Core EM - Emergency Medicine Podcast Core EM

We discuss an approach to the critically ill infant.

Hosts:

Ellen Duncan, MD, PhD

Brian Gilberti, MD







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







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Tags: Pediatrics











Show Notes

The Critically Ill Infant: THE MISFITS

Trauma



* ‘T’ in the mnemonic stands for trauma, which includes both accidental and intentional causes.

* Considerations for Non-accidental Trauma:



* Stresses the importance of considering non-accidental trauma, especially given that it may not always present with obvious external signs.





* Anatomical Vulnerabilities:



* Highlights specific anatomical considerations for infants who suffer from trauma:



* Infants have proportionally larger heads, increasing their susceptibility to high cervical spine (c-spine) injuries.

* Their liver and spleen are less protected, making abdominal injuries potentially more severe.











Heart



* 5 T’s of Cyanotic Congenital Heart Disease: Introduces a mnemonic to help remember key right-sided ductal-dependent lesions:



* Truncus Arteriosus: Single vessel serving as both pulmonary and systemic outflow tract.

* Transposition of the Great Arteries: The pulmonary artery and aorta are switched, leading to improper circulation.

* Tricuspid Atresia: Absence of the tricuspid valve, leading to inadequate development of the right ventricle and pulmonary circulation issues.

* Tetralogy of Fallot: Comprises four defects—ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta.

* Total Anomalous Pulmonary Venous Connection (TAPVC): Pulmonary veins do not connect to the left atrium but rather to the right heart or veins, causing oxygen-rich blood to mix with oxygen-poor blood.





* Other Significant Conditions:



* Ebstein’s Anomaly: Malformation of the tricuspid valve affecting right-sided heart function.

* Pulmonary Atresia/Stenosis: Incomplete formation or narrowing of the pulmonary valve obstructs blood flow to the lungs.





* Left-sided Ductal-Dependent Lesions:



* Conditions such as aortic arch abnormalities (coarctation or interrupted arch), critical aortic stenosis, and hypoplastic left heart syndrome are highlighted. These generally present with less obvious cyanosis and more pallor.





* Diagnostic and Management Considerations:



* Routine prenatal ultrasounds detect most cases, but conditions like coarctation of the aorta and TAPVC might not be apparent until after birth when the ductus arteriosus closes.

* Emphasizes the importance of a thorough physical exam: checking for murmurs, assessing hepatosplenomegaly, feeling for femoral pulses, measuring pre- and post-ductal saturations,

We review Acute Respiratory Distress Syndrome

Hosts:

Sadakat Chowdhury, MD

Brian Gilberti, MD







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







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Tags: Critical Care, Pulmonary











Show Notes



* Definition of ARDS:



* Non-cardiogenic pulmonary edema characterized by acute respiratory failure.

* Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio 5 cm H2O.





* Severity based on oxygenation (Berlin criteria):



* Mild: PaO2/FiO2 200-300 mmHg

* Moderate: PaO2/FiO2 100-200 mmHg

* Severe: PaO2/FiO2 100 mmHg





* Epidemiology:



* Occurs in up to 23% of mechanically ventilated patients.

* Mortality rate of 30-40%, primarily due to multiorgan failure.





* Differentiation from Cardiogenic Pulmonary Edema:



* Chest CT shows diffuse edema and pleural effusion in cardiogenic edema; patchy edema, dense consolidation in ARDS.

* Ultrasound may show diffuse B lines in cardiogenic edema; patchy B lines and normal A lines in ARDS.





* Pathophysiology:



* Exudative phase: Immune-mediated alveolar damage, pulmonary edema, cytokine release.

* Proliferative phase: Reabsorption of edema fluid.

* Fibrotic phase: Potential for prolonged ventilation.





* Etiology:



* Direct lung injury (pneumonia, toxins, aspiration, trauma, drowning) and indirect causes (sepsis, pancreatitis, transfusion reactions, certain drugs).





* Diagnostics:



* Comprehensive workup including imaging (chest X-ray, CT), laboratory tests (complete blood count, basic metabolic panel, blood gases), and specialized tests depending on suspected etiology.





* Management Strategies:



* Steroids: Beneficial in certain etiologies of ARDS, with specifics on dosing and duration.

* Fluid Management: Conservative fluid strategy, diuresis guided by patient condition.

* Ventilation: Non-invasive ventilation (NIV) preferred in specific cases; mechanical ventilation strategies to ensure lung-protective ventilation.

* Proning: Used in severe ARDS to improve oxygenation.

* Inhaled Vasodilators: Used for refractory hypoxemia and specific complications like right heart failure.

* Extracorporeal Membrane Oxygenation (ECMO): Considered for severe ARDS as salvage therapy.

* Supportive Care: Includes monitoring and management of complications, nutrition, and physical therapy.





* Ventilation Specifics:



* Tidal volume and pressure settings aim for lung-protective strategies to prevent ventilator-induced lung injury.

* Permissive hypercapnia, plateau pressure, PEEP,

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,

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. 

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.

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