181 episodes

Core EM is dedicated to bringing Emergency Providers all things core content Emergency Medicine. In the true spirit of Emergency Medicine our content is available to anyone, anywhere, anytime.

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    • Medicine

Core EM is dedicated to bringing Emergency Providers all things core content Emergency Medicine. In the true spirit of Emergency Medicine our content is available to anyone, anywhere, anytime.

    Episode 175.0 – Posterior Circulation Stroke

    Episode 175.0 – Posterior Circulation Stroke

    Diagnosing and managing one of our critical diagnoses - posterior stroke.



    Hosts:



    Mukul Ramakrishnan, MD

    Audrey Bree Tse, MD









    https://media.blubrry.com/coreem/content.blubrry.com/coreem/final_posterior_stroke_podcast_post_edit.mp3







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    Tags: Neurology, Posterior Stroke











    Show Notes

    See Dr. Newman-Toker demonstrate the HINTS exam here



    Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10



     



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    • 15 min
    Episode 174.0 – Homelessness

    Episode 174.0 – Homelessness

    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







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    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



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    • 21 min
    Episode 173.0 – Blunt Neck Trauma

    Episode 173.0 – Blunt Neck Trauma

    We go into one of the more complex injuries – blunt neck trauma.



    Hosts:

    Audrey Bree Tse, MD

    Brian Gilberti, MD







    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blunt_Neck_Injuries.mp3







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    Tags: Trauma











    Show Notes

    Overview



    Blunt neck trauma comprises 5% of all neck trauma

    Mortality due to loss of airway more so than hemorrhage



    Mechanism



    MVCs with cervical hyperextension, flexion, rotation during rapid deceleration, direct impact  

    Strangulation: hanging, choking, clothesline injury (see section on strangulation in this chapter)

    Direct blows: assault, sports, falls



    Initial Management/Primary Survey



    Airway



    Evaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromise

    Early aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema

    Assume a difficult airway 





    * Breathing





    Supplemental oxygen

    Assess for bilateral breath sounds 

    Can use bedside US to evaluate for pneumothorax or hemothorax





    * Circulation





    Assess for open wounds, bleeding, hemorrhage 

    IV access





    * Disability





    Maintain C-spine immobilization 

    Calculate GCS

    Look for seatbelt sign







    Secondary Survey



    Evaluate for specific signs of vascular, laryngotracheal, pharyngoesophageal, and cervical spinal injuries with inspection, palpation, and auscultation

    Perform extremely thorough exam to evaluate for any concomitant injuries (e.g. stab wounds, gunshot wounds, intoxications/ ingestions, etc.)



    Types of Injuries



    Vascular injury









    Overview

















    Carotid arteries (internal, external, common carotid) and vertebral arteries injured

    Mortality rate ~60% for symptomatic blunt cerebral vascular injury





    Mechanism



    Hyperextension and lateral rotation of the neck, direct blunt force, strangulation, seat belt injuries, and chiropractic manipulation

    Morbidity due to intimal dissections, thromboses, pseudoaneurysms, fistulas, and transections





    Clinical Features



    Most patients are asymptomatic and do not develop focal neurological deficits for days

    if Horner’s syndrome, suspect disruption of thoracic sympathetic chain (wraps around carotid artery)

    specific screening criteria are used to detect blunt cerebrovascular injury in asymptomatic patients (see below)

    • 12 min
    Episode 172.0 – Ankle Sprains

    Episode 172.0 – Ankle Sprains

    We dissect one of the most common injuries we see in the ER -- ankle sprains



    Hosts:

    Brian Gilberti, MD

    Audrey Bree Tse, MD





    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Ankle_Sprains.mp3







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    2 Comments











    Tags: Orthopedics











    Show Notes

    Background



    * Among most common injuries evaluated in ED

    * A sprain is an injury to 1 or more ligaments about the ankle joint

    * Highest rate among teenagers and young adults



    * Higher incidence among women than men





    * Almost a half are sustained during sports

    * Greatest risk factor is a history of prior ankle sprain



    Anatomy



    * Bone: Distal tibia and fibula over the talus → constitutes the ankle mortise

    * Aside from malleoli, ligament complexes hold joint together



    * Medial deltoid ligament

    * Lateral ligament complex



    * Anterior talofibular ligament



    * Most commonly injured

    * Weakest

    * 85% of all ankle sprains 





    * Posterior talofibular ligament

    * Calcaneofibular ligament





    * Syndesmosis







    Mechanism of Injury



    * Lateral ankle sprains 



    * Most common among athletes

    * ATFL most commonly injured



    * Combined with CFL in 20% of injuries





    * 2/2 inversion injuries





    * Medial ankle sprains



    * Less common than lateral because ligaments stronger and mechanism less frequent



    * More likely to suffer avulsion fracture of medial malleolus than injure medial ligament





    * 2/2 eversion +/- forced external rotation

    * Typically landing on pronated foot -> external rotation





    * High Ankle sprains



    * Syndesmotic injury

    * More common in collision sports (football, soccer, etc)









    * Grade I



    * Mild

    * Stretch without “macroscopic” tearing

    * Minimal swelling / tenderness

    * No instability

    * No disability associated with injury





    *     Grade II



    * Moderate

    * Partial tear of ligament

    * Moderate swelling / tenderness

    * Some instability and loss of ROM

    * Difficulty ambulating / bearing weight





    *     Grade III



    * Severe

    * Complete rupture of ligaments

    * Extensive swelling / ecchymosis / tenderness

    * Mechanical instability on exam

    * Inability to bear weight







    Examination



    *     Beyond visual inspection for swelling, ecchymoses, abrasions, or lacerations



    * Palpation 

    * Pain when palpating ligament is poorly specific but may indicate injury to structure

    • 11 min
    Episode 171.0 – Vaping Associated Lung Injury

    Episode 171.0 – Vaping Associated Lung 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







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    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

    • 16 min
    Episode 170.0 – Septic Arthritis

    Episode 170.0 – Septic Arthritis

    An overview of septic arthritis.



    Hosts:

    Audrey Bree Tse, MD

    Brian Gilberti, MD





    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Arthritis.mp3







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    Tags: Infectious Diseases, Orthopedics











    Show Notes

    Episode Produced by Audrey Bree Tse, MD







    Background



    Bacteria enters the joint by hematogenous spread due to absence of basement membrane in synovial space from invasive procedures, contiguous infection (e.g. osteomyelitis, cellulitis), or direct inoculation (e.g. plant thorns, nails)



    WBCs migrate into joint → acute inflammatory process → synovial hyperplasia, prevents new cartilage from forming, pressure necrosis on surrounding joint, purulent effusion





    Why do we care? 



    irreversible loss of function in up to 10% & mortality rate as high as 11%

    Cartilage destruction can occur in a matter of hours

    Complications include bacteremia, sepsis, and endocarditis







    Etiology



    Risk factors: extremes of age, RA, DJD, IVDA, endocarditis, GC, immunosuppression, trauma, or prosthesis

    Organisms: 



    Staph: staph aureus (most common), MRSA, Staph epidermis

    N gonorrhea: young healthy sexually active adults

    Strep: group A & B

    GNRs: IVDA, diabetics, elderly

    Salmonella: sickle cell disease

    Cutibacterium acnes: prosthetic shoulder infection

    Consider mycobacterial & fungal in more indolent courses







    Presentation



    Typically a single, warm, erythematous, tender joint (#1: knee (50% of cases) → hip, shoulder, ankle)



    *Any joint can be involved!

    IVDA can involve sacroiliac, costochondral, & sternoclavicular joints 

    Classic teaching: very painful with ROM, but this is not always present!

    Joint usually held in position of maximum joint volume

    Prosthetic joints may have less pain than expected for a septic joint given changed anatomy and disrupted nerve endings





    In 10-20% of cases, can see polyarticular involvement



    GC typically monoarticular but commonly polyarticular





    Often have fever & separate infection as well (only see fever in ~60% of cases)



    Diagnostics



    Arthrocentesis: 



    Gold standard 

    Tap joint even if acceptable ROM: septic joints can have normal motion so it does not exclude the diagnosis!

    Use ultrasound if possible

    Relative contraindications: overlying cellulitis (risk of seeding joint) or severe coagulopathies (weigh risk of creation or worsening of iatrogenic hemarthrosis)

    Keep in mind that a “dry tap” may occur due to incorrect needle placement, absent/ minimal joint effusion,

    • 11 min

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