
         
         
                     
      
      
      
         This episode reviews the highlights from the recent ACEP clinical policy on acute VTE management in the ED.
      
      
         
            https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_148_0_Final_Cut.m4a         
      
      
					
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					Tags: Deep Venous Thrombosis, DVT, PE, Pulmonary Embolism, VTE				
					
   

   
      
                  Show Notes
         Take Home Points

The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing.
Age-adjusted D-dimers are ready for use and it doesn’t matter if your assay uses FEU (cutoff 500) or DDU (cutoff 250). For FEU use an upper limit of 10 X age and for DDU use an upper limit of 5 X age.
For now, subsegmental PEs should continue to routinely be anticoagulated even in the absence of a DVT. Keep an eye out for more research on this area.
Although outpatient management of select PE patients (using sPESI or Hestia criteria) may be standard practice, the evidence wasn’t strong enough for ACEP to give it’s support
Patients with DVT can be started on a NOAC and discharged from the ED

sPESI Tool (MDCalc.com)
PERC Decision Tool (MDCalc.com)
Read More

REBEL EM: ACEP Clinical Policy on Acute VTE 2018
Core EM: PE Rule-Out Criteria RCT
Core EM: Age-Adjusted D-dimer (Using D-dimer Units)
Core EM: Age Adjusted D-dimer in PE – The ADJUST-PE Trial
REBEL EM: Is It PROER to PERC It Up

References

ACEP Clinical Policies Subcommittee. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71(5): e59-109. PMID: 29681319
Jaconelli T, Eragat M, Crane S. Can an age-adjusted D-dimer level be adopted in managing venous thromboembolism in the emergency department? A retrospective cohort study. European journal of emergency medicine : official journal of the Eur Soc Emerg Med. 2017. PMID: 28079562
Freund Y et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA 2018; 319(6): 559-66. PMID: <a href="https://www.ncbi.nlm.nih.

Episode 148.0 – ACEP VTE Clinical Policy 2018

Medicine

Science & Medicine

Health & Fitness


         
         
                     
      
      
      
         We review Acute Respiratory Distress Syndrome 
Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD
      
      
         
            https://media.blubrry.com/coreem/content.blubrry.com/coreem/ARDS.mp3         
      
      
					
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					Tags: Critical Care, Pulmonary				
					
   

   
      
                  Show Notes
         
* Definition of ARDS:

* Non-cardiogenic pulmonary edema characterized by acute respiratory failure.
* Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio <300 mmHg, even with positive end-expiratory pressure (PEEP) >5 cm H2O.


* Severity based on oxygenation (Berlin criteria):

* Mild: PaO2/FiO2 200-300 mmHg
* Moderate: PaO2/FiO2 100-200 mmHg
* Severe: PaO2/FiO2 <100 mmHg


* Epidemiology:

* Occurs in up to 23% of mechanically ventilated patients.
* Mortality rate of 30-40%, primarily due to multiorgan failure.


* Differentiation from Cardiogenic Pulmonary Edema:

* Chest CT shows diffuse edema and pleural effusion in cardiogenic edema; patchy edema, dense consolidation in ARDS.
* Ultrasound may show diffuse B lines in cardiogenic edema; patchy B lines and normal A lines in ARDS.


* Pathophysiology:

* Exudative phase: Immune-mediated alveolar damage, pulmonary edema, cytokine release.
* Proliferative phase: Reabsorption of edema fluid.
* Fibrotic phase: Potential for prolonged ventilation.


* Etiology:

* Direct lung injury (pneumonia, toxins, aspiration, trauma, drowning) and indirect causes (sepsis, pancreatitis, transfusion reactions, certain drugs).


* Diagnostics:

* Comprehensive workup including imaging (chest X-ray, CT), laboratory tests (complete blood count, basic metabolic panel, blood gases), and specialized tests depending on suspected etiology.


* Management Strategies:

* Steroids: Beneficial in certain etiologies of ARDS, with specifics on dosing and duration.
* Fluid Management: Conservative fluid strategy, diuresis guided by patient condition.
* Ventilation: Non-invasive ventilation (NIV) preferred in specific cases; mechanical ventilation strategies to ensure lung-protective ventilation.
* Proning: Used in severe ARDS to improve oxygenation.
* Inhaled Vasodilators: Used for refractory hypoxemia and specific complications like right heart failure.
* Extracorporeal Membrane Oxygenation (ECMO): Considered for severe ARDS as salvage therapy.
* Supportive Care: Includes monitoring and management of complications, nutrition, and physical therapy.


* Ventilation Specifics:

* Tidal volume and pressure settings aim for lung-protective strategies to prevent ventilator-induced lung injury.
* Permissive hypercapnia, plateau pressure, PEEP,

Episode 195: ARDS


         
         
                     
      
      
      
         We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview
Hosts:
Stefanie Biondi, MD
Brian Gilberti, MD
      
      
         
            https://media.blubrry.com/coreem/content.blubrry.com/coreem/Nitrous_Oxide_Toxicity.mp3         
      
      
					
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					Tags: Toxicology				
					
   

   
      
                  Show Notes
         Patient Case Illustration

* Hypothetical case: 21-year-old male with no previous medical history, experiencing a month of progressively worsening numbness, tingling, and weakness. Initially starting in his toes and spreading to his hips, and later involving his hands, the symptoms eventually escalated to the point of immobilization. Despite initially denying drug use, the patient admitted to using 40-60 canisters of nitrous oxide (whippets) every weekend for the last three months.

Background and Recreational Use of Nitrous Oxide

* Nitrous oxide, a colorless, odorless gas with anesthetic properties.
* Synthesized in the 18th century.
* Its initial medical purpose expanded into recreational use due to its euphoric effects.
* Resurgence as a recreational drug during the COVID-19 lockdowns.
* Accessibility and legal status.

Public Misconceptions and Health Consequences

* There are widespread misconceptions about nitrous oxide

* Particularly the belief in its safety and lack of long-term health risks.
* Contrary to popular belief, frequent use of nitrous oxide can lead to significant, sometimes irreversible, health issues.



Neurological Examination and Diagnosis

* Key components of the examination include assessing strength, sensation, cranial nerves, and proprioception, with specific abnormalities such as symmetrically decreased strength in a stocking-glove pattern, upgoing Babinski reflex, and positive Romberg sign being indicative of potential toxicity. 

Physical Exam Findings: Upper vs Lower Motor Neuron Lesions
Localize the Lesion- Differential Diagnoses for Extremity Weakness 
Localize the Lesion- Differential Diagnoses for Extremity Weakness
Localize the Lesion- Differential Diagnoses for Extremity Weakness
MRI Findings and Subacute Combined Degeneration

* The MRI displayed symmetric high signal intensity in the dorsal columns, a diagnostic feature identified as the inverted V sign or inverted rabbit ear sign.
* Significance of the Inverted V Sign: This MRI sign is pathognomonic for subacute combined degeneration, indicating it is a distinct marker for this condition.
* T2 Weighted Axial Images: The inverted V sign is observed in T2 weighted axial MRI images, which are used to evaluate the presence and extent of demyelination within the spinal cord.
* Interpretation of Hyperintense Signals: Hyperintense signals on T2 weighted images generally indicate demyelination, where the protective myelin sheath around nerve fibers is damaged or destroyed.
* Anatomical Location: The dorsal columns,

Episode 194: Nitrous Oxide Toxicity


         
         
                     
      
      
      
         We review threatened abortion and the complexities in its care. 
Hosts:
Stacey Frisch, MD
Brian Gilberti, MD
      
      
         
            https://media.blubrry.com/coreem/content.blubrry.com/coreem/Threatened_Abortion.mp3         
      
      
					
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					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.

Initial Assessment and Management

* Priority is to assess patient stability, establish good IV access, FAST may be helpful in identifying some ruptured ectopics early
* Broad differential diagnosis is crucial to avoid mistaking conditions like ectopic pregnancy for other emergencies.
* Importance of a detailed history and physical examination.

Diagnostic Approach

* Essential tests include HCG level, urinalysis, and possibly CBC + blood type/Rh status.
* Rhogam’s use is well-supported in second and third trimester bleeding; however, data is less robust for first trimester bleeding in preventing sensitization
* Importance of interpreting b-HCG with caution and understanding HCG discriminatory zones.
* Use of ultrasound imaging, both bedside and formal, to assess the pregnancy’s status.

Patient Counseling and Management

* Open and honest communication about the prognosis of threatened abortion.
* Addressing psychosocial aspects, including dispelling guilt and myths, and screening for intimate partner violence and mental health issues.
* Recommendations against bedrest and certain activities
* Lack of evidence supporting restrictions on sexual activity.
* Standard pregnancy guidelines: avoiding smoking, alcohol, drug use, and starting prenatal vitamins.

Follow-up and Precautions

* Adopting a wait-and-see approach for stable patients, with scheduled follow-ups for ultrasounds and beta-HCG tests.
* Educating patients on critical warning signs that require immediate medical attention.
* Emphasizing the importance of returning to the hospital if experiencing significant bleeding or other severe symptoms.

Take Home Points

* Threatened Abortion is defined as Experiencing abdominal pain and/or vaginal bleeding during early pregnancy (before 20 weeks), characterized by a closed cervical os and no expulsion of fetal tissue. In these cases, it is important to assess patient stability promptly.
* Keep your differential broad in these cases. The evaluation will in most cases involve a combination of labs and ultrasound imaging. 
* Understand that the Rhogam certainly has a role in second and third trimester vaginal bleeding in the Rh-negative patient, and that there is a dearth of good data on its role in the first trimester – it will ultimately be a decision that is made by you, OBGYN, and the patient. 

Episode 193: Threatened Abortion


         
         
                     
      
      
      
         We review a general approach to syncope in children. 
Hosts:
Brian Gilberti, MD
Ellen Duncan, MD
      
      
         
            https://media.blubrry.com/coreem/content.blubrry.com/coreem/Syncope_in_Children.mp3         
      
      
					
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					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.


* Dextrose Administration in Children:

* Explanation of the ‘rule of 50s’ for determining the appropriate dextrose solution and dosage for children.


* ECG Analysis:

* Importance of ECG in diagnosing dysrhythmias like long QT syndrome, Brugada syndrome, catecholamine polymorphic V tach, ARVD, ALCAPA, and Wolff-Parkinson-White syndrome.
* Younger children’s dependency on heart rate for cardiac output and the risk of arrhythmias in kids with congenital heart disease.






Condition
Characteristic ECG Findings
Congenital/Acquired




Long QT Syndrome (LQTS)
Prolonged QT interval
Congenital/Acquired


Wolff-Parkinson-White Syndrome (WPW)
Short PR interval, Delta wave
Congenital


Brugada Syndrome
ST elevation in V1-V3, Right bundle branch block
Congenital


Atrioventricular Block (AV Block)
PR interval prolongation (1st degree), Missing QRS complexes (2nd & 3rd degree)
Congenital/Acquired


Supraventricular Tachycardia (SVT)
Narrow QRS complexes, Absence of P waves, Tachycardia
Congenital/Acquired


Ventricular Tachycardia
Wide QRS complexes, Tachycardia
Congenital/Acquired


Arrhythmogenic Right Ventricular Dysplasia (ARVD/C)
Epsilon waves, V1-V3 T wave inversions, Right bundle branch block
Congenital


Hypertrophic Cardiomyopathy (HCM)
Left ventricular hypertrophy, Deep Q waves
Congenital


Pulmonary Hypertension
Right ventricular hypertrophy, Right axis deviation
Acquired


Athlete’s Heart
Sinus bradycardia, Voltage criteria for left ventricular hypertrophy
Acquired


Catecholaminergic Polymorphic VT (CPVT)
Bidirectional or polymorphic VT, typically normal at rest
Congenital


Anomalous Origin of Left Coronary Artery from Pulmonary Artery (ALCAPA)
May be normal, signs of ischemia or infarction in severe cases
Congenital




* History Taking:

* Key aspects include asking about syncope with exertion, syncope after being startled, and syncope after pain or emotional stress.

Episode 192: Syncope in Children


         
         
                     
      
      
      
         We go over the treatment of rapid atrial fibrillation (afib with RVR). 
Hosts:
Brian Gilberti, MD
Jonathan Kobles, MD
      
      
         
            https://media.blubrry.com/coreem/content.blubrry.com/coreem/Rapid_Atrial_Fibrillation.mp3         
      
      
					
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					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.

Stability Assessment in AF with RVR

ACLS Protocols: Distinction between unstable and stable patients.

Unstable Patients: Immediate need for synchronized cardioversion, standard dose at 200 J for adults.
Stable Patients: Rate vs. rhythm control strategies, consideration of underlying etiology.


Limitations in Chronic AF: Challenges in patients with AF secondary to critical illness.

ACLS Guidelines and ECG Findings

Tachycardia with a Pulse Approach: Initial assessment guidelines.
ECG Interpretation:

Irregularly Irregular Rhythm: Absence of discernible P waves.
Ventricular Rate: Typically over 100 bpm.
QRS Complexes: Usually narrow, alterations in the presence of bundle branch block or ventricular rate-related aberrancy.


Identifying Pre-Excitation Syndromes: Signs of shortened PR interval and slurred QRS, indication of Wolff-Parkinson-White Syndrome.

AF with Pre-Excitation (WPW Syndrome)

Risk Assessment: Dangers of using AV nodal blockers (BB/CCB, digoxin, adenosine).
Alternative Management: Utilization of procainamide or amiodarone for stable patients, synchronized electrical cardioversion for unstable patients.

Treatment Approaches for AF Types

General Rapid AF:

First Line Agents: Metoprolol vs. Diltiazem.
Metoprolol Considerations: Dosing (5 mg every 10-15 minutes, max 15 mg), benefits in CAD and HF, limitations in asthma/COPD patients.
Diltiazem Advantages: Faster action, suitability in asthma/COPD, typical dosing (0.25 mg/kg initial, followed by 0.35 mg/kg if needed).


Critically Ill Patients: Tailoring treatment to underlying pathology, avoiding typical AF pharmacologic treatments.

Systematic Evaluation of Tachycardia Causes (TACHIES Mnemonic)

Thyrotoxicosis, Alcohol withdrawal, Cardiac issues, Hemorrhage, Intervals (WPW), Embolus, Sepsis.
Application of the mnemonic for a comprehensive approach to differential diagnosis.

Ultrasound in Diagnostic Assessment

Application in Undiagnosed Tachycardia: Identifying EF, pericardial effusion, valvular pathology, and signs of pulmonary embolism.
Fluid Status Evaluation: Use of ultrasound for assessing b-lines in lung scans.

Management of Chronic AF with HD Instability


Episode 148.0 – ACEP VTE Clinical Policy 2018

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