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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.

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The Invictus curriculum continues to expand with new lectures, emphasized content, transcripts, and multiple-choice questions, with Matt Delaney now helping with development. We explore pneumomediastinum and pneumopericardium through a simple balloon analogy: two lungs squishing around the heart where air can leak into potential spaces, sometimes tracking into the neck or even dissecting into the pericardium.

• Invictus curriculum growing with new features and comprehensive content for residents
• Continuous board review is valuable throughout a medical career
• Pneumomediastinum occurs when air leaks into the mediastinum from lungs, esophagus, or trachea
• Air can track into subcutaneous tissues or dissect into the pericardium
• Most pneumomediastinum cases need no treatment and resolve spontaneously
• Tension pneumomediastinum or pneumopericardium may require intervention
• Pneumopericardium can cause tamponade requiring drainage
• Chris Riley demonstrates varying examples of pneumomediastinum on chest x-rays

Check out the full radiology x-ray fundamentals series on EM:RAP for more examples.

Link to YouTube Video

We explore the essential techniques for accurately interpreting elbow X-rays, focusing on key lines, fat pad signs, and common fracture patterns that help reveal hidden injuries.

• Standard elbow series includes AP, lateral, and oblique views, with the lateral being the most critical "money shot"
• Two essential lines to draw: anterior humeral line (should pass through middle third of capitellum) and radiocapitellar line (should bisect the capitellum)
• Fat pad signs are crucial indicators – posterior fat pads are NEVER normal and always indicate pathology
• Pediatric injuries typically involve supracondylar fractures (60% of all pediatric elbow fractures)
• Adult injuries commonly involve radial head fractures, with 20-40% showing only fat pad signs initially
• Always check and document neurovascular status before and after any intervention
• Displaced or comminuted fractures require urgent orthopedic consultation
• Simple non-displaced fractures can be splinted with outpatient orthopedic follow-up

Check out the complete lecture and more educational content coming soon to the Invictus Board Review site.

Link to Scott Course: https://guidewirecoaching.com/unburnable/

Scott Weingart discusses his journey into physician executive coaching, focusing on helping emergency medicine physicians overcome burnout through mindset shifts and practical skills development. 

• Burnout often stems from inner voice negativity that physicians mistake as their core identity
• Cognitive distancing teaches docs to separate unhelpful thoughts from themselves
• Stoic philosophy helps physicians accept unchangeable situations while finding meaningful challenges
• Communication techniques like nonviolent communication transform difficult consultant interactions
• "Fundies" (fundamentals) include maintaining basic physical needs during shifts
• Optimal pace is sustainable rather than superhuman, like a marathoner not a sprinter
• Sleep optimization requires avoiding alcohol after 5 pm and limiting caffeine
• Lifelong mastery and continued learning provide meaning and purpose
• Group coaching costs around $3000 for 12 sessions over 24 weeks
• Meditation practice is "the game changer" for emergency medicine physicians

The work matters and we need to help people stay in the game. If we can't fix the system yet, we need to focus on how to maintain ourselves within it.