EMToxCast

First in a series of PodCasts for Med Students and Interns on cardinal presentations in EM

Journal Club articles Podcast! Abscesses: Lancing the myths

If you are a med student getting ready for the start of fourth year and EM Clerkships and Sub Internships - this podcast is for you!

Some insights into the phenomenon of K2 Krash - hypotension and bradycardia after synthetic cannabinoid overdose.

In this podcast I review "Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess" Talan et al NEJM 2016;374:823-32 and see what the clinical advantage to adding TM-SMX to simple I&D. Then we take a quick turn to some Tox and look at "Extracorporeal membrane oxygenation in the treatment of poisoned patients" deLange et al in Clinical Toxicology 2013;51:385-393.

In this interview I am excited to introduce Ernie as the new Program Director for our incoming class of interns. I talk with Ernie about his new position, what motivates him to teach, and we have deep thoughts on autonomy, mastery, and purpose. Shout out to all our fantastic EM Program Candidates and I hope you enjoy the podcast. Get in touch for any questions you might have for Ernie (or anyone) and good luck in the Match! See you in June!

Journal Club PodCast: Flipped classroom!

Assignment is to read the articles, listen to the podcast, and be prepared to apply your knowledge to clinical scenarios when you come to Journal Club.

Articles are:

Acute stroke intervention: A systematic review JAMA April 14, 2015

Endovascular Therapy after IV TPA versus TPA alone for stroke NEJM March 7 2013

Comparative efficacy of different acute reperfusion therapies for acute ischemic stroke: a comprehensive benefit-risk analysis of clinical trials Brain and Behavior 2014

A review of decision support, risk communication and patient information tools for thrombolytic treatment in acute stroke: lessons for tools developers BMC Health Services Research 2013

Opinions are of course are own...!

Music is "Heartbeats" by Cat Hamilton created exclusively for this podcast - how cool is that!

Neurocritical Care Society and Society for Critical Care Medicine recommendations for reversal of antithrombotic agents in patients with intracranial hemorrhage

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage : A Statement for Healthcare Professionals from the Neurocritical Care Society... - PubMed - NCBI http://www.ncbi.nlm.nih.gov/pubmed/26714677

Antithrombotic: Timing, Antidote, Factor Replacement, antifibrinolytics

Vitamin K antagonists (warfarin) If INR > 1.3 then Vitamin K 10 mg IV, plus 3 or 4 factor PCC IV

(dosing based on weight, INR and PCC type) OR FFP 10–15 ml/kg IV if PCC not available

Direct factor Xa inhibitors: activated charcoal (50 g) within 2 h of ingestion, activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV

Direct thrombin inhibitors (dabigatran): Activated charcoal (50 g) within 2 h of ingestion, AND Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV Idarucizumab 5 g IV (in two 2.5 g/50 mL vials) consider hemodialysis or idarucizumab redosing for refractory bleeding after initial administration if 1) dabigatran was taken with 3-5 half lives and NO evidence of renal insufficiency or 2) dabigatran was taken beyond 3-5 half lives WITH renal insufficiency

For other DTIs: Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV

Unfractionated heparin: Protamine 1 mg IV for every 100 units of heparin administered in the previous 2–3 h (up to 50 mg in a single dose)

LMWH

Enoxaparin: Dosed within 8 h: Protamine 1 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Dosed within 8–12 h: Protamine 0.5 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Minimal utility in reversal >12 h from dosing

Dalteparin, Nadroparin and Tinzaparin: Dosed within 3–5 half-lives of LMWH: Protamine 1 mg IV per 100 anti-Xa units of LMWH (up to 50 mg in a single dose) OR rFVIIa 90 mcg/kg IV if protamine is contraindicated

Danaparoid: rFVIIa 90 mcg/kg IV

Pentasaccharides: Activated PCC (FEIBA) 20 units/kg IV or rFVIIa 90 mcg/kg IV

Thrombolytic agents (plasminogen activators): Cryoprecipitate 10 units IV OR antifibrinolytics (tranexamic acid 10–15 mg/kg IV over 20 min or e-aminocaproic acid 4–5 g IV) if cryoprecipitate is contraindicated

Antiplatelet agents: DDAVP 0.4 mcg/kg x 1, if neurosurgical intervention, transfuse one apheresis unit

I am joined by Tony Mazzeo MD Chairman of Emergency Medicine at Mercy Catholic Medical Center and Vice Chairman of Mercy Operations for Department of EM at Drexel University College of Medicine. In this podcast we talk about getting efficient in the ED:

Hot Stove Tips

1) empty the beds

2) Start with the dispo in mind (leave the room with a plan) and identify blockers

3) measure and track your throughput

4) anticipate problems

5)process in parallel and not serially

Hope you enjoy it and let me know if you agree!!!

What's ahead for pregnancy labeling categories - say goodbye to ABCDX!

Useful links http://www.cdc.gov/pregnancy/meds/treatingfortwo/data.html

http://www.nejm.org/doi/pdf/10.1056/NEJMp1316042