200 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.

Core EM - Emergency Medicine Podcast Core EM

    • Health & Fitness
    • 5.0 • 1 Rating

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.

    Nitrous Oxide Toxicity

    Nitrous Oxide Toxicity

    We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview

    Hosts:

    Stefanie Biondi, MD

    Brian Gilberti, MD







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







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    Tags: Toxicology











    Show Notes

    Patient Case Illustration



    * Hypothetical case: 21-year-old male with no previous medical history, experiencing a month of progressively worsening numbness, tingling, and weakness. Initially starting in his toes and spreading to his hips, and later involving his hands, the symptoms eventually escalated to the point of immobilization. Despite initially denying drug use, the patient admitted to using 40-60 canisters of nitrous oxide (whippets) every weekend for the last three months.



    Background and Recreational Use of Nitrous Oxide



    * Nitrous oxide, a colorless, odorless gas with anesthetic properties.

    * Synthesized in the 18th century.

    * Its initial medical purpose expanded into recreational use due to its euphoric effects.

    * Resurgence as a recreational drug during the COVID-19 lockdowns.

    * Accessibility and legal status.



    Public Misconceptions and Health Consequences



    * There are widespread misconceptions about nitrous oxide



    * Particularly the belief in its safety and lack of long-term health risks.

    * Contrary to popular belief, frequent use of nitrous oxide can lead to significant, sometimes irreversible, health issues.







    Neurological Examination and Diagnosis



    * Key components of the examination include assessing strength, sensation, cranial nerves, and proprioception, with specific abnormalities such as symmetrically decreased strength in a stocking-glove pattern, upgoing Babinski reflex, and positive Romberg sign being indicative of potential toxicity. 



    Physical Exam Findings: Upper vs Lower Motor Neuron Lesions

    Localize the Lesion- Differential Diagnoses for Extremity Weakness 

    Localize the Lesion- Differential Diagnoses for Extremity Weakness

    Localize the Lesion- Differential Diagnoses for Extremity Weakness

    MRI Findings and Subacute Combined Degeneration



    * The MRI displayed symmetric high signal intensity in the dorsal columns, a diagnostic feature identified as the inverted V sign or inverted rabbit ear sign.

    * Significance of the Inverted V Sign: This MRI sign is pathognomonic for subacute combined degeneration, indicating it is a distinct marker for this condition.

    * T2 Weighted Axial Images: The inverted V sign is observed in T2 weighted axial MRI images, which are used to evaluate the presence and extent of demyelination within the spinal cord.

    * Interpretation of Hyperintense Signals: Hyperintense signals on T2 weighted images generally indicate demyelination, where the protective myelin sheath around nerve fibers is damaged or destroyed.

    * Anatomical Location: The dorsal columns,

    Threatened Abortion

    Threatened Abortion

    We review threatened abortion and the complexities in its care.

    Hosts:

    Stacey Frisch, MD

    Brian Gilberti, MD







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







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    One Comment











    Tags: OBGYN











    Show Notes

    Background



    * Defined as vaginal bleeding during early pregnancy (before 20 weeks) with a closed cervical os, no passage of fetal tissue, and IUP on ultrasound

    * Occurs in 20-25% of all pregnancies.



    Initial Assessment and Management



    * Priority is to assess patient stability, establish good IV access, FAST may be helpful in identifying some ruptured ectopics early

    * Broad differential diagnosis is crucial to avoid mistaking conditions like ectopic pregnancy for other emergencies.

    * Importance of a detailed history and physical examination.



    Diagnostic Approach



    * Essential tests include HCG level, urinalysis, and possibly CBC + blood type/Rh status.

    * Rhogam’s use is well-supported in second and third trimester bleeding; however, data is less robust for first trimester bleeding in preventing sensitization

    * Importance of interpreting b-HCG with caution and understanding HCG discriminatory zones.

    * Use of ultrasound imaging, both bedside and formal, to assess the pregnancy’s status.



    Patient Counseling and Management



    * Open and honest communication about the prognosis of threatened abortion.

    * Addressing psychosocial aspects, including dispelling guilt and myths, and screening for intimate partner violence and mental health issues.

    * Recommendations against bedrest and certain activities

    * Lack of evidence supporting restrictions on sexual activity.

    * Standard pregnancy guidelines: avoiding smoking, alcohol, drug use, and starting prenatal vitamins.



    Follow-up and Precautions



    * Adopting a wait-and-see approach for stable patients, with scheduled follow-ups for ultrasounds and beta-HCG tests.

    * Educating patients on critical warning signs that require immediate medical attention.

    * Emphasizing the importance of returning to the hospital if experiencing significant bleeding or other severe symptoms.



    Take Home Points



    * Threatened Abortion is defined as Experiencing abdominal pain and/or vaginal bleeding during early pregnancy (before 20 weeks), characterized by a closed cervical os and no expulsion of fetal tissue. In these cases, it is important to assess patient stability promptly.

    * Keep your differential broad in these cases. The evaluation will in most cases involve a combination of labs and ultrasound imaging. 

    * Understand that the Rhogam certainly has a role in second and third trimester vaginal bleeding in the Rh-negative patient, and that there is a dearth of good data on its role in the first trimester – it will ultimately be a decision that is made by you, OBGYN, and the patient. 

    Syncope in Children

    Syncope in Children

    We review a general approach to syncope in children.

    Hosts:

    Brian Gilberti, MD

    Ellen Duncan, MD







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







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    Tags: Cardiology, Pediatrics











    Show Notes



    * Initial Evaluation and Management:



    * Similar initial workup for children and adults: checking glucose levels for hypoglycemia and conducting an EKG.

    * The history and physical exam are crucial.





    * Dextrose Administration in Children:



    * Explanation of the ‘rule of 50s’ for determining the appropriate dextrose solution and dosage for children.





    * ECG Analysis:



    * Importance of ECG in diagnosing dysrhythmias like long QT syndrome, Brugada syndrome, catecholamine polymorphic V tach, ARVD, ALCAPA, and Wolff-Parkinson-White syndrome.

    * Younger children’s dependency on heart rate for cardiac output and the risk of arrhythmias in kids with congenital heart disease.













    Condition

    Characteristic ECG Findings

    Congenital/Acquired









    Long QT Syndrome (LQTS)

    Prolonged QT interval

    Congenital/Acquired





    Wolff-Parkinson-White Syndrome (WPW)

    Short PR interval, Delta wave

    Congenital





    Brugada Syndrome

    ST elevation in V1-V3, Right bundle branch block

    Congenital





    Atrioventricular Block (AV Block)

    PR interval prolongation (1st degree), Missing QRS complexes (2nd & 3rd degree)

    Congenital/Acquired





    Supraventricular Tachycardia (SVT)

    Narrow QRS complexes, Absence of P waves, Tachycardia

    Congenital/Acquired





    Ventricular Tachycardia

    Wide QRS complexes, Tachycardia

    Congenital/Acquired





    Arrhythmogenic Right Ventricular Dysplasia (ARVD/C)

    Epsilon waves, V1-V3 T wave inversions, Right bundle branch block

    Congenital





    Hypertrophic Cardiomyopathy (HCM)

    Left ventricular hypertrophy, Deep Q waves

    Congenital





    Pulmonary Hypertension

    Right ventricular hypertrophy, Right axis deviation

    Acquired





    Athlete’s Heart

    Sinus bradycardia, Voltage criteria for left ventricular hypertrophy

    Acquired





    Catecholaminergic Polymorphic VT (CPVT)

    Bidirectional or polymorphic VT, typically normal at rest

    Congenital





    Anomalous Origin of Left Coronary Artery from Pulmonary Artery (ALCAPA)

    May be normal, signs of ischemia or infarction in severe cases

    Congenital









    * History Taking:



    * Key aspects include asking about syncope with exertion, syncope after being startled, and syncope after pain or emotional stress.

    • 10 min
    Rapid Atrial Fibrillation

    Rapid Atrial Fibrillation

    We go over the treatment of rapid atrial fibrillation (afib with RVR).

    Hosts:

    Brian Gilberti, MD

    Jonathan Kobles, MD







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







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    One Comment











    Tags: Cardiology











    Show Notes

    Understanding AF with RVR Categories



    General AF with RVR: Definition and basic understanding.

    Rapid AF with Pre-excitation: Characteristics and complications.

    Chronic AF in Critical Illness: Identification and special considerations.



    Stability Assessment in AF with RVR



    ACLS Protocols: Distinction between unstable and stable patients.



    Unstable Patients: Immediate need for synchronized cardioversion, standard dose at 200 J for adults.

    Stable Patients: Rate vs. rhythm control strategies, consideration of underlying etiology.





    Limitations in Chronic AF: Challenges in patients with AF secondary to critical illness.



    ACLS Guidelines and ECG Findings



    Tachycardia with a Pulse Approach: Initial assessment guidelines.

    ECG Interpretation:



    Irregularly Irregular Rhythm: Absence of discernible P waves.

    Ventricular Rate: Typically over 100 bpm.

    QRS Complexes: Usually narrow, alterations in the presence of bundle branch block or ventricular rate-related aberrancy.





    Identifying Pre-Excitation Syndromes: Signs of shortened PR interval and slurred QRS, indication of Wolff-Parkinson-White Syndrome.



    AF with Pre-Excitation (WPW Syndrome)



    Risk Assessment: Dangers of using AV nodal blockers (BB/CCB, digoxin, adenosine).

    Alternative Management: Utilization of procainamide or amiodarone for stable patients, synchronized electrical cardioversion for unstable patients.



    Treatment Approaches for AF Types



    General Rapid AF:



    First Line Agents: Metoprolol vs. Diltiazem.

    Metoprolol Considerations: Dosing (5 mg every 10-15 minutes, max 15 mg), benefits in CAD and HF, limitations in asthma/COPD patients.

    Diltiazem Advantages: Faster action, suitability in asthma/COPD, typical dosing (0.25 mg/kg initial, followed by 0.35 mg/kg if needed).





    Critically Ill Patients: Tailoring treatment to underlying pathology, avoiding typical AF pharmacologic treatments.



    Systematic Evaluation of Tachycardia Causes (TACHIES Mnemonic)



    Thyrotoxicosis, Alcohol withdrawal, Cardiac issues, Hemorrhage, Intervals (WPW), Embolus, Sepsis.

    Application of the mnemonic for a comprehensive approach to differential diagnosis.



    Ultrasound in Diagnostic Assessment



    Application in Undiagnosed Tachycardia: Identifying EF, pericardial effusion, valvular pathology, and signs of pulmonary embolism.

    Fluid Status Evaluation: Use of ultrasound for assessing b-lines in lung scans.



    Management of Chronic AF with HD Instability

    Electrical Storm

    Electrical Storm

    We discuss Electrical Storm (VT storm) and how to care for the very irritable heart.

    Hosts:

    Brian Gilberti, MD

    Reed Colling, MD







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







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    Tags: Cardiology











    Show Notes

    Background/Overview of VT:



    Definition: What makes it a storm 



    Three or more sustained episodes of VF, VT, or appropriate ICD shocks in a 24-hour period





    Pathophysiology: Understanding the origin and mechanism



    Sympathetic drive/adrenergic surge

    Underlying pathology: Sodium channelopathies, infiltrative disease like cardiac sarcoidosis, etc.





    RF’s / trigger / population (reversible cause in ~25% of patients)



    MI

    Electrolyte Derangements (emphasis on potassium and magnesium)

    New/worsening heart failure

    Catecholamine Surge

    Drugs (stimulants, cocaine, amphetamines, etc)

    QT Prolongation

    Thyrotoxicosis







    Clinical Presentation:



    Symptoms of VT: spectrum of symptoms – from palpitations to syncope to cardiac arrest

    Differentiating VT from other potential ER presentations.



    Diagnostics in ER:



    Electrocardiogram (ECG): Recognizing VT patterns.



    Monomorphic vs polymorphic (Torsades) may change management

    Wide QRS

    Fusion best

    Capture beats

    Concordance 

    AV-dissociation





    Lab tests: Potassium, magnesium, troponins, TFTs, etc.



    Acute Management in the ER:



    Hemodynamically stable vs. unstable V



    Unstable = cardioversion

    Sedation



    Catecholamine surge should be considered 

    No ideal agent 

    Etomidate or propofol can be considered 

    Ketamine may worsen irritability 









    Pharmacological treatments:



    Amiodarone



    Class III antiarrhythmic 

    Most studied in VT storm 

    First line





    Beta Blockers



    Propranolol

    B1 and B2 activity 









    Non-pharmacological approaches:



    Immediate synchronized cardioversion

    IABP / ECMO considered for HD unstable patient

    Cath lab if ischemic etiology suspected 

    Stellate Ganglion Block







    Take Home Points



    Definition: VT Storm is commonly defined as three or more sustained episodes of ventricular fibrillation, ventricular tachycardia, or appropriate ICD shocks within a 24-hour period.

    Varied Presentation: Patients may experience a range of symptoms from palpitations to severe hemodynamic instability.

    ECG and Diagnosis: Initial ECG may not show VT; continuous cardiac monitoring or device interrogation may be required for diagnosis.

    VT Identification: Look for wide QRS, rate over 100, fusion beats, capture beats, and AV dissociation to identify VT.

    Management in Hemodynamic Instability: Cardiovert if the...

    Hyperkalemia

    Hyperkalemia

    We revisit the topic of Hyperkelamia to update our prior episode from 2015 (pre-Lokelma)

    Hosts:

    Brian Gilberti, MD

    Jonathan Kobles, MD







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







    Download





    2 Comments











    Tags: Renal Colic











    Show Notes

    Introduction



    * Background









    Physiology:



    Normal range and the significance of deviations (>5.5 mEq/L)





    Epidemiology:



    Prevalence of hyperkalemia in the ER

    ESRD missed HD → ECG, monitor











    Causes / Risk Factors







    Causes



    Kidney Dysfunction, Medications,  Cellular Destruction,  Endocrine Causes, Pseudohyperkalemia

















    High-Risk Medications:

















    Antibiotics: Bactrim, antifungals





















    Calcineurin inhibitors





















    Beta-blockers





















    ACE/ARB





















    K+ Sparing diuretics





















    NSAIDs





















    Digoxin





















    SUX – high risks in neuromuscular disease

















    Lab errors, hemolysis in samples



    VBG vs Chem accuracy 

    When to repeat a hemolyzed sample 

    2023 study: Of the 145 children with hemolyzed hyperkalemia, 142 (97.9%) had a normal repeat potassium level. Three children (2.1%) had true hyperkalemia: one had known chronic renal failure and was referred to the ED due to concern for electrolyte abnormalities; the other 2 patients had diabetic ketoacidosis (DKA).











    Clinical Presentation / eval 



    Symptomatic vs. Asymptomatic:



    “First symptom of hyperkalemia is death” 

    If severe, ascending muscle weakness → paralysis 



    Point at which patients experience symptoms depends on chronicity



    >7 mEq/L if chronic and can be lower if acute









    Hyperkalemia can be a cause of non-specific GI symptoms





    EKG Changes:



    ECG findings may be the first marker the ER doc gets that something is wrong

    Typical changes: 



    Peaked T-waves, shortened QT

    Lengthening of PR interval and QRS duration 

    Bradycardia / Junctional rhythm



    Hyperkalemia can produce bradycardia without other ECG findings





    Ones associated with VT/VF/code, death in one study: QRS widening (RR = 4.74),

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