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**EMplify by EB Medicine**

Take a deeper dive into our peer-reviewed emergency medicine content with the EMplify podcast. Join hosts Sam Ashoo, MD and T.R. Eckler, MD for educational, conversational reviews of current evidence guaranteed to help you make your best clinical decisions. Each high-yield episode gives you practical, time-tested guidance from practicing emergency medicine clinicians and subject-matter experts. Listen and learn!

Latest Episodes:

Monkeypox May 23, 2022

Show notes

Epidemiology

Caused by double stranded DNA virus, genus orthopoxvirus, closely related to smallpox and cowpox.
Discovered in 1958 in monkeys with first human case recorded in 1970 in the Democratic Republic of Congo. (CDC)
It is a zoonotic disease , meaning it is transmitted from animal to humans, with primary reservoir in squirrels, Gambian poached rats, dormice, different species of monkeys and others.
First reported in the U.S. in 2003. Cases were related to pet prairie dogs that had been housed with monkeypox virus infected African rodents, imported from Ghana (WHO)
There are 2 clades (having evolved from same ancestral line) of the disease. The current outbreak is from the West African lineage. (WHO)
West African – milder disease, 1-3% fatality
Congo Basin – severe disease, 10% fatality
Due to the similarity in the viruses, immunization against smallpox has been found to prevent infection with monkeypox. The WHO believes that increasing frequency of worldwide infection may be related to waning immunity against smallpox, since that disease was eradicated in 1980 and the vaccine is no longer popularly used.

Transmission

Animal to human – contact with sick or dead animals, ingesting poorly cooked meat of infected animals.
Human to human -” Human-to-human transmission is thought to occur primarily through large respiratory droplets. Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required. Other human-to-human methods of transmission include direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens.” (CDC)

Symptoms

Initial 1-3 days – fever, lymphadenopathy, back pain, headache, myalgias, fatigue
2-4 weeks of rash progression: macules -> papules -> vesicles -> pustules -> scabs
The pox rash starts on the face and spreads to the rest of the body.

Testing

Detection is by PCR testing, ideally of body fluid contained in the pox blisters.
Test kits are available through local U.S. Health Departments and the CDC. All suspected cases should be reported to local authorities.

Treatment

Treatment includes vaccinating anyone who has been exposed with the smallpox vaccine (ring vaccination). The general population is no longer routinely vaccinated due to side-effects of the smallpox vaccine.
No current recommendation exists for antiviral therapy or smallpox immunoglobulin therapy.
See CDC recommendations

Prevention

The JYNNEOS vaccine was FDA approved in 2019 for adults > 18 against both smallpox and monkeypox. It is a 2 dose non-replicating attenuated virus that does not produce a lesion, and therefore can not cause transmission to others. The CDC Advisory Committee on Immunization Practices is currently evaluating vaccine data with a formal recommendation pending. Media reports note the U.S. government has ordered millions of doses.
The original smallpox vaccine (DRYVAX) is no longer in production. However, a second generation clone, ACAM2000, is produced by Synofi and approved by the FDA. The WHO notes that smallpox vaccine is 85% effective in preventing monkeypox.
Vaccination is recommended for lab workers and anyone exposed to monkeypox. The CDC recommends vaccination within 4 days of exposure to prevent disease, with ACAM2000. However, vaccination between days 4-14 is also recommended to reduce disease severity.
Vaccination does carry risks. The CDC estimates “Based on past experience, it is estimated that between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening complications from the vaccine” (ACAM2000) but notes that disease fatally is 1-10% outweighing the risk of vaccination.

Further Reading

Conversation- Airway Management May 18, 2022

Show notes

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

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

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

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

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

Thanks for being a listener.

Episode 69 – Cellulitis and Other Skin and Soft Tissue Infections May 09, 2022

Show notes

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

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

EMplify – May 2022

Episode Outline:

1. Why cellulitis/skin infections?

2. Terminology

Erysipelas vs cellulitis vs fasciitis
Purulent cellulitis

3. Most common pathogens

4. Special situations

5. Necrotizing infection classification system – is this helpful in the ED, and if so, why?

6. Differential – unilateral vs bilateral presentation

7. Prehospital care

8. ED evaluation

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

9. Diagnostics

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

10. Labs

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

11. Treatment

NSTI antibiotics
Abscesses

12. Special populations

IV drug users
Diabetic patients
Immunocompromised patients

13. Wound irrigation and loop drainage

14. Disposition

Conversations - Dr. Lorna Breen Legislation Apr 27, 2022

Show notes

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

Take the listener survey:

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

More on the Dr Lorna Green Legislation here:

https://www.ebmedicine.net/ebmblog/general-emergency-medicine/news-updates/dr-lorna-breen-health-care-provider-protection-act/

Episode 68 -- Meningitis and Encephalitis – An Interview with Dr. Andrew Hogan Apr 01, 2022

Show notes

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

EMplify -- April 2022

Interview with the Author: Andrew N. Hogan, MD

1.Meningitis vs encephalitis

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

2.Bacterial meningitis

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

3.Viral meningitis

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

4.Viral encephalitis

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

5.Fungal infections

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

6.Prehospital care:

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

7.ED evaluation: History

8.ED evaluation: Physical exam

9.Diagnostics: CSF

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

10.Serum labs

What is helpful?
Serum PCR
Serum cryptococcal antigen

11.Imaging

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

12.Treatment

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

13.Special populations

Autoimmune disease
Lacking childhood vaccines
Healthcare associated infections

14.Cutting edge

15.Disposition

Episode 67 – Managing Postpartum Complications in the Emergency Department – An Interview with Dr. Nicole Yuzuk, Dr. Joseph Bove, and Dr. Riddhi Desai Mar 07, 2022

Show notes

Episode 67 – Managing Postpartum Complications in the Emergency Department – An Interview with Dr. Nicole Yuzuk, Dr. Joseph Bove, and Dr. Riddhi Desai

EMplify – March 2022

Interview with the Authors: Nicole Yuzuk, DO, Joseph Bove, DO, and Riddhi Desai, DO

Episode Outline:

1.Why is this an important topic in EM?

2.Hemorrhage etiologies and definition

3.Headache etiologies, both common and the more dangerous (ICH)

4.Fever and infection

Mastitis
Endometritis

5.Preeclampsia/eclampsia

Definition, diagnosis, risk factors (Table 1)

6.HELLP syndrome

Definition, diagnosis (Table 2)

7.Peripartum cardiomyopathy

Time of onset, how to make the diagnosis, risks (Table 3)

8.Prehospital care

IV fluids
TXA
AMS evaluation
Chest pain
Fever/hypotension

9.ED evaluation

History (what kind of things should we remember to ask?)
Physical exam (what should we be paying attention to?)

10.Diagnostic studies

Hemorrhage (exam, vitals, labs, US)
Headache (labs, imaging – what type?)
Fever and infection (labs, imaging – US or CT, antibiotics)
Cardiopulmonary complaints (labs, imaging, ECG)

11.Treatment

Hemorrhage
Headache (CVT)
Infection (mastitis, endometritis, wound Infection)
Preeclampsia, eclampsia, HELLP, seizures
Cardiomyopathy

12.What about breastfeeding mothers?

13.Controversies and cutting edge

Endovascular therapy
Thromboelastography

Episode 66 - Acute Asthma Feb 07, 2022

Show notes

Episode 66 – Acute Asthma Exacerbations – An Interview with Dr. Steven Hochman and Dr. Brandon Somwaru

EMplify – February 2022

Emergency Department Management of Acute Asthma Exacerbations

Interview with the authors: Steven M. Hochman, MD, and Brandon Somwaru, DO

Episode Outline:

Epidemiology
Risk factors for death from asthma (Table 1)
Triggers for asthma attacks
Variants of asthma (Table 2)
Differential diagnosis (Table 3)
Can PE be a trigger for an acute asthma attack?
Prehospital care
ED care: history (what should we ask?)
ED care: physical exam (what are we looking for?)
Classifying mild/moderate/severe asthma
Lab studies
POCUS (Table 5 and Figure 3)
Peak expiratory flow
ETCO2 capnography and capnometry
Chest x-ray
Treatment (Table 6)
Medications
Oxygen
SABA vs LABA
What about MDIs?
Continuous nebs?
Anticholinergics
Steroids (IV, oral, inhaled; prednisone vs dexamethasone)
Magnesium sulfate
Epinephrine
Terbutaline
Ketamine
NIPPV
Intubation pearls and pitfalls (Table 8)
Special populations
Pediatrics
Pregnancy
COVID-19
Controversies and cutting edge
Biologics
Fractional exhaled nitric oxide
Heliox
High flow nasal cannula
Delayed sequence intubation
ECMO
Disposition

Episode 65 – Acute Joint Pain Jan 06, 2022

Show notes

Interview with author: Rachel Sullivan, MD

Why joint pain ?
Differential Diagnosis
Mono vs Poly Articular Presentation? Figure 1
Infectious, degenerative, autoimmune, crystal deposition, reactive, traumatic
Septic Arthritis-
Bimodal incidence
Risks
Septic arthritis is polyarticular in 15% to 20% of cases, and in these cases, the mortality is high
Gonococcal
Highest risk
Commonly affected joints
Symptomatic or asymptomatic infection
Lyme Arthritis
Viral – Zika, chikungunya, human parvovirus B19, hepatitis
Degenerative osteoarthritis
Autoimmune
Gout
CPPD
Prehospital
ED History – table 2, table 4
ED exam
Labs – do we need them?
Imaging
Arthrocentesis – Table 5
Treatment
Special Populations
Prostheses
Immunocompromised
HIV
Clinical Pathway

Episode 64 – Thoracic Aortic Syndromes- An Interview with Dr. Anthony Hackett Dec 01, 2021

Show notes

EMplify – December 2021

Announcements:

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

Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management

Interview with author: Anthony Hackett, MD

Thoracic Aortic Syndromes

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

Episode 63 – Rib Fracture- An Interview with Dr. Patrick Maher Nov 01, 2021

Show notes

EMplify – November 2021

Announcements:

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

Emergency Department Management of Rib Fractures

Author: Patrick Maher, MD

Episode Outline:

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

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