In response to Episode 59 with Dr. Sanjay Mehta and Dr. Dennis Scolnik on the emergency department diagnosis and management of Bronchiolitis, Dr. Amy Plint, one of Canada's most prominent researchers in Bronchiolitis and the Chair of Pediatric Emergency Research Canada, tells her practical approach to choosing medications in the emergency department, the take home message from her landmark 2009 NEJM study on the use of nebulized epinephrine and dexamethasone for treating Bronchiolitis, and the future of Bronchiolitis research.

Exploring the diagnosis and management of Bronchiolitis in children, with a focus on predicting severity and proper treatment practices. Highlighting challenges in treatment modalities, the use of medications like beta agonists and epinephrine, and the benefits of high-flow oxygen therapy. Discussing the importance of clinical judgment over oxygen saturation levels in discharging children, and evaluating admission criteria for severe cases.

David Carr discusses his top 10 pearls on endocarditis and blood culture interpretation in this Carr's Cases Best Case Ever on EM Cases - Endocarditis and Blood Culture Interpretation. [wpfilebase tag=file id=560 tpl=emc-play /] [wpfilebase tag=file id=561 tpl=emc-mp3 /]

In part 2 of our round-table discussion on EM Cases with sports medicine guru Dr. Ivy Cheng and orthopedic surgeon Dr. Hossein Mehdian we elucidate some key commonly missed uncommon orthopedic injuries that if mismanaged, carry significant long term morbidity. Injuries of the tendons and ligaments are often overlooked by emergency providers as relatively benign injuries and generally are not well understood. Syndesmosis Injuries typically occur in impact sports. They are missed in about 20% of cases, as x-rays findings are often subtle or absent. The mechanism, physical exam findings, such as the Hopkin's Test, and associated injuries are important to understand to help make the diagnosis and provide appropriate ED care. Distal Biceps Tendon Rupture is almost exclusively a male injury and occurs in a younger age group compared to the Proximal Biceps Rupture. It is important to distinguish these injuries as their management and outcomes are different. The mechanism and physical exam findings of Distal Biceps Tendon Rupture, such as the Hook Test, are key in this respect. Quadriceps Tendon Rupture is often misdiagnosed as a simple ‘knee sprain’, but should be consideration for surgical intervention. Quadriceps tendon ruptures are more commonly seen in patients older than 40 years and are more common than patella tendon ruptures which are more commonly seen in patients under 40 years of age. Interestingly, up to 1/3 of patients present with bilateral quadriceps tendon ruptures, so comparing to the contralateral knee may be misleading. There is a spectrum of knee extensor injuries that should be understood in order to provide proper care, with the Straight-Leg-Raise Test being abnormal in all of them. This is of the most important physical exam maneuvers to perform on every ED patient with a knee injury. The x-ray findings of these injuries may be subtle or absent, and proper immobilization of these injuries is important to prevent recoil of the tendon. Patients with calf pain and Gastrocnemius Tears are often misdiagnosed as having a DVT. In fact, one small study showed that gastrocnemius tears were misattributed to DVT in 29% of patients. This confusion occurs because sometimes patients who suffer a gastrocnemius tear report a prodrome of calf tightness several days before the injury, suggesting a potential chronic predisposition. With a good history and physical, and POCUS if you’re skilled at it, needless work-ups for DVT can be avoided. For well thought out approaches, pearls and pitfalls, to these 4 Commonly Missed Uncommon Orthopedic Injuries, listen to the podcast and read the rest of this blog post....

On this EM Cases Best Case Ever, Andrew Sloas, the brains behinds the fabulous PEM-ED podcast tells the tale of a pericardiocentesis gone bad and what he learned from it. Emergency pericardicentesis can be life saving, but it also carries risks. Dr. Sloas reviews the steps to take to ensure that the pericardiocentesis needle is the the correct place to minimize the risk of intubating the right ventricle of the heart. A discussion of errors of omission and ones of commission follows.... [wpfilebase tag=file id=540 tpl=emc-play /] [wpfilebase tag=file id=541 tpl=emc-mp3 /]

In this bonus EM Cases podcast, The Stiell Sessions 2, we have Dr. Ian Stiell discussing an update in Atrial Fibrillation 2014 management including the age-old question of rate control vs rhythm control, the new CHADS-65 algorithm for oral anticogulant therapy, the need to initiate anticoagulant therapy in the ED, the more aggressive use of the Ottawa Aggressive Protocol, the dangers of attempting to cardiovert unstable patients who are in permanent Atrial Fibrillation, the new 150 rule to help determine the likelihood of successful cardioversion and much more. Thanks to all the listeners who did the survey on clinical decision rules and the post-listen survey.

There are hundreds of clinical decision rules and risk scales published in the medical literature, some more widely adopted than others. Ian Stiell, the father of clinical decision rules, shares with us his views and experiences gained from co-creating some of the most influential CDRs and risk scales to date. He explains the criteria for developing a CDR, the steps to developing a valid CDR, how best to apply CDRs and risk scales to clinical practice, and the hot-off the-press new Ottawa COPD Risk Score and Ottawa Heart Failure Risk Score for helping you with disposition decisions. It turns out that in Canada, we discharge about two thirds of the acute decompensated heart failure patients that we see in the ED, while the US almost all patients with decompensated heart failure are admitted to hospital. Dr. Stiell's new risk scores may help physicians in Canada make safer disposition decisions while help physicians in the US avoid unnecessary admissions.

In this second part of the Weingart-Himmel Sessions on critical care pearls for the community ED on the EM Cases podcast, we discuss the many controversies and recent changes in fluid management in severe sepsis and septic shock. With the recently published ARISE trial, and some deviations from Early Goal Directed Therapy, we are changing the way we think about fluids in sepsis: the type of fluid, the volume of fluid, the rate of fluid administration, the timing of introducing vasopressors and the goals of fluid resuscitation. In the next section of the podcast we discuss the PAD mnemonic for post-intubation analgesia and sedation, the prevention of delirium, and medication choices to minimize time on the ventilator, and improve prognosis.

It makes sense that the treatment of primary spnontaneous pneumothorax would lend itself well to outpatient management, since patients are usually young and otherwise healthy, and the mortality and morbidity from these air leaks are really very low. Most patients would rather be managed as an outpatient rather than admitted to hospital and sending these patients home would probably end up saving the system resources and money. In this month's Journal Jam Podcast on small bore chest tube and outpatient management of pneumothorax, the highlighted article that Anton Helman and Teresa Chan discuss is Voison et al. on the “Ambulatory Management of Large Spontaneous Pneumothorax With Pigtail Catheters.” We hear from Michelle Lin, Seth Trueger, Heather Murray and the lead author himself, Stephan Jouneau. Questions posed include: In what ways is the use of small bore catheters with Heimlich valves for spontaneous pneumothorax better than needle aspiration? Is it necessary to repeat a CXR after placement of the catheter? Who should follow up these patients after they are discharged from the hospital? How can we minimize kinking and dislodgement of the catheter? and many more..... [wpfilebase tag=file id=523 tpl=emc-play /] [wpfilebase tag=file id=524 tpl=emc-mp3 /]

Hot on the heels of Dr. Weingart's latest publication in the Annal of EM on Preoxygenation & Delayed Sequence Intubation, we have Dr. Weingart, perhaps the world's most influential critical care educator, and Dr. Walter Himmel, 'The Walking Encyclopedia of EM' discussing how the community ED doc can use preoxygenation, apneic oxygenation and delayed sequence intubation to help improve airway management knowledge and skills. Whether you work in a rural setting or a big urban community hospital, Dr. Himmel and Dr. Weingart explain how these concepts and skills are easily adaptable to your work environment. We introduce the Triple 15 Rule for preoxygenation as a memory aid that will help you the next time you're faced with a critically ill patient who's oxygen saturation isn't good enough on a non-rebreather.