EMplify by EB Medicine

In this episode, Sam Ashoo, MD interviews Prayag Mehta, MD and Joshua Kern, MD – two of the authors of the June, 2022 EMP article on Procedural Sedation and Analgesia in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to sedation in adults and pediatrics !

Procedural Sedation and Analgesia in the Emergency Department

EMplify – June 2022

Episode Outline:

1.Procedural sedation and analgesia (PSA): terminology

2.Levels of sedation

• Minimal
• Moderate
• Deep
• General anesthesia

3.Prehospital care

4.ED care: patient assessment

• ASA class system
• Complications
• Equipment needed (Table 1)
• Larson maneuver (Figure 2)

5.Procedural technique

• Current ACEP and AAP recommendations
• Data for 1- or 2-physician sedation

6.Preprocedural fasting

• Do we even need to consider this in PSA?

7.Capnography

8.Oxygen supplementation

9.Preprocedural opioids

10.Preprocedural sedatives

11.Anticholinergics

12.Antiemetics

13.Treatment (Table 2)

• Fentanyl
• Remifentanil
• Midazolam
• Nitrous oxide
• Propofol
• Ketamine
• Ketofol
• Etomidate

14.Reversal agents

• Naloxone
• Flumazenil

15.Special populations

• Pediatrics
• Pregnancy
• Geriatrics

16.Cutting edge

• Dexmedetomidine

The war in Ukraine has now been ongoing for 100 days. In today’s episode of EMplify: Conversations we hear from Dr. J.P. McBryde about his experience as an emergency physician volunteering in Ukraine.

You can read more about Med Global and their efforts in Ukraine, on their home page:

https://medglobal.org/ukraine/

We would love to have your feedback. Please take the listener survey:

https://www.surveymonkey.com/r/ZQRWQFW

Thanks for being a listener.

Epidemiology

• Caused by double stranded DNA virus, genus orthopoxvirus, closely related to smallpox and cowpox.
• Discovered in 1958 in monkeys with first human case recorded in 1970 in the Democratic Republic of Congo. (CDC) 
• It is a zoonotic disease , meaning it is transmitted from animal to humans, with primary reservoir in squirrels, Gambian poached rats, dormice, different species of monkeys and others. 
• First reported in the U.S. in 2003. Cases were related to pet prairie dogs that had been housed with monkeypox virus infected African rodents, imported from Ghana (WHO)
• There are 2 clades (having evolved from same ancestral line) of the disease. The current outbreak is from the West African lineage. (WHO)
• West African – milder disease, 1-3% fatality
• Congo Basin – severe disease, 10% fatality 
• Due to the similarity in the viruses, immunization against smallpox has been found to prevent infection with monkeypox. The WHO believes that increasing frequency of worldwide infection may be related to waning immunity against smallpox, since that disease was eradicated in 1980 and the vaccine is no longer popularly used. 

Transmission

• Animal to human – contact with sick or dead animals, ingesting poorly cooked meat of infected animals.
• Human to human -” Human-to-human transmission is thought to occur primarily through large respiratory droplets. Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required. Other human-to-human methods of transmission include direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens.” (CDC)

Symptoms

• Initial 1-3 days – fever, lymphadenopathy, back pain, headache, myalgias, fatigue
• 2-4 weeks of rash progression: macules -> papules -> vesicles -> pustules -> scabs
• The pox rash starts on the face and spreads to the rest of the body.

Testing

• Detection is by PCR testing, ideally of body fluid contained in the pox blisters.
• Test kits are available through local U.S. Health Departments and the CDC. All suspected cases should be reported to local authorities.

Treatment

• Treatment includes vaccinating anyone who has been exposed with the smallpox vaccine (ring vaccination). The general population is no longer routinely vaccinated due to side-effects of the smallpox vaccine.
• No current recommendation exists for antiviral therapy or smallpox immunoglobulin therapy.  
• See CDC recommendations 

Prevention

• The JYNNEOS vaccine was FDA approved in 2019 for adults > 18 against both smallpox and monkeypox. It is a 2 dose non-replicating attenuated virus that does not produce a lesion, and therefore can not cause transmission to others. The CDC Advisory Committee on Immunization Practices is currently evaluating vaccine data with a formal recommendation pending. Media reports note the U.S. government has ordered millions of doses. 
• The original smallpox vaccine (DRYVAX) is no longer in production. However, a second generation clone, ACAM2000, is produced by Synofi and approved by the FDA. The WHO notes that smallpox vaccine is 85% effective in preventing monkeypox.
• Vaccination is recommended for lab workers and anyone exposed to monkeypox. The CDC recommends vaccination within 4 days of exposure to prevent disease, with ACAM2000. However, vaccination between days 4-14 is also recommended to reduce disease severity. 
• Vaccination does carry risks. The CDC estimates “Based on past experience, it is estimated that between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening complications from the vaccine” (ACAM2000) but notes that disease fatally is 1-10% outweighing the risk of vaccination. 

Further Reading

• Current WHO Outbreak Tracker
• CDC Monkeypox Reference
• Johns Hopkins Monkeypox Reference

This is the second episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.

This episode is a conversation between Dr. T.R. Eckler and Dr. Sam Ashoo about airway management and how it has changed in their practice over the last decade. This podcast makes reference to the EB Medicine course – Current Topics in Airway Management: Mechanical Ventilation, Supraglottic Airway Devices, and Intubating Patients With COVID-19, which can be found here:

https://www.ebmedicine.net/airway-training

We would love to have your feedback. Please take the listener survey:

https://www.surveymonkey.com/r/ZQRWQFW

Thanks for being a listener.

In this episode, Sam Ashoo, MD interviews Kyle Howarth, MD and Joby Thoppil, MD, PhD – two of the authors of the May, 2022 EMP article on Cellulitis and Skin and Soft Tissue Infections. Listen to the discussion to hear more about the emergency department management of cellulitis and necrotizing skin infections.

Episode 69 – Emergency Department Management of Cellulitis and Other Skin and Soft-Tissue Infections (https://www.ebmedicine.net/topics/infectious-disease/emergency-medicine-skin)

EMplify – May 2022

Episode Outline:

1. Why cellulitis/skin infections?

2. Terminology

• Erysipelas vs cellulitis vs fasciitis
• Purulent cellulitis

3. Most common pathogens

4. Special situations

5. Necrotizing infection classification system – is this helpful in the ED, and if so, why?

6. Differential – unilateral vs bilateral presentation

7. Prehospital care

8. ED evaluation

• History – what should we be asking?
• Examination: SSTI vs NSTI

9. Diagnostics

• POCUS: “cobblestoning” and fluid collection
• Xray: subcutaneous gas
• CT: when is this helpful?

10. Labs

• Blood cultures – if given the option, are they helpful? 
• Wound cultures – any role for these? 
• Routine labs (CBC, BMP, etc) – are they helpful? 
• LRINEC score – what is it and should we be using it? 

11. Treatment 

• NSTI antibiotics 
•  Abscesses 

12. Special populations 

• IV drug users 
• Diabetic patients 
• Immunocompromised patients 

13. Wound irrigation and loop drainage 

14. Disposition 

The first episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.

Take the listener survey:

https://www.surveymonkey.com/r/ZQRWQFW

More on the Dr Lorna Green Legislation here:

https://www.ebmedicine.net/ebmblog/general-emergency-medicine/news-updates/dr-lorna-breen-health-care-provider-protection-act/

Episode 68 -- Emergency Department Management of Adults With Infectious Meningitis and Encephalitis – An Interview with Dr. Andrew Hogan

EMplify -- April 2022

Interview with the Author: Andrew N. Hogan, MD

1.Meningitis vs encephalitis

• Why this topic?
• What do the words mean? What's the difference?

2.Bacterial meningitis

• How common is it in the US? Is it more common in third world countries?
• Mortality rate in the US
• Causes – if Neisseria and H influenzae improved post vaccination, why not S pneumoniae disease ? (Table 1)

3.Viral meningitis

• How common is it in the US?
• What are the common causes? (Table 2)

4.Viral encephalitis

• Same prognosis as viral meningitis?
• Same organisms as viral meningitis? (Table 2)
• Does COVID-19 cause this illness?

5.Fungal infections

• Who gets these?
• 60% die? 1 million cases a year, 600K deaths?

6.Prehospital care:

• What does EMS need to know?
• How do they protect themselves from being exposed?
• How can they help us make the diagnosis?
• EMS is giving antibiotics in some areas?
• PEP

7.ED evaluation: History

8.ED evaluation: Physical exam

9.Diagnostics: CSF

• What's large volume? Is it safe?
• Cell counts on tubes 1+4, all the time or only if traumatic and obviously bloody?
• Is opening pressure helpful?
• CSF lactate level – can this be run in a normal lactic acid analyzer?
• PCR/NAAT testing

10.Serum labs

• What is helpful?
• Serum PCR
• Serum cryptococcal antigen

11.Imaging 

• Is CT imaging before LP still necessary? Can we be selective?
• Is MRI helpful in the ED, or is there a role in encephalitis?

12.Treatment

• Antibiotics
• Steroids: Who gets them? When? Are there downsides of giving them?

13.Special populations

• Autoimmune disease
• Lacking childhood vaccines
• Healthcare associated infections

14.Cutting edge

15.Disposition

Episode 67 – Managing Postpartum Complications in the Emergency Department – An Interview with Dr. Nicole Yuzuk, Dr. Joseph Bove, and Dr. Riddhi Desai

EMplify – March 2022

Interview with the Authors: Nicole Yuzuk, DO, Joseph Bove, DO, and Riddhi Desai, DO

Episode Outline:

1.Why is this an important topic in EM? 

2.Hemorrhage etiologies and definition

3.Headache etiologies, both common and the more dangerous (ICH)

4.Fever and infection

• Mastitis
• Endometritis

5.Preeclampsia/eclampsia 

• Definition, diagnosis, risk factors (Table 1)

6.HELLP syndrome

• Definition, diagnosis (Table 2)

7.Peripartum cardiomyopathy

• Time of onset, how to make the diagnosis, risks (Table 3)

8.Prehospital care

• IV fluids
• TXA
• AMS evaluation
• Chest pain
• Fever/hypotension 

9.ED evaluation 

• History (what kind of things should we remember to ask?) 
• Physical exam (what should we be paying attention to?) 

10.Diagnostic studies

• Hemorrhage (exam, vitals, labs, US)
• Headache (labs, imaging – what type?)
• Fever and infection (labs, imaging – US or CT, antibiotics)
• Cardiopulmonary complaints (labs, imaging, ECG)

11.Treatment

• Hemorrhage 
• Headache (CVT)
• Infection (mastitis, endometritis, wound Infection)
• Preeclampsia, eclampsia, HELLP, seizures
• Cardiomyopathy

12.What about breastfeeding mothers? 

13.Controversies and cutting edge

• Endovascular therapy
• Thromboelastography