EM:RAP 2016 Year in Review
A bit of holiday goodness from the EM:RAP team.The highest of the high points and the pearliest pearls from each month in 2016.
Just Enough Ketorolac
How much ketorolac do you need to treat a patient’s pain? Historically, it’s been 60mg IM and 30 mg IV. We’ve heard over the years that the therapeutic ceiling is probably quite a bit lower and now a study has said just that.
Pneumonia in the Hotseat
For the final episode of 2016, Cam Berg returns with a new ADP. This time pneumonia gets put under the microscope and you may never think about it the same. Sol and Ilene learn that not all urticaria is an allergic reaction. Weingart walks us through his approach to post intubation care in head injury. Is your CPR high performance? It’s probably pretty good, but Josh Bucher is going to make it even better. Chris Doty gives a powerful and painful lesson on managing the stresses of EM. Foot fractures become demystified by Dr. Ramadorai and a new approach to febrile infants is revealed.
C3 - Back Pain
Most patients with back pain do not require extensive diagnostic evaluation in the ED. The role of the emergency provider is twofold – to help alleviate pain and to consider the life-threatening diagnoses that may present with back pain.
In this month's Hotsheet Rob and Mel go over the EM:RAP CME survey, ondansetron in pregnant patients, IV nitro in CHF, and tamsulosin in renal colic
Ultrasound of Abdominal Aortic Aneurysm (AAA)
How to do a Point of Care Ultrasound (POCUS) to assess for AAA. Presented by Dr. Jacob Avila of 5minsono.com and The Ultrasound Podcast.
C3 - Syncope
The majority of patients who present after a syncopal episode are safe for discharge from the ED after a focused history, physical examination and ECG. In some cases, a life-threatening cause will be found in the ED. In others, such as those with other cardiac symptoms and implantable cardiac devices, the risk for adverse events is too high and patients are admitted to a monitored setting for further evaluation. The C3 team discuss a practical step-by-step approach to the patient with syncope.
An overview of how to do a "Rapid IJ" aka "Easy IJ" as described on EMRAP November 2016, based on the article below. It's a quick and effective peripheral line, but in the internal jugular vein. Presented by Jess Mason, MD and thanks to UCSF Fresno Clinical Skills Lab.
Trigger Point Injections
A quick overview of how to do a trigger point injection for musculoskeletal back or neck pain, as described by Reuben Strayer and Rob Orman in EMRAP November 2016. Presented by Jess Mason, MD and Kathleen Cagle, NP. Thanks to UCSF Fresno emergency department.
Penetrating the Neck
Do you ever find yourself vacillating on whether or not to cric a critical patient? Weingart reveals his Cricon 2 system that simplifies the decision making. Greg Moran is back for a deeper dive into TB. That sounds unseemly. Hot prostates get an ice bath and Strayer injects some trigger points. Is that stab wound to the neck worth exploring? Miz and Kenji commune with the platysma. And are you a fan of succinylcholine, feeling like it’s gotten a bad rap? Sux Strikes Back!
Syncope and PE
In this short, we explore the unbelievable results of the PESIT study.
In this month’s Hotsheet, we dive deep into the naloxone autoinjector with emergency physicians Aaron Orkin and Michelle Klaiman.
A quick review of how to do a wrist arthrocentesis. Presented by Dr. Jess Mason and Dr. Dimitri Steblovsky at UCSF Fresno.
C3 October 2016 Letters Comments and Rants
Mel discusses some important questions from the C3 audience on vag bleeding in the pregnant and non-pregnant patient and the use of TXA, bed and pelvic rest. He also discusses reversing beta-blockers in the asthma patient and goes deep philosophical about C3 vs EMRAP main show. Enjoy.
How To Set Up A Chest Drain
This is an example how a single collection chest drain is setup. Each model will be a little different. This example does not have an autotransfusion option. Presented by Jess Mason, MD.
Ultrasound of Pulmonary Edema
How to do a Point of Care Ultrasound (POCUS) to assess for pulmonary edema. Presented by Dr. Jacob Avila of 5minsono.com and The Ultrasound Podcast.
Tips for Chest Tubes in Obese Patients
Here are six tips for placing chest tubes in obese patients, from EMRAP September 2016 with Drs. Kenji Inaba and Mizuho Spangler. Presented by Dr. Jess Mason.
C3 - Non Pregnant Vaginal Bleeding
After pregnancy has been ruled out, the differential diagnosis of patients with abnormal vaginal bleeding can be divided into structural and non-structural causes. Most are stable and can be managed safely as outpatients. The C3 team discuss a practical step-by-step approach to the non-pregnant patient with vaginal bleeding.
Say Hello to BRUE
ALTE gets a much deserved retirement as BRUE takes the stage. Are your discharge instructions all that they should be? Matt Delaney keeps it simple. Think you know pulmonary edema? Strayerisms takes it up a notch. Keeping it in the lungs, we’ve got a double header with Jeff Kline on PE EKGs and John Greenwood explaining the seemingly unexplainable-pulmonary hypertension. And everyone’s favorite bounceback, Mike Weinstock, is back with tips on communicating with midlevel providers.
15 years ago, EM:RAP got it’s bottom spanked and the world has never been the same.
September Hotsheet - EpiPen, PATCH, and PEAPETT
In this edition… 10 years ago, an EpiPen 2 pack cost around $100 US. Now, it’s $600. What’s going on? Rob and Mel discuss. The PATCH study found that in patients who were on antiplatelet agents and had a spontaneous cerebral haemorrhage, giving platelets increased the risk of both death and poor neurologic outcomes. Should you give lytics in the PEA patient in whom you suspect pulmonary embolism? A recent series of 23 patients with PE and PEA demonstrated survival after getting a dose of TPA.
C3 - First Trimester Vaginal Bleeding
The C3 gang discusses management of both the stable and unstable patient who presents with vaginal bleeding in the first trimester.
Ultrasound of Retinal vs Vitreous Detachment
How to differentiate a retinal detachment from a vitreous detachment using bedside point of care ultrasound. Presented by Dr. Jacob Avila, MD
The key steps to performing a successful lumbar puncture and a demonstration in a real patient. Presented by Jess Mason, MD.
This month we line up a series of mind blowing talks. From thinking about thinking to giving hypertonic saline to runners, from tricks about how to put chest tubes in obese patients to reducing the human right violation that is an NG tube. Mel Herbert makes a return to the main show with Miz Spangler while Rob and Anand get a much deserved rest. It is going to be big, large and huge and oh yes, bundt cake in nature!
August Hotsheet - Calf DVT
In this month’s hotsheet…A new emrap feature: The Mid Month Memory Massage. New data on what happens with calf clots that do and don’t get anticoagulation. Challenge coin winners
A method for a field block to anesthetize the ear. Presented by Jess Mason, MD.
Ultrasound of Testicular Torsion
An overview of the ultrasound findings in testicular torsion, grayscale and spectral analysis, and ultrasound guided manual detorsion. Corresponds to EMRAP September 2016. Presented by Dr. Robert Jones, Ultrasound Director at MetroHealth Medical Center.
Can You Pick Your Friend's Nose?
Reuben Strayerisms has fighting words for succinylcholine. Brace for impact! Confused in TIA management and dispo? Cam Berg clears the obfuscation. Patrick Bafuma tells us why we shouldn’t pick your friend’s nose, unless we use midazolam. Intussusception can masquerade as a seemingly benign presentation, but a few pearls may help make the diagnosis. Should we use phenylephrine in sepsis? Weingart weighs in. Frequent flyers, plastic surgeons, and a bunch of ganja problems all in this month’s star studded episode.
C3 - Asthma
This month Mel & Stuart discuss the "Crashing" & "Stable" asthmatic.
Procainamide vs Amiodarone
Published in the European Heart Journal on June 28, 2016: Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study.
Jessica Mason gives the basics and advanced course on the hows, whats, and whys of vagal maneuvers. Plus, Rob and Mel talk challenge coins and app updates.
Break Through The Plateau
It’s a case of classic trauma dogma: never ever splint a rib fracture. Rob and Swami explore the (limited) evidence supporting and refuting this idea. Sacchetti rediscovers empathy in an unlikely place. Kenji gives his thoughts on managing non-lethal stab wounds to the chest and abdomen. Billy and Stu troll for pyelo. Tibial plateaus get broken, fixed, and put under the microscope. First there was RSI, then DSI, now rapid sequence awake intubation. Whaaaat?? All that and much more on this month’s EM:RAP spectacular.
C3 - Dyspnea Part II
Most patients with dyspnea will have a common cardiopulmonary cause (i.e.: pneumonia, CHF, pulmonary embolism, MI, asthma, COPD etc.). The C3 team discusses a practical step-by-step approach to your patient with dyspnea, to help you determine what is their underlying cause of shortness of breath and what to do about it.
Fentanyl is Some Bad %&#*
Fentanyl is a potent opioid that we love for its fast on and fast off effects. However, it is widely abused as an illicit street drug, known as 50 times more potent than heroin.
Mel and Rob review the ATACH-2 study for BP management in intracranial bleeding. I got good news and bad news...the good news...we already know the bad news...
Dual Sequential Defibrillation
For patients in refractory V-fib you can try double sequential defibrillation. Here we show where to place the pads and how to do the procedure. Presented by Jess Mason, MD.
Shock, Asthma, and Fingertips
What do crushed fingertips and CHF have in common? Not much, except they’re both in this month’s episode. Kenji and Miz take on neurogenic shock and the nebulous ‘permissive hypotension’. Are some antibiotics worse when it comes to risk for C diff? You betcha. Jess tells the take of some weird neuro symptoms that ended up being a big deal. When it comes to managing critical kids, Simon Carley says our resuscitationist mindset will serve us well. Scotty W sets the vent for the intubated asthmatic. Our chest pain med mal case concludes. And should you medically treat your friends and family? Find out in this June 2016 EM:RAP.
C3 - Dyspnea - Part1
Most patients with dyspnea will have a common cardiopulmonary cause (i.e.: pneumonia, CHF, pulmonary embolism, MI, asthma, COPD etc.). For the sake of our learning, in Part 1 we are going to deal with all of the other major causes of dyspnea that are often missed when we assume a cause in the heart and lungs.
Active Shooter: Update 2016
We think this is an important topic, so we reached out to Dr. Mike Clumpner Ph.D. to give us an update.
Paper Chase Special
There’s no paperchase in this month’s EM:RAP episode, but fear not, we’ve got one for you right here!
How to perform a lateral canthotomy. With illustrations and real patient video of the procedure. Presented by Jess Mason, MD. Procedure performed by Dr. Bryan Kaye.
C3 - Minor/Stable GI Bleeding
In last month’s episode, we dealt with patients who were obviously bleeding to death. Most patients with GI bleeding present with far less drama. The stakes here are high because the mortality of patients with GI bleeding are substantial.
Snake Bites and The Missed MI
We send a lot of patients to the ICU, but what are the intensivists not telling us? Peter W gives the inside scoop. Ever delivered a baby in the ED? How about a breach? Chris Doty walks through managing perinatal disasters. Part one of a med mal case with recorded deposition testimony. Do you focus on wellness in your practice. Dike Drummond says you should. It’s OK to use peripheral vasopressors, as long as you're vigilant. Breast abscess doesn’t always need an I and D, so says Sacchetti. Ovarian torsion is often more myth than fact, Matt Delaney gives some clarity. And what’s the deal with seat belt signs? Kenji lifts the mist of confusion. All that and much more in the May 2016 EM:RAP.
Intraosseous Access with EZ-IO
How and where to place an EZ IO (intraosseous line) for vascular access. Presented by Jess Mason, MD.
Placement of a Linton Tube for Bleeding Varices
How to place a Linton tube for upper GI hemorrhage, by Jess Mason, MD.
Overview of GI Tamponade Balloons
Side-by-side comparisons of the Linton, Sengstaken-Blakemore, and Minnesota tube. Presented by Jess Mason, MD.
Chest Tube Placement
A quick step by step guide for tube thoracostomy. There are many methods for chest tube placement, suturing, and applying a dressing. Here's one method presented by Jess Mason, MD.
LMA Supraglottic Airway
How to place an LMA supraglottic airway, by Jess Mason, MD.
King LT Supraglottic Airway
How to place a King LT supraglottic airway, by Jess Mason, MD.
Abscess + Antibiotics = Better Outcome?
Current thinking is that incision and drainage of a simple cutaneous abscess is enough. Meaning no antibiotics needed. But can we do better?
Amiodarone, Lidocaine or Placebo for Cardiac Arrest?
Mel and Rob discuss a brand new randomized trial of active drugs vs. nothing for cardiac arrest that found that they still don’t work, but the door is not totally closed!
Placement of a Blakemore Tube for Bleeding Varices
How to place a Sengstaken-Blakemore tube for massive upper GI bleeding from esophageal or gastric varices. Presented by Jess Mason, MD.
AirQ Supraglottic Airway
How to place an Air-Q supraglottic airway, by Jess Mason, MD.
Real Footage of a Minnesota Tube Placement
This clip shows the difficulty of inserting a Minnesota tube on a real patient. Footage courtesy of UCSF Fresno emergency medicine program. Presented by Jess Mason, MD
ETAD Device to Secure Tubing
Here is a demonstration of the Scott Weingart, MD method, where the use of a second ETAD is applied for maintaining traction during a variceal tamponade. Presented by Jess Mason, MD.
C3 - Massive GI Bleed
The unstable patient with massive gastrointestinal (GI) bleeding is one of the most dramatic things we will encounter in the ED.
Stabbed With A Needlestick
Strap in for some splendidness, as trauma team leader Chris Hicks deconstructs the initial steps in managing a patient with penetrating chest trauma. Do you ever feel frustrated when managing patients with body fluid exposure? Greg Moran gives a primer on management and who you should consider for post exposure prophylaxis. Last month it was outpatient burns, now it’s time for the major players- third degree, Parkland formula, who needs intubation… Scotty Weingart opens the critical care mailbag on hypotensive SVT patients. Physostigmine, transvenous pacers, extraglottic airways, and Howie Mell’s top radio hits, all in this month’s EM:RAP!
Placement of a Minnesota Tube for Bleeding Varices
How to place a Minnesota tube for massive upper GI bleeding from esophageal or gastric varices. Presented by Jess Mason, MD.
New Venous Thromboembolism Guidelines
Hot off the press Antithrombotic Therapy for VTE Disease: CHEST Guideline published in February 2016 addresses the clinical quagmire debated in this month’s show: Should we anticoagulate patients with subsegmental pulmonary embolism?
Spring Forward Into PE
Spring is here and what a perfect time to talk PE. It’s a two for one special with a subsegmental PE battle for the ages between Tom Deloughery and Jeff Kline. Jeff returns later in the show for some PE in pregnancy mythbusting. Jess Mason and burn surgeon Chuck Yowler give us the skinny on second degree burns. Remember Icatibant, the miracle drug for ACE-I angioedema? There is some new data on it that may shock you. It seems like we talk low risk chest pain every month, but what does it really mean? Mike “Bouncebacks” Weinstock clears the air. That and so much more in this month's action packed medical exultation extravaganza.
C3 - Altered Mental Status - Part 2
Stuart and Mizuho continue their discussion about AMS, and discuss less common but interesting causes of AMS, including clinical findings, workup and management of these various diagnoses.
EM:RAP Special Report: Concussion
On this episode we discuss concussions, the sequelae that happen as a result of concussions, and the long term effects of repeated head trauma. We seek answers from “Captain Cortex”, Prof. Stuart Swadron. Medical team physician for the Cleveland Indians, Dr Tom Waters, explains the process of assessing when an injured player in the NFL can go back in the game. Dave’s personal trainer, Steven Yates, talks about his experience with concussions, as a former college football player, and Jess speaks to a young patient and his mother, who recently came into the ER after a head injury, about their story.
C3 - Altered Mental Status - Part 1
The differential diagnosis for altered mental status is extremely broad. Stuart Swadron MD and Mizuho Spangler DO discuss the most common causes of AMS and review a practical approach to initially assessing a patient with undifferentiated AMS.
A Fib Gets The Royal Treatment
It’s deep winter in the northern hemisphere which can only mean one thing… Cam Berg is back with a new treatment pathway. This time, it’s all about atrial fibrillation. Out of hospital cardiac arrest, using two defibrillators? It’s a real thing. Bryan Hayes puts NSAIDS, tramadol, and antidepressants under his jaundiced eye and the results may surprise you. We’ve got a trauma double feature - a new decision instrument for chest CT and thinking about retirement for the C-Collar. Reuben Strayer is back with a plea for more bougies, and more cowbell!
Just How Good is CT in Diagnosing Subarachnoid Hemorrhage?
Hot off the press, Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis
Ilene Claudius and Mizuho Spangler gives and short overview of the Zika virus
Vascular Injury in Extremity Trauma
A trauma patient rolls in the door following a gunshot wound to the leg. Do they need to go straight to the OR? Can they wait for a CT angiography? Are they just fine and not in need of any surgical management? Jess Mason reviews the hard and soft signs of extremity vascular injury.
Cracking The Chest
Happy New Year and welcome to the thoracotomy extravaganza! Kenji Inaba breaks down not only the indicators for, but a how to guide on, emergency department thoracotomy. When is a UTI not a UTI? When there are no symptoms (at least in adults). Amiodarone is becoming as ubiquitous as Mel saying “buttocks”, but patients on this drug are at risk for some serious complications. Should all agitated mental health patients get immediate high dose sedation? Dan Mccollum says we can be more thoughtful to each patient’s needs. And we can’t forget about THAM, you know, THAM, tris-hydroxymethyl aminomethane, yeah that stuff. The ‘better bicarb’. Don’t worry, we’d never heard of it either. January EMRAP, here we go!...
C3 - Headache
A unique approach to the patient with headache with an emphasis on “Red Flag” symptoms and signs