FOAMcast - Emergency Medicine Core Content

#smaccDUB day 2

Dr. Reuben Strayer - “Disruption, Danger, and Droperidol: Emergency Management of the Agitated Patient."  

Dr. Strayer presented a brilliant talk on dealing with the quintessential Emergency Medicine patient - the undifferentiated acutely agitated patient. These patients are high risk and require emergent stabilization and resuscitation.

Dr. Haney Mallemat - "The PEA Paradox"

The typical way we think about PEA, the "H's and T's," is overly complicated. Further, we are horrendous at pulse palpation (see this for more), and so what we think is PEA may not actually be PEA.  Dr. Mallemat proposed QRS duration as one way to think about PEA, although this has limitations.

Dr. Michele Dominico - "How Usual Resuscitative Maneuvers Can Kill Paediatric Cardiac Patients"

Interventions we jump to in sick patients - oxygenation, ventilation, vasopressors - these can kill pediatric patients with cardiac pathology. She gave examples of some high yield pearls in these already terrifying patients.

EM Literature update by Drs. Ashley Shreves and Ryan Radecki

Interesting and Ridiculous Research Pearls from Drs. Ashley Shreves and Ryan Radecki

  • Perception of dyspnea and pulmonary function tests change with stress - and rollercoaster rides.  Rietveld S, van Beest I. Rollercoaster asthma: when positive emotional stress interferes with dyspnea perception. Behaviour research and therapy. 45(5):977-87. 2007. [pubmed]
  • Cured pork for epistaxis? Possibly. Researchers will try everything, especially if it involves bacon. Humphreys I, Saraiya S, Belenky W, Dworkin J. Nasal packing with strips of cured pork as treatment for uncontrollable epistaxis in a patient with Glanzmann thrombasthenia. The Annals of otology, rhinology, and laryngology. 120(11):732-6. 2011. [pubmed]
Direct download: FOAMcastini_smacc_dub_day_2_undiff.mp3
Category:general -- posted at: 2:23pm EST

We are at SMACC in Dublin - thanks to the Rosh Review, an excellent board review question bank. Here are some of our favorite pearls.

Do We Make Saves?

Dr. Mervyn Singer "Is Survival Predetermined in the Critically  Ill?"

  • Many critical care studies are negative, but in some cases this may be because critically ill patients don't have a uniform prognosis.
  • Dr. Singer argues that some people may be "destined to die" and some may be "destined to live."  So, it's not really us "saving the patient", it's just the math playing out. Interventions may be harmful or futile in one group but beneficial in the other.  For example, Dr. Singer references the CORTICUS trial of steroids in septic shock. This was a negative trial.  Dr. Singer asserts that some evidence (of not great quality), purports that the sickest patients could benefit from steroids, while this same intervention could be deleterious in the healthier ones.
  • Problem: many of the studies that go back and re-analyze these groups looking at the sickest or least sick patients? They perform subgroup analyses, a form of data dredging that must be taken with a huge grain of salt.

Favorite Pearls

Dr. Suzanne Mason - "Acute Care of the Elderly"

  • Hospital admission may not benefit geriatric patients - interdisciplinary interventions involving nurses, consultants, pharmacists, physical therapy may be best.
  • If there is a single, free intervention that providers can do it's assessing for polypharmacy. Polypharmacy in the elderly is a huge problem.  Check the patient's medication list and beware adding new medications that may not be absolutely necessary.

Dr. Victoria Brazil - "So You Think You're a Resuscitationist?"

  • The Dunning-Kruger effect is real in medicine and this is why we MUST have and provide feedback.  A review of the Dunning-Kruger effect can be found here.  Essentially, people tend to overestimate what they know (i.e. overly confident in their knowledge). The exception?  Masters tend to underestimate their knowledge.
    • Our perception of reality is very skewed so, again, feedback is crucial. For example, Cemalovic and colleagues found that intubators underestimated the time they took to intubate: they estimated 23.5 seconds on average vs the 45.5 seconds intubation actually took. Additionally, they thought 13% of their patients desaturated during intubation but 23% actually desaturated.

 

Direct download: FOAMcastini_SmaccDub_Saves_day_1_-_6_14_16_7.56_PM.mp3
Category:general -- posted at: 3:05pm EST

We cover this short video from EMRAP on lateral canthotomies.  This is one of those rare procedures that is vision saving; hence, it is worthy of frequent review.

Then, we delve into core content on orbital fractures, hyphemas, and ocular burns using Tintinalli and Rosen's Emergency Medicine as a guide.

Show notes and references at foamcast.org

Thanks for listening!

Jeremy Faust and Lauren Westafer

Direct download: foamcast_51.mp3
Category:general -- posted at: 6:59am EST

We review the FOAM video by Dr. Anna Pickens of EMin5.com on "Special Seizures" including hyponatremia, isoniazid toxcitiy, alcohol withdrawal, and eclampsia.


Then we review core content on seizures using Rosen's Emergency Medicine and Tintinalli's Emergency Medicine: A Comprehensive Review.


Thanks for listening!

Jeremy Faust and Lauren Westafer

Direct download: FOAMcast_50_Seizures_v2.mp3
Category:neurology -- posted at: 11:51pm EST

ALTE is out and BRUE is in.

We review the American Academy of Pediatrics guideline on Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants 

Direct download: FOAMcast_49_BRUE.mp3
Category:general -- posted at: 5:58am EST

We cover a post by Dr. Seth Trueger (@MDaware) on false positives in the urine drug screen and review limitations of this test. 

Then we review some toxicology, including toxicity associated with cocaine and PCP using Rosen's Emergency Medicine (8e) and Tintinalli's (8e) as a guide.


Thanks for listening!

Lauren Westafer and Jeremy Faust

Direct download: FOAMcast_48_The_U_tox_v2.mp3
Category:general -- posted at: 6:36pm EST

In this episode we cover a post from Dr. Smith's ECG blog investigating ways to read ischemia on a ventricular paced ECG:  A Patient with Ischemic symptoms and a Biventricular Pacemaker.

Then we delve into core content on the Sgarbossa/modified Sgarbossa criteria as well as pacers and implantable defibrillators and their complications.

Thanks for listening!

Jeremy Faust and Lauren Westafer

Direct download: FOAMcast_47_pacers_.mp3
Category:general -- posted at: 9:01am EST

We cover a podcast from HEFT EMcast  demonstrating that needle decompression at the 2nd intercostal space at the midclavicular line (2ICS MCL) is likely to fail.  They review a systematic review and meta-analysis by Laan et al in 2015 that suggests the fifth intercostal space at the anterior axillary line (5ICS AAL) is less likely to fail.

Then we delve into core content on pneumothoraces and empyemas using Tintinalli and Rosen's Emergency Medicine as a guide.

Thanks for listening,

Jeremy Faust and Lauren Westafer

Direct download: FOAMcast_46_Needle_decompression_-_3-19-16_4.28_PM.mp3
Category:general -- posted at: 10:43pm EST

We cover a post from Life in the Fast Lane Research and Reviews (LITFL R&R) #121  featuring a section on the new American Gastroenterology Association (AGA) guidelines on diverticulitis. The game changer?  Antibiotics aren't a requirement in select patients with uncomplicated acute diverticulitis.

Then we delve into core content on diverticulosis, diverticulitis, and clostridium difficile using Rosen's Emergency Medicine (8e) and Tintinalli: A Comprehensive Review (7e).

Show notes at FOAMcast.org

Thanks for listening!

Jeremy Faust and Lauren Westafer

Direct download: FOAMcast_45_Diverticulitis_export.mp3
Category:gastroenterology -- posted at: 7:18am EST

We bring you breaking news on the updated sepsis definition from the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine.

SIRS and Severe Sepsis?   Out.

qSOFA (HAT - Hypotension, AMS, Tachypnea)?  In.

Septic Shock?  Sepsis + Vasopressors needed to maintain MAP >65 mmHg + Lactate >2 mmol/L (*after adequate fluids)

 

 

Direct download: FOAMcast_44_SEPSIS_DEFINITIONS.mp3
Category:general -- posted at: 6:22pm EST