We review the American College of Emergency Physicians (ACEP) clinical policy on headache from June 2019, most of which revolves around the diagnosis of subarachnoid hemorrhage. 

Show notes and references at FOAMcast.org

Thanks for listening!
Jeremy Faust and Lauren Westafer

We are at ACEP 2019 in Denver and do a deep dive on a topic introduced by Bryan Hayes (@PharmERToxGuy) in a talk on black boxed medications used in the ED.

We review the data underlying the FDA warning for olanzapine and benzodiazepines.

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Jeremy Faust and Lauren Westafer

In this episode covering the American College of Emergency Physicians (ACEP) 2019, we cover common black box warnings including

• fluoroquinolones
• midazolam
• droperidol
• NSAIDs
• and more

Thanks for listening!

Jeremy Faust and Lauren Westafer

We are at ACEP 2019 in Denver and cover pearls from interesting lectures. Today, that included concussion and VP shunts.

Vaping associated lung injury (VALI) has become a frequent topic in the news in the United States (US). In this episode we review the epidemiology, presumed pathophysiology, and new recommendations from the Centers for Disease Control (CDC) in the US.

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Jeremy Faust and Lauren Westafer

FOAMcast.org

References:

1. Morbidity and Mortality Weekly Report (MMWR). 2019; 68(40)
2. Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report. N Engl J Med. 2019; Sept 6.
3. Maddock SD, Cirulis MM, Callahan SJ, et al. Pulmonary Lipid-Laden Macrophages and Vaping. N Engl J Med. 2019;381:1488-1489.

In this episode we briefly review hyperkalemia and the principles of emergent treatment. Then we explore, in-depth, the role of insulin and dextrose including the incidence of hypoglycemia and pearls to reduce this side effect.

Pearls:

• 10-20% of patients treated with insulin/dextrose for hyperkalemia get hypoglycemic
• Consider giving 5 units insulin instead of 10 units
• Check the glucose for hours (dextrose lasts <1 hr, insulin lasts ≥2 hours)
• Beware of insulin in patients with renal insufficiency or with near normal starting glucose.

Thanks for listening!
Lauren

We discuss the US Food & Drug Administration's black box warning for droperidol and the evidence behind this warning.

We then discuss the use of butyrophenones such as droperidol and haloperidol for the treatment of agitation, headaches, nausea and vomiting, and gastroparesis/cannabinoid hyperemesis.

Thanks for listening!
Jeremy Faust and Lauren Westafer 

We discuss the coagulation test thromboelastography (TEG) / Rotational Thromboelastometry (ROTEM), reviewing the evidence behind the use of the tests as well as the clinical implications.

Show notes and graphics FOAMcast.org

Thanks for listening!
Jeremy Faust and Lauren Westafer

In this episode, we discuss important and "hot" articles thus far in 2019. These articles include:

• Testing for pulmonary embolism in pregnant patients

  • Van der pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019;380(12):1139-1149.

    Langlois E, Cusson-dufour C, Moumneh T, et al. Could the YEARS algorithm be used to exclude pulmonary embolism during pregnancy? Data from the CT-PE-pregnancy study. J Thromb Haemost. 2019; In Press

• Asymptomatic bacteriuria guidelines from the Infectious Disease Society of America (IDSA)
  • Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019.
• Dosing of benzodiazepines in seizures
  • Sathe AG, Tillman C, Coles LD, et al. Underdosing of benzodiazepines in patients with status epilepticus enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019 Jun 4.
• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma patients
  • Joseph B et al. Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma. JAMA Surg 2019. Mar 20.
• Mortality following opioid overdose
  • Weiner SG, Baker O, Bernson D, Schuur JD. One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose. Ann Emerg Med. 2019; In Press

Thanks for listening!

Jeremy Faust and Lauren Westafer

We review the entity formally known as pseudoseizures and psychogenic non-epileptic seizures (PNES), now referred to as psychogenic non-epileptic attacks (PNEA). 

We discuss the history of PNEA as well as relevant literature on the diagnosis and treatment of this entity.

Thanks for listening!
Jeremy Faust and Lauren Westafer

We review myths and reality in the management of patients with Sickle Cell Disease (SCD) 

• Are these patients typically opioid seeking? (No)
• If the patient appears comfortable I should withhold proper analgesia. (No).
• Should IV fluids be a routine part of the cocktail for vaso-occlusive pain episodes? (No)

We also review common emergencies in sickle cell disease that include

• Infections
• Acute chest syndrome
• Anemia (Aplastic crisis, splenic sequestration)
• Ischemia
  • Strokes
  • Avascular necrosis
  • Renal, pulmonary, splenic infarctions
• Vaso-occlusive pain episodes

Thanks for listening!
Lauren Westafer and Jeremy Faust

We are at #SMACC in Sydney, Australia, thanks to the Rosh Review, delivering updates from the conference to your earbuds.

Advocacy in Emergency Medicine - Esther Choo and Hugh Montgomery

Mechanical CPR vs Manual CPR - Ken Milne vs Salim Rezaie

Super sick massive GI bleeds and balloon tamponade - Sara Gray

Thanks for listening!
Jeremy Faust and Lauren Westafer

 We are at SMACC in Sydney, Australia, thanks to the Rosh Review, delivering updates from the conference to your earbuds. Today we cover resuscitation pearls.

Bougie vs Standard Stylet in emergency department (ED) rapid sequence intubation (RSI) - Brian Driver vs Rich Levitan

Rocuronium vs Succinylcholine Debate - Billy Mallon and Reuben Strayer

The Crashing Asthmatic - Haney Mallemat

Thanks for listening!

Lauren Westafer and Jeremy Faust

We are at #smacc in Australia thanks to the Rosh Review!

The opening session this morning was amazing and we can't do it justice on the podcast. Gill Hicks (@MadForPeace), a victim in the July 7, 2005 bombing attack on a London train spoke on how impactful everyone in the healthcare delivery system can be (from medics to detectives to nurses to physical therapists to physicians). Dr. Dara Kass delivered a powerful talk on vulnerability, responsibility, and lack of knowledge even in a super health care literate individual.....what it means to be a provider and a patient (and a mom and a medical home for the family and a wife) in her story of donating part of her liver to her son.

David Carr on anti-NMDA receptor encephalitis

 Anti-NMDA receptor encephalitis is the most common cause of encephalitis in young people (<30 years old), with an average age of ~20. We review the presentation, diagnosis, and treatment of this disease

Thanks for listening!
Jeremy Faust and Lauren Westafer

We co-hosted (with John Vassiliadis) the SMACC EM Updates half-day conference. We had amazing speakers. Salim Rezaie spoke on TXA for Everything, Ken Milne spoke on hot papers from 2018, and we learned about when ultrasound may be helpful in pediatric lumbar punctures. In addition, Jeremy spoke on what is usual care in sepsis and Lauren spoke on pulmonary embolism: the next generation. In this short podcast we highlight some of our other talks.

Aidan Baron (@Aidan_Baron) on Prehospital Updates in Cardiac Arrest

This talk focused on focusing on things that are most likely to make a difference in OHCA (bystander CPR and defibrillation) rather than on fun interventions like intubation and adrenaline (epinephrine). Aidan suggests that the future debates and questions in OHCA will be largely philosophical - what outcomes do we care about: neuro intact survival or ROSC or survival? 

1. Jabre P, Penaloza A, Pinero D, et al. Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiorespiratory arrest a randomized clinical trial. JAMA -2018;319(8):779–87.
2. Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779-791.
3. Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769-778

Barbra Backus on the future of the HEART score

Modified Heart Score (redefining the T or troponin based on newer assays) results in a NPV of 99.8% and classifies 48% of patients as low-risk.

Clinically Relevant Adverse Cardiac Events (CRACE) is way less common than major adverse cardiac events (MACE). HEART score of ≤3 ? CRACE is 0.05%

Hot Literature in 2019

1. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. N Engl J Med. 2019;NEJMoa1816897
2. Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, et al. Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med .2019;NEJMoa1900353.

We have previously podcasted on tachyarrythmias (Episode 34 Tachyarrhythmias), but in this episode, we focus specifically on the treatment of supraventricular tachycardia  (SVT),  specifically paroxysmal SVT.

We discuss the treatment options of adenosine and calcium channel blockers, weighing in with the evidence, the guidelines, and some opinion.

Thanks for listening!
Lauren Westafer and Jeremy Faust

Thanks to Figure 1 for supporting this episode. We do not make money off of this podcast, this support is just for operational costs associated with the podcast.

The US Food and Drug Administration (FDA) recently released another warning for fluoroquinolones, this time regarding aortic dissection and aneurysm.  We review the evidence behind this warning, including the following studies:

Lee CC  Risk of Aortic Dissection and Aortic Aneurysm in Patients Taking Oral Fluoroquinolone. JAMA Intern Med. 2015;175(11):1839-47.

Lee CC Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018;72(12):1369-1378.

Pasternak B Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study. BMJ. 2018;360:k678.

We then review the ACEP clinical policy on aortic dissection covering risk scores, d-dimers, and management of aortic dissection

Thanks for listening!

Jeremy Faust and Lauren Westafer