Short sweet and concise information on strokes for the general public. This episode aims at reducing the knowledge gap and improving the awareness regarding strokes in the community. 

In this episode I have spoken about the young adult epidemic that I have been talking about for months now linking it with metabolic syndromes. To check your metabolic health, you can get the following tests done -  "Fasting Hba1C, homocysteine, insulin, sugars, lipid profile, GGTP, SGOT, Uric acid". Please do your own research too. Everything I have spoken about in this episode is based on the research I have done in the past year, my knowledge as a doctor, my experiences and learnings from Dr Robert Lustig. 

What an academic feast organized by the SEMI-WB on the weekend of 16-17th July 2022 for the academic residents of emergency medicine. I start of the episode by talking about the EZECON. Also the 24th Annual Conference of SEMI is happening in Kerala from 23-27th November. Do register for it. In this episode I give an insight towards dealing with acid base disorders using the modified stewart's approach. Following are the references you can go through to understand more and change your practice - 

1. https://emcrit.org/wp-content/uploads/acid_base_sheet_2-2011.pdf

2. Story DA. Stewart Acid-Base: A Simplified Bedside Approach. Anesth Analg. 2016 Aug;123(2):511-5. doi: 10.1213/ANE.0000000000001261. PMID: 27140683.

3. Jones NL. A quantitative physicochemical approach to acid-base physiology. Clin Biochem. 1990 Jun;23(3):189-95. doi: 10.1016/0009-9120(90)90588-l. PMID: 2115411.

4. Mallat J, Michel D, Salaun P, Thevenin D, Tronchon L. Defining metabolic acidosis in patients with septic shock using Stewart approach. Am J Emerg Med. 2012 Mar;30(3):391-8. doi: 10.1016/j.ajem.2010.11.039. Epub 2011 Jan 28. PMID: 21277142.

5. Morgan TJ. The Stewart approach--one clinician's perspective. Clin Biochem Rev. 2009 May;30(2):41-54. PMID: 19565024; PMCID: PMC2702213.

6.Kaplan LJ, Kellum JA. Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury. Crit Care Med. 2004 May;32(5):1120-4. doi: 10.1097/01.ccm.0000125517.28517.74. PMID: 15190960.

7. Malatesha G, Singh NK, Bharija A, Rehani B, Goel A. Comparison of arterial and venous pH, bicarbonate, PCO2 and PO2 in initial emergency department assessment. Emerg Med J. 2007 Aug;24(8):569-71. doi: 10.1136/emj.2007.046979. PMID: 17652681; PMCID: PMC2660085.

8. Kelly AM, McAlpine R, Kyle E. Venous pH can safely replace arterial pH in the initial evaluation of patients in the emergency department. Emerg Med J. 2001 Sep;18(5):340-2. doi: 10.1136/emj.18.5.340. PMID: 11559602; PMCID: PMC1725689.

9. Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. Peripheral venous and arterial blood gas analysis in adults: are they comparable? A systematic review and meta-analysis. Respirology. 2014 Feb;19(2):168-175. doi: 10.1111/resp.12225. Epub 2014 Jan 3. PMID: 24383789.

A very Happy Doctors' Day to you all! In this episode I discuss some salient points regarding the physiologically difficult airway. There are many physicians I know who are still not aware regarding this concept that can kill patients as soon as we try and save them. Also - EZECON is being organised in Kolkata from 16-17th July,22 and it is going to be an academic feast for the residents. So do register for it. 

The references for reading up more on the physiologically difficult airways are as follows - 

1. Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC. The Physiologically Difficult Airway. West J Emerg Med. 2015 Dec;16(7):1109-17. doi: 10.5811/westjem.2015.8.27467. Epub 2015 Dec 8. PMID: 26759664; PMCID: PMC4703154.

2. Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015 Apr;65(4):349-55. doi: 10.1016/j.annemergmed.2014.09.025. Epub 2014 Oct 23. PMID: 25447559.

3. https://www.acepnow.com/article/crash-a-mnemonic-for-the-physiological-difficult-airway/

4. Myatra SN, Divatia JV, Brewster DJ. The physiologically difficult airway: an emerging concept. Curr Opin Anaesthesiol. 2022 Apr 1;35(2):115-121. doi: 10.1097/ACO.0000000000001102. PMID: 35165233.

5. Cai SR, Sandhu MRS, Gruenbaum SE, Rosenblatt WH, Gruenbaum BF. Airway Management in an Anatomically and Physiologically Difficult Airway. Cureus. 2020 Sep 24;12(9):e10638. doi: 10.7759/cureus.10638. PMID: 33123451; PMCID: PMC7584327.

6. Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier JM; Society for Airway Management’s Special Projects Committee. Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management. Anesth Analg. 2021 Feb 1;132(2):395-405. doi: 10.1213/ANE.0000000000005233. PMID: 33060492.

7. Mosier, Jarrod M. “Physiologically Difficult Airway in Critically Ill Patients: Winning the Race between Haemoglobin Desaturation and Tracheal Intubation.” British Journal of Anaesthesia 125, no. 1 (July 2020): e1–4. https://doi.org/10.1016/j.bja.2019.12.001.

8. Scott Weingart, MD FCCM. EMCrit 325 – The Hypoxemic Difficult Airway and Preox Discussion with Jarrod Mosier. EMCrit Blog. Published on June 5, 2022. Accessed on June 30th 2022. Available at [https://emcrit.org/emcrit/hypoxemic-difficult-airway/ ].

9. Salim Rezaie, "An Emergency Difficult Airway Predictor Would be From HEAVEN", REBEL EM blog, January 31, 2018. Available at: https://rebelem.com/emergency-difficult-airway-predictor-heaven/.

10. Salim Rezaie, "Critical Care Updates: Resuscitation Sequence Intubation – Hypotension Kills (Part 1 of 3)", REBEL EM blog, September 26, 2016. Available at: https://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypotension-kills-part-1-of-3/.

11. Salim Rezaie, "Critical Care Updates: Resuscitation Sequence Intubation – pH Kills (Part 3 of 3)", REBEL EM blog, October 3, 2016. Available at: https://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-ph-kills-part-3-of-3/.

So the International Conference on Emergency Medicine 2022 is on in Melbourne. There is quite a bit of representation from India at the biggest EM conference! In today's episode, I talk about how India emergency physicians are contributing to the academic fest in Melbourne. Enjoy!

In this episode I bid farewell to my passing out residents and discuss some trauma myths like Manual in line stabilization and the use of steroids in acute spinal cord injuries. You all can go through the following articles to learn more - 

1. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007 Dec;50(6):653-65. doi: 10.1016/j.annemergmed.2007.05.006. Epub 2007 Aug 3. PMID: 17681642.

2.Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med. 2007 Sep;50(3):236-45. doi: 10.1016/j.annemergmed.2007.01.009. Epub 2007 Mar 6. PMID: 17337093.

3. Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8. doi: 10.1007/s12630-009-9089-7. Epub 2009 Apr 24. PMID: 19396507.

4. Kapp JP. Endotracheal intubation in patients with fractures of the cervical spine [technical note]. J Neurosurg. 1975;42:731-732.

5. Hachen HJ. Idealized care of the acutely injured spinal cord in Switzerland. J Trauma. 1977;17:931-936

6. Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. 1979;61:1119-1142.

7. Podolsky S, Baraff LJ, Simon RR, et al. Efficacy of cervical spine immobilization methods. J Trauma. 1983;23:461-465.

8. Hugenholtz H, Cass DE, Dvorak MF, Fewer DH, Fox RJ, Izukawa DM, Lexchin J, Tuli S, Bharatwal N, Short C. High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option. Can J Neurol Sci. 2002 Aug;29(3):227-35. doi: 10.1017/s0317167100001992. PMID: 12195611.

9. Suberviola B, González-Castro A, Llorca J, Ortiz-Melón F, Miñambres E. Early complications of high-dose methylprednisolone in acute spinal cord injury patients. Injury. 2008 Jul;39(7):748-52. doi: 10.1016/j.injury.2007.12.005. Epub 2008 Jun 9. PMID: 18541241.

10. Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS, Eisenberg HM, Flamm E, Leo-Summers L, Maroon J, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990 May 17;322(20):1405-11. doi: 10.1056/NEJM199005173222001. PMID: 2278545.

11. Bracken MB, Collins WF, Freeman DF, Shepard MJ, Wagner FW, Silten RM, Hellenbrand KG, Ransohoff J, Hunt WE, Perot PL Jr, et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA. 1984 Jan 6;251(1):45-52. PMID: 6361287.

12. Evaniew N, Noonan VK, Fallah N, Kwon BK, Rivers CS, Ahn H, Bailey CS, Christie SD, Fourney DR, Hurlbert RJ, Linassi AG, Fehlings MG, Dvorak MF; RHSCIR Network. Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Propensity Score-Matched Cohort Study from a Canadian Multi-Center Spinal Cord Injury Registry. J Neurotrauma. 2015 Nov 1;32(21):1674-83. doi: 10.1089/neu.2015.3963. Epub 2015 Jul 17. PMID: 26065706; PMCID: PMC4638202.

In this episode of myths in emergency medicine, I talk about Oxygen in STEMI patients, Epinephrine in digital anaesthesia, C- line for CVP monitoring and MILS in trauma patients. You can go through some of the following papers and decide what you want to do with your EM practice - 

1. Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, Cameron P, Barger B, Ellims AH, Taylor AJ, Meredith IT, Kaye DM; AVOID Investigators. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015 Jun 16;131(24):2143-50. doi: 10.1161/CIRCULATIONAHA.114.014494. Epub 2015 May 22. PMID: 26002889.

2. Hofmann R, Befekadu Abebe T, Herlitz J, James SK, Erlinge D, Yndigegn T, Alfredsson J, Kellerth T, Ravn-Fischer A, Völz S, Lauermann J, Jernberg T, Lindahl B, Langenskiöld S. Routine Oxygen Therapy Does Not Improve Health-Related Quality of Life in Patients With Acute Myocardial Infarction-Insights From the Randomized DETO2X-AMI Trial. Front Cardiovasc Med. 2021 Mar 15;8:638829. doi: 10.3389/fcvm.2021.638829. PMID: 33791349; PMCID: PMC8006541.

3. Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol. 2004 Nov;51(5):755-9. doi: 10.1016/j.jaad.2004.05.028. PMID: 15523354.

4. Mohan, P P. “Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Epinephrine in digital nerve block.” Emergency medicine journal : EMJ vol. 24,11 (2007): 789-90. doi:10.1136/emj.2007.053793

5. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008 Jul;134(1):172-8. doi: 10.1378/chest.07-2331. PMID: 18628220.

6. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007 Dec;50(6):653-65. doi: 10.1016/j.annemergmed.2007.05.006. Epub 2007 Aug 3. PMID: 17681642.

7. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31. doi: 10.1097/ALN.0b013e318190b556. PMID: 19104166.

8. Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med. 2007 Sep;50(3):236-45. doi: 10.1016/j.annemergmed.2007.01.009. Epub 2007 Mar 6. PMID: 17337093.

9. Wiles MD. Manual in-line stabilisation during tracheal intubation: effective protection or harmful dogma? Anaesthesia. 2021 Jun;76(6):850-853. doi: 10.1111/anae.15472. PMID: 33939842.

In today's episode, I've discussed some myths that are still prevalent in emergency medicine practices across the world. They are still taught even if some clinicians do not practice it. do you own research. Don't take my word for it. Change your practice accordingly. You can go through some of the following references - 

1. SELLICK BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet (London, England). 1961; 2(7199):404-6. PMID:13749923

2. Birenbaum A, Hajage D, Roche S, et al. Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial. JAMA surgery. 2018; PMID:30347104

3. Allman KG. The effect of cricoid pressure application on airway patency. Journal of clinical anesthesia. 1995; 7(3):197-9. PMID:7669308

4. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Annals of emergency medicine. 2007; 50(6):653-65. PMID:17681642

5. Neilipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid sequence induction. Canadian journal of anaesthesia = Journal canadien d’anesthesie. 2007; 54(9):748-64. PMID:17766743

6. Palmer JH, Ball DR. The effect of cricoid pressure on the cricoid cartilage and vocal cords: an endoscopic study in anaesthetised patients. Anaesthesia. 2000; 55(3):263-8. PMID:10671846

7. Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. Peripheral venous and arterial blood gas analysis in adults: are they comparable? A systematic review and meta-analysis. Respirology. 2014 Jan 3. PMID: 24383789.

8. Kelly AM, McAlpine R, Kyle E. Venous pH can safely replace arterial pH in the initial evaluation of patients in the emergency department. Emerg Med J. 2001 Sep;18(5):340-2. PMID 11559602

9. Middleton P, Kelly AM, Brown J, Robertson M. Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. Emerg Med J. 2006 Aug;23(8):622-4. PMID16858095

10. Klein LR, Cole JB. Ketamine: Focusing on the Facts and Forgetting the Fiction. Ann Emerg Med. 2021 Jul;78(1):132-139. doi: 10.1016/j.annemergmed.2021.03.039. PMID: 34167728.

11. Godoy DA, Badenes R, Pelosi P, Robba C. Ketamine in acute phase of severe traumatic brain injury "an old drug for new uses?". Crit Care. 2021 Jan 6;25(1):19. doi: 10.1186/s13054-020-03452-x. PMID: 33407737; PMCID: PMC7788834.

12. Schofer JM. Premedication during rapid sequence intubation: a necessity or waste of valuable time? Cal J Emerg Med. 2006 Dec;7(4):75-9. PMID: 20505811; PMCID: PMC2872531.

13. Robinson N, Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg Med J 200;8:453-7.

In today's episode, I invite Drs Sanjay and Shivani back to the show to discuss the 6 steps to manage hyponatremia in your ED in a little bit more detail. This will be a learning curve for the young (and the old) emergency physicians. Later on, I would have them back to discuss real life cases that have been managed in our department using the 6 cases. Enjoy! For any questions you can DM us on our twitter handles -  @anksv25 (Ankur), @drshivanisarda (Shivani) and @drbobby71sanjay (Sanjay) 

In this episode, I have discussed a little bit about some advances in trauma resuscitation, some goals and how ATLS should be the basic trauma skill an emergency physician should have. I did not mean to break any hearts, but yes trauma resus goes beyond ATLS. Do not believe what I say blindly, do your research. You can go through the following mind blowing papers and up your trauma game and prepare your own trauma protocols for your emergency departments. 

The papers you can go through (not in any order of preference). And these are not exhaustive - 

1. Harris T, Davenport R, Mak M, Brohi K. The Evolving Science of Trauma Resuscitation. Emerg Med Clin North Am. 2018 Feb;36(1):85-106. doi: 10.1016/j.emc.2017.08.009. PMID: 29132583.

2. Leibner E, Andreae M, Galvagno SM, Scalea T. Damage control resuscitation. Clin Exp Emerg Med. 2020;7(1):5-13. doi:10.15441/ceem.19.089

3. Carrick MM, Leonard J, Slone DS, Mains CW, Bar-Or D. Hypotensive Resuscitation among Trauma Patients. Biomed Res Int. 2016;2016:8901938. doi: 10.1155/2016/8901938. Epub 2016 Aug 9. PMID: 27595109; PMCID: PMC4993927.

4.  https://www.jsomonline.org/References/PDF/Damage_Control_Resuscitation_03_Feb_2017_ID18.pdf

5. Petrosoniak A, Hicks C. Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock. Emerg Med Clin North Am. 2018 Feb;36(1):41-60. doi: 10.1016/j.emc.2017.08.005. PMID: 29132581.

6. Mutschler, M., Nienaber, U., Münzberg, M., Wölfl, C., Schoechl, H., Paffrath, T., Bouillon, B., Maegele, M., & TraumaRegister DGU (2013). The Shock Index revisited - a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU. Critical care (London, England), 17(4), R172. https://doi.org/10.1186/cc12851

7. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003 Jun;54(6):1127-30. doi: 10.1097/01.TA.0000069184.82147.06. PMID: 12813333.

8. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ, Cotton BA, Fabian TC, Inaba K, Kerby JD, Muskat P, O'Keeffe T, Rizoli S, Robinson BR, Scalea TM, Schreiber MA, Stein DM, Weinberg JA, Callum JL, Hess JR, Matijevic N, Miller CN, Pittet JF, Hoyt DB, Pearson GD, Leroux B, van Belle G; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015 Feb 3;313(5):471-82. doi: 10.1001/jama.2015.12. PMID: 25647203; PMCID: PMC4374744.

9. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23(1):98. doi: 10.1186/s13054-019-2347-3. PMID: 30917843; PMCID: PMC6436241.

10. Spinella PC, Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. 2009 Nov;23(6):231-40. doi: 10.1016/j.blre.2009.07.003. Epub 2009 Aug 19. PMID: 19695750; PMCID: PMC3159517.

11. Wiles MD. ATLS: Archaic Trauma Life Support? Anaesthesia. 2015 Aug;70(8):893-7. doi: 10.1111/anae.13166. PMID: 26152249.

12. Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Wyen H, Peiniger S, Paffrath T, Bouillon B, Maegele M; TraumaRegister DGU. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation. 2013 Mar;84(3):309-13. doi: 10.1016/j.resuscitation.2012.07.012. Epub 2012 Jul 24. PMID: 22835498.