EMplify by EB Medicine

Latest Episodes:

Special Message on Racism Jun 06, 2020

Show notes

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

Episode 42 -The New Orleans Experience and Palliative Care : An Interview with Dr. Ashley Shreves May 15, 2020

Show notes

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

Episode 41 - Mt Sinai COVID-19 Protocols - Interview with Dr. Legome May 01, 2020

Show notes

EMplify May 2020- Mt Sinai COVID-19 Protocols - Dr. Legome

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

Episode 40 - COVID-19: An Interview with Colby Redfield, MD-Tent Triage, Telemedicine, PPE, and EMS Apr 19, 2020

Show notes

EMplify April 2020 – Colby Redfield, MD

emplify@ebmedicine.net

1-678-336-8466, ext. 128

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

4. 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

Episode 39 - Discussion with MDCalc on COVID-19 risk scores & NYC Apr 02, 2020

Show notes

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.

Episode 38 - COVID-19 Update: An Interview with Andrea Duca, MD Mar 19, 2020

Show notes

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

Episode 37 - Novel Coronavirus COVID-19: An Overview for Emergency Clinicians Mar 10, 2020

Show notes

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

Episode 36 - Diagnosis and Management of Acute Gastroenteritis in the Emergency Department Mar 04, 2020

Show notes

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%.

Laboratory Testing and Imaging:

Dehydration is the biggest contributor to mortality, especially in the very young and elderly.
Lab evaluation for dehydration is recommended in these populations.
No consistent association between lab abnormalities and bacterial etiology.
WBC and differential does not differentiate bacterial vs viral, but may help in identifying severity of illness.
Hemoglobin and platelets are helpful if HUS is suspected.
Stool Cultures:
- 2017 IDSA guidelines recommends them in patients with fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis, noting these patients are at higher risk of bacterial infection. Specifically, Salmonella, shigella, Campylobacter, and Yersinia
- 2016 ACG guidelines recommend them for patients with watery diarrhea and moderate to severe illness with fever for at least 72 hours.
- Consider them for immunocompromised patients and those with recent abx use or hospitalization.
C Difficile testing is recommended for all patients with AGE who are age >2 with a history of recent abx use or recent hospitalization
Blood cultures are recommended for patients <3 months old and any patient with signs of sepsis.
Imaging is generally plain film to exclude free air of surgical abdomen, or CT with contrast to evaluate for complications of AGE like aortitis, mycotic aneurysm, toxic megacolon, abscess, or perforation.

Hydration:

Oral rehydration is preferred. Oral rehydration solutions in patients tolerating oral fluids.
- ORS packets
- Pedialyte, Hydralyte, etc
- Sports drinks are safe but have less potassium. Higher sugar solutions can be diluted 50%
- Coconut water
- Half strength apple juice has been studied in pediatrics and decreased treatment failure.
IV hydration for patients with severe dehydration, hypovolemic shock, septic shock, or failed oral rehydration.
Don't forget to replace electrolytes if giving IV hydration.

Meds:

Ondansetron (Zofran) reduces need for IV hydration in peds. (0.15mg/kg oral liquid) but doesn't reduce hospitalizations or return visits (low numbers)
No benefit to higher dose ondansetron.
IV ondansetron vs metoclopramide performance is similar in peds.
No benefit in studies to giving dexamethasone, or dimenhydrinate (dramamine)
Proshlorperazine 10mg IV was shown to be superior to promethazine 25mg IV for symptom relief in adults, with less sedation
No suggestions regarding medication choice from guidelines.
Sniffing isopropyl alcohol soaked pads twice q 2min was shown superior vs placebo in controlling nausea, but effect is gone at 30 minutes.
Ginger is reported to be helpful at 250mg QID in pregnant patients and post op patient. No data in AGE.
Loperamide is recommended as an adjunct to abx by the ACG. Risk is too high in patients <3 yo and 3-12 with moderate dehydration, blood stool, or severe disease.
Loperamide is also contraindicated if STEC is suspected, due to increased development of HUS
Probiotics may reduce diarrhea by one day.
World Health Organization recommends zinc supplements for children with diarrhea. In the US only recommended to reduce duration in severely malnourished children age 6mos-5yo.

Antibiotics:

Patients with traveler's diarrhea from Latin America, Caribbean, and Africa will improve faster with abx therapy. Azithromycin 1gm PO x 1, Cipro 750 mg PO x 1, or Cipro 500mg PO BID x 3 days.
Patients with traveler's diarrhea from South Asia and Southeast Asia have increased strains of fluoroquinolone resistant Campylobacter. Aizthromycin 1gm PO x 1 or 500mg PO daily for 3 days is recommended.
Great chart Table 4, page 12, on abx recommendations.
Shellfish ingestion - Doxy, Azithomycin, or Cipro.
C Diff - first line is oral vancomycin 125 mg PO QID for 10 days or Fidaxomicin 200mg PO BID for 10 days. Metronidazole is less effective due to resistance and is only used if the above is not available.

Episode 35 - Diabetic Hyperglycemic Emergencies: A Systematic Approach Feb 06, 2020

Show notes

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

Episode 34 - Emergency Department Management of Non–ST-Segment Elevation Myocardial Infarction Jan 10, 2020

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Show Notes

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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.

Show More v

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
1. > 2.5mm in med < 40 yrs old
2. >2 mm in men > 40 yrs old
3. >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
- 8. 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]
- 9. 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
Beta Blockers
Statins

Part 7: Revascularization

Immediate/urgent revascularization is recommended for all patients with NSTEMI who show signs of clinical instability, including refractory angina, sustained ventricular dysrhythmias, new or worsening heart failure, or shock (AHA class Ia recommendation; ESC class Ic recommendation). Otherwise, there is no clear benefit to immediate revascularization on all NSTEMI patients.

Part 8: The Specials…

Women
Black Patients
Young Patients
Diabetics
Cocaine Users

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