Core EM - Emergency Medicine Podcast

This week, we discuss Boerhaave syndrome focusing on making the diagnosis and managing the patient. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_66_0_Final_Cut.m4a Download One Comment Tags: Chest Pain, Pulmonary Show Notes Take Home Points Keep esophageal rupture on your differential for deadly causes of chest, epigastric or back pain.  We don’t see it often, but it’s a real thing.  Boerhaave Syndrome is the spontaneous rupture of the esophagus that is caused by a sudden increase in intraesophageal pressure, as seen in forceful vomiting.  So, if the patient presents with the right symptoms and any vomiting in their history, keep this diagnosis in mind.  Other causes you might see, though less common, are childbirth, seizure, prolonged coughing or laughing, or weightlifting. ED management is essentially ABCs and broad spectrum antibiotics, and maybe even antifungals. As soon as you make this diagnosis, get you CT surgeon on board as the length of time to definitive treatment is directly related to mortality. Read More Radiopaedia: Boerhaave Syndrome LITFL: Roast Duck and Juniper Beer Read More

This week we discuss the diagnosis and management of pericarditis with a focus on not missing the hidden STEMI. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_65_0_Final_Cut.m4a Download Leave a Comment Tags: ACS, Cardiology, Cardiovascular, Colchicine, Pericarditis, STEMI Show Notes Read More ECG Case of the Week (Amal Mattu): Acute STEMI vs. Pericarditis Part 1 + Part 2 REBEL EM: Colchicine for Treatment of Pericarditis SOCMOB: Pericarditis: Treatment and Diagnosis Pocket Card FOAMcast: Episode 54 – The Pericardium Core EM: Pericarditis Pericarditis PV Card (Chris Bond (socmob.org) References Brady W et al. Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment. Acad Emerg Med 2001;8:961–7. PMID: 11581081 Bischof JE et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med 2015 PMID: 26542793 Read More

This week we discuss an age-old debate: Calcium Channel Blockers or Beta Blockers for rate control in atrial fibrillation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_64_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation, Beta Blocker, Calcium Channel Blocker, Cardiology, Rate Control Show Notes CoreEM: Recent Onset Atrial Fibrillation ALiEM: Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers? ALiEM: Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED Fromm C, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015 Apr 22. PMID 25913166 Read More

This week we discuss a recent article looking at the relevance of d/c glucose levels to patient revisits and subsequent hospitalization https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_63_0_Final_Cut.m4a Download Leave a Comment Show Notes Driver BE et al. Discharge glucose is not associated with short-term adverse outcomes in emergency department patients with moderate to severe hyperglycemia. Ann Emerg Med 2016. PMID: 27353284 Read More

Delve into the urgent strategies for managing pulseless ventricular tachycardia and ventricular fibrillation. Timely defibrillation and high-quality chest compressions are crucial in cardiac arrest situations. Traditional ACLS guidelines are challenged, advocating for a more flexible approach to medication use. Discover insights on beta blockers and innovative dual defibrillation techniques that could enhance resuscitation outcomes. This discussion empowers emergency physicians to elevate their cardiac arrest response and improve patient care.

This week we discuss the presentation and treatment of hypokalemia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_61_0_Final_Cut.m4a Download Leave a Comment Show Notes Take Home Points Hypokalemia has a wide variety of presentations ranging from generalized weakness, to paralysis, to cardiac arrhythmia or cardiac arrest. When you discover hypokalemia, be sure to check and EKG. Think about underlying causes of hypokalemia, because it is rarely a solo event. Treat with oral potassium supplementation of 40-60 orally every 4-6 hours for mild hypokalemia and 10-20 mEq/hour IV for severe or symptomatic hypokalemia. Additional Reading LITFL: Hypokalemia LITFL: Hypokalemic Periodic Paralysis Core EM: Hypokalemia Read More

This week we discuss how to aggressively resuscitate patients with DKA as well as dispelling some dogmatic teachings on the topic. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_60_0_Final_Cut.m4a Download Leave a Comment Tags: Cerebral Edema, DKA, Hypokalemia, Insulin, Resuscitation Show Notes Take Home Points DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis. Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5 The insulin bolus isn’t necessary and appears to cause more episodes of hypokalemia. Just start insulin as an infusion at 0.14 units/kg Be vigilant about cerebral edema. Any change or deterioration in mental status should prompt treatment and evaluation. Mannitol in the euvolemic, normotensive patient and 3% hypertonic saline in the hypotensive/hypovolemic patient Finally, don’t forge to always hunt down the underlying cause of the DKA. Infection and non-compliance is the most common so liberally administer broad spectrum antibiotics if you’ve got even a hint of infection brewing https://www.youtube.com/watch?v=P9sKk4JZmso Additional Reading LITFL: EBM Diabetic Ketoacidosis Core EM: DKA Core EM: Episode 13.0 – Diabetic Ketoacidosis: A Case emDocs: Myths in DKA Management REBEL EM: Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis? References Aurora S et al. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med 2012; 30: 481-4. PMID: 21316179 Boyd JC et al. Relationship of potassium and magnesium concentrations in serum to cardiac arrhythmias. Clin Chem 1984; 30(5): 754-7. PMID: 6713638 Duhon B et al. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother 2013; 47: 970-5. PMID: 23737516 Fagan MJ et al. Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry arethey? Clin Ped 2008; 47(9): 851-6. PMID: Goyal N et al. Utility of Initial Bolus insulin in the treatment of diabetic ketoacidosis.  J Emerg Med 2010; 38(4): 422-7. PMID: 18514472 Green SM et al.  Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis.  Ann Emergency Medicine 1998; 31: 41-48. PMID: 9437340 Kitabchi AE et al. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis?  Diabetes Care. 2008;31(11):2081. PMID: 18694978 Lebovitz HE: Diabetic ketoacidosis.  Lancet 1995; 345: 767-772. PMID: 7891491 Morris LR et al.  Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern  Med 1986;105(6):836. PMID: 3096181 Muir AB et al. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care 2004; 27(7):1541-6. PMID: 15220225 Okuda Y et al.  Counterproductive effects of sodium bicarbonate in diabetic  ketoacidosis.  J Clinical Endocrinology Metabolism 1996; 81: 314-320. PMID: 8550770 Savage MW et al.  Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med. 2011 May;28(5):508-15. PMID: 21255074 Villon A et al.  Does bicarbonate therapy improve management of severe diabetic  ketoacidosis?  Crit Care Med 1999; 27: 2690-2693. PMID: 10628611 Read More

This week we discuss the recognition, diagnosis and treatment of severe decompensated hyperthyroidism or thyroid storm. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_59_0_Final_Cut.m4a Download Leave a Comment Tags: Thyroid Diseases, Thyroid Storm Show Notes Take Home Points Decompensated hyperthyroidism is a rare, life-threatening condition.  It can develop in patients with long-standing untreated hyperthyroidism and is often precipitated by another event such as an infection, surgery, or trauma. Patients present with tachycardia, fever, altered mental status and GI symptoms.  Keep thyroid storm in mind if a patient has a history of hyperthyroidism or if things just aren’t making sense with your patient, you can’t find a fever source, they have fever and new afib, things like that. You’re going to use a clinical scoring tool like the Burch-Wartofsky scoring system to make the diagnosis. Treatment is three-fold. First treat the peripheral effects with propranolol.  Then prevent further synthesis of thyroid hormone with PTU and corticosteroids.  And last prevent the further release of thyroid hormone with iodine.  Be sure to hold off on giving the iodine until at least 1 hour after the patient receives PTU to avoid worsening the hyperthyroid. Burch Wartofsky Scale (maryland.ccproject.com) Additional Reading ALiEM: Diagnosing hyperthyroidism: Answers to 7 common questions ALiEM: Thyroid Storm – Treatment Strategies LITFL: Thyroid Storm WikeEM: Burch and Wartofsky Diagnostic Criteria for Thyroid Storm Akamizu T et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012; 22(7): 661-79. PMC: 3387770 Read More

This week we discuss severe hyponatremia - presentation and treatment. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_58_0_Final_Cut.m4a Download Leave a Comment Tags: Electrolytes, Hypertonic Saline, Hyponatremia Show Notes EM Cases: Podcast 60: Emergency Management of Hyponatremia References Adrogue HJ, Maidas NE. Hyponatremia. NEJM 2000; 342(21): 1581-9. PMID: 10824078 Moritz ML, Ayus JC. 100 cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metab Brain Dis 2010; 25: 91-6. PMID: 20221678 Read More

This week we discuss the role of phenobarbital in the management of severe alcohol withdrawal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_57_0_Final_Cut.m4a Download One Comment Tags: Alcohol Withdrawal, Phenobarbital, Toxicology Show Notes References Riggan MA et al. Regarding “Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study.” J Emerg Med 2016; 50 (6): 895-8. PMID: 27221017 Rosenson J et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study. J Emerg Med 2013; 44(3): 592-8. PMID: 2299978 Read More