188 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

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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.

    Episode 182.0 – Wellens

    Episode 182.0 – Wellens

    An interesting back story on this must-not-miss EKG finding in the ED!







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    Tags: #FOAMed, #wellens, Cardiology, EKG, STEMI











    Show Notes

    Hosts: Joe Offenbacher MD, Audrey Bree Tse MD

    EKG Findings in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.



    Table 1 in de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.



    REFERENCES:

    de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.

    Lee, M., & Chen, C. (2015). Myocardial Bridging: An Up-to-Date Review. Journal of Invasive Cardiology, 27(11), 521–528.

     https://lifeinthefastlane.com/ecg-library/wellens-syndrome/

    Lin AN, Lin S, Gokhroo R, Misra D. Cocaine-induced pseudo-Wellens’ syndrome: a Wellens’ phenocopy. BMJ Case Rep. 2017 Dec 14;2017:bcr2017222835. doi: 10.1136/bcr-2017-222835. PMID: 29246935; PMCID: PMC5753703.

    Rhinehardt, J., Brady, W. J., Perron, A. D., & Mattu, A. (2002). Electrocardiographic manifestations of Wellens’ syndrome. The American Journal of Emergency Medicine, 20(7), 638–643. https://doi.org/10.1053/ajem.2002.34800

    Tandy, TK; Bottomy DP; Lewis JG (March 1999). “Wellens’ syndrome”. Annals of Emergency Medicine. 33 (3): 347–351. PMID 10036351. doi:10.1016/S0196-0644(99)70373-2. (via Wikipedia)





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    • 8 min
    Subarachnoid Hemorrhage

    Subarachnoid Hemorrhage

    We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage.

    Hosts:

    Mark Iscoe, MD

    Brian Gilberti, MD

    Bree Tse, MD







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







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    Tags: Critical Care, Neurology, Subarachnoid Hemorrhage











    Show Notes

    Non-contrast head CT showing SAH (Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 22770)



     

    Hunt-Hess grade and mortality (from Lantigua et al. 2015.)







    Hunt-Hess grade

    Mortality (%)





    1. Mild Headache

    3.5





    2. Severe headache or cranial nerve deficit

    3.2





    3. Confusion, lethargy, or lateralized weakness

    9.4





    4. Stupor

    23.6





    5. Coma

    70.5







     

    Ottawa Subarachnoid Hemorrhage Rule, and appropriate population for rule application (from Perry et al. 2017)

    Apply to patients who are:



    * Alert

    ≥ 15 years old

    Have new, severe, atraumatic headache that reached maximum intensity within 1 hour of osnet



    Do not apply to patients who have:



    New neurologic deficits

    Previous diagnosis of intracranial aneurysm, SAH, or brain tumor

    History of similar headaches (≥ 3 episodes over ≥ 6 months)



    SAH cannot be ruled out if the patient meets any of the following criteria:



    * Age ≥ 40

    Symptom of neck pain or stiffness

    Witnessed loss of consciousness

    Onset during exertion

    “Thunderclap headache” (defined as instantly peaking pain)

    Limited neck flexion on examination (defined as inability to touch chin to chest or raise head 3 cm off the bed if supine)





     

    ___________________________

    Special Thanks To:



    * Dr. Mark Iscoe, MD (Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue)



    ___________________________

    References:

    Bellolio MF, Hess EP, Gilani WI, et al. External validation of the Ottawa subarachnoid hemorrhage clinical decision rule in patients with acute headache. Am J Emerg Med. 2015;33(2):244-9.

    Carstairs SD, Tanen DA, Duncan TD, et al. Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage. Acad Emerg Med. 2006;13(5):486-492.

    Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711-1737.

    Czuczman AD, Thomas LE, Boulanger AB, et al. Interpreting red blood cells in lumbar puncture: distinguishing true subarachnoid hemorrhage from traumatic tap. Acad Emerg Med. 2013;20(3):247-256.

    Dugas C,

    • 19 min
    Urine Tox Screens

    Urine Tox Screens

    We discuss the (F)utility(?) of ED Utox screens with our very own Dr. Phil DiSalvo.

    Hosts:

    Bree Tse, MD

    Brian Gilberti, MD







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







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    Tags: Toxicology











    Show Notes





    Special Thanks To:

    Dr. Philip DiSalvo, MD

    Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue

    New York City Poison Control Center

     

    References:

    Christian MR, et al. Do rapid comprehensive urine drug screens change clinical management in children? Clin Toxicol (Phila). 2017;57:977-980.

    Grunbaum AM, Rainey PM (2019). Chapter 7: Laboratory Principles. In Goldfrank’s toxicologic emergencies. New York, NY: McGraw-Hill Education.

    Moeller K, Kissack J, Atayee R, Lee K.  Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens.  Mayo Clinic Proceedings Review.  Volume 92, Issue 5, p774-796, May 1, 2017.  https://www.mayoclinicproceedings.org/article/S0025-6196(16)30825-4/fulltext

    Table 2: Approximate Drug Detection Time in the Urine

    Table 4: Summary of Agents Contributing to Results by Immunoassay





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    • 19 min
    Episode 179.0 – Precipitous Breech Deliveries

    Episode 179.0 – Precipitous Breech Deliveries

    EM management of the rare but potentially complicated precipitous vaginal breech delivery.

    Hosts:

    Audrey Bree Tse, MD

    Masashi Rotte, MD MPH







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







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    Tags: Obstetrics, Precipitous Deliveries, Pregnancy











    Show Notes

    Frank Breech Presentation:



    Complete Breech Presentation:



    Incomplete Breech (“Footling”) Presentation:



     

    Pinard Maneuver:

     

    Mauriceau Maneuver:



    References:



    Cunningham FG et al.  Breech Presentation and Delivery.  Williams Obstetrics, 22nd ed. 2005.

    Desai S, Henderson SO. Labor and Delivery and Their Complications. Rosen’s Emergency Medicine, 8e. 2014. Chapter 181.

    Gabbe SG et al.  Obstetrics: Normal and Problem Pregnancies, 2nd e. 1991. p.479.

    Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet Gynecol Clin North Am. 2005; 32: 165.

    VanRooyen MJ, Scott J.  Emergency Delivery.  Tintanelli’s Emergency Medicine, 7th e.  2011.  Chapter 105.

    http://www.emdocs.net/the-complicated-delivery-what-do-you-do/#:~:text=Deliveries%20that%20occur%20in%20the,in%20denial%20of%20their%20pregnancies.

    https://ranzcog.edu.au/womens-health/patient-information-resources/breech-presentation-at-the-end-of-your-pregnancy

    https://wikem.org/wiki/Breech_delivery







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    • 14 min
    Episode 178.0 – Graduation Speech by Dr. Goldfrank

    Episode 178.0 – Graduation Speech by Dr. Goldfrank

    The speech given by Dr. Goldfrank at the 2020 NYU / Bellevue Emergency Medicine Graduation Ceremony







    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Goldfrank_Graduation_Speech_2020.mp3







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    Tags: Graduation. Goldfrank











    Show Notes

    Graduation 2020

    Lewis R. Goldfrank, MD

    June 17, 2020



    WELCOME TO THE GRADUATES

    Congratulations to a wonderful group of physicians. It is a pleasure to recognize your great accomplishments in the presence of your friends, families, loved ones and the residents and faculty who have learned so much from and with you. I would first like to recognize those of you who are members of the Gold Humanism Honor Society.

    There are a remarkable number of awardees in our graduating class of 2020.



    CLASS OF 2020

    Joe Bennett (R)

    Max Berger (R)

    Ashley Miller (R)

    Leigh Nesheiwat (S)

    Kristen Ng (R)

    Emily Unks (S)

    AND

    Arie Francis (R)

    Nisha Narayanan (S)

    FUTURE PGY-4

    Elena Dimiceli (S)

    Kamini Doobay (S)

    Mark Iscoe (R)

    FUTURE PGY-3

    Stasha O’Callaghan (S)

    Nicholus Warstadt (S)

    FUTURE PGY-1

    Aaron Bola (S)

    Alison (Ali) Graebner (S)

    Aron Siegelson (S)

    Melissa Socarras (S)

    Sarah Spiegel (S)

    Thomas Sullivan (S)

    Christy Williams (S)



    GOLD HUMANISM CORE VALUES

    Integrity, Excellence, Compassion, Altruism, Respect, Empathy, Service

    These are the values you want as a doctor for yourself or a loved one,



    * to have outstanding listening skills with patients

    * to be at your side during a medical emergency,

    * to have exceptional interest in service to the community,

    * to have the highest standards of professionalism

    * to integrate a humanistic approach in patient care.



    These values are what brought all of you to NYU-Bellevue and that you have honed throughout your training. The remainder of this talk shows how all of you have been successful and demonstrated these values some of you were elected to the Gold Humanism—all of you have achieved humanistic success.

    Your personal efforts in the face of uncertainty of the evolution of the pandemic, the inadequate supplies, the hospital and governmental problematic decisions are remarkable. In our country, the President did not mourn the loss of more than a 100,000 human beings and the needs of society. Nor did he provide the leadership and moral support that the country desperately needed to optimally handle this unprecedented crisis. You, in contrast, demonstrate unflappable commitment to address and overcome obstacles to care for your patients, assist your peers, educate and care for your families and friends, while also caring for yourselves. This is a tribute to your humanism. You created essential ways to help patients who were isolated from families and friends during the critical phases of COVID-19.

    • 5 min
    Hemoptysis

    Hemoptysis

    An overview and management tips of hemoptysis in the ED.

    Hosts:

    Brian Gilberti, MD

    Audrey Bree Tse, MD







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







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    One Comment











    Tags: Critical Care, Pulmonary











    Show Notes

    OVERVIEW:



    Definition:



    expectoration/ coughing of blood originating from tracheobronchial tree





    Sources:



    Bronchial arteries (90%): under systemic circulatory pressure to supply supporting structures of the lung → heavier bleeding

    Pulmonary arteries (5%): under low pressure to supply alveoli → milder bleeding

    Nonbronchial arteries (5%): intercostal arteries, coronary arteries, thoracic/ upper/ inferior phrenic arteries





    Quantification:



    Mild: 300mL-1L/ 24hr

    Mortality: 38% for massive (>500mL/ 24hr) vs 4.5% for nonmassive









    Etiology (in adults):



    Infectious (most common):



    Bronchitis

    PNA (necrotizing, lung abscess)

    TB

    Viral

    Fungal

    Parasitic





    Malignancy:



    Primary lung cancer vs metastatic disease





    Pulmonary:



    Bronchiectasis

    COPD

    PE/ infarction

    Bronchopleural fistula

    Sarcoidosis





    Cardiac:



    Mitral stenosis

    Tricuspid endocarditis

    CHF





    Rheumatological:



    Goodpasture Syndrome

    SLE

    Vasculitis (Wegener’s, HSP, Behcet)

    Amyloidosis





    Hematological:



    Coagulopathy/ thrombocytopenia/ platelet dysfunction

    DIC





    Vascular:



    Pulmonary HTN

    AA

    Pulmonary artery aneurysm

    Aortobronchial fistula

    Pulmonary angiodysplasia





    Toxins:



    Anticoagulation/ aspirin/ antiplatelets

    Penicillamine, amiodarone

    Crack lung

    Organic solvents





    Trauma:



    Tracheobronchial rupture

    Pulmonary contusion





    Other:



    bronchoscopy/ lung biopsy

    Pulmonary artery or central venous catheterization

    Foreign body aspiration

    Pulmonary endometriosis (catamenial hemoptysis)

    Idiopathic (up to 25% of cases)





    Pseudohemoptysis: 



    Sinusitis

    Epistaxis

    Rhinorrhea

    Pharyngitis

    URI

    Aspiration

    GIB











    WORKUP:



    HPI:



    CP, SOB

    B symptoms: fever, weight loss, chills, night sweats

    Lymphadenopathy

    Timeframe: acute vs chronic

    Prior lung/ renal/ cardiac disease

    Recreational drug/ cigarette/ chemical exposures

    travel/ infectious exposure

    Medications

    Any other sites of bleeding

    Precipitating factors

    Description of blood clots

    • 14 min

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