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Fever of Unknown Source - Part 1

Just in time for the winter season.....Have you seen a bunch of snot-nose kids with fever recently?  Do you want to put a needle in their back?  Better yet, do you not want to put a needle in their back, but feel really guilty about it?I sat down with Texas Children’s very own Dr. Andrea Cruz who is triple boarded in pediatrics, pediatric emergency medicine and pediatric infectious disease to talk about fever without a source in neonates/infants and who really needs that LP.There are so many pearls here that I am going to break  this into 2 podcasts.  Enjoy part one now and don’t forget to check out the link to my “fever without a source” algorithm link below.   iTunes Link Fever AlgorithmFever MP3 VersionPodcast 2 - Fever Unknown Source Part One

9 Oct 2011

Rank #1

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Asthma and the Vent

                                                              TOP  =  AUTO PEEP        BOTTOM  =  NORMAL FLOW “Set the Vent in SIMV at 7cc/kg and an I:E ratio of 1:4/1:5 and check a blood gas!” — Andrew Sloas, DO, RDMS, FAAEMiTunes Link Wow!  We've made it to the end of three episodes on asthma.  We've covered everything from diagnosis to treatment and everything in between.  We now know how to best educate our patients to empower them to treat their disease at home and prevent recitivism! Tune in this episode for the specifics on how to use a Peak Flow Meter, Bi-Pap, EtCO2 and of course how to set-up the ventilator in a way to maximize support and minimize chances of injury in your asthmatics.  EM Crit - Infamous Awake Sedated VideoEM Crit - Dominating the Vent Part 1EM Crit - Dominating the Vent Part 2

26 Aug 2014

Rank #2

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Asthma Andrews Style - What's the best oral steroid you ask?

What's the best oral steroid to treat acute asthma exacerbations you may ask? Well, we're here to answer that for you.  Please welcome Dr. Annie Andrews, MD, MSCR who has written all the articles you will find listed below on just that subject.  In this podcast we will prove that dexamethasone is not only the most cost effective steroid to prescribe in asthma exacerbations, decreases recidivism, and has the best compliance rates, but it tastes great too! http://www.paramedictorn.org/trauma-care.htmlAndrews AL, Simpson AN. Dexamethasone may be a viable alternative toprednisone/prednisolone for the treatment of acute asthma exacerbation in thepaediatric emergency department. Evid Based Med. 2014 Jun 10. pii:ebmed-2014-110006. doi: 10.1136/eb-2014-110006. [Epub ahead of print] PubMedPMID: 24919976.Andrews AL, Wong KA, Heine D, Scott Russell W. A cost-effectiveness analysisof dexamethasone versus prednisone in pediatric acute asthma exacerbations. Acad Emerg Med. 2012 Aug;19(8):943-8. doi: 10.1111/j.1553-2712.2012.01418.x. Epub 2012Jul 31. PubMed PMID: 22849379.Andrews AL, Teufel RJ, 2nd, Basco WT, Jr., Simpson KN. A Cost-Effectiveness Analysis of Inhaled Corticosteroid Delivery for Children with Asthma in the Emergency Department. Journal of Pediatrics. 2012 Nov;161(5):903-907Keeney GE, Gray MP, Morrison AK, Levas MN, Kessler EA, Hill GD, Gorelick MH, Jackson JL. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9. doi: 10.1542/peds.2013-2273. Epub 2014 Feb 10. Review. PubMed PMID: 24515516; PubMed Central PMCID: PMC3934336.Podcast 25 ~ Asthma and Steroids

1 Jul 2014

Rank #3

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Pediatric Concussion

I have had the opportunity to work with some truly amazing people in my life and Dr. Matt Bayes, sports medicine physician extraordinaire, is no exception.  Dr. Bayes is the only person I have known to successfully ask about a “code red” and somehow avoid receiving one.  Dr. Bayes now resides in St. Louis, Missouri (Bayes from The Lou) and has been part of the sports medicine team that delivers care to the St Louis Cardinals.   On this episode Dr. Bayes takes me through the intricacies of diagnosing and managing a pediatric concussion from the ER perspective. Hold on to your head because you’re about to get knocked out....Smokey ARTICLES:Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170.William R. Mower, MD.  What Rules Should Guide Imaging Decisions in Injured Children?  Medscape.  Posted: 02/23/2010. http://www.medscape.com/viewarticle/717110Evaluating Minor Head Injury - Sports Medicine UpdatePediatrics - Sports Related Concussions and ManagementPediatrics - Emergency Department Visits for Concussion in Young AthletesMisconceptions Common With Pediatric ConcussionsJosé Álvarez-Sabín, MD; Antoni Turon; Manuel Lozano-Sánchez; José Vázquez, MD; Agustí Codina, MD Delayed Posttraumatic Hemorrhage "Spät-Apoplexie"Stroke. 1995;26:1531-1535doi: 10.1161/01.STR.26.9.1531 SCAT 2 iPhone AppDr Matt Bayes Contact Info:  12855 North Forty DriveSuite 380St Louis, MO 63141Ph: 314-434-7784Fax: 314-434-4775www.bluetailmedicalgroup.comiTunes LinkPodcast 16 ~ Pediatric Concussion

1 Jun 2013

Rank #4

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The Eyes Have It..... Or At Least The Red Eyes Do

Harold Andrew Sloas Jr, DO, CAPT, USN-R is a board certified ophthalmologist (and my dad).  He had a competition with his son Harold Andrew Sloas III, DO, RDMS, FAAEM to see who could get get more letters behind their name. As it turns out none of those letters have any bearing on what we'll be talking about today. You're in for a real treat because I got to sit down with dear ole' dad and talk about some red eye disorders.  We explore all the threatening causes of the red eye on this podcast and move into the non-threatening red eye disorders on the next episode.  You need to know something about both so you can distinguish between the two.  Pull out your Kleenex and dry your eyes; you're going to need to see this. Eye Show NotesiTunes LinkPodcast 17 ~ The Threatening Red Eye

8 Jul 2013

Rank #5

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Calcium Channel Blockers, Beta Blockers and Undifferentiated Hypotension....OH MY!

One of the most sphincter tightening overdoses to deal with in adults and pediatrics is the CCB overdose.  In this podcast I cover all the treatments that work, don't work, and you would think should work to give you a recipe for success.  Hold on to your insulin; it's not just for diabetics and critically ill patients anymore.  Intralipids???  How the heck does that help???  Well you need to tune in to find out......CCB/BB/Undifferentiated Show NotesCCB/BB PDA CompanionHypotension Slide Dr. Levitan's Airway CourseDr. Levitan's AirwayCam WebsiteiTunes LinkPodcast 15 - CCB/BB/Undifferentiated Hypotension

15 Apr 2013

Rank #6

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2 - Red Eyes

Red eyes usually come in pairs and so do podcasts on the subject.  In part two of the red eye disorders we discuss the non-threatening maladies that can turn into eye threatening disorders if missed.  Sit back and relax and let dear ole' dad tell you one more time why it's going to be OK...If you listen to him.  Otherwise you may get spanked.  I'm serious he spanked me a lot for not listening.  Call CPS; there's still a chance for me....Eye Show NotesDr. Shenoi's Emergency Preparedness BookPEM ED Podcast iTunes LinkPodcast 18 ~ The Non-Threatening Red Eye

28 Aug 2013

Rank #7

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Pediatric Airway - The Advanced Course

This is the second part of a two part series in pediatric airway management.  Here we focus on how to use the "Airway Algorithm" that we have created and how to manage the more difficult airways we encounter in the emergency department.  The "Airway Algorithm" is designed to be used in both adults and children.  Mac Friendly Airway AlgorithmiTunes LinkReference: The Difficult Airway Course: Emergency™ (http://www.theairwaysite.com) and from Walls RM and Murphy MF: Manual of Emergency Airway Management, 4th Edition, Philadelphia, Lippincott, Williams and Wilkins, 2012.Podcast 7 - Pediatric Airway The Advanced Course

15 Apr 2012

Rank #8

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An Easy LP Technique

If you downloaded the fist version of this (no intro music), delete it and re-downlad.  The audio is much better on the second version.Practitioners have a love-hate relationship with this procedure.  Whether you embrace it or react to its’ necessity in the same manner you would when finding out you've just been cut-out out of your wealthiest relative’s will, the words “lumbar puncture” invoke emotion.  I would like to thank Dr. David Delemos for inventing this simple recipe for success. It is one of my favorite procedures and hopefully after hearing this podcast it will be one of yours as well.  Check out the PDA friendly companion file below.iTunes LinkPediatric LP Show NotesPodcast 4 - The Pediatric LP

22 Dec 2011

Rank #9

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Urological Complaints Part 1 - The Painful Scrotum

"Rub your balls, squeeze your balls so you don't get cancer"  ~  Tom GreenFew things cause more pain for the patient and fear in the practitioner than scrotal discomfort in a child.  I sat down with my good friend and pee-pee doctor CDR Sean Stroup, MD USN at the National Naval Medical Center in sunny, beautiful, oh how I miss it: San Diego, to discuss painful ballular complaints.  Dr. Stroup is a fellowship trained urologist practicing on the west coast and sees a ton of children at the Naval Medical Center.  Disclaimer:  If you are offended by jokes about pee-pee, the scroti, or not wearing appropriate underwear than it is probably best to skip this episode.  No testicles were injured or neutered in the production of this podcast. iTunes LinkPodcast 10 - Urological Complaints Part 1: The Painful Scrotum

5 Sep 2012

Rank #10

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Great Pedi Gallbladders of Fire

You may think that Miley Cyrus' on-stage theatrics was the most shocking thing to happen in 2013, but au contraire mon frère.  Hold on tight, because the most outrageous thing you've heard between stanzas of "Auld Lang Syn" is that kid's are getting gallbladder disease.  This is especially frequent in the good ole US of A where we have mid-morning cheese burgers for a snack.  Shocking I know.  In this episode Pediatric Gastroenterologist Dr. Doug Fishman, from the Texas Children's Hospital, is going to go through the In-N-Outs of pediatric cholecystitis.  Not that In-N-Out is in anyway responsible for pediatric gallstones...they make a tasty burger....try the double-meat animal style...it's fantastic....Thanks to Doug Fishman, MD.  Director, Gastrointestinal EndoscopyTexas Children's HospitalAssociate Professor of PediatricsPlease visit his website devoted to education and treatment of Celiac Disease belowCheck out the Celiac Universe Here Podcast 20 - Pediatric Cholecystitis

24 Nov 2013

Rank #11

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Clearing The Pediatric C-spine

Developing a good rule to clinically clear the pediatric cervical spine would be difficult.  Very few kids suffer injuries to that region of the body making it nearly impossible to create a well-powered decision instrument.  Like with many other attempts in pediatrics you would most likely end up with a guideline that would be fairly sensitive, but horribly specific.  Lets say we abstracted and validated a pediatric c-spine rule that was 95% sensitive and 50% specific.  With a disease that occurs at an incidence of less than 0.1% (1/1000), by employing a decision instrument that is 95% sensitive you would reduce your patient's risk of missed injury to say 0.005% (1/20,000) .  Sounds great right?  Hold on though; there's more.  If that same rule is 50% specific (which most peds clinical rules are) 50% of the kids you applied your rule to will have false positives.  Therefore 500 of every 1000 patients you employ your decision instrument for would actually be subjected to further workup and needless radiation. Does any of that sound familiar?  It's nearly identical to the use of D-Dimer in very low risk adults (probably better stated as no risk).  If you take a low to medium pre-test probability of disease (Wells Score of low-mod = 2-16% risk) and apply a D dimer (sensitivity > 95%) that comes back as a negative result (you now have reduced your 16% chance of having disease to less than 1% because 16% reduced 95% is 0.8%).  Well done!  You are done with the work-up and you have excluded disease.  If you apply the D-Dimer to a very low risk population (1-1000 to 1/10,000 depending on who you read) then you may further reduce your risk (I'm not sure how much lower you need to go to fell comfortable 1/1000 is pretty low), but just like in the example above, you will have subjected twice as many patients to needless CTA of their chests because your D-Dimer specificity was so poor (about the same 50% as above).   Sorry, that's a lot of stats, but here's the take-home message. Your pediatric patient doesn't need a decision instrument as much as they need a good doctor.  Any injury with extremely low prevelence will most likely end up below the test threshold of creating and validating a decision instrument that you can rely on.  It is hard to get objective data in pre-verbal children, but it is easy to play with them, earn their trust and make a good clinical decision.  NEXUS gets you to 8 years of age, but then it's up to you to make a decision based on experience.  iTunes Link  Podcast 5 - AVI Format (Larger Video Version) Podcast 5 - Pediatric C Spine Clearance

16 Jan 2012

Rank #12

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Penis Talk ~ With Your Hosts Sloas and Stroup

 The finale in the Urology trilogy.  In this episode Dr. Sean Stroup, CDR, USN, MC and I wrap-it-up with a series of "down-there" complaints (down-there does not imply that this episode is about Australians with grievances) with the most sensitive of subjects to any male patient, penile complaints, worries about the willie, persevering about the pee pee, jargon about the junk, etc.  Hold on to your hats....The Disclaimer hasn't changed: if you think jokes about "shrinkage" are funny than please listen to the podcast, but if you find those offensive then skip this episode and I wish you all the best in your attempt to make it through your career without encountering another penis...again....ever.iTunes LinkPodcast 12 - Penis Talk ~ With Your Hosts Sloas and Stroup

2 Dec 2012

Rank #13

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Urology Part 2 ~ The Painless Scroti

"Amigo, the only thing in this world that gives orders is balls. Balls. You got that?" ~  Scarface 1983Every man is attached to their nuts.  In this episode CDR Sean Stroup, MD USN and I continue to discuss non painful ballular complaints.  You make think your safe with a non-painful swollen scrotum, but oh contraire mon frere, you can lose a nut that way too.  A guy just can't get a break....The Disclaimer from the last episode still applies: if you think jokes about old man balls are funny then please proceed to listen to this podcast, but if you find those offensive then skip this episode and look into non-urologic career paths.  However, if you do listen to this podcast then the ball you save could be your own....iTunes LinkPodcast 11 - Urology Part 2 ~ The Painless Scroti

15 Oct 2012

Rank #14

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Sedation and Ketofol

There are a lot of ways to sedate, but I would like to provide you with a philosophy and the methodology to put together the safest possible sedation package. Please stay tuned for my next episode in which I get a chance to interview Dr. Amit Shah the lead author on the game-changing Ketofol article listed below. Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded,randomized controlled trial to evaluate ketamine/propofol versus ketamine alonefor procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425-33.e2.Epub 2010 Oct 13. PubMed PMID: 20947210Sedation Show NotesiTunes LinkPodcast 8 - Sedation and Ketofol

1 Jun 2012

Rank #15