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This is the video for cerebellar stroke diagnosis. Listen to the podcast first. Video clips are from Dr. David Newman-Toker's site and from the article: Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10.

What if I told you that I think that patient you just sent home with vertigo may have been a missed cerebellar stroke? Would you be dialing risk management or could you tell me all of the reasons why I'm wrong? Isolated vertigo without other neurological findings can't be a stroke, right? That is true, if you are doing the right exam, but if you are just doing your standard ED neuro screening exam then you might be missing serious pathology. In this episode of the EMCrit podcast, I discuss how to perform the tests that will differentiate a peripheral cause of continuous vertigo from a cerebellar stroke.

Drs. David Newman-Toker & Jorge Kattah, neurologists at John Hopkins, have done a ton of work on this topic. They have created an mnemonic for the exam you should be doing on all of your patients with continuous vertigo (as opposed to positional, intermittent vertigo, i.e. BPPV). Benign positional paroxysmal vertigo is not ED critical care. Continuous vertigo, also known as acute vestibular syndrome, may be. The mnemonic is HiNTS.

Hi for head impulse testing, or head thrust testing.

N for nystagmus to remind you to look for direction-changing or vertical nystagmus

TS for test of skew.

I will discuss what all of these terms mean and how to perform the exams in the podcast.

Here is the HiNTS article.

Here is a link to another study by the same authors on head impulse testing.

Here is a fantastic review article by James A. Nelson on the topic.

Here is a video demonstrating the exam with positives and negative examples.

Update

Insanely good systematic review on Dizzy Stroke Patients (CMAJ 2011;183(9):E571)

and maybe the best review on Vertigo ever!

Until this one was published: Edlow's New Approach to Dizziness (Emerg Med Clin North Am. 2016 Nov;34(4):717-742.)

and here is a fantastic journal club from EM Journal Club with Dr. Newman-Toker himself

and another Edlow et al. J Emerg Med 2018;54(4):469

TiTrATE (Neuro Clin 2015;33:577)

 

>> Update: For a new take on kayexalate, see Mak Moayedi's Lecture

Hey folks. As I get ready for ACEP, I just wanted to get a quick podcast put up. One of the listeners requested an episode on the treatment of hyperkalemia in the ED.

There was a fantastic article published in Critical Care Medicine on the topic by a Dr. Weisberg. I go through my management and discuss some of the pearls from the article.

Weisberg LS. Management of severe hyperkalemia. Crit Care Med. 2008 Dec;36(12):3246-51.

Additional References added Feb 2012

ECG is insensitive and non-specific for severe hyperkalemia issues; essentially is crap (Clin J Am Soc Nephrol 3: 324-330, 2008). ECG peaked T waves, that resolved after K normalized were noted in only 1 of the 14 hyperkalemic patients who went on to have arrhythmia or cardiac arrest. Only half of them had any T-wave changes.

Calcium Gluconate doesn't require Hepatic Metabolization before it is active

[cite source='pubmed']2360741[/cite]

Hyperkalemia and the ECG

Slow A-Fib

from Steve Smith's Blog

Learning Points:

1.  When a patient is bradycardic, especially if irregular, one must always think of hyperK and one must get a 12-lead ECG.

2. One must recognize this pattern as hyperK

3. Calcium's effect is almost miraculous

4. Slow atrial fibrillation implies an sick AV node, or one affected by electrolytes, ischemia, or medications/drugs.  Otherwise, the ventricular response should be fast.

Furosemide Dosing

Lasix Naive: 1 mg/kg

Prior Use: 1.5 mg/kg

Updates

* Fantastic EMPharm Review with my bud, Bryan Hayes

* Lactated Ringers is Safe and Probably Recommended

* This recent article showed a 100% preceding of bad events by altered ecg

* RCT of 7-day course of kayex1

* Risk of Hospitalization for Serious Adverse Gastrointestinal Events Associated With Sodium Polystyrene Sulfonate Use in Patients of Advanced Age. JAMA Intern Med. 2019 Jun 10. doi: 10.1001/jamainternmed.2019.0631.

and now to the podcast...

1.

Lepage L, Dufour A, Doiron J, et al. Randomized Clinical Trial of Sodium Polystyrene Sulfonate for the Treatment of Mild Hyperkalemia in CKD. Clin J Am Soc Nephrol. 2015;10(12):2136-2142. [PubMed]

Update: Some of the information in this post and podcast has been superseded by podcast 125; so click on over there.

This week we talk about managing the intra-arrest period of cardiac arrest. My paradigm has changed dramatically over the past few years. In the past, I viewed the arrest as a period to teach my residents how to place a subclavian central line, how to intubate when the patient is moving, and how to cram as many drugs as possible into a patient in a short period of time.

Looking at how I manage an arrest today, so much has changed.

I use the ACLS ABCDABCD mnemonic, though I've changed some of the intent:

A

Place an Oropharyngeal Airway

B

Place the patient on the ventilator with a BVM mask.

Set the vent to VT 500, Flow 30 lpm, Rate 10, FiO2 100%. Increase the pressure limit to 80-100 cm H20.

C

Compressions, Compressions, Compressions

The most important thing these days are continuous, rhythmic, chest compressions. If you want to get perfusion to the coronaries and get a chance at shocking (the only other effective therapy for arrest), you need perfect compressions.

I use a metronome and switch out providers every 1-2 minutes. Got the idea from this article.

Here is the metronome I use.

ETCO2 can be used as a marker of how well compressions are being performed.

D

Defib. Shock early and shock often.

You can shock without having the compressor stop compressions if they are wearing gloves and you have a biphasic defib with pads. (Circulation 2008;117:2510-2514.)

A

Advanced airway = LMA, not an ET Tube

Here is my LMA video

B

Advanced Breathing

Put the patient back on the vent. If you know how, switch them to pressure control at 20 cm H20, with an insp time of 1-2 seconds

C

Advanced circulation

pop in an IO

listen to the podcast for my feelings on meds

D

Differential

I recommend the RUSH exam created by my colleagues and me.

Last, we talk about when to stop: for me ETCO2 < 10 and no heart motion = stop, if I have been trying for 10-20 minutes.

This week we discuss the resuscitation of the hemorrhagic shock patient with Dr. Richard Dutton, MD.

Rick was director of trauma anesthesia at the Shock Trauma Center when I trained there. He is an incredible teacher, clinician, and researcher.

Here are the take home points:

* Induction agent choice does not matter in these patients; what matters is DOSE! Reduce dose to 1/10 of full intubating dose.

* Blood products need to be available in the trauma bay for when these patients arrive. If you need to give crystalloid while awaiting the products, give only small amounts just to keep the patients heart beating.

* A systolic of 80 with good perfusion and normal sized vessels is very different than that same SBP in a patient who is clamped down. The former is a resuscitated state, the latter =spiral of death.

* The resuscitation fluid for trauma is equal parts PRBC and FFP.

To read more of Dr. Dutton's thoughts, go to this article:

ITACCS Damage Control Anesthesia

Updates:

* This article is even better (Br J Anaes 2012;109(s1):139)

* You can see a full lecture by Rick from the EMCrit Conference

* Great Article from STC on choice of Anesthetics (Curr Anesthiol Rep 2014;4:225)

* Meta-analysis

It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. This continues the discussion started in Part I, where we discussed etomidate, ketamine, and versed/fentanyl. In this podcast, I discuss propofol, ketofol, and dexmedetomidine.

the emcrit procedural sedation chapter has tons of references for all of this

Propofol

great propofol articles:

Ann Emerg Med 2008;52:392-398

Ann Emerg Med. 2007;50:182-187

Start with fentanyl 1-1.5 mcg/kg

Then give propofol 0.5-1 mg/kg

may need additional injections of 0.5 mg/kg

When patient is where you want them, begin the procedure

May need to give additional 20-30 mgs if the patient becomes too light

Burns on injection, you can precede with 20-40 mg of lidocaine to numb the vessels

Ketofol

read more here: (Ann Emerg Med. 2007;49:23-30)

1:1 mix of ketamine and propofol

In 20 ml syringe, place 10 ml of propofol (10 mg/ml)

And 10 ml of ketamine at a concentration of 10 mg/ml

Note: your ketamine may come in a different concentration, if so dilute down to 10 ml of 10 mg/ml

Shake like a martini

Dexmedetomidine

Precede with fentanyl 1 mcg/kg

Start with 0.5-1 mcg/kg over 10 minutes for loading dose

then use an infusion 0f 0.2-1 mcg/kg/hr

Beware in the bradycardic, hypotensive or patients with heart blocks

May need to supplement with 1-2 mg of midazolam

Procedural Sedation Checklist

here it is

Stay tuned for part III coming to you some time in the future.

This is a piece I wrote for the excellent Emergency Medicine Practice Guidelines Update, edited by my friend, Reuben Strayer.

The audio only version of Part I of the sedation talk.

Remember to check out Part II next...

It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation for the maximal comfort and safety for our patients. This brief lecture was originally posted on the defunct EMCrit Lecture Site on 8/7/2009.

I'm reposting it here so I can post part II sometime this week.

This episode, Part I, covers general concepts on sedation as well as ketamine and etomidate/fentanyl.

Part II will cover propofol, ketofol, and dexmedetomidine.

Part III, to be done some time in the future, will cover really difficult sedations.

My friend Reub Strayer has a great PSA checklist as well

Here is the set-up for making your own ETCO2 Nasal Cannulae

 

 

 

Severe CNS Infections are time dependent diagnoses! You must have a high index of suspicion, a good plan for your work-up, and rapid provision of treatment. After seeing a severely ill meningitis patient, I figured I would do a podcast on some tips and pearls on this topic.

When to Suspect

Here is the article I mentioned on establishing pretest prob:

http://pmid.us/15509818

What Antibiotics

Ceftriaxone 2g as empiric therapy in any suspected meningitis patient

If high risk or LP results are positive, also give

* Vancomycin 1 G

* Ampicillin 2g if age > 50 y/o

* Acyclovir 10  mg/kg if high RBC count, obtundation, seizures, or focal neurologic deficit

* Dexamethasone 10 mg

* Cefepime or Imipenem if hospitalized or neurosurgery patient

listen to the podcast for more and see the EMCrit chapter for more.

photo by Lapoland

Update:

Def. give Dex. (PMID: 12432041)