Core EM - Emergency Medicine Podcast

Exploring recent updates in the workup and management of pneumonia, including considerations for sputum and blood cultures, testing for influenza, the role of Procal in determining antibiotic use, and updates in the treatment of community-acquired pneumonia.

Mukul Ramakrishnan, a resident physician at NYU Bellevue, shares vital insights into posterior circulation strokes. He discusses the nuances of diagnosis, emphasizing the common symptoms that can lead to missed cases. The importance of awareness around risk factors is highlighted, alongside the challenges of identifying these strokes, especially in younger patients. Mukul also explains the HINTS exam, detailing its effectiveness in stroke evaluation and the distinction between peripheral and central nystagmus, enhancing clinical practice in emergency medicine.

We discuss one of the most complex problems we face – Homelessness Hosts: Kelly Doran, MD Audrey Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Homelessness.mp3 Download One Comment Tags: Social Emergency Medicine Show Notes Special Thanks To: Dr. Kelly Doran, MD MHS Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue ___________________________ References: Doran, K.M.  Commentary: How Can Emergency Departments Help End Homelessness?  A Challenge to Social Emergency Medicine. Ann Emerg Med. 2019;74:S41-S44. Doran, K.M., Raven, M.C. Homelessness and Emergency Medicine: Where Do We Go From Here? Acad Emerg Med. 2018;25:598-600. Salhi, B.A., et al. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med. 2018;25:577-93. U.S. Department of Housing and Urban Development, Annual Homeless Assessment Report to Congress. Available at: https://www.hudexchange.info/resource/5783/2018-ahar-part-1-pit-estimates-of-homelessness-in-the-us/ U.S. Interagency Council on Homelessness. Home, Together Federal Strategic Plan to Prevent and End Homelessness. https://www.usich.gov/resources/uploads/asset_library/Home-Together-Federal-Strategic-Plan-to-Prevent-and-End-Homelessness.pdf Read More

Delve into the intricacies of blunt neck trauma, revealing its common causes like motor vehicle collisions and strangulation. The discussion emphasizes the critical nature of airway management and the structured assessment necessary to prevent complications. Explore the evaluation of vascular and laryngotracheal damage, as well as treatment strategies for blunt cerebrovascular injury. The conversation also highlights the importance of advanced imaging for detecting rare injuries and the need for teamwork among trauma specialists.

Explore the intricacies of ankle sprains, a prevalent injury especially among teens and athletes. Discover the critical role of the anterior talofibular ligament and the distinctions between lateral and medial sprains. Unpack the grading system that helps assess injury severity, along with essential examination techniques to differentiate sprains from fractures. Learn about effective rehabilitation strategies and the importance of tailored immobilization. Gain insights into recovery management and the risks of re-injury.

An overview of Vaping Associated Lung Injury (VALI) Hosts: Audrey Bree Tse, MD Larissa Laskowski, DO Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vaping_Associated_Lung_Injury.mp3 Download 2 Comments Tags: Pulmonary, Toxicology Show Notes Why this matters As of Oct 15, vaping has been associated with acute lung injury in over 1400 people 33 deaths have been confirmed in 24 states 70+% of those with VALI are young men A large number of patients are requiring ICU/ intubation/ ECMO 4 main ingredients in solvent +/- Flavor additives +/- Nicotine or THC (Tetrahydrocannabinol) Propylene Glycol (PG) Vegetable Glycerin (VG) CDC definition of VALI (Vaping Associated Lung Injury) Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset AND Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT AND Absence of pulmonary infection on initial work-up.  No evidence in the medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process). *Dabbing allows the user to ingest a high concentration of THC.  Butane Hash Oil (BHO), an oil or wax-like substance extracted from the marijuana plant, is placed on a “nail” attached to a specialized glass bong called a “rig.” A blow torch is used to heat the wax, which produces a vapor that can then be inhaled to supposedly produce an instantaneous effect. Pathophysiology At present, no single compound or ingredient has emerged as the cause, and there may be more than one cause The only common thread among the cases is that ALL patients reported using e-cig or vaping products Leading potential toxins: Vaping products containing THC concentrates: most cases are linked to THC concentrates that were either purchased on the street or from other informal sources (meaning not from a dispensary) Vitamin E acetate: nutritional supplement safe when ingested or applied to the skin (but likely not when inhaled) has been found in nearly all product samples of NY state cases of suspected VALI vitamin E acetate is NOT an approved additive at least by NYS Medical Marijuana program Other potential toxins: IT CANNOT BE UNDERSTATED that a small percentage of persons w/ VALI have reported exclusive use of nicotine-containing vape products, such as JUUL; as such, we must consider the potential toxicity of standard e-liquid or vape juice Flavor additives, that exists as chemical aldehydes: irritating and potentially damaging to lung tissue PG/VG: shown not only to break down to formaldehyde which is a known carcinogen, but also to produce lipoid pneumonia in rat lungs Some devices are easily manipulated to increase the capacity to produce vapor; increasing these settings may impact heating temperature, metabolic breakdown, and release of microscopic metal particles Lungs are multifunctional, including serving as an immune organ: lungs cleave proteins of all of the bacteria, viruses and other pathogens we are exposed to and inhale daily human studies on those that are chronic e-cig users or vapers have revealed that these products are shifting the balance of proteases and antiproteases in our lungs such that the proteases are destroying native lung tissue similar to how traditional cigarettes cause COPD Many potential reactions: NEJM article in references: details four radiographic phenotypes essentially reflecting different pathologic changes Long-term Effects Long term effects are unknown (some pts have required home oxygen on discharge) Risk for recurrence or relapse, especially if repeat exposure Presentation 95% of pts have had pulmonary sxs (cough, cp, dyspnea) 77% of pts have had GI sxs (abd pain, n/v/d) 85% of pts w/ constitutional sxs (f/c, weight loss) 57% w/ hypoxia (O2 < 95%) Unfortunately auscultation has been unreliable and poorly sensitive Workup There is no specific test or marker for dx, so VALI is still considered a dx of exclusion Labs: CBC ESR/CRP (93% w/ elevated ESR) LFTs (50% w/ transaminitis) ABG: hypoxia Imaging: CXR: typically shows bilateral infiltrates, although not always and there have even been some cases w/ unremarkable chest XR (so high degree of clinical suspicion in any person p/w hypoxia) CT: ground glass opacities, typically bilaterally  Management Dispo: 96% of cases required hospitalization Any pt w/ hypoxia, respiratory distress, or comorbidities Outpatient only if: no hypoxia or respiratory distress, reliable followup within 48h and good social support (keep in mind that some patients w/ mild symptoms of first presentation deteriorated rapidly within 48h) Empiric treatments for pneumonia inc abx, antivirals Steroids (methylpred 60mg q6h, based on how index cases in Illinois were managed) Case reports have documented improvement Mechanism: blunting of inflammatory response Aggressive supportive care Special Thanks To: Dr. Larissa Laskowski, DO Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue New York City Poison Control Center References: Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping.  https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html Carlos WG, Crotty Alexander LE, Gross JE, Dela Cruz CS, Keller JM, Pasnick SP, Jamil S.  Vaping-associated Pulmonary Illness (VAPI). Public Health Information Series. Am J Respir Crit Care Med Vol. 200, 13-15, 2019.  www.atsjournals.org/doi/pdf/10.1164/rccm.2007P13 Henry TS, Kanne JP, Kilgerman SJ.  Images of Vaping-Associated Lung Disease — Correspondence.  N Engl J Med. 2019 Oct 10; 381;15.   Layden JE, Ghana I, Pray I, Kimball A, Layer M, Tenforde M, Navon L, Hoots B, Salvatore PP, Elderbrook M, Haupt T, Kanne J, Patel MT, Saathaff-Huber L, King BA, Schier JG, Mikosz CA, Meiman J.  Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report.  N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print].  https://www.ncbi.nlm.nih.gov/pubmed/31491072?dopt=AbstractPlus Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019. MMWR Morb Mortal Wkly Rep 2019;68:919–927. DOI: http://dx.doi.org/10.15585/mmwr.mm6841e3external icon. https://www.health.ny.gov/press/releases/2019/2019-09-05_vaping.htm Read More

Dive into the world of septic arthritis with insights on how bacteria invade joints and the alarming consequences of delayed treatment. Discover the critical myths surrounding its presentation and the importance of accurate diagnosis through techniques like arthrocentesis. Learn about the diverse risk factors and pathogens involved, including the challenges posed by prosthetic joints. The conversation highlights diagnostic complexities and emphasizes the urgent need for effective management in emergency medicine to prevent irreversible joint damage.

A look at the most common type of seizures in the young pediatric population. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Febrile_Seizures.mp3 Download Leave a Comment Tags: Pediatrics Show Notes Background The most common type of seizure in children under 5 years of age Occur in 2-5% of children In children with a fever, aged 6 months to 5 years of age, and without a CNS infection Risk Factors 4 times more likely to have a febrile seizure if parent had one Also increase in risk if siblings or nieces / nephews had one Common associated infections Human Herpesvirus 6 Human Herpesvirus 7 Influenza A & B Simple Febrile Seizure Generalized tonic-clonic activity lasting less than 15 minutes in a child 6 months to 5 years of age Complex Febrile Seizure Lasts longer than 15 minutes, occurs in a child outside of this age range, are focal, or that recur within a 24-hour period. Diagnostics / Workup Gather thorough history and perform thorough physical exam Most cases will not require labs, imaging or EEG If e/o meningitis, perform LP AAP suggests considering LP in: Children 6-12 months who are not immunized for H flu type B or strep pneumo Children who had been on antibiotics For complex seizures, clinician may have a lower threshold for obtaining labs Hyponatremia is more common in this group than in the general population. LPs are more commonly done by providers, but these are low yield with one study showing bacterial meningitis being diagnosed in just 0.9% (Kimia 2010), all of whom did not have a normal exam or negative cultures. Neuroimaging is also exceedingly low yield if the patient returns to baseline (Teng 2006) One study that showed that the duration of complex febrile seizure, being greater than 30 minutes, was associated with a higher incidence of bacterial meningitis. (Chin 2005) Of they have history and exam concerning for meningitis, they should get an LP If they look dehydrated or edematous, you would have more of a reason to get a chemistry Treatment Benzodiazepine if seizure lasted for >5 minutes, either IV or IN Supportive care Tylenol or motrin if febrile Fluids if signs of dehydration Antipyretics “around the clock” A majority of data show no benefit in preventing recurrence of seizure One study (Murata 2018) found that giving tylenol q6h at 10 mg/kg for the first 24 hours following the initial seizure decreased the rate of recurrence when compared to children who did not receive antipyretics. NNT here was 7 Questionable whether we can generalize these findings from a single ED in Japan. No role for antiepileptics Prognosis High rate of recurrence (~1/3) within 1 year of initial seizure Risk increases for Younger age at which they had initial seizure Lower temperature at which they had seizure If initial febrile seizure was prolonged, more likely that the next will be prolonged 1-2% develop epilepsy for simple febrile seizure, slightly above risk of general population 5-10% develop epilepsy for complex febrile seizure Follow up with PMD Generally, peds neuro follow up is not necessary References Chin RF, Neville BG, Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child. 2005;90(1):66-9. Kimia A, Ben-Joseph EP, Rudloe T, Capraro A, Sarco D, Hummel D, et al. Yield of lumbar puncture among children who present with their first complex febrile seizure. Pediatrics. 2010;126(1):62-9. Murata S, Okasora K, Tanabe T, Ogino M, Yamazaki S, Oba C, et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. 2018;142(5). Patel N, Ram D, Swiderska N, Mewasingh LD, Newton RW, Offringa M. Febrile seizures. BMJ. 2015;351:h4240. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013;54(12):2101-7. Stapczynski, J. S., & Tintinalli, J. E. (2016). Tintinalli’s emergency medicine: A comprehensive study guide, 8th Edition. New York: McGraw-Hill Education. Subcommittee on Febrile S, American Academy of P. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-94. Teng D, Dayan P, Tyler S, Hauser WA, Chan S, Leary L, et al. Risk of intracranial pathologic conditions requiring emergency intervention after a first complex febrile seizure episode among children. Pediatrics. 2006;117(2):304-8. Warden CR, Zibulewsky J, Mace S, Gold C, Gausche-Hill M. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003;41(2):215-22. A special thanks to our editors: Michael A. Mojica, MD Director, Pediatric Emergency Medicine Fellowship Bellevue Hospital Center Christie M. Gutierrez, MD  Pediatric Emergency Medicine Fellow Columbia University Medical Center Morgan Stanley Children’s Hospital New York Presbyterian   Read More

This discussion delves into the rising prevalence of Lyme disease and the importance of recognizing tick bites, especially in summer. The hosts break down the tick's life cycle and the notorious erythema migrans rash. They highlight the varying stages and symptoms, including the potential complications affecting the nervous system. Additionally, they tackle the challenges in diagnosing Lyme disease, the role of patient history, and practical tips for managing ticks, making it a comprehensive guide for anyone concerned about this common illness.

An in depth review of this notorious parasite. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Malaria.mp3 Download Leave a Comment Tags: Infectious Diseases Show Notes Background In 2017, there were 219 million cases and 435,000 people deaths from malaria Five species: Falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. Falciparum, Vivax and Knowlesi can be fatal History of recent travel to Africa (69% of cases in US), particularly to west-Africa should raise suspicion for malaria Clinical Manifestations Average incubation period for Falciparum is 12 days 95% will develop symptoms within 1 month Clinical findings with high likelihood ratios include periodic fevers, jaundice, splenomegaly, pallor. Can also have vomiting, headache, chills, abdominal pain, cough, and diarrhea Severe malaria has a mortality of 5% to 30%, even with therapy Diagnostic criteria for severe malaria: Ashley 2018 Most common manifestations of severe malaria affect the brain, lungs, and kidneys Patients with cerebral malaria can present encephalopathic or comatose, some severe enough to exhibit extensor posturing, or seizures Can have acute lung injury with a quarter of these patients progressing to ARDS Can have AKI from ATN and resultant acidosis Labs may be unremarkable but watch for anemia and thrombocytopenia Hgb <5 has an OR = 4.9 for death Severe thrombocytopenia has an OR = 2.8 Anemia + Thrombocytopenia has an OR = 13.8 (Lampah 2015, PMID 25170106) Watch for hypoglycemia Be mindful of co-infection with salmonella and HIV Obtain BCx, cover with ceftriaxone Diagnosis Blood smear Thick smear to increase sensitivity for detecting parasites Thin smear for quantifying parasitemia and species The first smear is positive in over 90% of cases, but if suspicion is high, it has to be repeated BID for 2-3 days for proper exclusion of malaria (CDC 2019) Management For uncomplicated, non-severe cases, most patients with falciparum should be admitted, especially those with no prior exposure to malaria parasites Malarone is one of the first line options Check out other suggested regimens from the CDC Important to note that when they take this, ensure they take with milk or food containing fat to enhance absorption Severe Malaria Resuscitative efforts directed at affected organ Can deteriorate rapidly Initiate IV Artesunate if high level of suspicion Requires call to CDC: CDC Malaria Hotline: (770) 488-7788 or (855) 856-4713 (toll-free) Monday–Friday 9am–5pm EST – (770) 488-7100 after hours, weekends, and holidays Benzodiazepines for seizures Be judicious with fluids as this can precipitate pulmonary edema and cerebral edema a/w increased mortality in children at 48 hour (Maitland 2011, PMID: 21615299; Hanson 2013, PMID: 23324951) Take Home Points This is going to be a diagnosis that is mainly made through a thorough history, and pay particular attention to those with recent travel to West-Africa The incubation period for falciparum is 12 days, but there is a range of weeks and we should consider Malaria when consistent symptoms develop within 1 month of travel to an endemic area Typical signs and symptoms for uncomplicated malaria are periodic fevers, jaundice, pallor Be mindful of end organ involvement, such as cerebral edema, ATN, and pulmonary edema; these cases are considered to be severe and treated differently than uncomplicated  malaria Uncomplicated cases should get Malarone or Coartem Severe cases require IV Artesunate Be judicious with your fluid resuscitation as this can harm our patients References Centers for Disease Control and Prevention. CDC Parasites – Malaria. 2019 https://www.cdc.gov/parasites/malaria/index.html (7 July 2019, date last accessed) Ashley EA, Pyae Phyo A, Woodrow CJ. Malaria. Lancet. 2018;391(10130):1608-21. Hanson JP, Lam SW, Mohanty S, Alam S, Pattnaik R, Mahanta KC, et al. Fluid resuscitation of adults with severe falciparum malaria: effects on Acid-base status, renal function, and extravascular lung water. Crit Care Med. 2013;41(4):972-81. Lampah DA, Yeo TW, Malloy M, Kenangalem E, Douglas NM, Ronaldo D, et al. Severe malarial thrombocytopenia: a risk factor for mortality in Papua, Indonesia. J Infect Dis. 2015;211(4):623-34. Lokken KL, Stull-Lane AR, Poels K, Tsolis RM. Malaria Parasite-Mediated Alteration of Macrophage Function and Increased Iron Availability Predispose to Disseminated Nontyphoidal Salmonella Infection. Infect Immun. 2018;86(9). Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-95. Park SE, Pak GD, Aaby P, Adu-Sarkodie Y, Ali M, Aseffa A, et al. The Relationship Between Invasive Nontyphoidal Salmonella Disease, Other Bacterial Bloodstream Infections, and Malaria in Sub-Saharan Africa. Clin Infect Dis. 2016;62 Suppl 1:S23-31. Tintanelli, Judith E., et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Eighth edition. New York: McGraw-Hill Education, 2016: p.1070-1077 World Health Organization. Guidelines for the treatment of malaria. Third edition April 2015. WHO. 2015 https://www.who.int/malaria/publications/atoz/9789241549127/en/ (7 July 2019, date last accessed) A special thanks to our editor: Angelica Cifuentes Kottkamp, MD Infectious Diseases & Immunology NYU School of Medicine   Read More