Core EM - Emergency Medicine Podcast Core EM
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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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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
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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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
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. -
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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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
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
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
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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),