183 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

    • 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 177.0 – Hemoptysis

    Episode 177.0 – 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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    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

    • 14 min
    Episode 176.0 – Pneumonia Updates

    Episode 176.0 – Pneumonia Updates

    We go over the recent updates in the workup and management of pneumonia.



    Hosts:

    Brian Gilberti, MD

    Audrey Tse, MD





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







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    Tags: Infectious Diseases, Pulmonary











    Show Notes









    2007 Infectious Diseases Society of America/American Thoracic Society Criteria for Defining Severe Community-acquired Pneumonia



    Validated definition includes either one major criterion or three or more minor criteria



    * Minor criteria



    * Respiratory rate > 30 breaths/min PaO2/FIO2 ratio 20 mg/dl)

    * Leukopenia* (white blood cell count , 4,000 cells/ml)

    * Thrombocytopenia (platelet count , 100,000/ml)

    * Hypothermia (core temperature , 368 C) Hypotension requiring aggressive fluid

    * resuscitation





    * Major criteria



    * Septic shock with need for vasopressors

    * Respiratory failure requiring mechanical ventilation













    A special thanks to our Infectious Diseases Editor:



    Angelica Cifuentes Kottkamp, MD

    Infectious Diseases & Immunology

    NYU School of Medicine











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    • 10 min
    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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    One Comment











    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







    Download





    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

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