Core EM - Emergency Medicine Podcast

This discussion dives into urgent dialysis-related emergencies encountered in the ED. It highlights the critical assessment of dialysis access sites, emphasizing detection of complications. Bleeding management techniques for dialysis fistulas are shared, along with essential strategies for addressing bacterial peritonitis in patients. The conversation also sheds light on dialysis disequilibrium syndrome, detailing its symptoms and initial treatment approaches. Overall, it's a must-listen for emergency professionals tackling these complex cases.

This week we discuss a recent article in Annals of EM on contrast induced nephropathy and whether the phenomena is real or dogma. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_91_0_Final_Cut.m4a Download Leave a Comment Tags: AKI, CIN, Contrast Induced Nephropathy, Journal Update Show Notes ACR Table on CIN – FOAMCast FOAMCast: Episode 65 – Contrast Induced Nephropathy and Genitourinary Trauma REBEL EM: Contrast Induced Nephropahty: Fact or Myth Core EM: Acute Kidney Injury is not Associated with IV Contrast Use in the ED EM Lit of Note: Punching Holes in CIN EMCrit: Do CT Scans Cause Contrast Nephrophathy? EM Lit of Note: Punching Holes in CIN EM Docs: Contrast-Induced Nephropathy – Confounding Causation Read More

This week we dive into acute rhinosinusitis focusing on diagnosis and discussing the absence of utility for antibiotics in most patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_90_0_Final_Cut.m4a Download Leave a Comment Tags: ENT, Rhinosinusitis, Sinusitis, URI Show Notes Take Home Points Sinusitis is a clinical diagnosis. Patients typically present with purulent nasal discharge and facial pain or other URI symptoms. The vast majority of patients with acute rhino sinusitis will be viral in nature and will not benefit from antibiotics Patients with prolonged symptoms, more than 7-10 days, without improvement or continued fevers past 2-3 days should be considered for antibiotic treatment as should those who are immunocompromised. Show Notes Melio FR, Berge LR. Upper Respiratory Tract Infections, 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) 75: p 965-79. The NNT: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults The NNT: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Lemiengre MB et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012. PMID: 23076918 Ahovuo-Saloranta A et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2008. PMID: 18425861 Read More

This discussion dives into the management of nosebleeds, focusing on both anterior and posterior types. Solid pressure is emphasized as the first step in treatment. Intriguing techniques are shared, including the use of oxymetazoline and lidocaine for packing. Topical tranexamic acid emerges as a notable option for persistent cases. The podcast also covers effective nasal packing methods and addresses the use of Foley catheters for brisk bleeds. Listeners will gain valuable insights into the art of stopping the flow!

Learn a simplified method for tackling tachydysrhythmias by categorizing rhythms into four distinct boxes. Discover how to quickly differentiate between narrow and wide QRS complexes, and identify key rhythms like atrial fibrillation and ventricular tachycardia. Explore life-threatening conditions and the urgent treatments required for irregular rhythms. Anand emphasizes the importance of assuming VT for wide and regular rhythms and shares valuable resources for deeper understanding.

This week we discuss two recent journal articles - the POKER trial and the ketorlac analgesic ceiling https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_87_0_Final_Cut.m4a Download Leave a Comment Tags: Ketamine, Ketofol, ketorlac, POKER, Propofol, PSA Show Notes Take Home Points The POKER trial examined the difference between propofol and ketofol when it comes to adverse respiratory events.  They found no significant difference between the groups.  Given the increased risk of medication errors using two medication instead of one, you may want to avoid the mixture. Ketorolac has an analgesic ceiling effect lower than you may have thought.  When comparing IV doses of 10mg, 15mg and 30mg they found no difference in analgesic effect.  Given the risks of side effects may increase with higher doses, you may want to stick to the lower 10mg dose. RebelEM: The POKER Trial: Go All in on Ketofol? St. Emlyn’s: JC: Is Ketofol with the hassle? Core EM: Propofol vs. Ketofol in PSA EM: RAP: Just Enough Ketorlac RebelEM: The Ketorolac Analgesic Ceiling Core EM: Parenteral Ketorlac Dosing Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. PubMed ID: 27460905 Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. PubMed ID: 27993418 Read More

Do patients with 1st trimester bleeding need to get anti-D immunoglobulin if they're Rh negative? We dive into the topic this week. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_86_0_Final_Cut.m4a Download Leave a Comment Tags: Early Pregnancy, Obstetrics, RhoGam, Vaginal Bleeding Show Notes Take Home Points An Rh negative woman can become alloimmunized to Rh antigen if exposed to blood from an Rh positive fetus. Theoretically, this alloimmunization can occur even in early pregnancy While anti-D immune globulin has clearly been shown to be beneficial in preventing alloimmunization in 2nd and 3rd trimester pregnancy, there is no evidence supporting use specifically in the 1st trimester Despite the absence of evidence, RhoGam administration has become routine in many places. At this time, it’s advisable to follow local practice patterns regarding which patients should be given RhoGam. References ACOG Practice Bulletin. Prevention of Rh D Alloimmunization. Int J Gynaecol Obstet 1999; 66(1): 63-70. PMID: 10458556 Recommendations reaffirmed in 2016 Hahn SA et al. Clinical Policy: Critical Issues in the Initial Ealuation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med 2012; 60(3): 381-419. PMID: 22921048 Hannafin B et al. Do Rh-Negative Women with First Trimester Spontaneous Abortions Need Rh Immune Globulin. Am J Emerg Med 2006; 24: 487-9. PMID: 16787810 Visscher RD, Visscher HC. Do Rh-Negative Women with an Early Spontaneous Abortion Need Rh Immune Prophylaxis? Am J Obstet Gynecol 1972; 113(2): 158-65. PMID: 4623673 Read More

This discussion dives into three critical delivery complications: cord prolapse, nuchal cord, and shoulder dystocia. For cord prolapse, elevate the presenting part and prepare for an urgent c-section. Nuchal cords are common and typically manageable, but shoulder dystocia is a serious emergency requiring quick action. Techniques like the McRoberts maneuver and having an OR on standby can be lifesavers. The hosts emphasize the need for preparedness in these high-stakes situations—every second counts!

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