Emergency Medicine Cases Dr. Anton Helman

Topics in this EM Quick Hits podcast

Megan Landes on the importance of diagnosing HIV in the ED (1:10)

Jesse McLaren on the failed paradigm of STEMI criteria and ECG tips to identify acute coronary occlusion (22:33)

Anand Swaminathan on evidence for non-invasive airway management in the poisoned patient (29:25)

Brit Long and Hans Rosenberg on the identification, workup and management of spontaneous bacterial peritonitis (37:32)

Matt Poyner on the most lucrative side-gig, DIY investing (46:34)





Podcast production, editing and sound design by Anton Helman

Written summary & blog post by Shaila Gunn & Megan Landes, edited by Anton Helman

Cite this podcast as: Helman, A. Landes, M. McLaren, J. Swaminathan, A. Long, Rosenberg, H. B. Pointer, M.  EM Quick Hits 57 - HIV diagnosis, Failed Paradigm of STEMI Criteria, Poisoned Patient Airway Management, Spontaneous Bacterial Peritonitis, DIY Investments. Emergency Medicine Cases. June, 2024. https://emergencymedicinecases.com/em-quick-hits-june-2024/. Accessed June 19, 2024.

HIV diagnosis and why it's important in EM



HIV is a commonly missed diagnosis. 1 in 7 HIV+ Canadians are unaware of their diagnosis.

For many people at high risk for HIV, the ED is the only accessible place to get tested. An early diagnosis saves lives by initiating early treatment, thus preventing transmission of the infection by 96% (undetectable = untransmissible).

In whom should we consider testing for HIV in the ED?

1a) Major risk factor for HIV - persons who inject drugs (PWID), indigenous people, and people from endemic areas, suspect TB plus

1b) Clinical condition associated with HIV







* Acute retroviral syndrome: an influenza like illness that happens within the first month of seroconversion. Influenza like illness + risk factor = think HIV.

* Opportunistic infections: may include angular cheilitis, aphthous ulcers, oral candida, and hairy leukoplakia (from left to right in image below). The clues are in the mouth, so examine it! Be suspicious of unexpected weight loss and chronic diarrhea.







Opportunistic infections of the mouth in people with HIV, from left to right, angular cheilitis, aphthous ulcers, oral candida, and hairy leukoplakia







* AIDS defining illnesses: severe wasting, esophageal candida, and PCP/PJP pneumonia (may be identified by characteristic 'bag wing' bilateral pneumonia) are the most common. Also consider unusual CNS presentations including altered mental status, meningitis, and encephalitis.







2.Anyone who requests a test

3. Unexplained pancytopenia



* Other risk factors for HIV: People presenting with any STI,  people with multiple sexual partners and people with recurrent presentations for post-exposure prophylaxis (PEP).



=> Integrating IVDU and sexual history into your history for all adult patients presenting with a fever will improve your diagnostic pick up rate of HIV

Testing should be done through whatever means you have access to at your institution. This may include point of care testing, self-testing with oral swabs, or lab-based antigen-antibody tests. Note, if the test if negative and you have high suspicion, repeat testing in 1-3 months as false negatives are common early in the natural history of HIV.

Other illnesses to be aware of in HIV+ patients



* Immune reconstitution inflammatory syndrome: This is a paradoxical worsening of any pre-existing infectious p...

Once the diagnosis of nontraumatic subarachnoid hemorrhage (SAH) has been made, our job is not done. Mortality in SAH patients can be up to 30% even without neurological deficit. Paying attention to the time-sensitive details of ED management of SAH patients can have a significant impact on their outcome. In this second part of our 2-part podcast series on subarachnoid hemorrhage with Dr. Katie Lin and Dr. Jeff Perry we answer questions such as: what are the 4 critical priorities in the initial stabilization of the patient with a suspected massive subarachnoid hemorrhage? When is a CT plus CTA of the head indicated up front in the management of patients with suspected subarachnoid hemorrhage? What is the evidence for oral nimodipine in improving outcomes in patients with subarachnoid hemorrhage and how does it work? What can we do in the ED to prevent rebleeding in patients with subarachnoid hemorrhage? What are the simplest and best prognostic tools available for spontaneous subarachnoid hemorrhage to help counsel families and patients? and more...



Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary, algorithm and blog post by Hanna Jalali, edited by Anton Helman May, 2024

Cite this podcast as: Helman, A. Perry, J. Lin, K. Management of Spontaneous Subarachnoid Hemorrhage. Emergency Medicine Cases. May, 2024. https://emergencymedicinecases.com/ed-management-subarachnoid-hemorrhage. Accessed June 19, 2024

Résumés EM Cases 

Go to part 1 of this 2-part podcast on subarachnoid hemorrhage

Management of the undifferentiated crashing brain: Management of the patient with a suspected subarachnoid hemorrhage prior to CT imaging

Clinical features on their own have shown to not be reliable in distinguishing ischemic versus hemorrhagic CNS insult. While patients with head bleeds are more likely to complain of headache, nausea and vomiting compared to patients with ischemic strokes, a significant minority of patients with ischemic strokes do have these symptoms. Definitive management requires neuroimaging however we need to be able to empirically resuscitate the sick neurological patient keeping in mind important factors for the crashing brain.

4 critical priorities in the first 10 minutes:



* Check and correct the glucose or empirically give an amp of D50W

* Perform a rapid neurological exam prioritizing GCS, eyes (reaction to light, discongugate gaze, deviation), and motor response

* Avoid hypotension and hypoxia at all costs considering early airway management/capture if needed

* Resuscitate to get to the scanner so targeted treatment can be initiated after diagnosis is made



Initial imaging for suspected subarachnoid hemorrhage: Non-contrast CT vs CT plus CTA upfront?

In the crashing neurological patient we need more information than a plain CT head can offer to drive definitive management. The delay to definitive management can mean loss of brain viability. If available at your center, consider CT + CTA as the initial imaging modality of choice patients who:



* Have neurological deficits: speech or motor deficit, vision loss, decreasing or low GCS.

* Pre-existing intracranial vascular abnormality

* Have a contraindication to LP

* With shared decision-making >6 hours post headache onset (see SAH Part 1 a href="https://emergencymedicinecases.

Spontaneous subarachnoid hemorrhage is bad: Fifty percept mortality rate with half the survivors suffering from significant chronic disability. A whole one quarter of patients die in the field. Of those who make it to the ED, a few will be crashing in our resuscitation rooms, but most will just have a headache. So, the problem we face in the ED with SAH is two-fold: First, the clinical manifestations range from just a headache alone – maybe a sentinel leak, to comatose and death. The second problem is that once we identify a subarachnoid bleed, secondary bleeding and ischemia snowball fast leading to delayed badness. It follows that our job in the ED is two-fold: We need to find the needle in the haystack of headache-alone patients who have a SAH. That sentinel leak, that if you pick up now, can prevent a giant bleed and death later. And the literature suggests we’re not great at this – rates of misdiagnosis have been estimated to be as high as 7%. In this part 1 of our 2-part podcast series on subarachnoid hemorrhage, world-renowned EM researcher Dr. Jeff Perry and EM-stroke team clinician Dr. Katie Lin join Anton in a deep dive on SAH decision tools, key clinical clues, indications for CT/CTA, indications for LP, CSF interpretation so that we can safely improve our diagnostic accuracy and save lives...



Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Sara Brade, edited by Anton Helman May, 2024

Cite this podcast as: Helman, A. Lin, K. Perry, J. Episode 194 Subarachnoid Hemorrhage Recognition, Workup and Diagnosis. Emergency Medicine Cases. May, 2024. https://emergencymedicinecases.com/subarachnoid-hemorrhage-recognition-workup-diagnosis. Accessed June 19, 2024

Résumés EM Cases 

Go to part 2 of this 2-part podcast on subarachnoid hemorrhage

Traumatic vs atraumatic/spontaneous subarachnoid hemorrhage

The most common cause of SAH is head trauma. Trauma can cause SAH, but SAH can also cause trauma (ie. SAH causes syncope and patient falls or crashes their car, etc). Etiology (traumatic or atraumatic) dictates the work-up and management. Features to help distinguish the two:

Spontaneous subarachnoid hemorrhage is missed up to 7% of the time - why?

In 73% of cases of missed spontaneous SAH, the most common mistake was not considering the diagnosis and not ordering a non-contrast CT head (NCCTH). Spontaneous SAH has a spectrum of disease presentation. We can’t rely on the “classic presentation” as our only trigger for ordering imaging. We also have to understand the limitations of NCCTH and pursue additional follow-up testing when appropriate (ie. LP and/or CTA). More on work-up below.

“Thunderclap” headache - is it accurate for subarachnoid hemorrhage diagnosis?

“Thunderclap” headache can mean different things to different people. In the Ottawa SAH Rule for headache evaluation, “thunderclap” headache is defined as abrupt onset severe headache that peaks instantly at onset. While most patients with SAH experience headaches that peak in far less than 1 hour, in order to capture all patients with SAH we should still be concerned about SAH in patients with a severe headache peaking up to 1 hour after onset. When patients experience a sentinel bleed and the...

Topics in this EM Quick Hits podcast

Justin Morgenstern on the use of high dose nitroglycerin in SCAPE (1:08)

Andrew Neill and Leah Flanagan on Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) indications and evidence (8:33)

Brit Long on indications for CT in suspected diverticulitis (26:41)

Tahara Bhate on Central Retinal Artery Occlusion (CRAO) and diagnostic error (34:47)

Matthew McArthur on penicillin allergy and penicillin challenges (42:58)

Susan Lu on how ED physician personality influences patient outcomes (52:16)





Podcast production, editing and sound design by Anton Helman

Written summary & blog post by Shaila Gunn, Brit Long, Matthew McArthur, edited by Anton Helman

Cite this podcast as: Helman, A. Morgenstern, J. Neill, A. Long, B. Bhate, T. McArthur, M. Lu, S.  EM Quick Hits 56 - Nitroglycerin in SCAPE, REBOA, Diverticulitis, Diagnostic Error, Penicillin Allergy, Physician Personality. Emergency Medicine Cases. April, 2024. https://emergencymedicinecases.com/em-quick-hits-april-2024/. Accessed June 19, 2024.

High dose nitroglycerin for SCAPE - the first RCT



High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial by Siddiqua et al. 2024, the first RCT on this topic, suggests higher doses of nitroglycerin that are typically used are safe and effective.



P: 52 SCAPE patients with hypoxia, hypertension, respiratory distress; all were also receiving BiPAP

I: High dose nitroglycerin group; IV bolus nitroglycerin 600-1000 mcg followed by an infusion starting at 100 mcg/min

C: Usual dose nitroglycerin; no bolus; nitroglycerin infusion starting at 20-40 mcg/min, max 250 mcg/minute

O: Resolution of symptoms in 6 hours was 65% for the high dose group vs 12% in the usual dose group (NNT = 2); endotracheal intubation was 4% in the high dose group vs 19% in the usual dose group; the high dose group also had lower admission rate, shorter length of stay, fewer MACE; there was no hypotension in either group; the usual dose group reported more headaches compared to high dose group



Is this all too good to be true?



* Limitations: This was a small, single center, unblinded trial; even though these outcomes are largely objective, this does not mean they are not biased (i.e. only recording expected results); the results may also not be generalizable as the patients in this study were very sick



However, other literature would agree.



* Wilson et al. 2016: 2 mg (2000mcg) push doses were associated with decreased ICU admissions and only 2% having hypotension

* Matthew et al. 2021: high dose IV bolus of nitroglycerin 600-1000 mcg had no complications

* Houseman et al. 2023: Nitroglycerin infusions starting at >100 mcg/hr had a only a 4% rate of hypotension



Practical bottom line => Consider a nitroglycerin bolus dose 2-3 sprays SL (800-1200 mcg) OR IV bolus 500-1000 mcg if an IV is in place. Then start a nitroglycerin infusion at 100 mcg/min and titrate. Remember than BiPAP is another critical intervention for all of these patients.

More on Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

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In part 1 of this 2-part podcast series on asthma with Dr. Leeor Sommer and Dr. Sameer Mal we covered asthma mimics, risk stratification, ED treatment and who is safe to go home. We drove home that there are many important details in risk stratifying these patients, making sure they are on the right medications, and good discharge instructions to avoid bounce backs and morbidity. In this part 2, we dig into the recognition and management of the crashing asthmatic. We answer such questions as: what are the key elements in recognition of threatening asthma? What are the most time-sensitive interventions required to break the vicious cycle of asthma? What are the best options for dosing and administering magnesium sulphate, epinephrine, fentanyl and ketamine in the management of the crashing asthmatic? What is the role of NIPPV in the management of life-threatening asthma? What are the factors we should consider when it comes to indications for endotracheal intubation of the crashing asthmatic? What role do blood gases play in the decision to intubate? What are the most appropriate ventilation strategies in the intubated asthma patient? and many more...



Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Sara Brade, edited by Anton Helman April, 2024

Cite this podcast as: Helman, A. Sommer, L. Mal, S. The Crashing Asthmatic - Recognition and Management of Life-threatening Asthma. Emergency Medicine Cases. April, 2024. https://emergencymedicinecases.com/crashing-asthmatic-life-threatening-asthma. Accessed June 19, 2024

Résumés EM Cases 

Go to part 1 of this 2-part podcast on adult asthma exacerbations

Recognition of life-threatening, near fatal asthma



* Appearance: Agitated, obtunded, few word dyspnea, accessory muscle use/ tripoding, respiratory arrest

* Vitals: hypoxic, increased (>30) or decreased RR, elevated HR (>120), bradycardia indicative of impending arrest

* Physical exam: silent chest, biphasic wheeze

* Bedside investigations: Peak flow 25% patient’s best (although there is no role for measuring peak flows in the crashing asthmatic)

* Clinical course: Suboptimal/worsening response to initial therapies, fatiguing, decreasing LOC



Overview: Initial approach to management of the crashing asthmatic

Call for help

RNs/ RT/ another emerg doc/ ICU/ anaesthesia

B – C – A

Breathing THEN Circulation THEN Airway

Breathing



* O2 via NP

* Immediate inhaled bronchodilators



* Continuous nebulized salbutamol, up to 15 mg/hr

* Continuous nebulized ipratropium, up to 1.5mg/hr





* IV Methylprednisolone 125 mg

* IV Magnesium sulfate 2 g over 10-15 mins, repeat x3; consider IV fluid bolus before giving magnesium because of hypotension risk and to replace insensible losses from asthma

* Systemic bronchodilators



* IM/IV Epinephrine



* IM: 0.3 to 0.5 mg q 20 mins x 1-2 doses

* IV: ** preferred over IM ** initial 5 mcg/min, titrate up by 1-15 mcg/min every 2-3 mins, dose range: 0.05 to 0.5 mcg/kg/min, down titrate as soon as able











OR



* IV Salbutamol



* Give after push dose or IM epi as an alternativ...

Welcome to Part 1 of our two-part podcast series on Adult Asthma Exacerbations. Given this past summers' increase in the number and size of forest fires leading to increased asthma presentations to the ED, we are joined by Dr. Leeor Sommer from North York General Hospital and Dr. Sameer Mal, an ED-Intensivist and Transport Physician from London, Ontario to discuss the most important aspects of ED asthma care. Together, we'll explore a systematic approach to managing patients presenting to the ED with asthma exacerbations. Our discussion will emphasize the critical role of a thorough history and physical examination in effectively stratifying patient risk and guiding treatment/disposition decisions. Additionally, we'll examine the importance of providing comprehensive discharge medications and instructions to mitigate both mortality and morbidity associated with asthma exacerbations. We answer questions such as: which patients, if any, require peak expiratory flow measurements in the ED? Why is it so important to add steroid MDI therapy to oral steroid therapy in patients being discharged from the ED after an asthma exacerbation? What are the most predictive variables to risk stratify patients with asthma exacerbations to help guide treatment and disposition? and many more. Stay tuned for Part 2, where we'll delve deep into the management of the crashing asthmatic.



Podcast production, sound design & editing by Anton Helman; voice editing by Braedon Paul

Written Summary and blog post by Kate Dillon, edited by Anton Helman March, 2024.

Cite this podcast as: Helman, A. Mal, S. Sommer, L. Episode 192 Asthma Management Strategies for Improved Prognosis - A Stepwise Approach. Emergency Medicine Cases. March, 2024. https://emergencymedicinecases.com/emergency-asthma-management-strategies. Accessed June 19, 2024

Résumés EM Cases 

Go to part 2 of this 2-part podcast on adult asthma exacerbations

5 Simple Steps to managing asthma exacerbations in the ED

Step 1: Consider the asthma differential diagnosis carefully 

"Not all that wheezes is asthma, and asthma does not always present with a wheeze.”

While the diagnosis of asthma is often straightforward, especially in patients with a history of exacerbations and repeat ED visits, it is crucial to consider several other conditions in patients presenting to the ED with wheezing, including:



* Heart Failure ("cardiac asthma")

* Pulmonary embolism

* Pneumonia

* Pneumothorax

* Foreign body aspiration

* Bronchiolitis

* Anaphylaxis

* Stridor (primarily inspiratory, but can be expiratory, potentially mistaken for wheezing)



In cases where wheezing is absent, particularly in patients suspected of having an asthma exacerbation, be mindful that patients may exhibit a silent chest—a sign of a severe/life-threatening exacerbation where patients are unable to generate sufficient airflow to produce an audible wheeze.

Utilize adjuncts such as PoCUS and chest X-ray to help refine your differential diagnosis in conjunction with a thorough history and physical examination. Guard against diagnostic premature closure that might lead you to exclusively consider asthma upon hearing the term 'wheeze'.

Step 2: Risk stratification based on history

Effective risk stratification of patients presenting to the ED with asthma exacerbations,