In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2023 Emergency Medicine Practice article, Diagnosing and Treating Pericarditis and Myocarditis in the Emergency DepartmentEpidemiologyNomenclatureEtiologyDifferential diagnosisPrehospital careED history and physicalDiagnosticsECGLabsImaging (X-ray, CT, US, MRI)Treatment Special populationsCOVID-19AthletesMIS-C

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2023 Emergency Medicine Practice article,<a href="https://www.ebmedicine.net/topics/cardiovascular/emergency-medicine-pericarditis-myocarditis" rel="nofollow" target="_blank"> Diagnosing and Treating Pericarditis and Myocarditis in the Emergency Department</a> EpidemiologyNomenclatureEtiologyDifferential diagnosisPrehospital careED history and physicalDiagnostics<ul><li>ECG</li><li>Labs</li><li>Imaging (X-ray, CT, US, MRI)</li></ul>Treatment Special populations<ul><li>COVID-19</li><li>Athletes</li><li>MIS-C</li></ul>

Acute Pericarditis & Myocarditis

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the June 2023 Emergency Medicine Practice article, Hypertensive Emergencies: Guidelines and Best Practice RecommendationsEpidemiologyEtiologyDifferential diagnosisPrehospital careHistory and physical DiagnosticsTreatmentAcute decompensated heart failureAcute ischemic strokeAcute coronary syndromeIntracerebral hemorrhageSubarachnoid hemorrhageAortic dissectionHypertensive encephalopathySevere pre-eclampsia and eclampsiaControversiesArterial line placementBeta blockers and cocaineRisk management caveatsSummary

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the June 2023 Emergency Medicine Practice article, <a href="https://www.ebmedicine.net/topics/cardiovascular/emergency-medicine-hypertensive-emergencies" rel="nofollow" target="_blank">Hypertensive Emergencies: Guidelines and Best Practice Recommendations</a> Epidemiology Etiology Differential diagnosis Prehospital care History and physical  Diagnostics Treatment<ul><li>Acute decompensated heart failure</li><li>Acute ischemic stroke</li><li>Acute coronary syndrome</li><li>Intracerebral hemorrhage</li><li>Subarachnoid hemorrhage</li><li>Aortic dissection</li><li>Hypertensive encephalopathy</li><li>Severe pre-eclampsia and eclampsia</li></ul> Controversies<ul><li>Arterial line placement</li><li>Beta blockers and cocaine</li></ul> Risk management caveats Summary

Hypertensive Emergencies

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the May 2023 Emergency Medicine Practice article on Emergency Department Management of Gastrointestinal Foreign Body IngestionEpidemiologyEtiology - types of ingestionsAnatomy - common locations by ageFood impactionSharp objectsButton batteriesMagnetsColorectal foreign bodiesPrehospital careHistory and PhysicalImagingExpectant managementEndoscopic removalNon-endoscopic techniquesBody PackingGlucagonGastric button batteriesSummary

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the May 2023 Emergency Medicine Practice article on <a href="https://www.ebmedicine.net/topics/gastrointestinal/emergency-medicine-foreign-bodies" rel="nofollow" target="_blank">Emergency Department Management of Gastrointestinal Foreign Body Ingestion</a> EpidemiologyEtiology - types of ingestionsAnatomy - common locations by age<ul><li>Food impaction</li><li>Sharp objects</li><li>Button batteries</li><li>Magnets</li><li>Colorectal foreign bodies</li></ul>Prehospital careHistory and PhysicalImagingExpectant managementEndoscopic removalNon-endoscopic techniquesBody PackingGlucagonGastric button batteriesSummary

GI Foreign Body Ingestion

In this episode, Sam Ashoo, MD, talks with Rob Orman, MD, founder of Orman Physician Coaching, about longevity in emergency medicine.﻿Personal foundation Regular check-insBecoming an expert in… Job stressLiving beneath your meansRecharging and shift workBad outcomesPhysician loungeLearning to say noSet a reminderMore at Orman Physician Coaching 

In this episode, Sam Ashoo, MD, talks with Rob Orman, MD, founder of <a href="https://roborman.com/" rel="nofollow" target="_blank">Orman Physician Coaching</a>, about longevity in emergency medicine.﻿<ul><li>Personal foundation </li><li>Regular check-ins</li><li>Becoming an expert in… </li><li>Job stress</li><li>Living beneath your means</li><li>Recharging and shift work</li><li>Bad outcomes</li><li>Physician lounge</li><li>Learning to say no</li><li>Set a reminder</li></ul> More at <a href="https://roborman.com/" rel="nofollow" target="_blank">Orman Physician Coaching</a>

Career Longevity

Announcements: The interactive Clinical Pathways have launched and they are available for free! In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the March 2023 Emergency Medicine Practice article on Emergency Department Management of Infective Endocarditis-Associated StrokeEpidemiologyPathophysiologyPopulations at RiskComplicationsIntracranial hemorrhageAneurysmsHeart blockPrehospital CareED History and ExaminationImagingAntibiotic TherapySurgical TreatmentSpecial PopulationsSummary

Announcements: The interactive <a href="https://clinicalpathways.ebmedicine.net/" rel="nofollow" target="_blank">Clinical Pathways</a> have launched and they are available for free!  In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the March 2023 Emergency Medicine Practice article on <a href="https://www.ebmedicine.net/topics/stroke/emergency-medicine-endocarditis-stroke" rel="nofollow" target="_blank">Emergency Department Management of Infective Endocarditis-Associated Stroke</a> Epidemiology Pathophysiology Populations at Risk Complications<ul><li>Intracranial hemorrhage</li><li>Aneurysms</li><li>Heart block</li></ul> Prehospital Care ED History and Examination Imaging Antibiotic Therapy Surgical Treatment Special Populations Summary

Infective Endocarditis-Associated Stroke

Announcements:  The interactive Clinical Pathways have launched and they are available for free!  — In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the February 2023 Pediatric Emergency Medicine Practice article on Pediatric Electrolyte Emergencies: Recognition and Management in the Emergency Department — History Point-of-care testing I/O lines Presentation, differential, and treatment of:HyponatremiaHypernatremiaHypokalemiaHyperkalemiaHypocalcemiaHypercalcemiaHypomagnesemiaHypophosphatemia

Announcements:  The interactive <a href="https://clinicalpathways.ebmedicine.net/" rel="nofollow" target="_blank">Clinical Pathways</a> have launched and they are available for free!  — In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the February 2023 Pediatric Emergency Medicine Practice article on <a href="https://www.ebmedicine.net/topics/endocrine/pediatric-emergency-medicine-electrolyte-emergencies" rel="nofollow" target="_blank">Pediatric Electrolyte Emergencies: Recognition and Management in the Emergency Department</a> — History Point-of-care testing I/O lines Presentation, differential, and treatment of:<ul><li>Hyponatremia</li><li>Hypernatremia</li><li>Hypokalemia</li><li>Hyperkalemia</li><li>Hypocalcemia</li><li>Hypercalcemia</li><li>Hypomagnesemia</li><li>Hypophosphatemia</li></ul>

Pediatric Electrolyte Emergencies

Announcements: The interactive Clinical Pathways have launched and they are available for free! ___In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2023 Pediatric Emergency Medicine Practice article on the Responsible and Safe Use of Opioids in Children and Adolescents in the Emergency DepartmentDEA-X Waiver Repeal:The Mainstreaming Addiction ActThe Medication Access and Training Expansion Act (MATE)FOAMed postOpioids in Children and Adolescents: IntroductionEpidemiology and Statistics Medication safety at homeEscalation of pain meds at homeNaloxone prescriptionsMedications in childrenCodeineTramadolNSAIDsLocal anesthetics and nerve blocksIntranasal meds: Ketamine and fentanylOpioids and sedationRegional anesthesiaChronic pain

Announcements: The interactive <a href="https://clinicalpathways.ebmedicine.net/" rel="nofollow" target="_blank">Clinical Pathways</a> have launched and they are available for free! ___ In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2023 Pediatric Emergency Medicine Practice article on the <a href="https://www.ebmedicine.net/topics/pain-management/pediatric-emergency-medicine-responsible-use-of-opioids" rel="nofollow" target="_blank">Responsible and Safe Use of Opioids in Children and Adolescents in the Emergency Department</a> DEA-X Waiver Repeal:<ul><li>The <a href="https://www.congress.gov/bill/117th-congress/senate-bill/445" rel="nofollow" target="_blank">Mainstreaming Addiction Act</a></li><li>The <a href="https://www.congress.gov/bill/117th-congress/house-bill/2067?q=%7B%22search%22%3A%5B%22MATE+Act+2021%22%2C%22MATE%22%2C%22Act%22%2C%222021%22%5D%7D&amp;s=1&amp;r=1" rel="nofollow" target="_blank">Medication Access and Training Expansion Act (MATE)</a></li><li><a href="https://foamed.ebmedicine.net/general-emergency-medicine/news-updates/dea-x-waiver-ended/" rel="nofollow" target="_blank">FOAMed post</a></li></ul> Opioids in Children and Adolescents:  Introduction<ul><li>Epidemiology and Statistics </li></ul> Medication safety at home Escalation of pain meds at home Naloxone prescriptions Medications in children<ul><li>Codeine</li><li>Tramadol</li><li>NSAIDs</li><li>Local anesthetics and nerve blocks</li><li>Intranasal meds: Ketamine and fentanyl</li></ul> Opioids and sedation Regional anesthesia Chronic pain

Opioids in Children and Adolescents

Announcements: The interactive Clinical Pathways have launched and they are available for free! — In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2022 Emergency Medicine Practice article on the Management of Allergic Reactions and Anaphylaxis in the Emergency Department.  IntroThe number of ED visits and hospitalizationsStudies show up to 57% of anaphylactic reactions are not recognized, and epinephrine is not administered in up to 80% of cases. Criteria2006 Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN)WAO revised the criteria in 2020 Delphi group and Brown et alPathophysiology EpidemiologyMost common causes in children and adultsMore than half of deaths from anaphylaxis occur within the first hour of symptom onsetPrehospital CareGive epi, H1 blockersMainstay = recognitionED CareAirwayEpinephrineDecontaminationH1 and H2 blockersCorticosteroidsBiphasic reactionsGlucagonSpecial CasesAlpha-galScombroidKounis syndrome

Announcements: The interactive <a href="https://clinicalpathways.ebmedicine.net/" rel="nofollow" target="_blank">Clinical Pathways</a> have launched and they are available for free!  — In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2022 Emergency Medicine Practice article on the <a href="https://www.ebmedicine.net/topics/allergic-immunologic-inflammatory/emergency-medicine-allergy-anaphylaxis" rel="nofollow" target="_blank">Management of Allergic Reactions and Anaphylaxis in the Emergency Department</a>.  Intro<ul><li>The number of ED visits and hospitalizations</li><li>Studies show up to 57% of anaphylactic reactions are not recognized, and epinephrine is not administered in up to 80% of cases. </li></ul> Criteria<ul><li>2006 Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN)</li><li>WAO revised the criteria in 2020 </li><li>Delphi group and Brown et al</li></ul> Pathophysiology Epidemiology<ul><li>Most common causes in children and adults</li><li>More than half of deaths from anaphylaxis occur within the first hour of symptom onset</li></ul> Prehospital Care<ul><li>Give epi, H1 blockers</li><li>Mainstay = recognition</li></ul> ED Care<ul><li>Airway</li><li>Epinephrine</li><li>Decontamination</li><li>H1 and H2 blockers</li><li>Corticosteroids</li><li>Biphasic reactions</li><li>Glucagon</li></ul> Special Cases<ul><li>Alpha-gal</li><li>Scombroid</li><li>Kounis syndrome</li></ul>

Allergic Reactions and Anaphylaxis

Announcements: 1) The interactive Clinical Pathways have launched and they are available for free! 2) 2023 E/M coding guidelines are in effect. See the summary here. ___ In this episode, Sam Ashoo, MD, interviews Ara Festekjian, MD, one of the authors of the November 2022 Pediatric Emergency Medicine Practice article on Pediatric Septic Shock in the Emergency Department Introduction: How common is sepsis in kids and what is the mortality rate in the US? DefinitionsSeptic shockSepsis associated organ dysfunctionSepsis-3Compensated vs uncompensated shock EtiologyNeonateCentral line and VP shuntsAspleniaImmunocompromised children Differential Diagnosis Prehospital Care ED EvaluationHistoryExaminationSeptic shock + cardiogenic shockWarm vs cold shockEvolution of physical exam findingsDiagnosticsLabsImagingTreatmentIV/IO placementFluid bolusesAntibiotics Pressors Airway management Special PopulationsFebrile neutropeniaNewborns with septic shockControversiesFluid volumeFluid typeAntibiotic timingCorticosteroids

Announcements: 1) The interactive <a href="https://clinicalpathways.ebmedicine.net/" rel="nofollow" target="_blank">Clinical Pathways</a> have launched and they are available for free! 2) 2023 E/M coding guidelines are in effect. See the summary <a href="https://foamed.ebmedicine.net/rapid-reference/2023-e-m-coding-guidelines/" rel="nofollow" target="_blank">here</a>. ___ In this episode, Sam Ashoo, MD, interviews Ara Festekjian, MD, one of the authors of the November 2022 Pediatric Emergency Medicine Practice article on <a href="https://www.ebmedicine.net/topics/infectious-disease/pediatric-emergency-medicine-septic-shock" rel="nofollow" target="_blank">Pediatric Septic Shock in the Emergency Department</a> Introduction: How common is sepsis in kids and what is the mortality rate in the US? Definitions<ul><li>Septic shock</li><li>Sepsis associated organ dysfunction</li><li>Sepsis-3</li><li>Compensated vs uncompensated shock</li></ul> Etiology<ul><li>Neonate</li><li>Central line and VP shunts</li><li>Asplenia</li><li>Immunocompromised children</li></ul> Differential Diagnosis Prehospital Care ED Evaluation<ul><li>History</li><li>Examination</li><li>Septic shock + cardiogenic shock</li><li>Warm vs cold shock</li><li>Evolution of physical exam findings</li></ul> Diagnostics<ul><li>Labs</li><li>Imaging</li></ul> Treatment<ul><li>IV/IO placement</li><li>Fluid boluses</li><li>Antibiotics </li><li>Pressors </li><li>Airway management </li></ul> Special Populations<ul><li>Febrile neutropenia</li><li>Newborns with septic shock</li></ul> Controversies<ul><li>Fluid volume</li><li>Fluid type</li><li>Antibiotic timing</li><li>Corticosteroids</li></ul>

Pediatric Septic Shock

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2022 Evidence-Based Urgent Care article on Influenza in Urgent Care.EpidemiologyHistorical dataSince COVID, tracking "influenza-like illness" has been complicatedInfluenza deaths and ageAnnual mortality ﻿OutbreaksTransmissionClassificationInfluenza A, B, and CHemagglutinin and neuraminidase subgroupsAntigenic drift and shiftPathophysiologyTransmissionIncubation Secondary infectionH3N2VaccinesEgg-based, cell-based, and recombinant influenza vaccinesCDC recommendationsPatients aged &gt;65 yearsDifferential DiagnosisComplications TestingWhen is it indicated? What types of tests are available? Testing in periods of low and high prevalence TreatmentHigh-risk conditions that suggest treatment Antiviral medications Oseltamivir: NNT and NNHResistance patternsBilling and Coding

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2022 Evidence-Based Urgent Care article on <a href="https://www.ebmedicine.net/topics/infectious-disease/urgent-care-influenza" rel="nofollow" target="_blank">Influenza in Urgent Care</a>. Epidemiology<ul><li>Historical data</li><li>Since COVID, tracking "influenza-like illness" has been complicated</li><li>Influenza deaths and age</li><li>Annual mortality </li></ul> ﻿Outbreaks Transmission Classification<ul><li>Influenza A, B, and C</li><li>Hemagglutinin and neuraminidase subgroups</li><li>Antigenic drift and shift</li></ul>Pathophysiology<ul><li>Transmission</li><li>Incubation </li><li>Secondary infection</li><li>H3N2</li></ul>Vaccines<ul><li>Egg-based, cell-based, and recombinant influenza vaccines</li><li>CDC recommendations</li><li>Patients aged &gt;65 years</li></ul> Differential Diagnosis Complications Testing<ul><li>When is it indicated? </li><li>What types of tests are available? </li><li>Testing in periods of low and high prevalence</li></ul> Treatment<ul><li>High-risk conditions that suggest treatment </li><li>Antiviral medications </li><li>Oseltamivir: NNT and NNH</li><li>Resistance patterns</li></ul> Billing and Coding

Influenza

Take a deeper dive into our peer-reviewed emergency medicine content with the EMplify podcast. Join host Dr. Sam Ashoo 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!

This podcast is great review for us long-standing lovers of emergency medicine ❤️ Thank you for sharing your wisdom ! 🙏🏻

Ally Fields

Great podcast!

Great summaries of the evidence in emergency medicine. Enjoying listening every month!

Excellent content!

EMplify by EB Medicine

Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the June 2018 issue of Emergency Medicine Practice: Managing Shoulder Injuries in the Emergency Department Fracture, Dislocation, and Overuse.This month, Richard Pescatore, director of clinical research at Crozer-Keystone Health System and clinical assistant professor at the Rowan University School of Osteopathic Medicine, along with Andrew Nyce, vice chairman and associate professor at cooper medical school of Rowan University reviewed just over 100 articles to come up with their evidence-based recommendations.Their recommendations were then edited by John Munyak of Maimonides and Mark Silverberg of SUNY Downstate and Kings County Hospital.Most  Important  References* Ponce BA, Kundukulam JA, Pflugner R, et al. Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg. 2013;22(7):993-999. (Prospective cohort; 49 patients)* Slaven EJ, Mathers J. Differential diagnosis of shoulder and cervical pain: a case report. J Man Manip Ther. 2010;18(4):191-196. (Case report)* Helfen T, Ockert B, Pozder P, et al. Management of prehospital shoulder dislocation: feasibility and need of reduction. Eur J Trauma Emerg Surg. 2016;42(3):357-362. (Retrospective review; 70 patients)* Lenza M, Belloti JC, Andriolo RB, et al. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. 2014(5):CD007121. (Systematic review; 3 trials, 354 patients)* Neer CS, 2nd. Displaced proximal humeral fractures: part I. Classification and evaluation. 1970. Clin Orthop Relat Res. 2006;442:77-82. (Review article)* Sholsberg J, Jackson R. Best evidence topic report. Intra-articular corticosteroid injections in acute rheumatoid monoarthritides. Emerg Med J. 2004;21(2):204. (Systematic review; 1 study, 137 patients)

Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the June 2018 issue of Emergency Medicine Practice: Managing Shoulder Injuries in the Emergency Department Fracture, Dislocation, and Overuse. This month, Richard Pescatore, director of clinical research at Crozer-Keystone Health System and clinical assistant professor at the Rowan University School of Osteopathic Medicine, along with Andrew Nyce, vice chairman and associate professor at cooper medical school of Rowan University reviewed just over 100 articles to come up with their evidence-based recommendations. Their recommendations were then edited by John Munyak of Maimonides and Mark Silverberg of SUNY Downstate and Kings County Hospital. Most Important References * Ponce BA, Kundukulam JA, Pflugner R, et al. Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg. 2013;22(7):993-999. (Prospective cohort; 49 patients) * Slaven EJ, Mathers J. Differential diagnosis of shoulder and cervical pain: a case report. J Man Manip Ther. 2010;18(4):191-196. (Case report) * Helfen T, Ockert B, Pozder P, et al. Management of prehospital shoulder dislocation: feasibility and need of reduction. Eur J Trauma Emerg Surg. 2016;42(3):357-362. (Retrospective review; 70 patients) * Lenza M, Belloti JC, Andriolo RB, et al. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. 2014(5):CD007121. (Systematic review; 3 trials, 354 patients) * Neer CS, 2nd. Displaced proximal humeral fractures: part I. Classification and evaluation. 1970. Clin Orthop Relat Res. 2006;442:77-82. (Review article) * Sholsberg J, Jackson R. Best evidence topic report. Intra-articular corticosteroid injections in acute rheumatoid monoarthritides. Emerg Med J. 2004;21(2):204. (Systematic review; 1 study, 137 patients)

Episode 17 - Managing Shoulder Injuries in the Emergency Department Fracture, Dislocation, and Overuse

Show Notes Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness. This episode reviews risk factors for apnea and severe bronchiolitis; discusses treatments/therapies and provides evidence-based recommendations for the management of pediatric patients with bronchiolitis. Show More v Pathophysiology   Bronchiolar narrowing and obstruction is caused by: 		  Increased mucus secretion  Cell death and sloughing  Peri-bronchiolar lymphocytic infiltrate  Submucosal edema    Smooth muscle constriction seems to have a limited role, perhaps explaining the lack of response to bronchodilators.  Median duration of illness is 12 days in children &lt;24 months  18% still ill at 3 weeks.2  9% still ill at 4 weeks.2  Etiology   RSV accounts for 50-80% of cases, but rare in children &gt;2 yo.3   Late fall epidemic peaking Nov-March, in the US.4    Human Metapneumovirus (HMPV) accounts for 3-19% 5,6   Similar seasonal variation to RSV.    Parainfluenza, influenza, adenoviruses, coronaviruses, rhinoviruses, and enteroviruses are other causes.4-6  Rhinoviruses have been shown to play a larger role in Asthma.7  Presentation   The American Academy of Pediatrics defines it as any of the following in infants: 1   Rhinitis  Tachypnea  Wheezing  Cough  Crackles  Use of accessory muscles  Nasal flaring    Differential Diagnosis   Emergent Causes   Infection: pneumonia, chlamydia, pertussis  Foreign body: aspirated or esophageal  Cardiac anomaly: congestive heart failure, vascular ring  Allergic reaction  Bronchopulmonary dysplasia exacerbation    Non-acute Causes   Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia  Gastroesophageal reflux disease  Mediastinal mass  Cystic fibrosis    Clinical Pearls   Vomiting, wheezing, and coughing associated with feeding; consider GERD.  Wheezing associated with position changes; consider tracheomalacia or great vessel anomalies.  Wheezing exacerbated by flexion of neck and relieved by neck hyperextension; consider vascular ring.  Multiple respiratory tract infections and failure to thrive; consider cystic fibrosis or immunodeficiency.  Wheezing with heart murmur, cardiomegaly, cyanosis, exertion or sweating with feeding; consider cardiac disease.  Sudden onset of wheezing and choking; consider foreign body.    Risk Factors for Severe Bronchiolitis   Age &lt; 6-12 weeks11-13  Prematurity &lt; 35-37 weeks’ gestation11-13  Underlying respiratory illness such as bronchopulmonary dysplasia1  Significant congenital heart disease; immune deficiency including HIV, organ or bone marrow transplants, or congenital immune deficiencies14,15  Altered mental status (impending respiratory failure)  Dehydration due to inability to tolerate oral fluids  Ill appearance12  Oxygen saturation level ≤ 90%1  Respiratory rate: &gt; 70 breaths/min or higher than normal rate for patient age1,12  Increased work of breathing: moderate to severe retractions and/or accessory muscle use1  Nasal flaring  Grunting  Risk Factors for Apnea   Full-term birth and &lt; 1 month of age16,17  Preterm birth (&lt; 37 weeks’ gestation) and age &lt; 2 months post birth11-13,17  History of apnea of prematurity  Emergency department presentation with apnea17  Apnea witnessed by a caregiver17  Diagnostic Testing   Xray 		  Radiographs increase the likely hood of a physician giving antibiotics, even if the X-ray is negative.18-20  Routine radiography is discouraged, but may be helpful when severe disease requires further evaluation or exclusion of foreign body.    Viral testing is not necessary for the diagnosis but may help when searching for the cause of fever in young infants. 		  2016 ACEP fever guidelines note that positive viral testing can impact further workup of fever for a serious bacterial infection (SBI).21    In infants &lt;28 days, serious bacterial infection is high, even in patients with bronchiolitis: 10% (RSV+) and 14% (RSV -)22. Standard fever evaluation is recommended.  In the 28-60 day old group, SBI rates were 5.5% (RSV+) and 11.7% (RSV-). All were UTIs.22 Urinalysis is recommended.  Emergency Department Treatment   Oxygen   Keep O2 saturation &gt;90%  Clinicians may choose not to use continuous pulse oximetry (weak recommendation due to low-level evidence and reasoning)1    Fluids   IV or NG administration of fluids to combat dehydration, until respiratory distress and tachypnea resolve.    Suctioning   Routine use of “deep” suctioning may not be beneficial and may be harmful.1  Nasal suction should be used to help infants with respiratory distress, poor feeding or sleeping.    Bronchodilators1,25,26   Generally nor recommended for routine use.  May trial in infants with:  Severe bronchiolitis (these were excluded in the studies).  History of prior wheezing.  Family history of atopy/asthma in an older infant.    Anticholinergic Agents (ipratropium bromide) 		  No evidence for improvement in bronchiolitis.31-34    Corticosteroids   AAP1, Cochrane Review27, and PECARN28 study all recommend against, finding no evidence for improvement.  One small study (70 patients) found a benefit utilising 1 mg/kg oral dexamethasone followed by 0.6 mg/kg daily for 5 days. However, the study limited by size and increased prevalence of family history of atopy.  Recommendations remain against use in first time wheezers with bronchiolitis.    Racemic Epinephrine   Not recommended1. Further study needed.    Racemic Epinephrine + Oral Dexamethasone   Pediatric Emergency Research Canada trial at 8 Canadian pediatric EDs involving 800 infants aged 6 weeks to 12 months with bronchiolitis found that the epinephrine-dexamethasone group had a lower admission rate over 7 days than the placebo group (17.1% vs 26.4%). This was not statistically significant. Further study needed. 30    Hypertonic Saline   AAP guidelines do not recommend use in the ED but note clinicians may utilize it in the inpatient setting. 1  Cochrane reviews in 2013 and 2017 found some inpatient benefit, but a conflicting publication found it may worsen cough.35-37    High Flow Nasal Cannula (HFNC)   Several small pediatric ICU studies show a benefit in severe cases. No large ED randomized trials exist, to date.  Study protocols included weight based or age based flow rates.    Nasal CPAP   Shows benefit in pediatric ICU settings. Evidence vs HFNC is limited.    Disposition   Consider admission if any of the following are present: 		  Risk for apnea  Risk for severe bronchiolitis  Respiratory distress, particularly if it interferes with feeding  Hypoxia (oxygen saturation ≤ 90%)  Decreased feeding and/or dehydration  An unreliable caregiver (ie, unable to ensure patient care and appropriate 24-hour follow-up)    All patients with severe bronchiolitis should be admitted.

<h2>Show Notes</h2> Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness. This episode reviews risk factors for apnea and severe bronchiolitis; discusses treatments/therapies and provides evidence-based recommendations for the management of pediatric patients with bronchiolitis. <a href="#showNotes" rel="nofollow" target="_blank">Show More v</a> <h3>Pathophysiology</h3> <ul> <li> Bronchiolar narrowing and obstruction is caused by: 		 <ul> <li> Increased mucus secretion</li> <li> Cell death and sloughing</li> <li> Peri-bronchiolar lymphocytic infiltrate</li> <li> Submucosal edema</li> </ul> </li> <li> Smooth muscle constriction seems to have a limited role, perhaps explaining the lack of response to bronchodilators.</li> <li> Median duration of illness is 12 days in children &lt;24 months</li> <li> 18% still ill at 3 weeks.2</li> <li> 9% still ill at 4 weeks.2</li> </ul> <h3>Etiology</h3> <ul> <li> RSV accounts for 50-80% of cases, but rare in children &gt;2 yo.3 <ul> <li> Late fall epidemic peaking Nov-March, in the US.4</li> </ul> </li> <li> Human Metapneumovirus (HMPV) accounts for 3-19% 5,6 <ul> <li> Similar seasonal variation to RSV.</li> </ul> </li> <li> Parainfluenza, influenza, adenoviruses, coronaviruses, rhinoviruses, and enteroviruses are other causes.4-6</li> <li> Rhinoviruses have been shown to play a larger role in Asthma.7</li> </ul> <h3>Presentation</h3> <ul> <li> The American Academy of Pediatrics defines it as any of the following in infants: 1 <ul> <li> Rhinitis</li> <li> Tachypnea</li> <li> Wheezing</li> <li> Cough</li> <li> Crackles</li> <li> Use of accessory muscles</li> <li> Nasal flaring</li> </ul> </li> </ul> <h3>Differential Diagnosis</h3> <ul> <li> Emergent Causes <ul> <li> Infection: pneumonia, chlamydia, pertussis</li> <li> Foreign body: aspirated or esophageal</li> <li> Cardiac anomaly: congestive heart failure, vascular ring</li> <li> Allergic reaction</li> <li> Bronchopulmonary dysplasia exacerbation</li> </ul> </li> <li> Non-acute Causes <ul> <li> Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia</li> <li> Gastroesophageal reflux disease</li> <li> Mediastinal mass</li> <li> Cystic fibrosis</li> </ul> </li> <li> Clinical Pearls <ul> <li> Vomiting, wheezing, and coughing associated with feeding; consider GERD.</li> <li> Wheezing associated with position changes; consider tracheomalacia or great vessel anomalies.</li> <li> Wheezing exacerbated by flexion of neck and relieved by neck hyperextension; consider vascular ring.</li> <li> Multiple respiratory tract infections and failure to thrive; consider cystic fibrosis or immunodeficiency.</li> <li> Wheezing with heart murmur, cardiomegaly, cyanosis, exertion or sweating with feeding; consider cardiac disease.</li> <li> Sudden onset of wheezing and choking; consider foreign body.</li> </ul> </li> </ul> <h3>Risk Factors for Severe Bronchiolitis</h3> <ul> <li> Age &lt; 6-12 weeks11-13</li> <li> Prematurity &lt; 35-37 weeks’ gestation11-13</li> <li> Underlying respiratory illness such as bronchopulmonary dysplasia1</li> <li> Significant congenital heart disease; immune deficiency including HIV, organ or bone marrow transplants, or congenital immune deficiencies14,15</li> <li> Altered mental status (impending respiratory failure)</li> <li> Dehydration due to inability to tolerate oral fluids</li> <li> Ill appearance12</li> <li> Oxygen saturation level ≤ 90%1</li> <li> Respiratory rate: &gt; 70 breaths/min or higher than normal rate for patient age1,12</li> <li> Increased work of breathing: moderate to severe retractions and/or accessory muscle use1</li> <li> Nasal flaring</li> <li> Grunting</li> </ul> <h3>Risk Factors for Apnea</h3> <ul> <li> Full-term birth and &lt; 1 month of age16,17</li> <li> Preterm birth (&lt; 37 weeks’ gestation) and age &lt; 2 months post birth11-13,17</li> <li> History of apnea of prematurity</li> <li> Emergency department presentation with apnea17</li> <li> Apnea witnessed by a caregiver17</li> </ul> <h3>Diagnostic Testing</h3> <ul> <li> Xray 		 <ul> <li> Radiographs increase the likely hood of a physician giving antibiotics, even if the X-ray is negative.18-20</li> <li> Routine radiography is discouraged, but may be helpful when severe disease requires further evaluation or exclusion of foreign body.</li> </ul> </li> <li> Viral testing is not necessary for the diagnosis but may help when searching for the cause of fever in young infants. 		 <ul> <li> 2016 ACEP fever guidelines note that positive viral testing can impact further workup of fever for a serious bacterial infection (SBI).21</li> </ul> </li> <li> In infants &lt;28 days, serious bacterial infection is high, even in patients with bronchiolitis: 10% (RSV+) and 14% (RSV -)22. Standard fever evaluation is recommended.</li> <li> In the 28-60 day old group, SBI rates were 5.5% (RSV+) and 11.7% (RSV-). All were UTIs.22 Urinalysis is recommended.</li> </ul> <h3>Emergency Department Treatment</h3> <ul> <li> Oxygen <ul> <li> Keep O2 saturation &gt;90%</li> <li> Clinicians may choose not to use continuous pulse oximetry (weak recommendation due to low-level evidence and reasoning)1</li> </ul> </li> <li> Fluids <ul> <li> IV or NG administration of fluids to combat dehydration, until respiratory distress and tachypnea resolve.</li> </ul> </li> <li> Suctioning <ul> <li> Routine use of “deep” suctioning may not be beneficial and may be harmful.1</li> <li> Nasal suction should be used to help infants with respiratory distress, poor feeding or sleeping.</li> </ul> </li> <li> Bronchodilators1,25,26 <ul> <li> Generally nor recommended for routine use.</li> <li> May trial in infants with:</li> <li> Severe bronchiolitis (these were excluded in the studies).</li> <li> History of prior wheezing.</li> <li> Family history of atopy/asthma in an older infant.</li> </ul> </li> <li> Anticholinergic Agents (ipratropium bromide) 		 <ul> <li> No evidence for improvement in bronchiolitis.31-34</li> </ul> </li> <li> Corticosteroids <ul> <li> AAP1, Cochrane Review27, and PECARN28 study all recommend against, finding no evidence for improvement.</li> <li> One small study (70 patients) found a benefit utilising 1 mg/kg oral dexamethasone followed by 0.6 mg/kg daily for 5 days. However, the study limited by size and increased prevalence of family history of atopy.</li> <li> Recommendations remain against use in first time wheezers with bronchiolitis.</li> </ul> </li> <li> Racemic Epinephrine <ul> <li> Not recommended1. Further study needed.</li> </ul> </li> <li> Racemic Epinephrine + Oral Dexamethasone <ul> <li> Pediatric Emergency Research Canada trial at 8 Canadian pediatric EDs involving 800 infants aged 6 weeks to 12 months with bronchiolitis found that the epinephrine-dexamethasone group had a lower admission rate over 7 days than the placebo group (17.1% vs 26.4%). This was not statistically significant. Further study needed. 30</li> </ul> </li> <li> Hypertonic Saline <ul> <li> AAP guidelines do not recommend use in the ED but note clinicians may utilize it in the inpatient setting. 1</li> <li> Cochrane reviews in 2013 and 2017 found some inpatient benefit, but a conflicting publication found it may worsen cough.35-37</li> </ul> </li> <li> High Flow Nasal Cannula (HFNC) <ul> <li> Several small pediatric ICU studies show a benefit in severe cases. No large ED randomized trials exist, to date.</li> <li> Study protocols included weight based or age based flow rates.</li> </ul> </li> <li> Nasal CPAP <ul> <li> Shows benefit in pediatric ICU settings. Evidence vs HFNC is limited.</li> </ul> </li> </ul> <h3>Disposition</h3> <ul> <li> Consider admission if any of the following are present: 		 <ul> <li> Risk for apnea</li> <li> Risk for severe bronchiolitis</li> <li> Respiratory distress, particularly if it interferes with feeding</li> <li> Hypoxia (oxygen saturation ≤ 90%)</li> <li> Decreased feeding and/or dehydration</li> <li> An unreliable caregiver (ie, unable to ensure patient care and appropriate 24-hour follow-up)</li> </ul> </li> <li> All patients with severe bronchiolitis should be admitted.</li></ul>

Episode 33 - Acute Bronchiolitis: Assessment and Management in the Emergency Department (Pharmacology CME)

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

<h2>Show Notes</h2> <a></a>Please take our listener survey at <a href="https://forms.gle/spMwHJS795Qnfgww7" rel="nofollow" target="_blank">https://forms.gle/spMwHJS795Qnfgww7</a> 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: <ul> <li>Etiology and pathophysiology of DKA and HHS</li> <li>Precipitating causes</li> <li>Differential diagnosis</li> <li>Diagnostic studies <ul> <li>ECG</li> <li>Lab</li> <li>Imaging</li> </ul> </li> <li>Treatment <ul> <li>IV fluids</li> <li>Insulin therapy</li> <li>Potassium</li> <li>Sodium bicarbonate</li> <li>Phosphate</li> </ul> </li> <li>Pediatrics <ul> <li>IVF changes</li> <li>Insulin changes</li> <li>Cerebral edema</li> </ul> </li> <li>Airway management</li> <li>Euglycemia DKA</li> <li>Thrombosis and anticoagulation.</li> </ul> Time stamps: <ul> <li>00 Introduction</li> <li>1:34 Cases</li> <li>21:47 Summary of key points</li> <li>26:37 Closing</li></ul>

Episode 35 - Diabetic Hyperglycemic Emergencies: A Systematic Approach

Episode 20 - Emergency Department Management of North American Snake Envenomations 

Episode 19 - Cannabinoids: Emerging Evidence in Use and Abuse 

Show NotesJeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases.Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes.Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe.Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network.Jeff: Thanks, team for this deep dive.Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers.Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually.Nachi: 20 million! Kinda scary if you step back and think about it.Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult.Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse.Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&amp;P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding.Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams.Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER.Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence.Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs.Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?”Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections.

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&amp;P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections.

Episode 27 - Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases (Pharmacology CME and Infectious Disease CME)

Episode 31 - Emergency Department Management of Patients Taking Direct Oral Anticoagulant Agents (Pharmacology CME)

Jaundice is a manifestation of elevated serum bilirubin, and can have many causes, some of which can be life-threatening.Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the April 2018 issue of Emergency Medicine Practice: Jaundice in the Emergency Department: Meeting the Challenges of Diagnosis and Treatment.This month’s issue was authored by Dr. Taylor and Dr. Wheatley both of the Emory School of Medicine.  It was peer reviewed by Dr. Chung of the Icahn School of Medicine at Mount Sinai, and Dr. Horan of Our Lady of Lourdes Medical Center.

Jaundice is a manifestation of elevated serum bilirubin, and can have many causes, some of which can be life-threatening. Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the April 2018 issue of Emergency Medicine Practice: Jaundice in the Emergency Department: Meeting the Challenges of Diagnosis and Treatment. This month’s issue was authored by Dr. Taylor and Dr. Wheatley both of the Emory School of Medicine.  It was peer reviewed by Dr. Chung of the Icahn School of Medicine at Mount Sinai, and Dr. Horan of Our Lady of Lourdes Medical Center.

Episode 15 - Jaundice in the Emergency Department: Meeting the Challenges of Diagnosis and Treatment

Episode 29 - Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy

Episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management

Episode 30 - Emergency Department Management of Patients With Complications of Bariatric Surgery

Episode 28 - Depressed and Suicidal Patients in the Emergency Department: An Evidence-Based Approach

Show NotesDr. Susan Kirelik, a concussion specialist and emergency medicine physician, discusses the key points of concussion diagnosis and management from the perspective of the emergency medicine clinician. The topics covered include:  The signs and symptoms of concussion and how it is diagnosed in the ED  The initial evaluation of a patient presenting with a head injury, including tools for determining when neuroimaging is indicated  Screening tools for the evaluation of patients with suspected concussion, such as the VOMS examination and the SCAT5 and Child SCAT5 tools  Management of patients in the ED after making a concussion diagnosis and the role of rest, antiemetics, and acute pain management for these patients  The importance of aftercare instructions when discharging concussed patients, in the context of new guidelines for concussion recovery  The risk factors for prolonged recovery from concussion and resources for concussion recovery  Patients seeking concussion clearance in the ED  Addressing patient or parent questions about the long-term complications of concussion, such as second impact syndrome, the potential for cumulative effects of multiple concussions, and risk for CTE (chronic traumatic encephalopathy) Susan B. Kirelik is the Medical Director of the Rocky Mountain Pediatric OrthoONE Center for Concussion and is an attending pediatric emergency medicine physician at the Rocky Mountain Hospital for Children in Denver, Colorado.Read the article: Concussion in the Emergency Department: A Review of Current Guidelines  - Trauma EXTRA Supplement (Trauma CME)ReferencesMcCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838- 847. (Consensus statement)Meeuwisse WH, Schneider KJ, Dvorak J, et al. The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport. Br J Sports Med. 2017;51(11):873-876. (Conference summary)Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort study; 42,412 patients)Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. (Prospective cohort study; 3121 patients)Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42(10):2479-2486. (Cross-sectional study; 64 patients)Links to tools and publications mentioned in the podcast:PECARN Pediatric Head Trauma: Official Visual Decision Aid for CliniciansVestibular/Ocular-Motor Screening (VOMS) for ConcussionSCAT5 toolChild SCAT5 toolREAP concussion management (NOTE: this is the new URL for “center4concussion.com,” which is mentioned in the podcast)Tip sheets for educators, parents, and healthcare providers on managing concussion recovery in the classroom

<h2>Show Notes</h2>Dr. Susan Kirelik, a concussion specialist and emergency medicine physician, discusses the key points of concussion diagnosis and management from the perspective of the emergency medicine clinician. The topics covered include:<ul> <li> The signs and symptoms of concussion and how it is diagnosed in the ED</li> <li> The initial evaluation of a patient presenting with a head injury, including tools for determining when neuroimaging is indicated</li> <li> Screening tools for the evaluation of patients with suspected concussion, such as the VOMS examination and the SCAT5 and Child SCAT5 tools</li> <li> Management of patients in the ED after making a concussion diagnosis and the role of rest, antiemetics, and acute pain management for these patients</li> <li> The importance of aftercare instructions when discharging concussed patients, in the context of new guidelines for concussion recovery</li> <li> The risk factors for prolonged recovery from concussion and resources for concussion recovery</li> <li> Patients seeking concussion clearance in the ED</li> <li> Addressing patient or parent questions about the long-term complications of concussion, such as second impact syndrome, the potential for cumulative effects of multiple concussions, and risk for CTE (chronic traumatic encephalopathy)</li> </ul>Susan B. Kirelik is the Medical Director of the Rocky Mountain Pediatric OrthoONE Center for Concussion and is an attending pediatric emergency medicine physician at the Rocky Mountain Hospital for Children in Denver, Colorado.<a href="https://www.ebmedicine.net/topics/trauma/concussion-mtbi-guidelines-sport" rel="nofollow" target="_blank">Read the article: Concussion in the Emergency Department: A Review of Current Guidelines - Trauma EXTRA Supplement (Trauma CME)</a><h3>References</h3>McCrory P, Meeuwisse W, Dvorak J, et al.<a href="https://bjsm.bmj.com/content/51/11/838" rel="nofollow" target="_blank"> Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016</a>. Br J Sports Med. 2017;51(11):838- 847. (Consensus statement)Meeuwisse WH, Schneider KJ, Dvorak J, et al. <a href="https://bjsm.bmj.com/content/51/11/873" rel="nofollow" target="_blank">The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport</a>. Br J Sports Med. 2017;51(11):873-876. (Conference summary)Kuppermann N, Holmes JF, Dayan PS, et al.<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61558-0/fulltext" rel="nofollow" target="_blank"> Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study</a>. Lancet. 2009;374(9696):1160-1170. (Prospective cohort study; 42,412 patients)Stiell IG, Wells GA, Vandemheen K, et al. <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04561-X/fulltext" rel="nofollow" target="_blank">The Canadian CT Head Rule for patients with minor head injury</a>. Lancet. 2001;357(9266):1391-1396. (Prospective cohort study; 3121 patients)Mucha A, Collins MW, Elbin RJ, et al. <a href="https://journals.sagepub.com/doi/10.1177/0363546514543775" rel="nofollow" target="_blank">A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings</a>. Am J Sports Med. 2014;42(10):2479-2486. (Cross-sectional study; 64 patients)<h3>Links to tools and publications mentioned in the podcast:</h3><a href="https://www.aliem.com/2017/06/pecarn-pediatric-head-trauma-official-visual-decision-aid/" rel="nofollow" target="_blank">PECARN Pediatric Head Trauma: Official Visual Decision Aid for Clinicians</a><a href="https://journals.sagepub.com/doi/suppl/10.1177/0363546514543775" rel="nofollow" target="_blank">Vestibular/Ocular-Motor Screening (VOMS) for Concussion</a><a href="https://bjsm.bmj.com/content/bjsports/51/11/851.full.pdf" rel="nofollow" target="_blank">SCAT5 tool</a><a href="https://bjsm.bmj.com/content/bjsports/51/11/862.full.pdf" rel="nofollow" target="_blank">Child SCAT5 tool</a><a href="https://reapconcussion.com/" rel="nofollow" target="_blank">REAP concussion management</a> (NOTE: this is the new URL for “<a href="http://center4concussion.com" rel="nofollow" target="_blank">center4concussion.com</a>,” which is mentioned in the podcast)<a href="http://www.getschooledonconcussions.com" rel="nofollow" target="_blank">Tip sheets for educators, parents, and healthcare providers on managing concussion recovery in the classroom</a>

EXTRA Supplement Podcast - Concussion in the Emergency Department: A Review of Current Guidelines - Trauma EXTRA Supplement (Trauma CME)

Episode 25 - Evaluation and Management of Life-Threatening Headaches in the Emergency Department

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:   &gt; 1 episode of vomiting and/or &gt; 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 &lt;14 days  Persistent episode 14-29 days  Chronic diarrhea &gt;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 &gt;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 &gt;2 with a history of recent abx use or recent hospitalization  Blood cultures are recommended for patients &lt;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 &lt;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.  STEC should not be treated with abx due to increased HUS, neither should close contacts be prophylaxed with abx.  Hospitalized patients should be treated empirically pending stool studies.  Giardia is self-limited but can be treated with abx therapy.  Cryptosporidium is also self-limited but abx therapy is recommended for diarrhea &gt;1-2 weeks, or immunocompromised patients.   Diet:   No specific recommendations. Just prove patient is tolerating adequate oral fluids first.   Special Populations:   Immunocompromised (HIV/AIDS, etc) and patients &lt;3 mos or &gt;65 yo are at increased risk   Extend work up  Treat with abx more liberally because of higher risk of cryptosporidium, Cyclospora, cystoisospora, microsporidia, and MAC.  IDSA recommend abx therapy in immunocompromised patients and avoidance of probiotics due to lack of evidence.  Loperamide is safe in these patients with acute watery diarrhea    Patients on PPI and H2 blockers   Increasing evidence that these meds increase susceptibility to viral and bacterial pathogens.  Suspension of these meds in patients with AGE is reasonable.  No formal guidelines on this.    Post infectious irritable bowel syndrome results in persistent abdominal pain and diarrhea after an episode of AGE   Management is supportive     Disposition:   OK for discharge if vitals are better after fixing dehydration and tolerating oral hydration. Remember to treat electrolyte abnormalities.  Higher risk patients (&lt;3 mos, &gt;65 yo, immunocompromised) should be considered for admission until they demonstrate clinical improvement.

Acute Gastroenteritis- Author: Dr. Brian Geyer Introduction: <ul> <li>Do both vomiting and diarrhea have to be present? No <ul> <li>1996 AAP guidelines, 2016 ACG guidelines, and 2017 IDSA guidelines all note diarrhea illness but may be vomiting predominant. </li> </ul> </li> <li>Studies use more vague definitions like: <ul> <li>&gt; 1 episode of vomiting and/or &gt; 3 episodes of diarrhea in 24 hours without known chronic cause like inflammatory bowel disease. </li> <li>Diarrhea is at least 3 unformed stools per day. </li> <li>Acute episode &lt;14 days </li> <li>Persistent episode 14-29 days </li> <li>Chronic diarrhea &gt;29 days </li> </ul> </li> <li>Patients in the ED may present with only some of these symptoms depending their time in course of illness. </li> </ul> Literature Review: <ul> <li>There is abundant literature on pediatric AGE but sparse research on AGE in adults. Therefore, many recommendations are extrapolated from the pediatric literature. </li> </ul> Causes: <ul> <li>70% of US cases are estimated to be caused by viruses, norovirus being most common. <ul> <li>o 26% norovirus </li> <li>o 18% rotavirus </li> </ul> </li> <li>Among bacterial causes: <ul> <li>o 5.3% Salmonella, most common </li> <li>o 5.3% Clostridium </li> <li>o 3% Campylobacter </li> <li>o 3% parasitic infections </li> </ul> </li> <li>Large portion, 51%, have no cause identified. (In ED patients) </li> <li>Interestingly, 79% of cases never have a cause identified (not ED specific) </li> <li>In ED patients, only 25% ever have a cause identified, this increases to 49% when a stool sample is obtained. (not ED specific) </li> <li>Food poisoning is responsible for 5% of AGE but results in 30% of deaths. Most commonly: <ul> <li>Salmonella, Clostridium perfringens, and Campylobacter </li> <li>Majority of foodborne illness is still viral, mostly norovirus </li> </ul> </li> <li>E Coli is normal in the gut, but two most common causes are: <ul> <li>Shiga toxin Ecoli (STEC) AKA enterohemorrhagic Ecoli (EHEC) - causes Hemolytic Uremic Syndrome in 5-10% </li> <li>Entertoxigenic Ecoli (ETEC) - causes traveler's diarrhea </li> <li>Both cause self-limited illness. </li> </ul> </li> </ul> Alternate Diagnoses: <ul> <li>Appendicitis: In the peds literature, misdiagnosis of appendicitis as AGE leads to 47% absolute increased risk of perforation. Suggestive findings include: <ul> <li>Migration of pain to RLQ </li> <li>RLQ tenderness on exam (initial or repeat) </li> <li>Absence of diarrhea </li> <li>Pain not improved with episodes of diarrhea </li> <li>Negative factors include multiple ill family members, recent international travel, presence of diarrhea (as defined above). </li> </ul> </li> <li>Ciguatera Fish Poisoning <ul> <li>Toxin produced by algae consumed by reef fish like grouper, red snapper, sea bass and Spanish mackerel. </li> <li>Symptoms begin 6-24 hours post ingestion. </li> <li>Fish tastes normal. </li> <li>Patients may develop neurological symptoms like paresthesias, generalized pruritis, and reversal of hot/cold sensation. </li> <li>Symptoms resolve spontaneously, and treatment with mannitol is controversial. </li> </ul> </li> <li>Scombroid Poisoning <ul> <li>Ingesting fish in the Scombroidae family - mackerel, bonito, albacore, and skipjack - that have been stored improperly </li> <li>Bacteria produce histidine decarboxylase which converts histidine to histamine </li> <li>Causes abdominal cramps and diarrhea, and may cause metallic bitter or peppery taste in mouth, and facial flushing within 20-30 min of ingestion </li> <li>Can be confused with allergic reaction </li> <li>Symptoms resolve in 6-8 hours </li> <li>Notification of health dept may prevent others from being infected. </li> </ul> </li> <li>Page 5 Table 1- Distinguishing Factors in the Differential Diagnosis of AGE</li> </ul> History: <ul> <li>Table 2, page 6 has key questions to ask. </li> <li>Onset, timing, number of stools, presence of blood, fever, quality of abdominal pain and location, recent antibiotics, etc. </li> <li>Extremes of age, immunosuppression, and pregnancy should be identified. Mortality is highest in the patients &gt;65 yo. </li> </ul> Physical Exam: <ul> <li>We talked about RLQ abd pain, but what about bloody stool? </li> <li>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%. </li> </ul> Laboratory Testing and Imaging: <ul> <li>Dehydration is the biggest contributor to mortality, especially in the very young and elderly. </li> <li>Lab evaluation for dehydration is recommended in these populations. </li> <li>No consistent association between lab abnormalities and bacterial etiology. </li> <li>WBC and differential does not differentiate bacterial vs viral, but may help in identifying severity of illness. </li> <li>Hemoglobin and platelets are helpful if HUS is suspected. </li> <li>Stool Cultures: <ul> <li>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 </li> <li>2016 ACG guidelines recommend them for patients with watery diarrhea and moderate to severe illness with fever for at least 72 hours. </li> <li>Consider them for immunocompromised patients and those with recent abx use or hospitalization. </li> </ul> </li> <li>C Difficile testing is recommended for all patients with AGE who are age &gt;2 with a history of recent abx use or recent hospitalization </li> <li>Blood cultures are recommended for patients &lt;3 months old and any patient with signs of sepsis. </li> <li>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. </li> </ul> Hydration: <ul> <li>Oral rehydration is preferred. Oral rehydration solutions in patients tolerating oral fluids. <ul> <li>ORS packets </li> <li>Pedialyte, Hydralyte, etc </li> <li>Sports drinks are safe but have less potassium. Higher sugar solutions can be diluted 50% </li> <li>Coconut water </li> <li>Half strength apple juice has been studied in pediatrics and decreased treatment failure. </li> </ul> </li> <li>IV hydration for patients with severe dehydration, hypovolemic shock, septic shock, or failed oral rehydration. </li> <li>Don't forget to replace electrolytes if giving IV hydration. </li> </ul> Meds: <ul> <li>Ondansetron (Zofran) reduces need for IV hydration in peds. (0.15mg/kg oral liquid) but doesn't reduce hospitalizations or return visits (low numbers) </li> <li>No benefit to higher dose ondansetron. </li> <li>IV ondansetron vs metoclopramide performance is similar in peds. </li> <li>No benefit in studies to giving dexamethasone, or dimenhydrinate (dramamine) </li> <li>Proshlorperazine 10mg IV was shown to be superior to promethazine 25mg IV for symptom relief in adults, with less sedation </li> <li>No suggestions regarding medication choice from guidelines. </li> <li>Sniffing isopropyl alcohol soaked pads twice q 2min was shown superior vs placebo in controlling nausea, but effect is gone at 30 minutes. </li> <li>Ginger is reported to be helpful at 250mg QID in pregnant patients and post op patient. No data in AGE. </li> <li>Loperamide is recommended as an adjunct to abx by the ACG. Risk is too high in patients &lt;3 yo and 3-12 with moderate dehydration, blood stool, or severe disease. </li> <li>Loperamide is also contraindicated if STEC is suspected, due to increased development of HUS </li> <li>Probiotics may reduce diarrhea by one day. </li> <li>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. </li> </ul> Antibiotics: <ul> <li>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. </li> <li>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. </li> <li>Great chart Table 4, page 12, on abx recommendations. </li> <li>Shellfish ingestion - Doxy, Azithomycin, or Cipro. </li> <li>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. </li> <li>STEC should not be treated with abx due to increased HUS, neither should close contacts be prophylaxed with abx. </li> <li>Hospitalized patients should be treated empirically pending stool studies. </li> <li>Giardia is self-limited but can be treated with abx therapy. </li> <li>Cryptosporidium is also self-limited but abx therapy is recommended for diarrhea &gt;1-2 weeks, or immunocompromised patients. </li> </ul> Diet: <ul> <li>No specific recommendations. Just prove patient is tolerating adequate oral fluids first. </li> </ul> Special Populations: <ul> <li>Immunocompromised (HIV/AIDS, etc) and patients &lt;3 mos or &gt;65 yo are at increased risk <ul> <li>Extend work up </li> <li>Treat with abx more liberally because of higher risk of cryptosporidium, Cyclospora, cystoisospora, microsporidia, and MAC. </li> <li>IDSA recommend abx therapy in immunocompromised patients and avoidance of probiotics due to lack of evidence. </li> <li>Loperamide is safe in these patients with acute watery diarrhea </li> </ul> </li> <li>Patients on PPI and H2 blockers <ul> <li>Increasing evidence that these meds increase susceptibility to viral and bacterial pathogens. </li> <li>Suspension of these meds in patients with AGE is reasonable. </li> <li>No formal guidelines on this. </li> </ul> </li> <li>Post infectious irritable bowel syndrome results in persistent abdominal pain and diarrhea after an episode of AGE <ul> <li>Management is supportive </li> </ul> </li> </ul> Disposition: <ul> <li>OK for discharge if vitals are better after fixing dehydration and tolerating oral hydration. Remember to treat electrolyte abnormalities. </li> <li>Higher risk patients (&lt;3 mos, &gt;65 yo, immunocompromised) should be considered for admission until they demonstrate clinical improvement.</li></ul>

Episode 36 - Diagnosis and Management of Acute Gastroenteritis in the Emergency Department

Episode 32 - Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls (Ethics CME)

Episode 23 - Influenza Diagnosis and Management in the Emergency Department 

Episode 21- Updates and Controversies in the Early Management of Sepsis and Septic Shock

Episode 26 – Blunt Cardiac Injury: Emergency Department Diagnosis and Management (Trauma CME)

Show Notes   Please click here and take our listener survey 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 &gt;1mm in two or more contiguous leads other than V2-V3  ST elevation in V2-V3 		  &gt; 2.5mm in med &lt; 40 yrs old  &gt;2 mm in men &gt; 40 yrs old  &gt;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&lt;40 is 1%, age &gt;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 &lt;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

<h2>Show Notes</h2> <a href="https://forms.gle/spMwHJS795Qnfgww7" rel="nofollow" target="_blank">Please click here and take our listener survey</a> Emergency Department management of Non-St Segment Elevation Myocardial Infarction, by Drs Julianna Jung and Sharon Bord. <ul> <li> Chest pain is the second most common complaint</li> <li> Over 6.4 million visits to US EDs annually include chest pain.</li> <li> 25% will be diagnosed with ACS</li> <li> 1/3 will have STEMI, 2/3 NSTEMI.</li> </ul> Guidelines reviewed include those from: <ul> <li> AHA/ACC</li> <li> ACEP</li> <li> European Society of Cardiology</li> <li> In addition to reviewing the primary literature each of them used as a basis for their recommendations.</li> </ul> <a href="#showNotes" rel="nofollow" target="_blank">Show More v</a> <a href="https://forms.gle/spMwHJS795Qnfgww7" rel="nofollow" target="_blank">Please click here and take our listener survey</a> <h3>Part 1: Definitions</h3> <ul> <li> 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).</li> <li> 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.</li> </ul> STEMI definition from the European Society of cardiology: <ol> <li> ST elevation &gt;1mm in two or more contiguous leads other than V2-V3</li> <li> ST elevation in V2-V3 		<ol> <li> &gt; 2.5mm in med &lt; 40 yrs old</li> <li> &gt;2 mm in men &gt; 40 yrs old</li> <li> &gt;1.5mm in woman, regardless of age.</li> </ol> </li> </ol> MACE= Major Adverse Cardiovascular Event: including re-infarction, stroke, dysrhythmia, heart failure, cardiogenic shock, and death. <h3>Part 2 : Why do we care?</h3> <ul> <li> In-hospital mortality rates are about the same for STEMI and NSTEMI, about 10%.</li> <li> 1-year fatality rate in NSTEMI is more than double that of STEMI, at about 25%</li> </ul> <h3>Part 3: Pathophysiology</h3> <ul> <li> Type 1 MI (Infarction) is caused by atherosclerotic plaque rupture.</li> <li> 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.</li> </ul> <h3>Part 4: Pre-hospital care</h3> <ul> <li> Prehospital ECGs decrease time to intervention. (PCI) in STEMI</li> <li> 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)</li> </ul> <h3>Part 5: ED evaluation: Some of the interesting highlights</h3> <h4>History</h4> <ul> <li> Diaphoresis</li> <li> Vomiting</li> <li> Radiation of pain to both arms or shoulders</li> <li> Radiation of pain to right shoulder</li> <li> 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)</li> </ul> <h4>Past Medical History</h4> <ul> <li> Family and personal history of CAD</li> <li> Other medical diagnoses</li> <li> Tobacco use</li> <li> Illicit substance abuse</li> <li> Age (CAD prevalence in age&lt;40 is 1%, age &gt;80 is 25%)</li> <li> ** HIV - find citing 		 <ul> <li> 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]</li> <li> 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]</li> </ul> </li> <li> ** <a href="https://www.acc.org/latest-in-cardiology/articles/2018/05/24/01/44/radiation-induced-cad" rel="nofollow" target="_blank">Cancer with hx of radiation to the chest </a></li> </ul> <h4>Exam</h4> <ul> <li> Neurological neurologic deficit may point to aortic dissection</li> <li> Friction rub may be heard</li> <li> New murmur associated with papillary muscle rupture.</li> </ul> <h4>Diagnostics</h4> <ul> <li> Telemetry</li> <li> ECG. Patterns to know…</li> <li> Troponin... you should get it</li> </ul> <h4>Scoring systems</h4> <ul> <li> Heart Score</li> <li> Grace</li> <li> TIMI</li> </ul> <h4>Imaging in the ED</h4> <ul> <li> CXR</li> <li> CT angiography, CT PE, CCTA</li> <li> Echocardiography - POC or formal</li> </ul> <h3>Part 6: Medications</h3> <ul> <li> Oxygen (if sat &lt;90%)</li> <li> Morphine (no)</li> <li> Nitrates</li> <li> Aspirin</li> <li> Antiplatelet agents 		 <ul> <li> PSY12 inhibitors</li> <li> IIb/IIIa inhibitors</li> </ul> </li> <li> Heparins</li> <li> Beta Blockers</li> <li> Statins</li> </ul> <h3>Part 7: Revascularization</h3> 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. <h3>Part 8: The Specials…</h3> <ul> <li> Women</li> <li> Black Patients</li> <li> Young Patients</li> <li> Diabetics</li> <li> Cocaine Users</li></ul>

Episode 34 - Emergency Department Management of Non–ST-Segment Elevation Myocardial Infarction

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