ERCAST
current issues in emergency medicine, reviews, opinion and curbside consults

An unexpected podcast with Dr. Dike Drummond, otherwise known as The Happy MD.

Dike coaches physicians through the stressful aspects of medical practice and has written a book on working though BURNOUT: Burnout Prevention Matrix

In this show

  • How to be an effective educator.
    • Effective teaching isn't about disgorging information while the Powerpoint slides flow by. It's about giving your listeners new skills to be better at what they do.
  • The secret to dealing with hospital administrators by acting like Columbo
  • Recognizing and overcoming burnout

 

Direct download: The_Happy_MD_podcast.output.mp3
Category:podcasts -- posted at: 6:45 PM

The way we learn to manage pulseless electrical activity (PEA) from the Advanced Cardiac Life Support course is a mockery wrapped up in a sham. The mnemonic is cumbersome and the treatment (such as CPR for all, empiric epinephrine) is not always appropriate for a patient with normal electrical activity and a pulse. Fear not, because there is a way out of this madness. Joe Bellezzo from the ED ECMO project joins the show to talk about his thoughts on PEA and what I think is a revolutionary approach to evaluating and treating PEA. Instead of lumping all patients with electrical activity and no palpable pulse in to one group, the authors make use of ultrasound and common sense.

PEA made easy

Step one. Look at the QRS. Is it wide or narrow?

Narrow QRS is often from some sort of right side of the heart inflow or outflow problem. The electricity is working just fine. There’s either not enough blood coming in or not enough blood going out. What are some things that can cause that? Cardiac tamponade, tension pneumothorax, mechanical hyperinflation and pulmonary embolism, severe hypovolemia.

Wide QRS. What are some things that cause PEA and impaired conduction? Hyperkalemia, sodium channel blocker toxicity such as you would see in an OD, ischemia, massive pulmonary embolism.

Myocardial infarction can cause PEA in both the narrow and wide complex groups and these patients usually do poorly. In the setting of MI, think myocardial rupture.

Step two. Look at the heart with ultrasound

Narrow QRS. If you see a collapsing RV and an effusion, that's tamponade. Collapsed RV could also be from a pneumothorax or hyperinflation. A dilated right ventricle may indicate pulmonary embolism.

Wide QRS. Ultrasound will usually show a hypo kinetic heart or it may not be beating at all.

Step three. Empiric Treatment

Narrow QRS. This is often a flow problem so unleash the wide open fluids. Then focus on specific treatment if you have identified a cause by ultrasound. Cardiac tamponade- pericardiocentesis, Tension pneumothroax-decompress the chest, massive pulmonary embolism- thrombolytics, hyperinflation- adjust the vent settings

Wide QRS. There's a fair chance that your patient has some sort of metabolic problem (hyperkamemia or sodium channel OD) so push an amp of sodium bicarbonate and an amp of calcium.

 

Littmann, Laszlo, Devin J. Bustin, and Michael W. Haley. "A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity." Medical Principles and Practice 23.1 (2013): 1-6.

Direct download: PEA_is_a_bunch_of_BS.output.mp3
Category:podcasts -- posted at: 3:52 PM

What's it like to be an emergency physician? Take a look inside the psyches of ED docs from around the planet.

So, you want to be an ER doctor. What does that mean? Is it even possible to understand the reality of life as a full time emergency physician when you make the leap of faith on Match day? Because that's what it is, isn't it? The match, a leap of faith? You spend, at best, a few months in medical school doing all of the fun stuff in a specialty and then you need to decide the course of the rest of your life as a physician. It's analogous to emergency medicine in a way, making a monumental and critical decision based on insufficient information.

I graduated from medical school in the mid 90s. I was certain, CERTAIN, that I was going to be an orthopedic surgeon. That idea was locked in until I actually rotated in ortho. The comraderie was great, the OR was fun, clinic always interesting, but it didn't feel like it fit my personality. As I rotated through each medical specialty in the third year of med school, there was always time spent in the ED. Whenever I was there, in the emergency department, I loved it. The pathology, the pace, procedures, and the challenge of diagnosing and managing undifferentiated complaints and…. the people who worked in the ED were my sort of folk: A) Smartasses B) Short attention spans C) Excited at the uncertainty of what was lying behind curtain number one and D) What I hoped would be part of my persona some day- taking care of business in the critically ill patient, getting it done like there was nothing to it. Caring for patients in the ED, I  felt like I was making a difference. But, as I said, the downsides aren't as apparent when you're in the infatuation stage. I later leaned what stressed me out, and believe me, even if you think you're invincible, you too have a stress point. For me, it was task saturation. Too much to do all at once. When you get out of training and it's just you with a fully loaded ED with lots of sick patients,  phone calls to make, procedures to do, conversations, charting, and on and on... task saturation. It's one of the skills you learn in residency but nothing can fully prepare you for your first day at the captains helm. That was something I had to learn, not only to live with, but how to manage. Task saturation happens at least once every shift.

This episode is intended to give you a peek inside the mind of the workaday ED doc. The lessons they've learned  and what can they pass on to you. Don't get me wrong, it's still the best job in the world, at least I think so, but it's also not easy. If you're thinking about emergency medicine as a career, you should go into it with open eyes and understand  the highs, the lows, the sexy resuscitation, burnout, all of it, warts and all.

Direct download: So_you_want_to_be_an_ER_doc.output.mp3
Category:general -- posted at: 3:34 PM

Legal analyst Gunnar Schwartzbaum (nom de plume) joins the show to talk about the legal ramifications of quarantine and isolation orders.

In this episode

  • What to do if a patient with suspected Ebola wants to leave the hospital against medical advice.
  • What is the difference between isolation and quarantine?
  • How do you enforce an isolation order?
  • What is home quarantine?
  • Can you refuse to care for a patient with suspected Ebola?

 

CDC Ebola Reference Page

 

Direct download: Ebola_quarantine_and_the_law.output.mp3
Category:podcasts -- posted at: 4:12 AM

It’s well accepted that the window for acute atrial fibrillation cardioversion of atrial fibrillation ends at  48 hours post onset. We did a whole episode on that very point.  The 48 hour window is now being challenged by the biggest study to date looking on  this topic.

Time to Cardioversion for Acute Atrial Fibrillation and Thromboembolic Complications was published as a letter to JAMA on August 13, 2014. Ryan Radecki sent the first FOAMed shot across the bow with this review.  You can stop now and check out Ryan's review; he's far more erudite than I. If you need more info, read on...

Study in a nugget: This was a retrospective study from Finland that looked at around 2500 patients with a primary diagnosis of atrial fibrillation (AF), aged 18 years or older, with successful cardioversion in the emergency department within the first 48 hours of AF onset.  The primary outcome, a thromboembolic event, was defined as a clinical stroke or systemic embolism confirmed by computerized tomography or magnetic resonance imaging, surgery, or autopsy. Time to cardioversion was determined as the difference between the beginning of arrhythmic symptoms to the exact time of cardioversion. There were 3 groups: less than 12 hours, 12 hours to less than 24 hours, and 24 hours to less than 48 hours.

Thromboembolism Rates

Overall:0.7%.

Under 12 hours: 0.3%

24 to 48 hours: 1.1%.

It seems like 12 hours is the inflection point when risk went up and a CHADS VASC score of greater than 1 increased risk.

I’m not sure where this leaves us, maybe risk stratification in ED cardioversion? This was observational, retrospective, and did not include post cardioversion anticoagulation as an intervention. There is no definitive answer or management change from this letter. It does raise the question of whether we should anticoagulate cardioverted AF patients with over 12 hours of symptoms, or those with a CHADS VASC over 1. However, there is no evidence that a post cardioversion anticoagulation strategy would decrease thromboembolic event rate. Also, the incidence of post cardioversion thromboembolic events in this letter is far higher than reported in other literature.

Rob's practice changers

Cunningham Technique

Loop Abscess Drain Technique

Delayed Sequence Oxygenation

Swami's  practice changers

Nasal Cannula Apneic Oxygenation

Tranexamic Acid for Mucosal Bleeds

 

Nuotio, Ilpo, et al. "Time to cardioversion for acute atrial fibrillation and thromboembolic complications." JAMA 312.6 (2014): 647-649.

CABO CME Retreat December 5-9, 2014

Primary Care RAP

Direct download: A_fib_cardioversion_.output.mp3
Category:podcasts -- posted at: 3:51 AM

How often do you see patients who tell you they are having a sinus headache need antibiotics. There are so many things wrong with that, not the least of which is the antibiotics part, but ….what about the cause of the headache in the first place?

 Is this headache a migraine?

2006 JAMA Rational Clinical Exam Series: Does This Patient With Headache Have a Migraine or Need Neuroimaging?

If you have a patient who has some scomoata, maybe shimmering lights that start small, get bigger, a little nausea followed by headache-  what is that? it’s a migraine. Done. But it’s not always so clear cut.

The POUNDing mnemonic can help sort this out.

  1. Is it a Pulsating head- ache?
  2. Does it last between 4 and 72 hOurs without medication?
  3. Is it Unilateral?
  4. Is there Nausea?
  5. Is the headache Disabling? Disabling headaches are those that disrupt a patient’s daily activities.

If the patient answers “yes” to 4 or more of the 5 ques- tions, the LR is 24. We like to see a positive likelihood ration of at least 10 to indicate something is useful. Twenty four: is very useful.  For 3 criteria, the LR is 3.5, not too impressive. For 1 or 2 criteria, the LR is 0.41, weak.

What about photophobia, the absence of photophobia makes migraine less likely, we know that migraines can cause debilitating photosensitiy, but interestinly, the presence f photophobia doesn’t make migraines MORE likely because in the great headache ven diagram, there is tremendous overlap in symtoms, and photophobia is one of those symptoms that many headaches share.

Sinus headaches. What's in a name?

Sinus headache, so easy to say, it just rolls off the tongue. We say it, patients say it, but is it really a sinus headache?

Arch Intern Med. 2004 Prevalence of Migraine in Patients With a History of Self-reported or Physician-Diagnosed "Sinus" Headache.

Study Bottom Line: About 3000 patients, most carrying a diagnosis of sinus headaches. The overwhelming majority of patients met International Headache Society migraine headache criteria.

We’re not talking about patients with fever and purulent discharge. This is the patient with sinus pressure, sinus pain, even nasal congestion. So that sinus headache may not be a sinus headache after all, but a migraine with pain localized to a sinus area. But, you say, there’s overlap between sinus and migraine headaches,. That is true, but a 2008 study from Laryngoscpoe of patients seen at an ENT clinic with a previous diagnosis of sinus headache (either from a physician or themselves)  suggests that many sinus headaches do not have objective evidence of sinusitis AND get better with migraine treatment. Patients with a negative workup by exam, nasal endoscopy and CT scan were treated with triptans and the majority, over 80%,  got better. Migraine treatment made what was previously diagnosed as sinus headache better.

Maybe triptans help with sinus headaches, but maybe, and the evidence suggests this, many of what we and our patients call  sinus headaches are actually migraines.

 

Check out Primary Care RAP

Check out the CABO CME Retreat

 

Direct download: Ercast_headaches.output_1.mp3
Category:podcasts -- posted at: 2:38 PM

An unruly, intoxicated and violent patient rolls into the ED. The situation and the patient are both in need of control. How do you go about it? Redirection? Calming words? Sometimes those things aren't quite enough and chemical sedation is in order. When it comes to choice of sedating agent, everyone seems to have their secret formula. We canvassed the planet to see how chemical takedowns are done across the globe.

Our Panel

ZdoggMD Art of the chemical takedown FOAMed World Premier

Scott Weingart  5mg of droperidol and 2mg of midazolam mixed together in a syringe with 11⁄2 inch needle and jabbed into whatever large muscle is available. Wait a few minutes. If necessary, will repeat once. Then establish IV

Minh Le Cong Ketamine  IV, IM, or IO.

Cliff Reid Ketamine

Chris Nickson Benzo, olanzipine or droperidol

Sean Nordt The B-52.  5mg Haldol, 2mg Ativan and 50mg of benadryl mixed together in a single syringe and given IM

Katrin Hruska abusive patients are asked to leave the emergency department

Amit Maini 5mg of IM droperidol. Repeat in 5-10 minutes if needed

Sa'ad Lahri: lorazepam (4 to 8 mg IV) and haloperidol (5mg IV)

Yosef Leibman midazolam, droperidol. Starting to use clotiapine -  a dibenzothiazepine anti-psychotic and a phenothiazine with anti-anxiety properties.

Gerry O'Malley Burly security guards and a show of force. If that doesn't work- benzodiazepine

Ray Moreno:  Toxin related or sympathomimetic: midazolam 5 - 10mg IM. Psychiatric related- olanzipine. No idea what's causing the agitation- midazolam

Chris Richards- The B-52.  5mg Haldol, 2mg Ativan and 50mg of benadryl mixed together in a single syringe and given IM

Bonus section:

Droperidol,  QTc prolongation, and the Black Box with toxicologist Sean Nordt....

When droperidol was 'black boxed' in the US, it sent shockwaves across the emergency medicine community because this drug was, for many of us, the go to agent for sedation of combative and agitated patients. Over the past several years, the pendulum has swung away from the black box and toward increasing use of droperidol. Why is that? Have we all gone mad? Are we putting patients in danger?

The history (or the conspiracy, depending on how you look at it) is expertly explained in the below article. It involves big pharma, outlier case reports of patients given much higher doses than are used in the ED for either nausea or sedation, and suspicious timing. There is no doubt that butyrophenones can influence the QTc, but so can a lot of other meds we use (that are not black boxed).

Sean Nordt's approach to giving droperidol in the agitated patient

  1. Give the med
  2. When the patient has calmed, get an EKG.
  3. If the QTc is prolonged, put the patient on a cardiac monitor

Horowitz, B. Zane, Kenneth Bizovi, and Raymond Moreno. "Droperidol—behind the black box warning." Academic Emergency Medicine 9.6 (2002): 615-618.

 

Interested in checking out the best emergency medicine CME and CNE on the planet?

EM:RAP

EM:RAP RN Edition

Direct download: Art_of_the_chemical_takedown_podcast.output.mp3
Category:podcasts -- posted at: 5:05 PM

Rich Levitan, pioneer in airway management, talks about operator stress response in the difficult airway. Referenced in this discussion: The laryngeal handshake,  books On Combat and Warrior Mindset. Rich offers several courses including the one of a kind Practical Emergency Airway Management Course and the Advanced Airway Endoscopy Course in Yellowstone.

 

Interested in a truly unique CME experience? Join Rich Levitan, Scott Weingart, Matt Dawson, Mike Mallin, Andy Sloas and me December 6-8, 2014 for a 5 star, all inclusive vacation in Cabo San Lucas and earn your CME credits in style. The 2014 Cabo CME Retreat will focus on the newest emergency medical practices and technologies in the areas of ultrasound and airway medicine. Our lineup of leading emergency doctors and medical speakers will present at Secret’s Resort, the newest all inclusive luxury resort in San Jose del Cabo. Secrets Puerto Los Cabos Golf & Spa Resort boasts five gourmet restaurants, incredible views, infinity pools, and world renowned golf courses designed by Greg Norman and Jack Nicklaus. At this limited-access retreat, you will experience a CME conference unlike any other.

httpvh://vimeo.com/88372941

To register and/or find out more, go to the Cabo CME homepage

Direct download: Psychology_of_the_difficult_airway.output.mp3
Category:podcasts -- posted at: 6:22 PM

Cardiac arrest. It seems so easy. Just follow the algorithm on the reference card, and all cardiac arrest issues will be solved. The truth is that codes can be messy, chaotic and scattered. On this episode of ERcast, we hear from the RAGE podcast  experts on how to take control of the room and run an effective resuscitation.

The medicine isn't always the hard part. Being an effective leader,  communicating well,  and making things happen are often the bigger challenges. And speaking of Making things happen. Click that link for one of the greatest medical lectures. Ever.

 

Adenosine vs Verapamil Articles

Adenosine versus Verapamil for termination of SVT (AVNRT)

Comparison of adenosine and verapamil for termination of paroxysmal junctional tachycardia

Adenosine versus verapamil in the treatment of supraventricular tachycardia: A randomized double-crossover trial

Comparative clinical and electrophysiologic effects of adenosine and verapamil on termination of paroxysmal supraventricular tachycardia.

Contemporary management of paroxysmal supraventricular tachycardia.

 

 

 

Direct download: How_to_run_a_code.output.mp3
Category:general -- posted at: 4:42 PM

Which is more effective for pain and fever control: Acetaminophen or Ibuprofen? Should a patient in the emergency department with upper GI pain be started on an H2 blocker or a proton pump inhibitor? Special guest Anand 'The Swami' Swaminathan joins ERCast to explore these and many more medical quagmires. 

Bonus segment: How can a medical students present themselves well during critical rotations? In this case, we are talking about emergency medicine rotations.

Rob Says

  1. Work hard, always be curious, donʼt stress getting out right on time
  2. Presenting patients is one of your critical skills as a medical student
  3. Get the Emergency Medicine Secrets book so you know a rational approach to common medical emergencies, and keep the EMRA ddx card/ book in your pocket
  4. Present to the attendings but don't be a kiss ass
  5. Present patients the same way each time. Be concise with pertinent positives and negatives. When you give your differential diagnosis,, ALWAYS starting with the life threats based on the chief complaint. Even itʼs a typical migraine, emergency medicine is in the business of ruling out the life threats. As one of my internal medicine colleagues says, EM is in the business  of 'not to lose'
  6. As attendings, we want to know that the student ʻgetsʼ emergency medicine

Swami Says

  1. Show up to work on time. By on time, I mean the Joe Lex on time – 15 minutes early
  2. Recognize when it’s too busy and go into helper mode. This means not taking patients primarily (which is more work for us). Starting IVs, do EKGs, draw blood, sew lacerations, etc.
  3. Work hard. It’s as simple as that. When I work, I rarely sit, I keep moving all time. I should see the same from the students.
  4. There are three unforgivable sins in emergency medicine – laziness, stupidity and arrogance. It's preferable to have none of these. If you have one, you may be able to squeak by. If you have two, you are a waste of space. 

Acetaminophen versus Ibuprofen

Perrott DA et al. Efficacy and safety of acetaminophen vs ibuprofen for treating children’s pain and fever: a meta-analysis. Arch Pediatr Adolesc Med 2004; 158(6): 521-6.

2004 meta-analysis - summarized the findings from 17 randomized, controlled trials comparing the two drugs in children <18 years of age. Three studies involved pain, 10 involved fever, and all 17 involved safety. 

Findings

1. Pain – no difference between ibuprofen 4-10 mg/kg vs. APAP 7-15 mg/kg

2. Fever – ibuprofen 5-10 mg/kg superior to APAP 10-15 mg/kg (at 2 hours and more pronounced at 4-6 hours)

15% more children were likely to have reduced fever with ibuprofen compared to acetaminophen. 

When selecting for studies using only the 10mg/kg dose of ibuprofen, there was a doubling of the effect in support of ibuprofen. 

Safety: there was no evidence that one drug was less safe than the other (or placebo). The authors determined that this data was inconclusive and that more large studies would be needed to identify small differences in safety 

Pierce CA et al. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother 2010; 44(3): 489-506.

First meta-analysis looking at the question in adults.

Qualitative review revealed that ibuprofen was more effective than acetaminophen for pain and fever reduction, and that the two were equally safe. 

From the quantitative data, the authors found that for pain, ibuprofen was superior in children and adults. For fever, ibuprofen was superior in children, but conclusions could not be made for adults due to insufficient data.

What about alternating acetaminophen and ibuprofen?

Malya RR. Does combination treatment with ibuprofen and acetaminophen improve fever control? Ann Emerg Med 2013; 61(5): 569-70.

1. Identified 4 studies that the author deemed high-quality and relevant to emergency practitioners.  

2. Three of the four studies found that the combination was more effective at reducing fever than either alone.

One study that looked at alternating regimens over 24 hours found that 6-13% of parents exceeded the maximum number of recommended doses (Hay, 2008). 

There is suggestion that the two drugs could act synergistically to cause renal tubular injury; however, acetaminophen and ibuprofen have different pathways of metabolism, and adverse effects in patients taking both have only been described in rare case reports.

EM Lyceum Review of APAP (acetaminophen) vs NSAIDS (ibuprofen). This review also includes a breakdown of PPIs vs H2 blockers, medical treatment for vertigo, and calcium channel blockers versus beta blockers for atrial fibrillation with rapid ventricular response (RVR)

Check out the RAGE podcast. In this episode of ercast, we discuss a recent round table on managing SVT (AVNRT) with verapamil versus adenosine.

Direct download: APAP_vs_NSAIDs.output.mp3
Category:general -- posted at: 6:25 PM