EMplify by EB Medicine

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the May 2023 Emergency Medicine Practice article on Emergency Department Management of Gastrointestinal Foreign Body Ingestion

Epidemiology

Etiology - types of ingestions

Anatomy - common locations by age

• Food impaction
• Sharp objects
• Button batteries
• Magnets
• Colorectal foreign bodies

Prehospital care

History and Physical

Imaging

Expectant management

Endoscopic removal

Non-endoscopic techniques

Body Packing

Glucagon

Gastric button batteries

Summary

In this episode, Sam Ashoo, MD, talks with Rob Orman, MD, founder of Orman Physician Coaching, about longevity in emergency medicine.



• Personal foundation 
• Regular check-ins
• Becoming an expert in… 
• Job stress
• Living beneath your means
• Recharging and shift work
• Bad outcomes
• Physician lounge
• Learning to say no
• Set a reminder

More at Orman Physician Coaching 

Announcements: 

The interactive Clinical Pathways have launched and they are available for free! 

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the March 2023 Emergency Medicine Practice article on Emergency Department Management of Infective Endocarditis-Associated Stroke

Epidemiology

Pathophysiology

Populations at Risk

Complications

• Intracranial hemorrhage
• Aneurysms
• Heart block

Prehospital Care

ED History and Examination

Imaging

Antibiotic Therapy

Surgical Treatment

Special Populations

Summary

Announcements: 

The interactive Clinical Pathways have launched and they are available for free! 

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the February 2023 Pediatric Emergency Medicine Practice article on Pediatric Electrolyte Emergencies: Recognition and Management in the Emergency Department

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History

Point-of-care testing

I/O lines

Presentation, differential, and treatment of:

• Hyponatremia
• Hypernatremia
• Hypokalemia
• Hyperkalemia
• Hypocalcemia
• Hypercalcemia
• Hypomagnesemia
• Hypophosphatemia

Announcements: 

The interactive Clinical Pathways have launched and they are available for free! 

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2023 Pediatric Emergency Medicine Practice article on the Responsible and Safe Use of Opioids in Children and Adolescents in the Emergency Department

DEA-X Waiver Repeal:

• The Mainstreaming Addiction Act
• The Medication Access and Training Expansion Act (MATE)
• FOAMed post

Opioids in Children and Adolescents: 

Introduction

• Epidemiology and Statistics 

Medication safety at home

Escalation of pain meds at home

Naloxone prescriptions

Medications in children

• Codeine
• Tramadol
• NSAIDs
• Local anesthetics and nerve blocks
• Intranasal meds: Ketamine and fentanyl

Opioids and sedation

Regional anesthesia

Chronic pain

Announcements: 

The interactive Clinical Pathways have launched and they are available for free! 

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In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2022 Emergency Medicine Practice article on the Management of Allergic Reactions and Anaphylaxis in the Emergency Department. 

Intro

• The number of ED visits and hospitalizations
• Studies show up to 57% of anaphylactic reactions are not recognized, and epinephrine is not administered in up to 80% of cases. 

Criteria

• 2006 Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN)
• WAO revised the criteria in 2020 
• Delphi group and Brown et al

Pathophysiology

Epidemiology

• Most common causes in children and adults
• More than half of deaths from anaphylaxis occur within the first hour of symptom onset

Prehospital Care

• Give epi, H1 blockers
• Mainstay = recognition

ED Care

• Airway
• Epinephrine
• Decontamination
• H1 and H2 blockers
• Corticosteroids
• Biphasic reactions
• Glucagon

Special Cases

• Alpha-gal
• Scombroid
• Kounis syndrome

Announcements: 

1) The interactive Clinical Pathways have launched and they are available for free! 

2) 2023 E/M coding guidelines are in effect. See the summary here. 

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In this episode, Sam Ashoo, MD, interviews Ara Festekjian, MD, one of the authors of the November 2022 Pediatric Emergency Medicine Practice article on Pediatric Septic Shock in the Emergency Department

Introduction: How common is sepsis in kids and what is the mortality rate in the US?

Definitions

• Septic shock
• Sepsis associated organ dysfunction
• Sepsis-3
• Compensated vs uncompensated shock

Etiology

• Neonate
• Central line and VP shunts
• Asplenia
• Immunocompromised children

Differential Diagnosis

Prehospital Care

ED Evaluation

• History
• Examination
• Septic shock + cardiogenic shock
• Warm vs cold shock
• Evolution of physical exam findings

Diagnostics

• Labs
• Imaging

Treatment

• IV/IO placement
• Fluid boluses
• Antibiotics 
• Pressors 
• Airway management 

Special Populations

• Febrile neutropenia
• Newborns with septic shock

Controversies

• Fluid volume
• Fluid type
• Antibiotic timing
• Corticosteroids

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2022 Evidence-Based Urgent Care article on Influenza in Urgent Care.

Epidemiology

• Historical data
• Since COVID, tracking "influenza-like illness" has been complicated
• Influenza deaths and age
• Annual mortality 

Outbreaks

Transmission

Classification

• Influenza A, B, and C
• Hemagglutinin and neuraminidase subgroups
• Antigenic drift and shift

Pathophysiology

• Transmission
• Incubation 
• Secondary infection
• H3N2

Vaccines

• Egg-based, cell-based, and recombinant influenza vaccines
• CDC recommendations
• Patients aged >65 years

Differential Diagnosis

Complications

Testing

• When is it indicated? 
• What types of tests are available? 
• Testing in periods of low and high prevalence

Treatment

• High-risk conditions that suggest treatment 
• Antiviral medications 
• Oseltamivir: NNT and NNH
• Resistance patterns

Billing and Coding

In this episode, Sam Ashoo, MD, interviews Prayag Mehta, MD, and Nikola Milanko, MD, two of the authors of the October 2022 Emergency Medicine Practice article on Angioedema in the Emergency Department

Pathophysiology: Non-pitting edema of respiratory or GI tract

• Histamine meditated, bradykinin mediated, or idiopathic
• Acquired, inherited, or idiopathic
• Do they present differently? (Urticaria, speed of onset)

Histamine Mediated

• Most common form: 40%-70%
• Can be triggered by NSAIDs
• Can be induced by physical mechanism like cold, vibration
• Is rash a reliable method of distinguishing the types?

Bradykinin Mediated

• May progress slowly
• Can be inherited or acquired
• Common triggers include ACE inhibitors and TPA

Table 1 Differential Diagnosis

Prehospital Care

• Protect airway
• Epi, steroids, antihistamines
• Avoid CPAP

ED History

• Figure 2: Distinguishing characteristics of histamine vs bradykinin mediated

ED Exam

• Importance of repetitive exams
• Airway examination
• Laryngoscopy?

Diagnostics

• Figure 6: Flow diagram of ED workup
• Labs
• Imaging

Treatment

• Airway: Intubation
• Medication

Special Populations

• Pediatric
• Pregnant/lactating patients

Controversies

• TXA

Disposition

In this episode, Sam Ashoo, MD, interviews Ami Shah, MD, MPH, and Don Walker, MD, about eye injuries in the pediatric population. 

Why ocular injuries? Why did you pick this topic?

What kind of injuries are included and at what age are they most common?

Injury zones and terminology

Differential Diagnosis

• What should we keep in mind when we are confronted with an ocular injury? (Table 3)

Prehospital Care

• What do our EMS colleagues need to keep in mind when transporting a child with an ocular injury?
• How can they help us in the ED?

ED Evaluation

• History: What's important to know?
• Physical: Visual acuity and eye exam
• Diagnostics: Slit lamp, ocular pressure, US, CT, MRI

Treatment

• Lid lacerations: Who repairs and when?
• Orbital fractures: What should we be looking for? Why is it different in children? When does repair typically occur?
• Corneal abrasions
• Corneal foreign body
• Chemical injuries: Irrigate with what and for how long?
• Traumatic hyphema: Treatment, disposition
• Traumatic iritis: Treatment, outcome
• Open globe injuries
• Retrobulbar hematoma - First 10 EM

Special Populations

• Hemophilia, Von Willebrand disease
• Sickle cell and trait
• Neonates and infants
• Contact lenses

Controversies and Cutting Edge

• Ketamine
• Tetanus
• NSAIDs, topical?
• Topical anesthetics
• Visual acuity apps