Core EM - Emergency Medicine Podcast

A look at this common and controversial topic. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Otitis_Media.mp3 Download Leave a Comment Tags: Pediatrics Show Notes Background: The most common infection seen in pediatrics and the most common reason these kids receive antibiotics The release of the PCV (pneumococcal conjugate vaccine), or Prevnar vaccine, has made a big difference since its release in 2000 (Marom 2014) This, along with more stringent criteria for what we are calling AOM, has led to a significant decrease in the number of cases seen since then 29% reduction in AOM caused by all pneumococcal serotypes among children who received PCV7 before 24 months of age The peak incidence is between 6 and 18 months of age Risk factors: winter season, genetic predisposition, day care, low socioeconomic status, males, reduced duration of or no breast feeding, and exposure to tobacco smoke. The predominant organisms: Streptococcus pneumoniae, non-typable Haemophilus influenzae (NTHi), and Moraxella catarrhalis. Prevalence rates of infections due to Streptococcus pneumoniae are declining due to widespread use of the Prevnar vaccine while the proportion of Moraxella and NTHi infection increases with NTHi now the most common causative bacterium Strep pneumo is associated with more severe illness, like worse fevers, otalgia and also increased incidence of complications like mastoiditis. Diagnosis The diagnosis of acute otitis media is a clinical one without a gold standard in the ED (tympanocentesis) Ear pain (+LR 3.0-7.3), or in the preverbal child, ear-tugging or rubbing is going to be the most common symptom but far from universally present in children. Parents may also report fevers, excessive crying, decreased activity, and difficulty sleeping. Challenging especially in the younger patient, whose symptoms may be non-specific and exam is difficult Important to keep in mind that otitis media with effusion, which does not require antibiotics, can masquerade as AOM AAP: Diagnosis of Acute Otitis Media (2013)* In 2013, the AAP came out with a paper to help guide the diagnosis of AOM Moderate-Severe bulging of the tympanic membrane or new-onset otorrhea not due to acute otitis externa (grade B) The presence of bulging is a specific sign and will help us distinguish between AOM and OME, the latter has opacification of the tympanic membrane or air-fluid level without bulging (Shaikh 2012, with algorithm) Bulging of the TM is the most important feature and one systematic review found that its presence had an adjusted LR of 51 (Rothman 2003) Classic triad is bulging along with impaired mobility and redness or cloudiness of TM Mild bulging of the tympanic membrane AND (grade C) Recent onset (48hrs) Ear pain (verbal child) Holding, tugging, rubbing of the ear (non-verbal child) OR Intense erythema of the tympanic membrane * The diagnosis should not be made in the absence of a middle ear effusion (grade B) Treatment Options A strategy of “watchful waiting” in which children with acute otitis media are not immediately treated with antibiotic therapy, has been endorsed by the American Academy of Pediatrics. Who gets antibiotics? Depends on age, temperature, duration of otalgia, laterality / otorrhea, and access to follow up Get’s antibiotics: <6 months: Treat 6 months to 2 years: Treat Exception, AAP permits initial observation: unilateral AOM with mild symptoms (mild ear pain, <48h, T <102.2) But know that there is a high rate of treatment failure (Hoberman 2013) >2: Treat Unless they have mild symptoms and it’s unilateral, you can observe for 48-72 hours Why do we give antibiotics? Demonstrated reduction in pain, TM perforations, contralateral episodes of AOM They are no walk in the park, with increased adverse events (vomiting, diarrhea, rash) Two well-designed clinical trials (2011) randomized approximately 600 children meeting strict diagnostic criteria for acute otitis media to receive Augmentin or placebo. These studies demonstrated a significant reduction in symptom burden and clinical failures in those who received antibiotics. The authors conclude that those patients with a clear diagnosis of acute otitis media would benefit from antibiotic therapy AAP AOM Treatment Algorithm Antibiotic Selection High-dose amoxicillin in most (for now) Amoxicillin should not be used if the patient has received Amoxicillin in the past 30 days, has concomitant purulent conjunctivitis (likely H flu) or is allergic to penicillin. beta lactamase resistant antibiotic should be used. Amoxicillin clavulanate or 2nd or 3rd generation cephalosporins (including intramuscular ceftriaxone). Patients with a history of type 1 hypersensitivity reactions to penicillin should be treated macrolides. Studies on duration of therapy have shown better results with 10-day duration in children younger than 2 years and suggest improved efficacy in those 2-5 years. For patients older than 5 years, shorter course therapy (5-7 days) can be utilized. Pain Control Motrin and APAP may have benefit with otalgia reduction Other Decongestants and antihistamines have been shown to not benefit patients in terms of duration of symptoms or complication rate. Not surprisingly, these agents increase the side-effects experienced by patients. Follow up If you chose to observe, let the parents know to return to ED or f/u with their provider in 48-72 hours if they symptoms do not improve. Providing a prescription to parents with clear instructions on when to fill it is also an acceptable option. Strict return precautions should be given if patient develops meningismus or facial nerve palsy. If antibiotics were initiated, and there isn’t improvement in 2-3 days, the diagnosis of AOM should be revisited and, if still suspected, we have to consider that the causative bug is resistant to the prescribed antibiotic. These patients should RTED or f/u with their pediatrician for escalation of care Amoxicillin → Augmentin Augmentin → Ceftriaxone IM Macrolide → no clear antimicrobial agent, consult pediatric ENT If antibiotics are initiated with resolution of symptoms, the patient should f/u in 2-3 months to ensure resolution of the middle ear effusion and ensure that there is no associated conductive hearing loss References: Coker TR, Chan LS, Newberry SJ, Limbos MA, Suttorp MJ, Shekelle PG, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA. 2010;304(19):2161-9. Hoberman A, Ruohola A, Shaikh N, Tahtinen PA, Paradise JL. Acute otitis media in children younger than 2 years. JAMA Pediatr. 2013;167(12):1171-2. Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-99. Marom T, Tan A, Wilkinson GS, Pierson KS, Freeman JL, Chonmaitree T. Trends in otitis media-related health care use in the United States, 2001-2011. JAMA Pediatr. 2014;168(1):68-75. Rothman R, Owens T, Simel DL. Does this child have acute otitis media? JAMA. 2003;290(12):1633-40. Shaikh N, Hoberman A, Rockette HE, Kurs-Lasky M. Development of an algorithm for the diagnosis of otitis media. Acad Pediatr. 2012;12(3):214-8. Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2013(1):CD000219. See our core article on the topic by Dr. Deborah Levine and Dr. Michael Mojica here 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

Discover the complexities of foot fractures, particularly the notorious Jones fracture and its healing challenges. Delve into the mechanics and symptoms of various fractures, including fifth metatarsal injuries and the Liz Frank injuries. Learn about classification systems and the critical need for accurate diagnosis, imaging, and tailored treatment options. The discussion also touches on non-operative approaches and rehabilitation strategies for athletes, making this a must-listen for anyone interested in emergency medicine and orthopedic insights.

A discussion with Drs. McNamara and Leifer on the essentials and beyond of debriefing Hosts: Brian Gilberti, MD Audrey Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Debriefing.mp3 Download One Comment Tags: Resuscitation, Simulation Show Notes TAKE HOME POINTS Debriefing after a clinical case in the ED is a way to have an interprofessional, reflective conversation with a focus on improving for the next patient.  We can debrief routine cases, challenging cases, or even cases that go well. Follow a structure when leading a debrief. The prebrief sets ground rules and informs the team that the debrief is optional and will only take 3-5 minutes. Introduce names and roles Then give a one-liner about what happened in the case, followed by a plus/ delta: address  what went well and why, then how to improve Finally, wrap up with take home points Pitfalls to watch out for in clinical debriefing include: Avoid siloing or alienating any learners.  Learn from all your colleagues on your team- it’s less about medicine and more about interprofessional and systems issues Don’t pick on individual performance.  It’s not about shaming- it’s about improving patient care Avoid “guess what I’m thinking” questions; ask real questions Proceed with caution in order to dampen or avoid psychological trauma and second victim syndrome.  The learner may ask “was this my fault?”; we never want a learner to feel this way.  Ask, what systems supported or did not support you today?  Talk about what happened.  Avoid shame and blame. Have the right values and do it for the right reasons. ADDITIONAL TOOLS PEARLS Debriefing Tool INFO Model: GUESTS Dr. Shannon McNamara completed residency in Emergency Medicine at Temple University hospital and fellowship in Medical Simulation at Mount Sinai St. Lukes-Roosevelt. She now is the Director of the Simulation Division in the NYU Department of Emergency Medicine. She’s thrilled to have somehow made a career out of teaching people to talk about their feelings using big computers shaped like people. Dr. Jessica Leifer attended NYU for medical school and completed her residency training in emergency medicine at Mount Sinai St. Luke’s-Roosevelt. She completed a fellowship in medical simulation at the Mount Sinai Hospital. She is now simulation faculty in the NYU department of Emergency Medicine. Her academic interests include using simulation for patient safety, operations, and improving teamwork. Read More

Croup is a common viral infection that strikes children, leading to a barking cough and inspiratory stridor. The hosts unpack its causes, primarily the parainfluenza virus, and discuss the typical presentation of croup, including the alarming 'steeple sign' seen on X-rays. They also emphasize the critical importance of assessing symptom severity through tools like the Westley Croup Score and offer management strategies for mild to severe cases. Learn how to navigate this challenging condition in young patients!

A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/SJS.mp3 Download Leave a Comment Tags: Critical Care, Dermatology Show Notes Episode Produced by Audrey Bree Tse, MD Rash with dysuria should raise concern for SJS with associated urethritis Dysuria present in a majority of cases SJS is a mucocutaneous reaction caused by Type IV hypersensitivity Cytotoxic t-lymphocytes apoptose keratinocytes → blistering, bullae formation, and sloughing of the detached skin Disease spectrum SJS = <10% TBSA TEN = >30% TBSA SJS/ TEN Overlap = 10-30% TBSA Incidence is estimated at around 9 per 1 million people in the US Mortality is 10% for SJS and 30-50% for TEN Mainly 2/2 sepsis and end organ dysfunction. SJS can occur even without a precipitating medication Infection can set it off especially in patients with risk factors including HIV, lupus, underlying malignancy, and genetic factors SATAN for the most common drugs Sulfa, Allopurinol, Tetracyclines, Anticonvulsants, and NSAIDS Anti-epileptics include carbamazepine, lamictal, phenobarb, and phenytoin Can have a curious course Hypersensitivity reaction can develop while taking medication, or even one to four weeks after exposure In pediatric population, mycoplasma pneumonia and herpes simplex have been identified as precipitating infections Patients often have a prodrome 1-3 days prior to the skin lesions appearing May complain of fever, myalgias, headaches, URI symptoms, and malaise Rash may be the sole complaint Starts as dark purple or erythematous lesions with purpuric centers that progress to bullae Skin surrounding the lesions detaches from the dermis with just light pressure (Nikolsky Sign) Up to 95% of patients will have mucous membrane lesions ~85% will have conjunctival lesions Symptoms: Burning or itching eyes, a cough or sore throat, pain with eating, pain with urinating or defecating Source: JAMA Dermatol. 2017 Differential Diagnosis: SSSS, autoimmune bullous diseases, bullous fixed drug eruption, erythema multiforme, thermal burns, phototoxic reactions, and TSS SJS is a clinical diagnosis Basic workup: CBC, chemistry panel, LFTs, and a UA Treatment Supportive care IV fluid repletion guided by TBSA affected, as well as electrolyte, protein, and energy supplementation Consider protecting airway if significant oral mucosal involvement Stop the offending agent (if there is one) Advanced wound care and pain control Consults: Derm to do a biopsy, +/- ophthalmology, gyn / urology to prevent strictures or contractures Consider transferring to a burn center Dispo: Low threshold for ICU admission SCORTEN ( max of 7 points) 1 point each for Age over 40 Current cancer >30% body surface area affected HR >120 BUN >28 Glucose >240 Bicarb <20 Score of 2 points or higher should -> ICU Take Home Points SJS may begin like the flu, with lesions appearing 1-3 days after the prodrome starts Have to have a high suspicion for SJS because it is deadly. It’s a clinical diagnosis — derm biopsy is supportive A thorough history and physical exam are key.  Remember the characteristic rash and bullae, and always look in the mouth and eyes.  Ask about dysuria, sore throat, and eye irritation, as well as preceding medications or infections.  Think SATAN! Prompt supportive care focused on ABCs and IVF repletion are critical.  These patients can get sick really fast, so consider an ICU or burn unit. References: Barrett W.  Quick Consult: Symptoms: Rash, Dysuria, and Mouth Sores.  Emergency Medicine News.  41(4): 15-16, April 2019. Bivins H, Comes J.  Stevens-Johnson Syndrome.  Rosen and Barkin’s 5-Minute Emergency Medicine Consult.  2015; 1076-1077. Ergen EN, Hughey LC. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. JAMA Dermatol.2017;153(12):1344. doi:10.1001/jamadermatol.2017.3957 Gerull R, Nelle M, Schaible T.  Toxic epidermal necrolysis and Stevens-Johnson syndrome: A review.  Crit Care Med.  2011; 39:1521-1532. Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Current Perspectives on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Clin Rev Allergy Immunol. 2018;54(1):147-76. McNeil, D. (2019). Measles Cases Surpass 700 as Outbreak Continues Unabated. [online] Nytimes.com. Available at: https://www.nytimes.com/2019/04/29/health/measles-outbreak-cdc.html [Accessed 6 May 2019]. Mustafa SS, Ostrov D, Yerly D. Severe Cutaneous Adverse Drug Reactions: Presentation, Risk Factors, and Management. Curr Allergy Asthma Rep. 2018;18(4):26. Read More

A look at the opioid epidemic and what ED providers can do to combat this formidable foe. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Opioid_Epidemic.mp3 Download Leave a Comment Tags: Opioid Dependence, Opioid Free ED Show Notes Consider alternatives to opiates for acute pain NSAIDs Subdissociative ketamine Nerve blocks Curb misuse and diversion through prescribing a short supply and perform I-STOP checks Narcan is not just for acute overdose treatment by EMS or within the ED anymore We can equip patients, family members and friends with Narcan kits prior to discharge In New York state, can prescribe Narcan to patients with near fatal overdoses or who screen positive for an opioid use disorder Intranasal formulation is cheaper and more commonly prescribed than IM Buprenorphine induction can be done in the ED for patients in active withdrawal, as calculated by the COWS score. MDcalc calculator: https://www.mdcalc.com/cows-score-opiate-withdrawal Providers do not need an X-waiver to give a dose of Buprenorphine in the ED for 3 days Home induction can be considered for patients not actively withdrawing but would like to enter medication assisted treatment Some considerations: Contraindicated in patients with severe liver dysfunction and with hypersensitivity reaction to drug Oversedation can occur with concurrent use of benzodiazepines and alcohol Will precipitate withdrawal if concurrently using full opioid agonists Longitudinal care has to be established for patients started on Buprenorphine SAMHSA’s Buprenorphine practitioner locator site: https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator Buprenorphine Induction Pamphlet Read More

Dive into the world of measles as the hosts unpack the latest outbreak and how emergency departments should gear up for it. They break down the virus's contagiousness and key symptoms, including the notorious Koplik spots. Learn how to differentiate between measles and chickenpox at the bedside. The discussion covers critical triage precautions, vaccination effectiveness, and supportive care strategies, including the role of vitamin A. Plus, get insights on managing complications and post-exposure prophylaxis. Essential listening for healthcare providers!

In this episode, we discuss acute decompensated heart failure and how to best manage these dyspneic patients in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_ADHF.mp3 Download Leave a Comment Tags: Cardiology, Respiratory Show Notes Features that increase the probability of heart failure. (Wang 2005) B-lines seen in pulmonary edema. Positioning of ultrasound probe in BLUE protocol. (Lichtenstein 2008) Read More

In this episode, we discuss Boxer's fractures and how to best manage them in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Boxer_s_Fracture_eq.m4a Download One Comment Tags: Orthopedics, Trauma Podcast Video https://youtu.be/UreET5eLHas Show Notes Background: 40% of all hand fractures A metacarpal fracture can occur at any point along the bone (head, neck, shaft, or base) “Boxer’s” fractures classically at neck Most common mechanism: direct axial load with a clenched fist Most common metacarpal injured is the 5th A majority of these injuries are isolated injuries, closed and stable Examination: Ensure that this is an isolated injury May note a loss of knuckle contour or shortening A thorough evaluation of the skin is important Patients may also have fight bites and require irrigation and antibiotics Tender along the dorsum of the affected metacarpal Evaluate the range of motion as the commonly seen shortening results in extension lag For every 2 mm of shortening there is going to be a 7 degree decrease in ability to extend the joint Check rotational alignment of digits with the MCP and PIP at 50% flexion. Partially clench their fist and ensure that the axis of each digit converges near the scaphoid pole / mid wrist Deformity is often seen due to the imbalance of volar and dorsal forces Dorsal angulation AP, lateral and oblique views should be obtained on XR The degree of angulation is estimated with the lateral view NB: Normal angle between the metacarpal head and neck is 15 degrees Management: Most may be splinted with an ulnar gutter splint Must be closed, not significantly angulated, and not malrotated When splinting, place the wrist in slight extension, MCP (knuckles) at 90 degrees and the DIP and PIP in a relaxed, slightly flexed position A closed reduction is indicated if there is significant angulation “20, 30, 40” rule If angulation is more than: 20 in the middle finger metacarpal 30 in the ring finger metacarpal 40 in the pinky finger metacarpal Analgesia with a hematoma block or ulnar nerve block Reduction technique: https://www.aliem.com/2013/01/trick-of-trade-reducing-metacarpal/ Referral: May have mild deformity or decreased functionality and strength in hand grip after this injury Emergent evaluation if: Open fracture Neurovascular compromise Follow up: Refer to hand specialist Within 1 week if fractures of 4thand 5thmetacarpals with angulation 3 to 5 days if the 2ndand 3rd metacarpalsare affected Immobilized for three to four weeks in splint Healing may take up to six weeks Take Home Points: This is one of the most common fractures we will see as emergency physicians When evaluating these patients, ensure that this are no other more severe, life-threatening injuries, and pay particular attention to the skin exam so that you do not miss a fight-bite Reductions may be required if there is significant angulation, which is guided by the 20, 30, 40 rule Finally, emergent specialist evaluation is indicated if there is an open fracture or evidence of neurovascular compromise Read More

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