Core EM

FEBRUARY 1, 2024

We review threatened abortion and the complexities in its care. Hosts: Stacey Frisch, MD Brian Gilberti, MD [link] Download Leave a Comment 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.

OR 162

OR 162

Core EM

OCTOBER 31, 2023

Author: Stefanie Biondi, MD Editors: Mallika Singh, MD Jonathan Kobles, MD Definition: Acute infection of the upper genital tract: uterus (endometritis), fallopian tubes (salpingitis), and ovaries (oophoritis). Complications may include progression to perihepatitis (Fitz-Hugh-Curtis syndrome), peritonitis, or tubo-ovarian abscess. Pathogenesis Microorganisms compromise the endocervical barrier, allowing for upward migration and infection of the upper genital tract including the uterus, fallopia

OR 130

OR ED 130

Core EM

NOVEMBER 1, 2023

We discuss Electrical Storm (VT storm) and how to care for the very irritable heart. Hosts: Brian Gilberti, MD Reed Colling, MD [link] Download Leave a Comment 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 li

OR 130

OR 130

Core EM

NOVEMBER 13, 2023

The primary survey in trauma management is a critical initial assessment to identify and address life-threatening conditions. It follows the ABCDE approach: Airway maintenance with cervical spine protection, Breathing and ventilation, Circulation with hemorrhage control, Disability (neurological status), and Exposure/Environmental control. This systematic method ensures prompt identification and immediate treatment of urgent medical issues, enhancing the chances of survival and recovery in traum

130

130

Core EM

NOVEMBER 15, 2023

The Case A 62-year-old male with a history of Hypertension, Hyperlipidemia, Coronary Artery Disease with stents, Pulmonary Embolism on Eliquis, presents with sudden onset, severe, mid-sternal chest pain that started 15 minutes prior to arrival. He arrived initially with diaphoresis and pallor which have self-resolved following arrival to the ED. EKG Show Details EKG Characteristics Rate 95 BPM Rhythm Normal Sinus Rhythm Intervals PR 164, QRS 82, QT/QTc 360/452 (normal) Axis Normal Additional Fea

Coronary 130

Coronary STEMI ED 130

Core EM

DECEMBER 1, 2023

We go over the treatment of rapid atrial fibrillation (afib with RVR). Hosts: Brian Gilberti, MD Jonathan Kobles, MD [link] Download Leave a Comment 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.

CAD 130

CAD OR 130

Core EM

DECEMBER 12, 2023

Authors: Samantha Kerester, MD Sarah Fetterolf, MD Colleen Denny, MD Danielle Wright, MD Editor: Jonathan Kobles, MD The State of Unintended Pregnancy in the United States Nearly half of all pregnancies in the United States are unintended, and more than one-third of these pregnancies, totaling approximately one million, end in elective abortion. Unintended pregnancy disproportionately affects women: Between the ages of 18 to 24 From marginalized and historically underrepresented groups From eco

Emergency Department 130

Emergency Department OR ALS Coronary 130

Core EM

JANUARY 2, 2024

We review a general approach to syncope in children. Hosts: Brian Gilberti, MD Ellen Duncan, MD [link] Download Leave a Comment 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.

Coronary 130

Coronary OR 130

Core EM

JANUARY 8, 2024

Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department. JAMA Network, 2023 Background Computed tomography of the abdomen and pelvis (CT AP) is the most common diagnostic imaging test to evaluate abdominal pain in the ED. Intravenous (IV) and oral contrast improve diagnostic accuracy of CT AP.

Emergency Department 100

Emergency Department EMS ED OR 100

Core EM

JANUARY 24, 2024

Background Around 6 million people in the U.S. are on oral anticoagulants (Ref 1) Common causes for oral anticoagulation uses include: Atrial fibrillation Venous thromboembolism Stroke Heart valve replacement The number of patients on direct oral anticoagulants is steadily increasing, and about 3% experience life-threatening bleeding annually (Ref 2) Anticoagulation status leads to increased mortality despite the availability of reversal agents in patients with severe bleeding (ref 2) Indicat

FFP 130

FFP Frozen Plasma Plasma ALS 130

Core EM

JANUARY 24, 2024

The Case An elderly male with a past medical history of hypertension and diabetes presents to the emergency department with a chief complaint of diarrhea and shortness of breath. His vital signs are: HR 60, BP 105/65, RR 30, O2 100% on room air, oral T 98.6 F, and FSG 120. EKG Show Details EKG Characteristics Rate 60 BPM Rhythm Regular, no discernible P-waves Intervals PR na; QRS complex > 160 ms; QT Prolonged Axis LAD ST Segments Wide QRS complexes slurring into very large pointed T waves Diagn

Plasma 130

Plasma Emergency Department Overdose OR 130

Core EM

JANUARY 25, 2024

Patient Case: History: A 60-year-old male with history of schizophrenia and depression on multiple unknown antipsychotic medications presents with unresponsiveness x 1 day. One week prior to ED arrival, the patient was becoming progressively despondent, less interactive with peers, exhibiting slow speech and movements, and was not eating. Physical exam: Vital signs – febrile, tachycardic, hypertensive General – posturing with arms stretched out in front, eyes open without blinking, akinetic, no

MICU 188

MICU Emergency Department OR ED 188

Core EM

JANUARY 25, 2024

Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma J Surg Res., 2021 Background Prehospital trauma team activation criteria allow for prompt mobilization of personnel and resources. Prehospital hypotension is one of those criteria. Pulse pressure is the difference between systolic and diastolic blood pressure.

Operating Room 188

Operating Room EMS ED ICU 188

Core EM

JANUARY 25, 2024

How and when to reverse anticoagulation in the bleeding EM patient. Hosts: Joe Offenbacher, MD Audrey Bree Tse, MD [link] Download Leave a Comment Tags: Anticoagulation , Critical Care , Resuscitation Show Notes Coagulation Cascade: Algorithm for Anticoagulated Bleeding Patient in the ED: Indications for Anticoagulation Reversal: References: Baugh CW, Levine M, Cornutt D, et al.

Frozen Plasma 188

Frozen Plasma FFP Plasma Critical Care 188

Core EM

JANUARY 25, 2024

Background & Pathophysiology: An inflammatory colitis caused by fecal impaction Marked distension and increased intraluminal pressure leads to ischemic pressure necrosis of the colonic wall and compromise of vascular supply and mucosal perfusion Risk of progression to colonic perforation and peritonitis Multiple areas of ulceration occur adjacent to the fecaloma; most commonly in the rectosigmoid colon Diagnosis: Lab findings are non-specific – may reveal increased WBC and/or acute phase rea

E-9-1-1 188

E-9-1-1 OR 188

Core EM

JANUARY 25, 2024

Background and Pathophysiology: Comorbidities, physiologic changes, and medication-associated effects leave elderly patients more susceptible to injury from “minor” mechanisms. Diminished functional reserves decrease compensatory ability for any injury, regardless of severity. 1 Despite adjustments for injury severity, significantly increased mortality occurs ≥70 years regardless of mechanism, compared to younger counterparts.

ALS 188

ALS ED ICU OR 188

Core EM

JANUARY 25, 2024

Relevance: In 07/2021, the CDC released the first updates to their guidelines in 5 years on the treatment of sexually transmitted infections (STIs). These are consensus guidelines meant to provide an approach for those providers treating suspected and documented sexually transmitted infections, especially in the setting of increasing antibiotic resistance and globalization resulting in increasing prevalence of STIs previously seen mostly abroad.

OR 188

OR ALS ED 188

Core EM

JANUARY 25, 2024

Background: An update to our 2015 post on HIET for beta-adrenergic receptor and calcium channel antagonists overdose. Beta-adrenergic receptor antagonists (Beta blockers, BB) and calcium channel antagonists (calcium channel blockers) are common drugs that can produce profound cardiac depression and shock when taken in overdose. 2020 National Poison Data System report: 10,994 beta blocker overdoses 18 deaths 6,132 calcium channel blocker overdoses 45 deaths High case fatality rate, behind only ac

Overdose 188

Overdose ALS Epinephrine Critical Care 188

Core EM

JANUARY 25, 2024

Background: The lumbar puncture (LP or spinal tap) is a procedure that has been in the medical arsenal since first described in 1891 by German physician Heinrich Quincke. It can be both diagnostic and therapeutic, utilized in the diagnosis (meningitis, Guillain-Barre syndrome, subarachnoid hemorrhage) and symptomatic treatment (idiopathic intracranial hypertension, normal pressure hydrocephalus) of diseases of the central nervous system, respectively.

ALS 188

ALS Critical Care OR 188

Core EM

JANUARY 25, 2024

A quick primer on hypocalcemia in the ED. Hosts: Joseph Offenbacher, MD Audrey Bree Tse, MD [link] Download Leave a Comment Tags: calcium , Critical Care , Endocrine Show Notes Swami’s CoreEM Post Hypocalcemia Repletion: IV calcium supplementation with 100-300 mg Ca2+ raises serum Ca2+ by 0.5 – 1.5 mEq For acute but mild symptomatic hypocalcemia: 200-1000mg calcium chloride IV or 1-2g IV calcium gluconate over 2 hours For severe hypocalcemia: 1g calcium chloride IV or 1-2g IV calcium gluc

Critical Care 188

Critical Care ED ALS OR 188

Core EM

JANUARY 25, 2024

BACKGROUND: Necrotizing soft tissue infections are a rare but potentially lethal condition that can quickly lead to severe morbidity and mortality if not identified by clinical history and physical exam. It is a rapidly progressing infection that moves along fascial planes, often evading the immune system. This is a tricky diagnosis that can often be inconspicuous, so clinical gestalt is key.

E-9-1-1 188

E-9-1-1 Emergency Department OR 188

Core EM

JANUARY 25, 2024

Background: The immediate post intubation period in the ED is a critical time for continued patient stabilization. While physical adjuncts like securing the tube, in line suctioning, and head positioning are part of general post intubation management, a better understanding of analgesics and sedatives have offered newer approaches and improved outcomes down the line during the patient’s hospital stay.

Emergency Department 188

Emergency Department ICU Critical Care ALS 188

Core EM

JANUARY 25, 2024

Written By: Kaitlynn Tracy, MD Edited By: Sean Schnarr, MD and Gregg Chesney, MD Definition/Background: Burns are classified as being major, moderate, or minor in severity. The American Burn Association classifies a burn as “minor” if it meets the following criteria: 2 Partial thickness < 15% BSA in a patient between the ages of 10-50 Partial thickness < 10% BSA in a patient younger than 10 or older than 50 Full thickness < 2% BSA In general, a “minor” burn should also be without a

ED 188

ED E-9-1-1 OR First Aid 188

Core EM

JANUARY 25, 2024

Written by: Samantha Kerester, MD Naillid Felipe, MD Edited by: Gregg Chesney, MD Jonathan Kobles, MD Background: Thrombotic thrombocytopenic purpura (TTP) is a hematologic disorder caused by platelet aggregation and thrombus formation in the microvasculature, resulting in severe thrombocytopenia, hemolytic anemia, and multi-organ ischemia. Annual incidence of approximately 2-4 cases/million/year (Kappler, 2017), with 90% of cases occurring in adulthood.

Plasma 188

Plasma Frozen Plasma Emergency Department FFP 188

Core EM

JANUARY 25, 2024

The SQuID Protocol (Subcutaneous Insulin in Diabetic Ketoacidosis): Impacts on ED Operational Metrics. Academic Emergency Medicine, 2023 Background Diabetic ketoacidosis (DKA) is an endocrine emergency. The standard of care of treating DKA is fluid resuscitation, electrolyte management, and intravenous insulin infusion in the intensive care unit (ICU) setting for close glucose and electrolyte monitoring.

EMS 188

EMS ICU ED OR 188

Core EM

JANUARY 25, 2024

We discuss the diagnosis and management of septic arthritis in the pediatric population. Hosts: Brian Gilberti, MD Ellen Duncan, MD [link] Download Leave a Comment Tags: Infectious Diseases , Pediatrics Show Notes General Pain in joint for pediatric patient has a broad differential, including transient synovitis and septic arthritis Transient synovitis, also known as toxic synovitis, is a common condition affecting kids aged 3-10 and often occurs after a viral infection.

OR 188

OR 188

Core EM

JANUARY 25, 2024

Written by: Sadakat Chowdhury MD Edited by: Mak Sarich MD, Jay Lin MD, Jonathan Kobles MD Background: Ultrasound (US) guided nerve blocks offer an applicable option for achieving analgesia in the emergency department. As an alternative to parenteral or oral analgesia, nerve blocks have the potential for improved pain control, decreased risk of harm (hypoventilation, compromised airway or perfusion, potential for addiction), and decreased length of hospital stay. 1 2 3 4 This article will focus o

Epinephrine 188

Epinephrine ED OR Emergency Department 188

Core EM

JANUARY 25, 2024

The Case A 41-year-old male presents to the ED with constant palpitations for one day. The patient's medical history is notable for a congenital bicuspid aortic valve, four months post aortic valve replacement with a post-surgical ejection fraction of 30%. The following ECG is obtained: EKG Show Details EKG Characteristics Rate Fast Rhythm Wide complex tachycardia Intervals Wide complex QRS (146 ms) Axis Left axis deviation ST Segments Non-specific Additional Features Right bundle branch block m

Coronary 188

Coronary Emergency Department ED OR 188

Core EM

JANUARY 25, 2024

We go over the essential and complex topic of vasopressors in the ED. Hosts: Brian Gilberti, MD Catherine Jamin, MD [link] Download Leave a Comment Tags: Critical Care Show Notes Introduction Host: Brian Gilberti, MD Guest: Catherine Jamin, MD Associate professor of Emergency Medicine at NYU Langone Health Vice Chair of Operations Triple-boarded in Emergency Medicine, Internal Medicine, and Critical Care Medicine Topic: Vasopressors: Essential agents for supporting critically ill patients in the

Epinephrine 188

Epinephrine Critical Care Emergency Department ED 188

Core EM

JANUARY 25, 2024

Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for GRACE-3 Academic Emergency Medicine, 2023 Background GRACE Background The GRACE guidelines – “Guidelines for Reasonable and Appropriate Care in the Emergency Department” – are a Society for Academic Emergency Medicine (SAEM) program designed to “ reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and de

EMS 188

EMS Emergency Department OR ED 188

Core EM

JANUARY 25, 2024

We revisit the topic of Hyperkelamia to update our prior episode from 2015 (pre-Lokelma) Hosts: Brian Gilberti, MD Jonathan Kobles, MD [link] Download Leave a Comment 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, Pseudohyperkalem

Epinephrine 188

Epinephrine OR ED 188