses the important aspects of managing ARDS in patients with COVID-19 infections.

Trauma and Pregnancy Feb 25, 2020

OB Trauma Core Concepts

Physiologic changes of pregnancy: physiologic anemia, decreased SVR, increased HR, increased RR, and pelvic vessel engorgement
Traumatic complications: placental abruption, preterm labor (PTL), uterine rupture, and pelvic fx
Abruption triad = abd pain, large for dates uterus, vaginal bleeding
Perform cervical check to eval for PTL
Obtain Type and Screen and KB test
Give Rhogam if mom is Rh neg. 50 mcg if 12 wks
Check fetal HR after E-FAST, nml is 120-160

-Travis Barlock

Ludwig's Angina Jan 30, 2020

Join the EMGuideWire Crew from CMC EM Residency Program as they discuss Ludwig's Angina and the management Priorities!!!

BACKGROUND

Angina = “Strangling”
Bilateral infection of submental, submandibular, and sublingual spaces
70-85% of cases arise from odontogenic source
- Periapical abscesses of mandibular molars
- Piercings (frenulum)
- URI more common cause in children

Source of infection often polymicrobial
- Most commonly viridans; also Staphylococcus and Bacteroides species
Patients usually 20-60 years-old; more common in males1
Mortality in treated Ludwig’s Angina = 8%7
***Airway compromise = leading cause of death8

Who Is At Risk?

Diabetes mellitus
Chronic alcohol abuse
IVDA
HIV/AIDS
Malnutrition
Poor oral hygiene
Smokers

Anatomy & Pathophysiology

Mylohyoid subdivides submandibular space:
- Sublingual space
- Submaxillary (submylohyoid) space
Infection extends posteriorly and superiorly, elevating tongue against hypopharynx
If left untreated, can extend inferiorly to retropharyngeal space and into superior mediastinum3

Clinical Signs & Symptoms

Dysphagia
Odynophagia
Trismus
Edema of upper midline neck and floor of mouth
- Raised tongue
"Woody" or brawny texture to floor of mouth with visible swelling and erythema

Late Findings

Drooling
Tongue protrusion
Trismus
Dysphonia
Cyanosis
Acute laryngospasm
Stridor
Patients may demonstrate signs of systemic toxicity → fever, tachycardia, and hypotension

How Do I Make the Diagnosis?

Clinically!
Consider CT head/neck
- Can help evaluate extent of infection if clinical situation persists
CBC
Chemistry
Lactate
Blood Cultures

Management

Emergent ENT/OMFS consult for I&D in OR and extraction of dentition if source is dental abscess
Airway Management
- Intubation will be VERY difficult due to trismus and posterior pharyngeal extension
- Ideal situation = awake fiberoptic intubation in OR
ALWAYS have a surgical airway ready as your back up plan
Blind insertion devices (e.g. intubating LMA) are NOT recommended

Management - Antibiotics

Must cover typical polymicrobial oral flora
Immunocompetent
- 3rd-generation Cephalosporin + (Clindamycin or Metronidazole)
- Ampicillin/Sulbactam
- Penicillin G + Metronidazole
- Clindamycin (allergic to penicillin)
Immunocompromised → *Need MRSA and GNR coverage!3
- Cefepime + Metronidazole
- Meropenem
- Piperacillin-tazobactam
- Add Vancomycin if concern for MRSA risk factors

Steroids
- Dexamethasone 10 mg IV
  - Thought to chemically decompress for airway protection and increase antibiotic penetration6
- Nebulized epinephrine
- Resuscitation and pain control

Complications

Intracranial infections (e.g. CST, brain abscess)
IJ thrombophlebitis (Lemirre’s Syndrome)
Mediastinitis
Mandibular osteomyelitis
Empyema

Pearls

Three characteristics of Ludwig’s angina can be remembered as the 3 Fs:

Feared
Often Fatal
Rarely Fluctuant
ABCs—Sit upright
Early notification of ENT/OMFS and anesthesia to facilitate definitive airway management
Arrange for the patient to be admitted to ICU

Priorities!!!

Secure the airway EARLY!
- Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway
Prevent the development of septic shock and multi-organ failure — give antibiotics early

References

Lin HW, O’Neil A, Cunningham MJ. Ludwig’s Angina in the Pediatric Population. Clin Pediatr (Phila) 2009;48:583-7.
Baez-Pravia, Orville V. et al. “Should We Consider IgG Hypogammaglobulinemia a Risk Factor for Severe Complications of Ludwig Angina?: A Case Report and Review of the Literature.” Medicine. 2017;96(47):e8708.
Pandey M, Kaur M, Sanwal M, Jain A, Sinha SK. Ludwig’s Angina in children anesthesiologist’s nightmare: Case series and review of literature. J Anaesthesiol Clin Pharmacol. 2017 Jul-Sep;33(3):406-409.
Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig’s Angina Ann Maxillofac Surg. 2015 Jul-Dec;5(2):168-73.
Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110: 1051, 2001.
Saifeldeen K, R Evans. Ludwig’s Angina. Emerg Med J 2004; 21: 242-243
Nanda N, Zalzal HG, Borah Gl. Negative-Pressure Wound Therapy for Ludwig’s Angina: A Case Series.Plast Reconstr Surg Glob Open2017 Nov 7;5(11):e1561.
Pak S, Cha D, Meyer C, Dee C, Fershko A.Ludwig’s Angina. Cureus. 2017 Aug 21;9(8):e1588.

SVC Syndrome Jan 15, 2020

Join the EMGuideWire team as they discuss Superior Vena Cava Syndrome!

Shownotes:

Definition:

Any condition leading to obstruction of blood flow through the SVC

Pathophysiology:

Pathology in adjacent anatomy (lung, lymph node, thymus, mediastinum) or within the SVC itself obstructs venous return to the right atrium. As the SVC is compressed, venous collaterals form alternative pathways returning blood to the right atrium which can dilate over several weeks. As a result, upper body venous pressure increases, which in extreme cases lead to airway congestion and venous cerebrovascular congestion and edema. Hemomdynamic compromise is most often by direct compression of the heart, not from SVC obstruction.

Risk factors:

Indwelling device through the SVC (Central line, dialysis catheter, pacemaker)
Lung cancer
Lymphoma
Thymoma

Presentation:

Signs – plethoric appearance, dilated neck and chest veins, swollen face/neck/chest
Symptoms – congestive symptoms (head fullness, swelling), cardiopulmonary symptoms (chest pain, dyspnea, stridor, hoarseness), and neurologic symptoms (headache, confusion, obtundation, visual disturbances)

Work-up:

Is the patient unstalbe? Do they have severe SVC?
- If yes, secure airway, support breathing, support circulation
- Consult vascular/cardiothoracic surgery
If patient is stable, then:
- Confirm diagnosis and evaluate for malignant obstruction
  - CBC, CMP, PT/INR, CXR, CT chest w/contrast
- Does the patient have a malignant obstruction or thrombosis?
  - Yes -> consult heme/onc and admit
  - No -> observe in ED

References:

García Mónaco R, Bertoni H, Pallota G, et al. Use of self-expanding vascular endoprostheses in superior vena cava syndrome. Eur J Cardiothorac Surg 2003; 24:208.

Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore) 2006; 85:37.

Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior vena caval obstruction. Is it a medical emergency? Am J Med 1981; 70:1169.

Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356:1862.

NonFatal Strangulation and Domestic Violence Nov 08, 2019

October was Domestic Violence month and in an effort to help highlight this very important topic, join Drs. Salzman, Dragoo, and Richardson from Carolinas Emergency Medicine Residency while they discuss the very important presentation of Strangulation. This is not a mere gesture of power, it may be our last opportunity to save this patient's life!

Pearls

Strangulation victims are 750% more likely to become a homicide victim.
Strangulation is not choking. Call it what it is.
External exam findings are often not present and do not rule out internal injury.
History is key. Look for neck pain, dizziness, vision/hearing changes, dysphagia, and SOB.
Most common internal injury is hyoid fracture.
Suspect strangulation? Get CTA neck. Neuro findings? Get non-con CT head + MRI brain.

Summarized by Travis Barlock, MD PGY-1

Running a Code Oct 25, 2019

Join the EMGuideWire crew as they discuss some tips and pearls on how to skillfully run a medical resuscitation.

Pearls

Preparation is everything. Get your staff, and get your stuff!
Call out names, be redundant, and say what you are thinking out loud.
Don’t go for the tube! Supraglottic airways are quicker and safer!
High quality compressions are life saving.
V-tach and V-fib are usually ischemic. PEA is usually non-cardiac.
PEA? Is it Wide or Narrow? Narrow - think procedural. Wide - think chemical.
Ultrasound is your friend. RV strain, pericardial tamponade, and pneumothorax can all be quickly found!
Wide complex (but not V-tach) is hyperkalemia until proven otherwise. Provide Calcium Chloride (not gluconate).

Summarized by Travis Barlock, MD PGY-1

Sepsis Management in the ICU Oct 10, 2019

The EMGuideWire Team is visited by a prior crew member, Russell Trigonis, MD! Join them as they discuss how the patient diagnosed with Sepsis in your ED has their care continued in the ICU!

Pearls

Start pressors with IVF (30-40cc/kg). NE at 7mcg/min peripherally can always be stopped, but better earlier than later.
Increase NE until at 20mcg/min, if still hypotensive, then add a 2nd pressor like Vasopressin at 0.03units/min and 100mg Hydrocortisone Q8h.
Start antibiotics early and identify source. CXR, US lungs/abd, UA, CT abd should all be considered.
Procalcitonin is helpful for stopping abx. Doesn’t change ED treatment.
Don’t order Vitamin C or thiamine in ED.

-Travis Barlock, MD

Pediatric Sepsis Sep 30, 2019

It it the end of Sepsis Awareness Month, but there is a BONUS Monday (Sept. 30th), so why not a BONUS episode! Join the EMGuideWire Team as they explore the challenges the children bring to this clinical condition. Let's review Pediatric Sepsis!

Pearls:

Screening should be age adjusted. Identify severe sepsis. Treat w/early antibiotics, balanced fluid administration, and EPI if needed.
SIRS in children must be age-adjusted. HR & RR > 2 standard deviations of nml; WBC age adjusted.
Screen: high risk medical history + vital sign abnormalities (age based SIRS) require check of cap refill, mental status, and general appearance followed by a physician assessment.
Identify: Severe sepsis = sepsis + organ dysfunction (CV/resp/neuro/renal/hepatic dysfunction). Order a lactate, CBC, CMP, and blood cultures, and consider CXR and UA. CRP is helpful for inpatient team.
Higher lactate has higher mortality and is associated with septic shock.
Treat: Start 20cc/kg bolus LR and reassess. Those with heart disease can’t take anymore fluids after this, so only add pressors if needed. Continue to 40cc/kg and up to 60cc/kg total bolus prior to pressors for other patients.
If still hypotensive, start 0.1 mcg/kg/min of EPI (peripheral or IO).
Early antibiotics saves lives.
LR is better than NS.

Summarized by: Travis Barlock, MD PGY-1 References:

Emrath ET, Fortenberry JD, Travers C, McCracken CE, Hebbar KB. Resuscitation With Balanced Fluids Is Associated With Improved Survival in Pediatric Severe Sepsis. Critical Care Medicine. 2017 Jul;45(7):1177-1183

Ventura et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Critical Care Medicine. 2015; 43(11):2292-302

Guided Resuscitation for Sepsis Sep 23, 2019

Join the EMGuideWire Crew as they continue to explore the High Yield management points for Sepsis!

This week's Episode's Pearls:

Early fluids save lives. Give 40cc/kg bolus in first 3 hours. But don’t fluid overload the patient!
U/S the heart and lungs: A plethoric IVC, immobile mitral valve, and B lines on the lungs should urge you to be more cautious with fluids.
Goal in all patients is to establish an adequate MAP ASAP! Fluids + Vasopressors!
Vasopressor titration algorithm: First low dose NE (10mcg/min); if still in shock, initiate vasopressin (0.04 units/min); do not wait on providing vasopressin if EPI is readily available (establish MAP ASAP!).
Initiate vasopressors early with fluids! NE can be initiated peripherally, so don’t wait for a central line!
Only consider dopamine for absolute bradycardia.
Methylene blue is a last resort consideration.
Vasopressors are commonly needed at high doses (i.e., 1mcg/kg/min EPI).
Hydrocortisone 50-100mg for patients with septic SHOCK, not sepsis alone.

Summarized by: Travis Barlock, MD PGY-1

References:

Farkas J. PulmCrit- Epinephrine challenge in sepsis: An empiric approach to catecholamines. EMCrit Project. https://emcrit.org/pulmcrit/epi/. Published August 21, 2018. Accessed September 17, 2019.
Dellinger RP, Levy MM, Rhodes A, et al. 2017. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2016. Critical Care Medicine. 44(3):486-552.

Antibiotics for Sepsis Sep 16, 2019

Join the EMGuideWire crew once again for this month's series on Sepsis in honor of Sepsis Awareness month. Episode 3 will cover antibiotic use and selection.

Antibiotics for Sepsis

Take a history and perform a chart biopsy first! Consider past infections, bug susceptibilities, healthcare acquired vs. community acquired infection, foreign travel, and comorbidities.
Always check local antibiogram and prior culture results.
Septic shock - Start broad spectrum antibiotics within 1 hour.
Stable patient - find the source! UA, CXR, and a good skin exam are fast and can help guide antibiotic choice. Remember some patients need surgical management!
Antibiotic choice in septic shock.
- 1st agent - Piperacillin/Tazobactam (covers GP/GN + Pseudo)
- 2nd agent - Choose based on patient characteristics
- - Ceftriaxone - simple community acquired infections.
  - Vancomycin - covers MRSA.
  - Meropenem - use for patients with a hx of ESBL.
  - Flagyl + cefepime/meropenem - Use for intra-abdominal infections.
  - Clindamycin - Useful for skin infections (toxin suppression).
  - Cefazolin - IV line infections, endocarditis, soft tissue infections w/o MRSA (covers MSSA, GAS, GBS).

Summarized by: Travis Barlock, MD PGY-1

References:

Alam N et al. 2018. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet. Respiratory Medicine. 6(1): 40-50.
Dellinger RP, Levy MM, Rhodes A, et al. 2017. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2016. Critical Care Medicine. 44(3):486-552.

Fluids in Sepsis Sep 09, 2019

Sepsis Awareness Month continues! Join the EMGuideWire Team as they dive into the issues of Fluid selection for resuscitation.

1) Fluids are not all created equal. Use balanced fluids for large volume resuscitation.

2) Lactated Ringers is likely the best choice available in the ED. Plasmalyte is also a good option, if you have it.

3) You can start low dose vasopressors peripherally if you need to, rather than continuing to flood patients with fluids for hypotension.

Sepsis Definitions Sep 02, 2019

Join the EMGuideWire Team,from Carolinas Emergency Medicine Residency Program in Charlotte, NC, as they explore the critical core concepts on the important topic of Sepsis. In this first episode, the team will discuss the definitions of Sepsis.

Pearls:

Sepsis is a dysregulated systemic inflammatory response to infection causing intravascular inflammation, tissue ischemia, cytopathic injury, and dysregulated apoptosis.
SIRS terminology is now outdated. Current terminology is “Sepsis” (SIRS, suspected source, end organ damage) and “Septic Shock.”
Septic shock: SBP 22, AMS, SBP < 100; 2-3 points = poor outcomes.
Epidemiology: 164,000 cases annually. Bacterial etiology most common. Mortality for sepsis and septic shock is 10 and 40% respectively.

Summarized by Travis Barlock, MD PGY-1

References:

Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. New England Journal of Medicine 2003; 348:1546.
Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:762.

Sepsis Awareness Month Core Concepts Sep 01, 2019

Join the EMGuideWire Team, from Carolinas Emergency Medicine Residency Program in Charlotte, NC, as they explore the critical core concepts on the important topic of Sepsis. Over the course of September, Sepsis Awareness Month, the group will cover a variety of high-yield points to help make us all better at recognizing, evaluating, and managing Sepsis. This is the Intro to the month. Follow us every week for more information... and maybe even get a Bonus 5th episode as a reward!

Thyroid Storm and Thyrotoxicosis Aug 02, 2019

Join the EMGuideWire team from Carolinas Medical Center Emergency Medicine Residency Program as they discuss the challenging condition of thyrotoxicosis and thyroid storm! From evaluation to management, this critical state requires our respect and attention!

Skin Soft Tissue Infections Jul 30, 2019

Join the EMGuideWire crew as they explore the various skin and soft tissue infections that are commonly encountered and considered in the Emergency Department. While some may be minor, like furuncles, others can be life-threatening, like necrotizing fasciitis.

Pediatric Difficult Airway Review Jul 21, 2019

Join the EMGuideWire Team as they explore the Basic Principles that must be considered when managing a pediatric airway. Knowledge of the anatomic and physiologic differences that exist between adults and children is paramount! Assuming that all pediatric airways are going to be "difficult" may help keep us prepared.

Transition of Care Jul 13, 2019

Join the EMGuideWire Team as they discuss some of the tips for having a successful and safe Sign-Out in the ED. Hear from recent graduates from the Carolinas Medical Center Emergency Medicine Program as they discuss their perspectives on Transition of Care in the ED.

Pediatric Non-Accidental Trauma (NAT) May 19, 2019

Join the EMGuideWire Team as they are joined by two Pediatric EM experts (Drs. Simone Lawson and Pat Morgan) to discuss the very important and challenging topic of Pediatric Non-Accidental Trauma (NAT). Let's discover ways to remain help pick up on the subtle and sentinel cases to help protect our most vulnerable patients.

Sudden Cardiac Death in Athletes May 03, 2019

Join Dr. Driscoll from the EMGuideWire crew as he enters the Sports Medicine Corner once again. Today, he covers some of the issues with athlete cardiac screening and sudden cardiac death in athletes.

Myasthenic Crisis Mar 22, 2019

Join the EMGuideWire Team as they discuss the evaluation and management of Myasthenia Gravis and a Myasthenic Crisis! Learn about the means to assess a patient's ability to maintain her/his own airway.

Hyperkalemia EKG Changes Feb 22, 2019

Join the EMGuidewire team from CMC EM program as they discuss a potentially critical condition, HyperKalemia. Review the important HyperKalemia EKG Changes and be ready to take action!

Pediatric Urinary Tract Infections Feb 15, 2019

Join the Ped EM Fellows from Carolinas Medical Center and the EMGuideWire as they discuss the seemingly simple issue of Pediatric Urinary Tract Infections. Who needs to be test and how do we do so? Let's review this less than simple topic.

Vasopressors in the ED Feb 08, 2019

Join Drs. Trigonis and Murray from the EMGuideWire team as they discuss use and selection of Vasopressors in the ED.

Aspirin (ASA) Toxicity Feb 07, 2019

Join the EMGuideWire Team, from the CMC EM program, as they enter the TOXIDome once again to wrestle with Aspirin (ASA) Toxicity!

TOXIDOME's Approach to the Agitated Patient Feb 03, 2019

The patient is agitated and combative and a danger to everyone in the ED. What do you give? Haloperidol and lorazepam? Maybe there are better choices. Join the EMGuideWire crew as they enter the TOXIDome to discuss a better approach to the management of the Agitated Patient.

Toxicology 101 Part 2: Toxidromes Feb 03, 2019

Join the EMGuideWire team as they enter the TOXIDome once again and review Toxidromes with Dr. Kopec!

Tylenol TOXICITY Jan 12, 2019

Join the EMGuideWire team as they introduce a new Toxicology Series. Enter the TOXIDome with them as they wrestle with Tylenol Toxicity and discuss when and why to use NAC!

LVADs Jan 04, 2019

Join the EMGuideWire Team as they discuss a simple approach to the very complex and complicated patients with a Left Ventricular Assist Device (LVAD). "LVAD" is for "Look & Listen, Ventricle, Anticoagulation, and Driveline."

Ischemic CVA Dec 13, 2018

Join the EMGuideWire Team as they discuss the current core concepts of imaging and management of patients with findings concerning for Ischemic CVA (stroke). The EMGuideWire crew is joined by world renowned Emergency Neurology expert, Dr. Andrew Asimos!

Morsels Rebaked FLU Dec 06, 2018

Join Drs. Richardson and Potter as they ReBake a Morsel of Pediatric Emergency Medicine. It is Flu Season in the Northern Hemisphere. Let's review some Morsels on Pediatric Flu!

Ped EM Morsels REBAKED - Chest Pain Nov 30, 2018

Join Drs. Nicholena Richardson and Jennifer Potter from the EMGuidewire Team as they review and REBAKE previous Ped EM Morsels (www.pedemmorsels.com). In this episode, they discuss three important potential causes of chest pain in the pediatric patient.

Exertion Related Heat Illness Nov 19, 2018

Join Dr. Driscoll from the EMGuideWire team as he discusses the very important topic of exertion related heat illness. The Sports Medicine Corner can be helpful for everyone who cares for our patients who may overexert themselves. Know how to stay cool when they get too hot!

Pericarditis Nov 15, 2018

Join the EMGuideWire crew as they review Pericarditis evaluation and management in the ED. Are those ST segments more concerning for ischemia? Are steroids helpful? These questions and more will be answered!

Ventilator Set Up Nov 02, 2018

Join the EMGuideWire Team as they discuss some basic concepts to help you make decisions about initial ventilator settings after intubation.

LisFranc Fracture Oct 26, 2018

Join Dr. Jeremy Driscoll and his Sports Medicine Corner as the EMGuideWire addresses LisFranc Fracture. Know how to evaluate and manage this important foot injury!

Patellar Dislocation Oct 26, 2018

Join Dr. Jeremy Driscoll of the EMGuideWire Team for this episode of his Sports Medicine Corner. In this episode, Dr. Driscoll covers Patellar Dislocation!

Procedural Sedation Oct 19, 2018

Join the EMGuideWire team as they discuss the basics of successful procedural sedation. Explore the various medication options that can keep our patients comfortable.

Toxicology 101 Oct 11, 2018

Join the Dr. Kathryn Kopec as she joins the EMGuideWire team to discuss how the Toxicologist approaches the patient who has a potential exposure to an intoxicant. Review your basic evaluation and treatment options and learn how to recognize those all important toxidromes!

Peritonsillar Abscess (PTA) Oct 04, 2018

Join the EMGuideWire Team as they discuss the evaluation and management of Peritonsillar Abscess (PTA) in adults and children.

Lupus in the ED Sep 26, 2018

Join the EMGuideWire team as they discuss some of the subtle and severe presentations of Lupus, a condition that can affect every organ system, in your ED.

Knee Dislocations Sep 21, 2018

Join the EMGuideWire Team and Dr. Jeremy Driscoll as he covers the evaluation and management of Knee Dislocations.

Clavicle Fracture Sep 15, 2018

Join Dr. Driscoll and the EMGuidewire Team in this episode of Sports Medicine Corner. This episode will discuss evaluation and management of Clavicle Fracture.

Biceps Tendon Rupture Sep 15, 2018

Join Dr. Driscoll and the EMGuidewire Team in this episode of Sports Medicine Corner. This episode will discuss evaluation and management of Biceps Tendon Rupture.

Achilles Tendon Injury Sep 07, 2018

Join the Dr. Jeremy Driscoll as he discusses Achilles Tendon Injury in this episode of the EMGuideWire's Sports Medicine Corner.

Mallet Finger Injuries Sep 07, 2018

Join the EMGuidewire Team as they introduce a new series, the Sports Medicine Corner. This episode will cover a common finger injury, the Mallet Finger.

Nasotracheal Intubation Sep 03, 2018

Join the EMGuideWire team as they discuss the core concepts of this critical procedure that can be extremely challenging. Learn the basic steps and some expert tips to help make your next Nasotracheal Intubation go as smoothly as possible.

TRAUMA TALKS Lower Extremity Injuries Aug 24, 2018

Join the EMGuideWire Team as they discuss some of the common and some of the easily missed traumatic injuries that can involve the lower extremities. Know how to be aware of them and learn how to initially manage them.

PAIN Management in Our EDs Aug 16, 2018

Join the EMGuideWire Team as we discuss Pain Management issues and options in our Emergency Departments. EM physicians Sergey Motov and Chris Griggs discuss concepts that may help alleviate not only the patients' pain, but also the challenges physicians face in today's environment.

What's in Your Code Cart Aug 09, 2018

Join the EMGuideWire Team as they review some of the important medications in your typical "Code Cart." Know the important details about these medications that will enable you to use them most effectively!

Pediatric Nasal Foreign Bodies Aug 03, 2018

Join the EMGuideWire team as they discuss the common, and sometimes frustrating, complaint of Pediatric Nasal Foreign Body. What are some of the approaches to help alleviate the problem?

Hyperemesis Gravidarum Jul 27, 2018

Join the EMGuideWire team as they review the Core Concepts that will help you manage the challenging cases of Hyperemesis Gravidarum. From initial evaluation to medications, what can we do to help our pregnant patients with this condition feel better? Let's find out.

Pediatric Diabetic Ketoacidosis and Fluid Management Jul 17, 2018

Join the Pediatric Emergency Medicine Fellows and the EMGuideWire crew as they discuss the challenges of fluid resuscitation in pediatric patients with diabetic ketoacidosis (DKA). What does the most recent literature say we should do?

Upper GI Bleeds Core Concepts Jul 14, 2018

Join the EMGuideWire team as they tackle the tough core concepts of how to manage the patients with simple and critical Upper Gastrointestinal Bleeds. Know what medicines are imperative to start and what ones may be discussed with your consultants.

HepatoRenal Syndrome Jul 03, 2018

Join the EMGuideWire Team as they explore the basic issues with managing patients with the dreaded Hepatorenal Syndrome. Do you use Albumin? Do you use Pressors? Do you use Both? A little understanding of the pathophysiology will help us answer those questions.

A Better PEA Algorithm by Dr. Littmann May 27, 2018

Join the crew from EMGuideWire as they review a clinically useful approach to and management of PEA. Dr. Laszlo Littmann will, once again, be our guide on this Cardiology Core Concepts tour.

Wide Complex Tachycardia Part 3 May 19, 2018

Join the EM GuideWire team as they complete the journey through management of Wide Complex Tachycardia with Dr. Laszlo Littmann with the 3rd installment. This time, you'll treat the unstable and critically ill patient.

Acute Urinary Retention May 06, 2018

Join the EMGuideWire team as they explore the painful, and personal, aspects of Acute Urinary Retention. Learn what issues must be considered and some strategies to help you manage the patient with acute urinary retention in your Emergency Department.

Wide Complex Tachycardia in Rhythm Strips Apr 26, 2018

Join the EMGuideWire crew as they learn from the master, Dr. Laszlo Littmann, how to interpret patients' rhythm strips to discern whether there is VTach, SVT, or even artifacts.

Wide Complex Tachycardia Part 2 Apr 19, 2018

Join the EMGuideWire crew at CMC in Charlotte, NC as they take on the complex and scary topic of Irregular Wide Complex Tachycardia in Part 2 of the 3 part series on the approach to Wide Complex Tachycardia. Dr. Laszlo Littmann's expert advice, once again, saves the day!

The Dying Asthma Patient Apr 12, 2018

Join the EMGuideWire crew as they discuss how to manage the dying asthma patient. Dr. David Pearson will help guide the team through the management of these severely ill patients while helping to anticipate the pitfalls and, hopefully, avoiding them.

Increased ICP Mar 25, 2018

Join the EM GuideWire team as they discuss some simple strategies to manage increased intracranial pressure (ICP). From intubation to administration of hypertonic saline, the group will discuss the basic steps to help your most critical patients.

Wide Complex Tachycardia Cardio Core Concepts Mar 16, 2018

Wide Complex Tachycardia will grab everyone's attention. Let's join the crew from EMGuideWire and Dr. Littmann to review a simplified approach to evaluation and management of Wide Complex Tachycardia!

Methylene Blue Core Concepts Mar 08, 2018

Aside from making your fingers blue, Methylene Blue is a very useful dye that know how and when to use in the Emergency Department! Join the EM GuideWire Team as they explore this potentially life saving medication!

A Fib Management in the ED Mar 07, 2018

A Fib is the most common arrhythmia that is encountered in the ED. Knowing how to manage it when it is causing problems is important! Join the EM GuideWire Team as they discuss a-fib with RVR management with esteemed Cardiologist (and friend of us in the ED), Dr. Laszlo Littmann.

Asymptomatic Hypertension Core Concepts Feb 28, 2018

Hypertension may be a medical emergency, but many time EM physicians are faced with the patient with asymptomatic hypertension. Join the EM GuideWire Team as it address with issue and helps us all know how to appropriately evaluate and manage these situations.

HyperKalemia Core Concepts Feb 28, 2018

Hyperkalemia can present subtly or as a critical condition. Join the EM GuideWire Team as they discuss how to address the issues of Hyperkalemia and manage it successfully!

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