Rank #1: Episode 82.0 – ED Management of Seizures
Take Home Points
- Get a detailed history to tease out whether the patient had a seizure or a syncopal event. Regardless, get an EKG on 1st time seizures in case it was actually syncope.
- BZDs are first line therapy for seizure termination. If you don’t have IV access, go with 10 mg of midazolam or 2-4 mg of lorazepam IM
- Always review the 5 main categories for causes of seizures in order to make sure you’re not missing anything. Those categories once again are vital sign abnormalities, CNS infections, toxic/metabolic issues, CNS space occupying lesions including masses and bleeds and finally epilepsy.
- In patients with a first time seizure without a particular cause and return to baseline neurologic status, there’s unlikely to be any benefit to a NCHCT or to starting an AED. Scheduling close follow up with a neurologist is very reasonable. The key is to do a thorough examination and make sure you’re not missing a subtle abnormality.
- Finally, in status epilepticus hit the patient with 2-3 hefty doses of BZDs and if the seizure is still ongoing, strongly consider moving to propofol and intubation in order to rapidly control the seizure activity.
Core EM: Parenteral Benzodiazepines
Huff SJ et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Seizures. Ann Emerg Med 2014; 43(5): 605-25. PMID: 15111920
Jan 30 2017
Rank #2: Episode 71.0 – Acute Pulmonary Edema
Show NotesRead More
Core EM: Acute Pulmonary Edema
Nov 07 2016
Rank #3: Episode 20.0 – AVNRT
AVNRT with Aberrancy vs. VT
REBEL EM: SVT with Aberrancy Versus VT
Amal Mattu’s ECG Case of the Week: August 26th, 2013
St. Emlyn’s: JC The REVERT Trial
Adenosine in AVNRT
Larry Mellick: Treating SVT with Adensoine
ALiEM: Trick of the Trade: Combining Adenosine with the Flush
Verapamil in AVNRT
RAGE Podcast: Rage Session Two
ERCast Podcast: How to run a code
Appleboam A et al. Postural mdodification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised trial. Lancet 2015. PMID: 26314489
Nov 02 2015
Rank #4: Episode 49.0 – Alcohol Withdrawal
Yip L. Chapter 77. Ethanol. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e. New York, NY: McGraw-Hill; 2011.
EmCrit Podcast: Delirium Tremens
Life in the Fast Lane: Alcohol Withdrawal
EM Updates: Avoid Alcohol Withdrawal Admissions
May 30 2016
Rank #5: Episode 17.0 – Asthma and COPD
EMCrit: Delayed Sequence Intubation
REBEL EM: The Crashing Asthmatic
EM:RAP: The Rule of 2sAbdo WF, Heunks LM. Oxygen-induced hypercapnia in COPD: myths and facts. Critical Care 16(5):323. PMID: 23106947
Oct 12 2015
Rank #6: Episode 48.0 – Anticholinergic Poisoning
Howland M. Antidotes in Depth (A12): Physostigmine Salicylate. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e . New York, NY: McGraw-Hill; 2011.
Velez LI, Feng SY: Anticholinergics, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 150: p 1970-5.[caption id="attachment_3127" align="aligncenter" width="640"] Anticholinergic Infographic (BrianandKloss.com)[/caption] [caption id="attachment_3128" align="aligncenter" width="573"] Drugs Exhibiting Anticholinergic Toxicity (Rosen's)[/caption]
May 23 2016
Rank #7: Episode 121.0 – Pancreatitis
Show Notes[caption id="attachment_6188" align="aligncenter" width="593"] Ranson's Criteria for Pancreatitis-Associated Mortality (Rosen's)[/caption]
Take Home Points
- Pancreatitis is diagnosed by a combination of clinical features (epigastric pain with radiation to back, nausea/vomiting etc) and diagnostic tests (lipsae 3x normal, CT scan)
- A RUQ US should be performed looking for gallstones as this finding significantly alters management
- The focus of management is on supportive care. IV fluids, while central to therapy, should be given judiciously and titrated to end organ perfusion
- Patients will mild pancreatitis who are tolerating oral intake and can reliably follow up, can be discharged home
Hemphill RR, Santen SA: Disorders of the Pancreas; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 91: p 1205-1226
Nov 13 2017
Rank #8: Episode 84.0 – Traumatic ICH Management
Show NotesTake Home Points
- If you get a heads up from EMS on an incoming trauma, take the lead time you get to clearly delineate everyone’s roles to help ensure the resuscitation runs smoothly.
- In the severe TBI patient, the key is in preventing secondary injury to the brain. We do this by guarding against hypoxia, hypercarbia, hypotension and aspiration. Max your pre-ox, get the ETT in quickly to prevent oxygenation and ventilation issues and keep the head up if possible
- Hypotension is rarely seen in isolated head trauma. If the patient is or becomes hypotensive, reassess for any sources of hemorrhagic shock that may have been missed and consider whether the meds you gave may have caused the problem.
- Hypertension is much more common and despite extensive research, we haven’t shown that dropping the patient to normal levels is beneficial. Keeping the SBP < 180 seems reasonable but check your local protocol as well.
- If the patient’s ICP spikes or your concerned about herniation, administer mannitol or hypertonic saline and get your neurosurgeon to the bedside since the patient is gonna need decompression
- Finally, make sure to reverse any anticoagulant the patient may have on board as this will hopefully prevent hematoma expansion.
Hopper AH. Hyperosmolar therapy for raised intracranial pressure. NEJM 2012; 367(8): 746-52. PMID: 22913684
Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014; 28(6): 821-7. PMID: 24859931
Zeiler FA et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014; 21(1): 163-73. PMID: 24515638
Feb 13 2017
Rank #9: Episode 8.0 – Chest Pain
How to Build a Great Talk
- The Teaching Course Podcast: How to Build a Talk - Part I
- The Teaching Course Podcast: How to Build a Talk - Part II
Chest Pain Workshop
- Core EM: Chief Complaint - Chest Pain
- REBEL EM: Is it time to start using the HEART pathway in the Emergency Department?
- EMCast November 2014: Low Risk Chest Pain
- Backus BE et al. Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department. Curr Card Rev 2011; 7: 2-8. PMC: 3131711
- Mahler SA et al. The HEART Pathway Randomized Trial Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circ Cardiovasc Qual Outcomes March 2015; 8 (2): 195 – 203. PMID: 25737484
- Goldberg H et al. Oral steroids for actue radiculopathy due to a herniated disk - a randomized clinical trial. JAMA 2015; 313(19): 1915-23. PMID: 25988461
Aug 10 2015
Rank #10: Episode 23.0 – SBO
Show Notes5 Minute Sono: Small Bowel Obstruction EM Lyceum: GI Imaging FOAMCast: Episode 23 – SBO and Mesenteric Ischemia
Nov 23 2015
Rank #11: Episode 83.0 – Lumbar Radiculopathy
St. Emlyn’s: Back to Basics: Back Pain in the ED
Edlow JA. Managing nontraumatic acute back pain. Ann Emerg Med 2015; 66: 148-53. PMID: 25578887
Goldberg H et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA 2015; 313 (19): 1915-23. PMID: 25988461
Friedman BW et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 2015; 314 (15): 1572-80. PMID: 26501533
Feb 06 2017
Rank #12: Episode 39.0 – Killer Back Pain
Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med 2015; 66: 148-53. PMID: 25578887
Mar 21 2016
Rank #13: Episode 52.0 – Anaphylaxis
Show Notes[caption id="attachment_3303" align="aligncenter" width="624"] Anaphylaxis Definition[/caption] Read More Tran TP, Muelleman RL: Allergy, Hypersensitivity, Angioedema, and Anaphylaxis, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 119: p 1543-1560.
YouTube: Epinephrine Auto-Injector Use
Grunau BE et al. Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis. Ann Emerg Med 2014; 63(6): 736-44. PMID: 24239340
Grunau BE et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis is Not Associated with Decreased Relapses. Ann Emerge Med 2015; 66(4): 381-9. PMID: 25820033
Jun 27 2016
Rank #14: Episode 93.0 – Meningitis
Show Notes[caption id="attachment_5041" align="aligncenter" width="948"] CSF Analysis (LITFL)[/caption]
EM Lyceum: Viral Meningitis “Answers”
EM RAP: Meningitis
LITFL: Bacterial Meningitis
LITFL: CSF Analysis
Attia J et al. Does this adult patient have acute meningitis. JAMA 1999; 281(2): 175-81. PMID: 10411200
Brouwer MC et al. Corticosteroids for acute bacterial meningitis (review). Cochrane Database Syst Rev 2015. PMID: 26362566
Cooper DD, Seupaul RA. Is adjunctive dexamethasone beneficial in patients with bacterial meningitis? Ann Emerg Med 2012; 59(3): 225-6. PMID: 22088494
de Gans J et al. Dexamethasone in adults with bacterial meningitis. NEJM 2012; 347(20): 1549-57. PMID: 12432041
Hasbun R et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. NEJM 2001; 345(24): 1727-34. PMID: 11742046
Sakushima K et al. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. J Infection 2011; 62: 255-62. PMID: 21382412
Tunkel AR et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39: 1267-84. PMID: 15494903
Apr 17 2017
Rank #15: Episode 7.0 – Hyperkalemia + Rate Control in AFib
Show NotesCore EM: Hyperkalemia REBEL EM: Is Kayexalate Useful in the Treatment of Hyperkalemia in the Emergency Department? Core EM: Diltiazem vs. Metoprolol for Rate Control in Atrial Fibrillation
Aug 03 2015
Rank #16: Episode 24.0 – Hepatic Encephalopathy
Nov 30 2015
Rank #17: Episode 13.0 – Diabetic Ketoacidosis: A Case
LITFL: EBM Diabetic Ketoacidosis
emDocs: Myths in DKA Management
Core EM: Hyperkalemia
Core EM: Podcast 7.0
Intubation in Severe Metabolic Acidosis
Core EM: Podcast 4.0
Sep 14 2015
Rank #18: Episode 75.0 – Fluid Responsiveness + Resuscitation
Marik PE. Fluid responsiveness and the six guiding principles of fluid resuscitation. Crit Care Med 2016. PMID: 26571187
LITFL: Adrenal Insufficiency
Core EM: Adrenal Crisis
Core EM: Episode 15.0 - Adrenal Crisis
Cavallaro F et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systemic review and meta-analysis of clinical studies. Intensive Care Med. 2010:36(9):1475-83. PMID: 20502865.
Cecconi M et al. Fluid challenges in intensive care: the FENICE study: A global inception cohort study. Intensive Care Med. 2015:41(9):1529-37. PMID: 26162676.
Landesberg G et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J. 2012:33(7):895-903. PMID: 21911341.
Lee CV et al. Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound. J Crit Care. 2016:31(1):96-100. PMID: 26475100.
Marik PE. Noninvasive cardiac output monitors: a state-of the-art review. Cardiothorac Vasc Anesth. 2013:27(1):121-34. PMID: 22609340.
Dec 05 2016
Rank #19: Episode 133.0 – Initial Trauma Assessment
Show NotesTake Home Points
- Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures
- Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team
- Complete the primary survey (ABCDEs) and address immediate life threats
- Round out your assessment with a good medical history and remember to complete a comprehensive head-to-toe exam
Shlamovitz GZ, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007;50(1):25-33, 33.e1. PMID: 17391807
EM:RAP: Do We Still Need The C-Collar?
Life in the Fast Lane: Digital rectal exam (DRE) in trauma
Feb 19 2018
Rank #20: Episode 88.0 – Simplified Approach to Tachydysrhythmias
Take Home Points
- When looking at a tachy rhythm that isn’t sinus tach, quickly differentiate by determining if the QRS complexes is narrow or wide and then determine if the rhythm is regular or irregular. This approach quickly drops the rhythm into 1 of 4 boxes and makes rhythm determination much easier
- Each of those 4 categories has a small set of rhythms included. Narrow and irregular - AF, Aflutter with variable block or MFAT. Narrow and regular - SVT or Aflutter. Wide and irregular - Torsades, VF, AF with aberrancy or a BBB. Wide and regular - VTach, SVT with aberrancy or SVT with a BBB.
- If you see wide and regular, the top 3 diagnoses are VT, VT and VT. Assuming VT and treating for that will almost never send you astray
EM: RAP: Episode 84 - Tachycardia
Core EM: Ventricular Tachycardia
Core EM: Recent-Onset Atrial Fibrillation[caption id="attachment_1697" align="aligncenter" width="1003"] Simplified Approach to Tachydysrhythmias Diagnosis[/caption] [caption id="attachment_1700" align="aligncenter" width="1543"] Tachydysrhythmias Therapeutic Algorithm[/caption] [caption id="attachment_4740" align="aligncenter" width="904"] Torsades de Pointes[/caption] [caption id="attachment_4741" align="aligncenter" width="865"] Torsades de Pointes[/caption]
Mar 13 2017