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!
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.
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.
C3 - Headache
A unique approach to the patient with headache with an emphasis on “Red Flag” symptoms and signs
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!...
Holiday Sepsis Special
What says ‘happy holidays” more than sepsis? Probably a lot of things, but just in time for the new year, Cam Berg is back to answer your sepsis questions.
Top 5 ACLS Updates
At the 2015 AHA meeting, ACLS got a few updates and some may surprise you!
The Psychiatry of Peds C-Spine
2015 is about to come to a close but not before an EM:RAP Master Class. You know the long angiocath in a central line kit? Ever wonder what it’s for? Reuben Strayer shows us how to use it to make central line placement easier and safer. Clearing the peds c-spine can cause stress, debate, and consternation. Probably because there are no validated decision instruments. Mizuho and Kenji clear the air and break down the evidence. Is the emergency department your tribe? Sometimes that’s a good thing, but it can also be bad. Victoria Brazil explains. Billy Mallon makes a guest appearance to espouse his favorite ED lab test. It’s not the sed rate. And are we underutilizing epinephrine in patients with anaphylaxis? Howie Mell and Bryan Hayes say… probably so. That and so much more on this month’s EM:RAP…
Sexual intercourse for the treatment of ureteral colic
New Xa Inhibitor Reversal Agent
Dabigatran now has a reversal agent, so it was only a matter of (short) time that one would come along for the oral Xa inhibitors.
How To Use An MDI
Rarely a shift goes by that we don’t see someone with an asthma exacerbation. Most of these patients will have the discharge instruction to use a metered dose inhaler at home. But are they using it correctly? Probably not. Jess Mason breaks down the steps of proper MDI use (and how to teach it to patients).
CPR- To Pause Or Not To Pause
A GIANT study in NEJM asks the question should you cause to give a few breaths during CPR or do continuous CR with breaths during compression. We take a first pass at this big study.
Codes and Cath Labs
It’s time for November EM:RAP. Rob and Swami cut through the complexity and give their basic approach to vasopressors. Andy Sloas is back and he is mad about something. This time it’s NPO sedation rules in kids. Should all post arrest patients with ROSC go to the cath lab? Amal Mattu gives some guidance on making the decision. Intrathecal pumps can seem like alien implants that are impossible to understand. The LIN sessions cut through the mystery. Traumatic cervical artery dissection in kids- it’s rare but it happens. Bell’s palsy, have we learned anything new in the last deceased. All that and more on this month’s EM:RAP…
Can you feel the HEAT?
Should we treat febrile patients in whom we suspect infection? The HEAT trial, just published in NEJM, studied 700 ICU patients with fever (and either infection or suspected infection). Half got acetaminophen and half placebo. Primary outcome was ICU free days and there was no significant difference in this outcome between the two groups. So should we treat fever, should we not? Swami sums it up like this: Fever need not always be treated in patients with suspected infectious causes. It appears reasonable to give acetaminophen to patients in whom the fever is causing distress but it is similarly reasonable to withhold it in patients who are not distressed.
New CMS Sepsis Core Measures
While sepsis continues its role as a scourge of humanity, the Centers for Medicare and Medicaid Services have changed the definition. What does this mean for you? Dr. Cam Berg breaks it down.
Vents, Scabies, and IV Fluid Cage Match
Do you feel comfortable with vent settings? Most of us don’t, and Haney Mallemat is here to fix that. Sam Ashoo begins a three part series on improving ED throughput. Should we get head CTs on patients with syncope? Probably not. Weingart referees a saline versus Ringer’s’ battle in care of the acidotic patient. Scabies, scabies, everywhere. And to cap it off, we have the Case of the Purple Pee. Let’s get to it!
Linezolid, MAOI, and The Boards
Over the next few days, several thousand EM:RAP listeners will be taking their board re-certification exams. Here is one final pearl, not just for the boards, but also for clinical practice. Also, we introduce the EM:RAP challenge coin. What’s that? All is explained in this shorty short.
STD Guideline Updates
The 2015 CDC sexually transmitted disease updates have arrived and our in-house toxico-pharmacologist Bryan Hayes is here to break down what’s new…
A Better Valsalva for SVT
How often does Valsalva stop SVT? Not as often as we’d like! The REVERT trial, just published in Lancet, may have discovered the Valsalva maneuver we’ve been looking for to treat patients with supraventricular tachycardia. After usual straining (the classic Valsava), patients were laid flat and had their legs raised for 15 seconds. The results? Forty three percent converted to sinus rhythm compared to 17% with standard Valsava.
Empathy, Lytics, and Butt Pus
It’s September and that can only mean one thing… Jeff Kline is back to talk PE! This time, should we thrombolyse patients with submassive PE? Casey Parker teaches us how to show empathy (even when it’s in short supply). Is a Salter-Harris I really a feature? David Newman sets the record straight. Quinolones are great for infections but bad for tendons. Do critically ill obese patients need special treatment? Haney Mallemat gives a string of pearls to keep the resuscitation running smoothly. And that’s just a hint of the chocolatey good, bundt cake infused goodness on this month’s show!
Thrombolysis for MI: A Board Review Short
Mel reviews the indications and contraindications to thrombolytic therapy in acute MI.
Can Ultrasound Predict Who Will Survive After Thoracotomy?
What does ultrasound have to do with resuscitative thoracotomy? Isn’t one done with a knife and scissors while the other uses a sound wand? It turns out that ultrasound may be able to predict who will and will not survive after having their chest cracked. A study coming out in the September 2015 Annals of Surgery found that patients in traumatic cardiac arrest who had no cardiac motion and no pericardial fluid on point of care ultrasound had a zero survival rate following thoracotomy.
Nothing is perfect, not even contraception. And sometimes, there’s no contraception to speak of. Preventing pregnancy, however, doesn’t need to be complicated. Copper IUDs and oral agents like ulipristal are effective and relatively easy methods of preventing unintended pregnancy. To help make sense of it all, Jan Schoenberger and Stuart Swadron review the 2015 NEJM article Emergency Contraception
Toxic Alcohols: A Board Review Short
A review of the toxic alcohols for your board review prep.
Hypertonic Saline for HypoNatremia and Sounding: A Board Review Short
This is a board review short - when to use hypertonic saline in hyponatremia. Also a case of sounding, not for the kids but fascinating if not disturbing!
Quality Review Gets Septic
August brings part four of our conversation with Dr. Cam Berg on how his hospital standardizes, optimizes, and improves care of common conditions. This time, it’s the leviathan: SEPSIS. Reuben Strayer gives lessons hard learned from QA, while our in-house pharmacologist Bryan Hayes gives the final word on which agent is better for A. Fib rate control. Amal Mattu is back with a cardiology corner on the scoundrel of cardiothoracic life threats: aortic dissection. Weingart dissects a complex case of post ROSC airway management and paper chase digs deep into blunt trauma thoracotomy. Annals of EM, LIN sessions, clinical sobriety and so much more!
Animal Bites: A Board Review Short
A brief review of animal bites, human, dog and cat...
The new ACC algorithm for cardiac arrest
A quick look at the brand new ACC algorithm for the treatment of cardiac arrest without return of consciousness.
A Totally Rad Month Worth it's Weight in CT Scans
Sean and Stuart are back for an action packed July. How should we manage acute pericarditis? Amal Mattu has you covered. Who needs a tetanus shot and what does the booster actually do? The evidence may surprise you. What are the priorities in resuscitating a post drowning patient? We break down the steps to take and erase the background noise. David Newman deconstructs and analyzes new literature on endovascular treatment for stroke. Is there finally a therapy we can all agree on? Human trafficking victims pass through our EDs every day, but can we recognize them? More importantly, can we help them? And the paper chasers explore an abscess technique that’s been catching on across the globe.
Burning with Knowledge So Sick it Will Give You a Subdural
This June it’s all about the sun (at least in the northern hemisphere). Sunblock, kids in hot cars, and that trip to a sunny beach that ends up with you stooling your guts out from travelers diarrhea. Pediatric resuscitationist Andy Sloas gives high yield pearls on critically ill asthmatics and croupers. Is there still a role for oral contrast? An ED doc and radiologist square off in a cage match that will leave one in tears. Cam Berg acts as cat herder in chief with another accelerated diagnostic pathway: CHF. Our year long review of a chest pain medicolegal case comes to a surprise conclusion, and the paper chasers ask, “Which subdural hematoma need surgery?” It’s all here, and then some!
MET for Renal Colic
What makes renal stones fly out of your urine stream? Neither tamsulosin nor nifedipine, it appears.
A Totally Mental Month of Education!
Did you know that sitting is considered the ‘new smoking’? Not that we sit much in our profession, but something to think about when you’re in a chair punching out a bolus of dictations or EMRs. Cam Berg (the chest pain ADP guy) is back with a rational pulmonary embolism diagnostic pathway. Are there geriatric patients in your ED? Rhetorical. The Italian stallion, Al Sacchetti, goes pearl diving into the mind of an ED geriatrician. Intubating kids, curing strokes, making patients happy with text messages, and, of course, ketamine! All that, and more, in May 2015 EM:RAP…
Hypothermia for Pediatric Cardiac Arrest?
A large study on hypothermic therapy for pediatric cardiac arrest just has been published online; we take a first pass.
The Poetry of Emergency Medicine
Spring is here! At least in the northern hemisphere. And what says spring more than a discussion of red, swollen, proptotic eyeballs? Cricoid pressure has not met its final repose. Swami and Minh Le Cong debate its merits and downsides. Olympic snowboarder Shaun White had Tetralogy of Fallot, but a few surgeries later- gold medal. Some kids are not so lucky and have recurrent TET spells. We discuss a novel treatment for these cyanotic emergencies. Scotty Weingart gives his opinion on endtidal CO2. Is it staph, is it strep? Bryan Hayes reviews current lit on managing soft tissue infections. LIN sessions, paper chasing and so much more.
Promise: The Latest sepsis megatrial
The latest sepsis mega-trial results are in, we take a quick look.
Early Release: Endovascular Therapy for Stroke
A few weeks ago we promised a deeper review of endovascular therapy for stroke, with Dave Newman. Dr. Newman has done his usual exceptional work and we are happy to release this to you now, before it comes out on EM:RAP since the topic is so timely.
Getting Psyced About Airway Management While Dying of a Peanut Allergy
Tis March ladies and gents a time to think before you relocate, this is a strong suggestion so take it or I will lacerate your kids heads, or make you think you have a heart attack, I will make you obese and dislocate your knee, I will poison you with cyanide, if you arrest I will NOT resuscitate, I will blow warm wet oxygen up your nose and bust your pelvis and make you bleed, I will punch your kid in the neck and not CT them, ODDA know what I am talking about! All this and I will then OD you on acetaminophen, come on MAC lets score on this and just run a marathon til we poop blood...yeah is March EM:RAP!
Special Edition: ADP for Chest Pain with Amal Mattu
Dr. Mattu reviews an Accelerated Diagnostic Protocol for Chest Pain based on the guidelines of the American Heart Association. This is an important topic for all Emergency Physicians and presented gratis by EM:RAP.
The FAST-MAG trial
The FAST-MAG trial has just been published in the NEJM. Great to see ED docs publishing at the highest level... pity it didn't work
PROPPR Study Published Today!
The PROPPR study was published today - we give it a first look over.
MR CLEAN Trial Just Published
Another BIG stroke study just published. We give it a first pass because lots of discussion will be going on about this puppy!
It is Hard to Breathe When Your Vocal Cords Don’t Work!
It’s February and time for some infectious disease! Swami introduces the idea of discharging patients with neutropenic fever from the ED. Is he mad?! Mizuho sits down with the CDC’s leading measles epidemiologist to get the straight facts on vaccination, outbreaks and what we should do if a measles patient strolls into our department. Need to transfer a trauma patient but overwhelmed by all the details? Not to worry, Howie Mell gives his ‘“clip ‘n save” breakdown on making the process smoother than a baby’s bottom. How many things do you need to know about the patient in respiratory distress? Two! Paper chase, vocal cord dysfunction, steroids in asthma, tissue adhesive magic and so much more.
What Could be Better than Patients with Total Body Weakness that Need ECMO
It’s the start of a new year and time to get busy! Did you drink a little too much and get a hangover? Now do you feel a little weak and dizzy, like a little sick neonate with a broken heart. You may have some migrating weakness, some confusion, you feel like you had a stroke, or maybe developed endocarditis? You certainly have some ABx associated diarrhea, and your seratonin level is way too high, you feel so bad you might need ECMO but are afraid of getting sued! Yes it’s going to be a busy month.