Core EM - Emergency Medicine Podcast

This week we look at TBI and discuss some of the pitfalls and pearls in early management of traumatic ICH. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_84_0_Final_Cut.m4a Download 2 Comments Tags: Head Injury, Hyperosmolar Therapy, ICH, Resuscitation, RSI, TBI, Trauma Show Notes Take Home Points If you get a heads up from EMS on an incoming trauma, take the lead time you get to clearly delineate everyone’s roles to help ensure the resuscitation runs smoothly. In the severe TBI patient, the key is in preventing secondary injury to the brain. We do this by guarding against hypoxia, hypercarbia, hypotension and aspiration. Max your pre-ox, get the ETT in quickly to prevent oxygenation and ventilation issues and keep the head up if possible Hypotension is rarely seen in isolated head trauma. If the patient is or becomes hypotensive, reassess for any sources of hemorrhagic shock that may have been missed and consider whether the meds you gave may have caused the problem. Hypertension is much more common and despite extensive research, we haven’t shown that dropping the patient to normal levels is beneficial. Keeping the SBP < 180 seems reasonable but check your local protocol as well. If the patient’s ICP spikes or your concerned about herniation, administer mannitol or hypertonic saline and get your neurosurgeon to the bedside since the patient is gonna need decompression Finally, make sure to reverse any anticoagulant the patient may have on board as this will hopefully prevent hematoma expansion. Read More emDocs: Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI Core EM: Podcast 31.0 – Rocuronium vs. Succinylcholine Core EM: Intensive Blood Pressure Lowering in Intracerebral Hemorrhage (ATACH-2 Trial) PulmCCM: Hyperosmolar Therapy for Increased Intracranial Pressure (Review) EM Cases: Episode 89 – DOACs Part 2: Bleeding and Reversal Agents Hopper AH. Hyperosmolar therapy for raised intracranial pressure. NEJM 2012; 367(8): 746-52. PMID: 22913684 Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014; 28(6): 821-7. PMID: 24859931 Zeiler FA et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014; 21(1): 163-73. PMID: 24515638 Read More

This week we discuss a bit about back pain and specifically, lumbar radiculopathy with a focus on causes and red flags. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_83_0_Final_Cut.m4a Download One Comment Tags: Back Pain, Low Back Pain, Musculoskeletal, Steroids Show Notes Read More St. Emlyn’s: Back to Basics: Back Pain in the ED Edlow JA. Managing nontraumatic acute back pain. Ann Emerg Med 2015; 66: 148-53. PMID: 25578887 Goldberg H et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA 2015; 313 (19): 1915-23. PMID: 25988461 Friedman BW et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 2015; 314 (15): 1572-80. PMID: 26501533 Read More

Delve into the intricacies of emergency management for seizures. Learn the vital distinctions between seizures and syncopal events, with essential interventions highlighted. Discover the first-line use of benzodiazepines for seizure termination. Explore the five categories of causes to ensure no potential issues are overlooked. For first-time seizures, a thorough evaluation is key, and follow-up with a neurologist is recommended. In cases of status epilepticus, aggressive benzodiazepine administration may pave the way for advanced treatments.

This week, the podcast features a talk on Visualization given at the All NYC EM conference in October 2016. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_81_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, Human Factors, Performance Psychology, Sports Psychology Show Notes Read More EMCrit: EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria Read More

This week we feature a short primer on penetrating chest trauma focusing on circulation first over airway and breathing. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_80_0_Final_Cut.m4a Download Leave a Comment Tags: ED Thoracotomy, EFAST, Resuscitative Thoracotomy, Trauma, Ultrasound Show Notes Take Home Points Don’t rush to the airway. In most situations, you have some time so resuscitate before you intubate. Give blood products and get the BP up a bit to give yourself a little better physiologic situation in which to intubate. Start your massive transfusion immediately if the patient is shocked. There’s always a delay in getting products but the earlier you start, the shorter the delay. Include US in your primary survey. Your E-FAST should start with the cardiac window, then go to the lungs and then, finally, the abdomen. This order focuses on finding pathology you can fix immediately. If the patient is shocked and peri-arrest or recently lost vitals, open the chest and look for a fixable injury. Start with opening the pericardium to relieve tamponade, identify and repair cardiac wounds and cross clamp the aorta. Read More Larry Mellick: Open Thoracotomy Video EMCrit: Podcast 081 – An Interview on Severe Trauma with Karim Brohi LITFL: Penetrating Chest Trauma EM:RAP: How to Crack the Chest EM: RAP: Stabbed in the Chest Read More

This week we discuss facial trauma and the disasters it can cause to your airway management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_79_0_Final_Cut.m4a Download 2 Comments Tags: Airway, Cricothyroidotomy, RSI, Trauma Show Notes Take Home Points In a patient with significant head and neck trauma, EACH step of the airway management can be more difficulty. BVM may be hard, LMA may be hard, RSI may be hard, so don’t be afraid to ask for help early. Decide whether the patient has an actual obstruction of their airway. If they are obstructed above the larynx, don’t bother with your usual airway maneuvers, go directly to the surgical airway. When you do attempt RSI, have double suction and multiple airway techniques set up. This is the time to have your friend standing at your side, scalpel in hand and ready to move directly down the difficult airway algorithm if trouble arises. Finally, consider keeping the patient awake and preserving their own respiratory drive as it may give you more time to secure the airway. Read more LITFL: Facial Trauma LITFL: Airway in Maxillofacial Trauma EMCrit: Real Surgical Airway Read More

This week we discuss the OXYGEN-ICU trial exploring the effect of excess oxygen on ICU mortality. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_78_0_Final_Cut.m4a Download Leave a Comment Tags: Critical Care, ICU, OXYGEN-ICU Study Show Notes Read More The Bottom Line: Normal Oxygen Versus Hyperoxia in the Intensive Care Unit (ICU) (OXYGEN-ICU) ScanCrit: Avoid the Oxygen Reflex REBEL EM: July 2015 REBEL Cast References Giradis M et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 316(15):1583-1589. 2016. PMID: 27706466 Meyhoff CS et al. PROXI Trial Group. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009; 302(14):1543-1550. PMID: 19826023 Stub D et al. AVOID Investigators. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150. PMID: 26002889 Read More

This week the podcast features a talk Jenny Beck-Esmay gave at the 11th All NYC EM Conference entitled "Give TXA Now!" https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_77_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, CRASH-2, Massive Transfusion Protocol, MATTERS, Trauma, TXA Show Notes Take Home Points Giving TXA provides a significant mortality benefit to the any trauma patient requiring massive transfusion with an NNT = 7 for mortality TXA must be given early. Give within 1 hour of injury if possible but the benefit remains up to 3 hours out TXA administration: 1 gram as a bolus followed by 1 gram over the next 8 hours Show Notes Intensive Care Network: Karim Brohi on TXA in Trauma EMCrit: Podcast 67 – Tranexamic Acid (TXA) Core EM: CRASH-2 Tranexamic Acid in Major Trauma References CRASH-2 trial collaborators. Effects of tanexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a ransomised placebo-controlled trial. Lancet 2010; 376: 23-32. PMID: 20554319 Guerriero C et al. Cost-effectiveness analysis of administering tranexamic acid to bleeding trauma patients using evidence from the CRASH-2 trial. PLoS One 2011; 6(5): e18987. PMID: 21559279 Ker K et al. Avoidable mortality from giving tranexamic acid to bleeding trauma patients: an estimation based on WHO mortality data, a systematic literature review and data from the CRASH-2 trial. BMC Emerg Med 2012; 12:3. PMID: 22380715 Morrison JJ et al. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) Study. Arch Surg 2012; 147 (2): 113-9. PMID: 22006852 Read More

This week we discuss Lisfranc injuries with a focus on a diagnostic pathway and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_76_0_Final_Cut.m4a Download Leave a Comment Tags: Lisfranc Fracture, Lisfranc Injury, Orthopedics, Trauma Show Notes Take Home Points A Lisfranc injury is a midfoot injury that results in displacement of one or more of the metatarsal bones from tarsus.  XR will show widening of the space between the 1st and 2nd metatarsals. Getting contralateral XR may help you identify this. Even if you don’t see that widening on the XR, the patient could still have a Lisfranc injury. If they cannot walk due to pain, get a weight bearing XR or CT scan to look further. Once the injury is identified, the patient must be strict non-weightbearing. Place them in a posterior splint and get orthopedics involved either in the ED or for prompt follow up as the patient will probably need surgery. Foot Bones (Google Images) Normal Foot X-ray Series (Case courtesy of Dr Andrew Dixon, Radiopaedia.org. From the case rID: 36688) Lisfranc Injury AP X-ray (Radiopaedia Image #1: Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. From the case rID: 10919) Divergent Lisfranc Injury Read More LITFL: Eponymous Fractures Radiopaedia: Lisfranc Injury Core EM: Compartment Syndrome Read More

Explore the complexities of adrenal insufficiency and learn key management techniques that involve both volume expansion and steroid use. Discover the vital principles of fluid resuscitation and the importance of assessing fluid responsiveness, particularly in critical care settings. Delve into the risks associated with fluid management, emphasizing careful approaches to avoid the pitfalls of aggressive resuscitation strategies. This insightful discussion is packed with relevant guidelines and practical applications for improving patient outcomes.