Core EM - Emergency Medicine Podcast

This week we discuss a quick case leading into the management of MALA. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_124_0_Final_Cut.m4a Download 2 Comments Tags: Metformin, Toxicology Show Notes Take Home Points In patients with shortness of breath and clear lungs, consider metabolic acidosis with respiratory alkalis as a potential cause Suspect MALA in any patient on metformin who presents with abdominal pain, nausea and vomiting and/or AMS Patients with MALA will have a low pH, a high-anion gap metabolic acidosis and high lactate levels Call your tox consultant to assist with management which will focus on fluid resuscitation with isotonic bicarbonate and dialysis Read More Bosse GM. Antidiabetics and Hypoglycemics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Accessed October 31, 2017 LITFL: Metformin-Associated Lactic Acidosis LITFL: Metformin The Poison Review: 6 Pearls About Metformin and Lactic Acidosis Read More

This week we dive into a recent journal article questioning whether we should tap all ascites. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_123_0_Final_Cut.m4a Download Leave a Comment Tags: Albumin, Cirrhosis, Paracentesis, SBP, Spontaneous Bacterial Peritonitis Show Notes Take Home Points SBP is a difficult diagnosis to make clinically. While patients may have the triad of fever, abdominal pain and increasing ascites, they are far more likely to only have 1 or 2 of these symptoms In patients admitted to the hospital with ascites, consider performing a diagnostic paracentesis on all patients as limited literature shows an association with decreased mortality and, the procedure is simple and low risk Once you get the fluid, focus on the cell count: WBC > 500 or PMN > 250 should prompt treatment with a 3rd generation cephalosporin and albumin infusion Gaetano et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. Journal of Gastroenterology and Hepatology 2016. PMID: 26642977 Read More EMRAP: C3 Live Paracentesis Video LITFL: Spontaneous Bacterial Peritonitis SinaiEM: SBP Pearls REBEL EM: Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)? Approach to the Diagnosis and Treatment of SBP (University of Washington)   Read More

Dive into the complexities of true knee dislocations and the critical need for thorough evaluations. Discover how many of these injuries may spontaneously reduce and the telltale signs to watch for. The discussion emphasizes the importance of neurovascular exams to assess potential popliteal artery injuries. Learn the vital management strategies, including the role of CT angiography in identifying vascular damage and the protocols for timely interventions. It's a must-listen for those in emergency medicine!

This week we dive into the diagnosis and management of pancreatitis in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_121_0_Final_Cut.m4a Download Leave a Comment Tags: Gastroenterology, GI, Pancreatitis Show Notes Ranson’s Criteria for Pancreatitis-Associated Mortality (Rosen’s) Take Home Points Pancreatitis is diagnosed by a combination of clinical features (epigastric pain with radiation to back, nausea/vomiting etc) and diagnostic tests (lipsae 3x normal, CT scan) A RUQ US should be performed looking for gallstones as this finding significantly alters management The focus of management is on supportive care. IV fluids, while central to therapy, should be given judiciously and titrated to end organ perfusion Patients will mild pancreatitis who are tolerating oral intake and can reliably follow up, can be discharged home Read More Hemphill RR, Santen SA: Disorders of the Pancreas; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 91: p 1205-1226 PulmCrit: The Myth of Large-Volume Resuscitation in Acute Pancreatitis PulmCrit: Hypertriglyceridemic Pancreatitis: Can We Defuse the Bomb? Read More

This week we discuss common bites, stings and envenomations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_120_0_Final_Cut.m4a Download Leave a Comment Tags: Bee Sting, Black Widow, Brown Recluse Spider, Hymenoptera Show Notes Take Home Points The most common bites and stings you will see are by bees and ants.  These can present as a local reaction, toxic reaction, anaphylaxis or delayed reaction.  For all of these, treat with local wound care and epinephrine for any systemic symptoms. The brown recluse spider is found in the Midwest and presents as local pain and swelling but carries the risk of a necrotic ulcer The black widow spider is found all around the US and presents with either localized or generalized muscle cramping, localized sweating and potentially tachycardia and hypertension.  Treatment is symptom management with analgesics and benzos. The bark scorpion usually presents with localized pain and swelling, but particularly in children, may present with a serious systemic presentation including jerking muscle movements, cranial nerve dysfunction, hypersalivation, ataxia and opsoclonus, which is the rapid, involuntary movement of the eyes in all directions. Treatment is supportive cares, but remember to call your poison center to ask about antivenin. Read More WikEM: Brown Recluse Spider Bite WikEM: Black Widdow Spider Bite WikEM: Hymenoptera Stings Read More

This week we review 4 articles discussed in our conference in the last month. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_119_0_Final_Cut.m4a Download Leave a Comment Tags: ACS, AMI, Cardiac Arrest, Cardiology, Oxygen, Pediatrics, POCUS, Syncope Show Notes Take Home Points Tachycardia in peds patients at discharge was associated with more revisits but not with more critical interventions. If your workup is reassuring, isolated tachycardia in and of itself shouldn’t change your disposition. Supplemental O2 is not necessary in the management of AMI patients with an O2 sat > 90% and, may be harmful Until further study and prospective validation has been performed, we’re not going to recommend embracing the Canadian decision instrument on predicting dysrhythmias after a syncopal event. Finally, our agreement on what cardiac standstill is isn’t great. We need a unified definition going forward to teach our trainees and for the purposes of research. Read More Core EM: ED POCUS in OHCA – The REASON Study ALiEM: Management of Syncope EM Nerd: The Case of the Liberated Radicals ScanCrit: O2 Not Needed in Myocardial Infarction Core EM: Predicting Dysrhythmia after Syncope Gaspari R et al. Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital  and in-ED Cardiac Arrest. Resuscitation 2016; 109: 33 – 39. PMID: 27693280 References Wilson PM et al. Is Tachycardia at Discharge from the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study.Ann Emerg Med. 2017. PMID: 28238501 Hofmann R et al. Oxygen Therapy in Suspected Acute Myocardial Infarction. NEJM 2017. PMID: 28844200 Thiruganasambandamoorthy V  et al. Predicting short-term risk of arrhythmia among patients with syncope: the Canadian syncope arrhythmia risk score. Acad Emerg Med 2017. PMID: 28791782 Hu K et al. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med 2017. PMID: 28870394 Read More

Part II of II on gallbladder disorders finishing up with acute cholangitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_118_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder, Gastroenterology, General Surgery, GI Show Notes Take Home Points Cholangitis is an acute bacterial infection of the bile ducts resulting from common bile duct obstruction and is potentially life-threatening (mortality 5-10%, acute bacterial infection of the bile ducts Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic. Look for RUQ tenderness with peritoneal signs and fever A normal ultrasound does not rule out acute cholangitis Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery) Read More Radiopaedia: Acute cholangitis Core EM: Cholangitis Read More

This podcast discusses acute cholecystitis, an inflammation of the gallbladder. It covers diagnostic criteria, imaging modalities, and treatment options. Lab tests are not reliable for diagnosis. Treatment includes fluid resuscitation, supportive care, antibiotics, and surgical consultation. Complications can include gangrene, necrosis, perforation, and sepsis.

This podcast discusses the presentation and management of button battery ingestions in kids. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_116_0_Final_Cut.m4a Download One Comment Tags: Button Battery, GI, Pediatrics Show Notes NBIH Button Battery Ingestion Algorithm Button Battery XR (scielo.br) Take Home Points Button battery ingestions are extremely dangerous. Necrosis, perforation and erosion into vessels can occur in as little as 2 hours ALL esophageal button batteries should be removed within 2 hours of presentation to minimize mucosal damage Consider button battery ingestion in children presenting with dysphagia, refusal to eat and hematemesis Co-ingestion of a button battery with a magnet requires emergency removal regardless of where it is in the GI system Read More National Capital Poison Center: NBIH Button Battery Ingestion Triage and Treatment Guideline Pediatric EM Morsels: Button Battery Ingestion St. Emlyn’s: Button Batteries – Hide and Seek in the Emergency Department ENT Blog: Lithium Disc Battery Danger for Kids Read More

This week we sit down with toxicologist Meghan Spyres to talk about Wernicke's Encephalopathy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_115_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Abuse, Thiamine, Toxicology, Wernicke's Encephalopathy Show Notes Take Home Points Consider the diagnosis in all patients with nutritional deficiencies, not just alcoholics. Look for ophthalmoplegia, ataxia and confusion in patients that have risk factors for thiamine deficiency. Don’t think that it can’t be Wernicke’s because the triad isn’t complete; any two of the components (dietary deficiency, oculomotor abnormalities, cerebellar dysfunction or altered mental status) makes the diagnosis. Treat Wernicke’s with an initial dose of 500 mg of thiamine IV and admit for continued parenteral therapy. Read More LITFL: Thiamine Deficiency EMRAP: Remember to Take Your Vitamins ALiEM: Mythbusting the Banana Bag Read More