Coming Soon: Invictus.Reviews

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We reframe “drowning” as submersion incidents and lay out a simple path from shore to safe disposition. Hypoxia drives arrest, observation prevents misses, and ECMO has a clear role when ventilation fails or hypothermia persists.

• replacing drowning with submersion incidents
• hypoxia as the primary cause of arrest
• selective C‑spine precautions based on mechanism
• ECMO for refractory hypoxemia or hypothermia
• normal chest X‑ray can mislead after aspiration
• strict four to six hour observation window
• discharge only if fully asymptomatic with normal vitals and exam
• admit for any symptoms, abnormal gases, dysrhythmia, or abnormal imaging
• use NIV for symptomatic, alert patients; intubate if needed
• avoid steroids and routine antibiotics; exception for sewage exposure
• active rewarming as a core treatment step
• board strategy: read stems literally and match management to symptoms

Our oral board review course is going to be out soon, like really soon. The written board review will be delayed until early next year; we’ll restart a new and better podcast with more people in the Invictus part of things—stay tuned.

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Dr. Sean Nordt delivers a comprehensive pharmacology lecture on antidepressants, their mechanisms, and the management of toxicity cases in emergency settings. The board-certified emergency physician, pharmacologist, and toxicologist walks through the complex pharmacology of psychiatric medications, focusing on their potentially deadly complications and how to recognize and treat them.

• Cyclic antidepressants cause toxicity through fast sodium channel blockade, leading to QRS widening and ventricular dysrhythmias
• Sodium bicarbonate is the cornerstone treatment for cyclic antidepressant toxicity, working by increasing pH and altering cardiac binding
• SSRIs and SNRIs have distinct adverse effect profiles, with SNRIs posing greater risk in overdose scenarios
• Bupropion overdose commonly causes seizures and QRS widening through cardiac gap junction blockade
• MAOIs can cause hypertensive crisis and severe serotonin syndrome, especially with tyramine-rich foods or drug interactions
• Serotonin syndrome is characterized by hyperreflexia and clonus, distinguishing it from neuroleptic malignant syndrome
• Treatment approaches differ for serotonin toxicity (benzodiazepines, cooling), NMS (supportive care), and malignant hyperthermia (dantrolene)
• Antiemetics like metoclopramide and promethazine can cause extrapyramidal effects treatable with anticholinergics

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Updates on the Invictus medical review courses with "baby Invictus" for oral exams coming soon and a comprehensive border review course in development. Dr. Sean Nort shares vital insights on common household ingestions, challenging assumptions about what substances actually pose dangers to children.

• Household bleach (3% sodium hypochlorite) ingestion typically requires only reassurance and discharge home
• Industrial bleach is more concerning due to higher concentration
• Most cosmetics, window cleaners, soaps and detergents have minimal toxicity
• Laundry pods can cause more significant caustic burns and sometimes reduced consciousness
• Silica gel packets are extremely safe despite "do not eat" warnings
• Poison control centers are the best resource for managing potential ingestions

Visit invictusreviews.com to learn about our expanding medical education resources and upcoming course offerings.

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Dr. Mel Herbert provides a crucial update on the Invictus Board Review program alongside critical pearls for identifying and managing deadly necrotizing infections. These rapidly progressing infections require immediate recognition, prompt treatment, and surgical intervention to prevent death from these tissue-destroying processes.

• Necrotizing infections include necrotizing fasciitis, Fournier's gangrene, Ludwig's angina, and malignant otitis externa
• Key warning signs include pain out of proportion to physical findings, rapidly progressive spread, dishwater discharge, and woody edema
• "La belle indifference" describes patients who appear strangely calm despite severe infection
• Polymicrobial infections often start as normal infections before turning necrotizing days later
• Monomicrobial forms (often Strep A) progress extremely rapidly in otherwise healthy individuals
• Seawater exposures can introduce deadly Clostridium or Vibrio species through minor skin breaks
• Treatment priorities: rapid diagnosis, fluid resuscitation, antimicrobials, and immediate surgical debridement

The full Invictus Board Review program and OSCE preparation materials will be available soon to address declining emergency medicine board exam pass rates and provide continuous education for practicing clinicians.

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Tracheostomy and laryngectomy emergencies demand specific knowledge and immediate action to prevent devastating complications. Jess Mason delivers critical pearls on managing occluded, dislodged, and bleeding tracheostomies that are essential for both board exams and clinical practice.

• Cuffed tracheostomies have a pilot balloon and are required for positive pressure ventilation
• Uncuffed tracheostomies are more common in established patients but cannot be used with ventilators
• Occluded tracheostomies should be managed with oxygen first, followed by suctioning and inner cannula cleaning
• Dislodged tracheostomies require immediate replacement to prevent stomal narrowing
• Bleeding tracheostomies may signal a tracheo-innominate artery fistula, especially with "sentinel bleeds"
• Laryngectomies fundamentally differ from tracheostomies in that they have no communication between mouth/nose and lungs
• You can ONLY manage a laryngectomy patient's airway through their stoma

Visit us at Invictus for comprehensive board review resources that deliver continuous education through videos, audio, written summaries, question banks, and live events designed to help you maintain mastery of emergency medicine throughout your career.

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Status epilepticus has been redefined from 30 minutes to just 5 minutes of continuous seizure activity, aligning better with current treatment approaches that emphasize early intervention. This includes recognizing non-convulsive status, which often presents as a prolonged postictal state with subtle eye movements or gaze deviation.

• Systematic assessment includes history of seizures, medications, shunts, trauma, potential ingestions
• Lab evaluation should include glucose, electrolytes, calcium, pregnancy testing when applicable
• Initial treatment involves two doses of benzodiazepines via IV, rectal, buccal, or intranasal routes
• Simplified dosing: midazolam/diazepam 0.2 mg/kg (max 10mg); lorazepam 0.1 mg/kg (max 4-5mg)
• Second-line agents include levetiracetam (60 mg/kg), fosphenytoin (20 PE/kg), or valproate
• For refractory status, consider ketamine, phenobarbital, or continuous infusions after intubation
• Propofol is generally avoided in children under age 3 and carries risk of propofol infusion syndrome

Season two of "The Pit" is in production with writers writing, actors acting, and producers producing. It's scheduled for release in January of next year.

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Staph Scalded Skin Syndrome presents with terrifying skin desquamation but typically heals without scarring within two weeks. This case demonstrates the classic presentation in a three-year-old child with recent URI, highlighting the typical appearance, clinical course, and management principles.

• Staph Scalded Skin Syndrome results from staphylococcal toxins that cleave the epidermis
• Most common in young children, often following upper respiratory infections
• No mucosal involvement - key differentiating factor from Stevens-Johnson Syndrome
• Treatment includes anti-staphylococcal antibiotics and supportive care
• Colonization site may be difficult to identify, often in nares or umbilical region
• Adults with renal disease are at higher risk due to impaired toxin clearance
• Requires burn-like supportive care for temperature regulation and prevention of secondary infections
• Historically had 5% mortality, likely lower with modern intensive care

Stay tuned for our upcoming comprehensive Immunism Medicine Boards preparation resources, featuring videos, questions, summaries, and study guides designed to help you excel on your exam.

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Try and guess before reading the summary.

Stevens-Johnson Syndrome presents a critical dermatological emergency characterized by mucosal lesions and diffuse rash with high mortality if untreated. Recognizing this condition requires understanding its presentation, pathophysiology, and immediate management strategies to improve patient outcomes.

• Case presentation of 20-year-old female with fever, mucosal lesions, and diffuse rash
• Mucosal involvement is the key diagnostic feature of Stevens-Johnson syndrome
• Common triggers include sulfa drugs, anti-epileptics, NSAIDs, and infections like mycoplasma
• Positive Nikolsky sign where skin cleaves and sloughs off when pressed
• SJS affects less than 10% of body surface area while TEN involves more than 30%
• Treatment includes supportive care, fluids, nutrition, and controversial steroids
• IVIG, plasmapheresis, and TNF blockers may be beneficial treatment options
• Approach treatment similar to severe burns with non-adherent dressings
• Secondary infections may require antimicrobials, but not as initial treatment
• Eye involvement requires artificial tears and careful monitoring

Join us for our upcoming Encore program focused on preparation for the new oral exam, followed by our comprehensive Invictus board review course.

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Britt Guest's lecture on pregnancy complications with expert emphasis from Matt Delaney. This preview focuses on differentiating normal pregnancy nausea from hyperemesis gravidarum while demonstrating effective board exam question strategies.

• Normal pregnancy nausea can be managed with pyridoxine (B6), doxalamine, ondansetron, ginger, and eating smaller frequent meals
• Hyperemesis gravidarum causes severe dehydration, weight loss, vitamin deficiencies, and potential complications including Wernicke's encephalopathy
• Severe vomiting can lead to mechanical complications like Mallory-Weiss tears, pneumomediastinum, and pneumothorax
• Treatment escalation includes IV/IM medications and possibly steroids (with caution in first trimester)
• Board-style questions demonstrate proper management of a dehydrated pregnant patient and recognition of molar pregnancy signs
• Matt Delaney demonstrates how to work through unfamiliar terms on exams using clinical reasoning

Check out the full video version with visuals on YouTube - link in the show notes.

Link to CXR Fundamentals Series on EM:RAP

We explore Rubella (German measles or three-day measles), a disease that remains clinically relevant despite being considered nearly eradicated in the US due to vaccination.

• Congenital rubella syndrome can cause severe complications including cataracts, cardiac abnormalities, growth restriction, and hearing loss
• Rubella typically presents with cephalocaudal rash, low-grade fever, and arthralgia 
• The disease is less severe than measles but still concerning for pregnant women
• Written documentation of at least one MMR dose is sufficient evidence of immunity
• PCR testing provides the most accurate diagnosis during acute infection
• Isolation period is seven days after rash onset to prevent transmission
• Rubella has a long 17-day incubation period with contagiousness spanning 7 days before and after rash
• Droplet precautions are appropriate for hospitalized patients
• Management of exposed pregnant women involves isolation and post-delivery vaccination
• Global vaccination coverage varies significantly, with lower rates in low-income regions

The full Invictus program is coming soon with continuous updates, comprehensive videos, MCQs, and resources to support physicians throughout their careers.