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As part of an annual review of medical literature, this podcast will dissect several medical journal articles, discuss some of their finer points, and how it can relate to medical practice today. In this podcast Dr. Valerie Johnson, an emergency medicine physician with EMPAC, and Dr. Abby Elliott, a family medicine physician with Lakeview Clinic, cover a variety of topic areas from five journal articles. If you like to skip to the conclusion part of the article, this podcast is for you. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Define non-consensus TIA. Identify long-term risks of non-consensus TIA. Recognize the mechanism of action of GLP-1 agonists. Summarize key principles of sepsis recognition, early screening/detection, early management, and titration of care. Name significant/relevant findings of the journal articles being reviewed and discussed. Select a credible/relevant journal article. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.  CME Evaluation (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker's outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES:  *See the attachment for article discussion summaries.  Journal Article 1: "Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined" CITATION:  Lundgren, J., Janus, C., Jensen, S., Juhl, C., Olsen, L., Christensen, R., Svane, M., Bandholm, T.,Bojsen-Møller, K., Blond, M., Jensen, J., Stallknecht, B., Holst, J., Madsbad, S. and Torekov, S.,  2021. Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined. New England Journal of Medicine, 384(18), pp.1719-1730. Available: https://www.nejm.org/doi/full/10.1056/nejmoa2028198 Journal Article 2: "Diagnosis of Non-Consensus Transient Ischaemic Attack with Focal, Negative, and Non-Progressive Symptoms: Population-Based Validation By Investigation and Prognosis" CITATION:  Tuna, M. and Rothwell, P.,  2021. Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis. The Lancet, 397(10277), pp.902-912. Available: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31961-9/fulltext Journal Article 3: "Cardiovascular Outcomes and Mortality Associated with Discontinuing Statins in Older Patients Receiving Polypharmacy" CITATION:  Rea, F., Biffi, A., Ronco, R., Franchi, M., Cammarota, S., Citarella, A., Conti, V., Filippelli, A., Sellitto, C.and Corrao, G., 2021. Cardiovascular Outcomes and Mortality Associated With Discontinuing Statins in Older Patients Receiving Polypharmacy. JAMA Network Open, 4(6), p.e2113186. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2780952 Journal Article 4: "Early Care of Adults with Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report" CITATION:  Yealy, D., Mohr, N., Shapiro, N., Venkatesh, A., Jones, A. and Self, W.,  2021.  Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Annals of Emergency Medicine, 78(1),pp.1-19. Available: https://www.annemergmed.com/article/S0196-0644(21)00117-7/fulltext Journal Article 5: "Associations of Suicidality Trends with Cannabis Use as Function of Sex/Depression Status" CITATION:  Han, B., Compton, W., Einstein, E. and Volkow, N., 2021. Associations of Suicidality Trends With Cannabis Use as a Function of Sex and Depression Status. JAMA Network Open, 4(6), p.e2113025. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781215

Join the podcast crew as they discuss a recent study investigating the risk of being awake while paralyzed when intubated in the emergency department setting. This is definitely an under-discussed topic in the EMS world, especially considering the recent swing from succinylcholine to rocuronium for prehospital medication assisted intubation. This conversation should make us all a bit nervous and better focused the next time we intubate. REFERENCES 1. https://www.annemergmed.com/article/S0196-0644(20)31314-7/fulltext

Get Surfshark VPN at https://surfshark.deals/minuteearth and enter code MINUTEEARTH for 83% off and 3 extra months free! The body can get a whole lot colder - but not a whole lot hotter - before we die. Why is that? LEARN MORE ************** To learn more about this topic, start your googling with these keywords: Hyperthermia: a medical condition where an individual's body temperature is elevated beyond normal Hypothermia: a medical doncition that occurs when an individual's body loses heat faster than it can produce heat, causing a dangerously low body temperature Thermoregulation is the ability of an organism to keep its body temperature within certain boundaries, even when the surrounding temperature is very different Denaturation: the alteration of a protein shape through some form of external stress (for example, heat), so that it can no longer carry out its cellular function If you liked this week’s video, you might also like: A great article from Outside on hyperthermia: https://www.outsideonline.com/2398105/heat-stroke-signs-symptoms Learn more about the woman who survived the lowest known body temp: https://www.atlasobscura.com/articles/the-woman-who-survived-the-lowest-body-temperature-ever SUPPORT MINUTEEARTH ************************** If you like what we do, you can help us!: - Become our patron: https://patreon.com/MinuteEarth - Share this video with your friends and family - Leave us a comment (we read them!) CREDITS ********* Kate Yoshida | Script Writer, Narrator and Director Sarah Berman | Illustration, Video Editing and Animation Nathaniel Schroeder | Music MinuteEarth is produced by Neptune Studios LLC https://neptunestudios.info OUR STAFF ************ Sarah Berman • Arcadi Garcia Rius David Goldenberg • Julián Gustavo Gómez Melissa Hayes • Alex Reich • Henry Reich Peter Reich • Ever Salazar • Kate Yoshida OUR LINKS ************ Youtube | https://youtube.com/MinuteEarth TikTok | https://tiktok.com/@minuteearth Twitter | https://twitter.com/MinuteEarth Instagram | https://instagram.com/minute_earth Facebook | https://facebook.com/Minuteearth Website | https://minuteearth.com Apple Podcasts| https://podcasts.apple.com/us/podcast/minuteearth/id649211176 REFERENCES ************** Lepock JR (2004). Role of nuclear protein denaturation and aggregation in thermal radiosensitization, International Journal of Hyperthermia, 20:2, 115-130, https://www.tandfonline.com/doi/abs/10.1080/02656730310001637334 Leuenberger, P, Ganscha S, Kahraman A, Cappelletti V, PJ Boersema, Mering Cv, Claassen M, Picotti P (2017). Cell-wide analysis of protein thermal unfolding reveals determinants of thermostability Science, 355: eaai7825. https://science.sciencemag.org/content/355/6327/eaai7825 Roti Roti J (2008) Cellular responses to hyperthermia (40–46 degrees C): cell killing and molecular events. International Journal of Hyperthermia 24(1): 3–15. https://www.tandfonline.com/doi/full/10.1080/02656730701769841 Sawka MN, Leon LR, Montain SJ, Sonna LA (2011). Integrated physiological mechanisms of exercise performance, adaptation, and maladaptation to heat stress. Comprehensive Physiology 1: 1883-1928. https://onlinelibrary.wiley.com/doi/abs/10.1002/cphy.c100082 Slovis CM, Anderson GF, Casolaro A (1982). Survival in a heat stroke victim with a core temperature in excess of 46.5 C. Annals of Emergency Medicine 11(5):269-271. https://linkinghub.elsevier.com/retrieve/pii/S0196-0644(82)80099-1

Episode 34 is here! LJ and Zach are here with the first episode of the new decade! They talk about Catholic hospitals, a study of what happens to people after they survive an opioid overdose, and finish with another news roundup. If you've got a question or comment for us, send us an email at chiefcomplaintpod@gmail.com, tweet us @ChiefPod, or find us on Instagram @ChiefComplaintPodcast. See you next week for a brand new episode!Links:Catholic Hospitals: https://fivethirtyeight.com/features/why-religious-health-care-restrictions-often-take-patients-by-surprise/Opioid Mortality: https://www.annemergmed.com/article/S0196-0644(19)30343-9/fulltextPhilippines Coconut Wine Poisoning: https://www.usatoday.com/story/news/world/2019/12/24/philippines-coconut-wine-lambanog-poisonings-least-11-dead-hundreds-sickened/2743366001/Texas nurse shooting: https://www.houstonchronicle.com/news/houston-texas/houston/article/Nurse-killed-by-stray-bullet-during-New-Year-s-14943880.phpYear of the Nurse: https://news.un.org/en/story/2020/01/1054531Music:You're There by The Mini VandalsAll Night by IksonNews Sting by Kevin McCleod (incompetech.com)

Björgvin Óli Ingvarsson Sjúkraflutningamaður og forgangsakstursþjálfari kom til okkar í Bráðavarpið og fór yfir það með okkur hvernig ber að haga akstri á forgangi. Hvaða tækni er gott að nota, hvað ber að varast og svo framvegis. Hér kemur linkur á rannsókn sem gefin var út í Bandaríkjunum í Júlí 2019: https://www.annemergmed.com/article/S0196-0644(18)31325-8/pdf

Objectives: -       To introduce the concept of social determinants of health -       To outline the ways in which social determinants of health affect the practice of emergency medicine -       To highlight key reasons why emergency providers should care about social determinants of health -       Introduce ways in which emergency providers can effectively identify social issues that might be affecting their patients’ health     Take-home points: -       Try to avoid compartmentalizing your patients’ health. Social issues affect their health and you should take the time to identify and address them in the emergency department. -       Recognize when it is important to practice “slow medicine” and take the time to talk with your patients about how you can best help them. -       To change the culture of your department, first try to find, or create, impactful data. Then seek out funding to support your work. Data and funding will help garner support. -       Think about how you can make an impact on the population level. Be bold. Step outside your comfort zone and always do the right thing for the patient.   Additional resources: A centralized website for all things Social EM, highlighting important literature, a library of social EM initiatives, and creating a network for the social EM community.  www.SocialEMpact.com   ACEP Social Emergency Medicine Section. https://www.acep.org/how-we-serve/sections/social-emergency-medicine/   SAEM Social Emergency Medicine and Population Health Section. https://www.saem.org/resources/social-emergency-medicine-and-population-health/research   "Inventing Social Emergency Medicine," supplement to Annals of Emergency Medicine www.annemergmed.com/issue/S0196-0644(19)X0013-X   Anderson ES, Lippert S, Newberry J, Bernstein E, Alter HJ, Wang NE. Addressing social determinants of health from the emergency department through social emergency medicine. Western Journal of Emergency Medicine. 2016 Jul;17(4):487.   Alter HJ. Social determinants of health: from bench to bedside. JAMA internal medicine. 2014 Apr 1;174(4):543-5.   IDHEAL Social Emergency Medicine Teaching Modules. http://www.idheal-ucla.org/page-12/ Episode transcript   Contributors: Ayesha Khan Quincy Moore    

Objectives: Outline the scope of the opioid epidemic as it relates to Emergency Medicine Detail innovative treatment options for opioid use disorder and overdose Discuss strategies and barriers to implementing ED-based Medication for Opioid Use Disorder (MOUD) Provide possible future strategies and necessary policy changes   Take-home points:  Opioid use disorder is a disease that is often chronic and relapsing Prescribing buprenorphine is easy and it only takes one person to start doing it. See the show notes for resources to help.  It’s helpful to have a champion for OUD treatment in the ED. The medical director is well positioned for this.  Find a community champion who can help continue treatment outside of the ED Stigma affects both providers and patients. Learn your terms and try to be consistent with their use: opioid use disorder (OUD), Medication for Addiction Therapy (MAT), and Medication for Opioid Use Disorder (MOUD).  Treatment for OUD can be with naltrexone, methadone, and buprenorphine. Buprenorphine is a partial opioid agonist and the best-suited for ED treatment.  You can use the COWS score to assess your patients for opioid withdrawal.   Outside resources:  Emergency Department Contribution to the Prescription Opioid Epidemic https://www.ncbi.nlm.nih.gov/pubmed/29373155 What Role Has Emergency Medicine Played in theOpioid Epidemic: Partner in Crime or Canary in theCoal Mine? https://www.annemergmed.com/article/S0196-0644(18)30046-5/pdf ACEP opioid resources https://www.acep.org/by-medical-focus/mental-health--substance-abuse/opioids/#sm.0001e74hrth2sdxcqs82pd3l195ch Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial https://www.ncbi.nlm.nih.gov/pubmed/25919527   Resources that support medication-based treatment in the ED https://medicine.yale.edu/edbup/ https://www.bridgetotreatment.org/   Contributors: John Purakal Maureen Gang Caleb Scarth Nate Coggins Guests: Gail D’Onofrio, MD, MS, is the chair of emergency medicine at Yale Medicine. She is internationally known for her work in substance use disorders, women’s cardiovascular health, and mentoring physician scientists in developing independent research careers. For the past 25 years she has developed and tested interventions for alcohol, opioids and other substance use disorders, serving as the principal investigator (PI) on several large NIH, SAMSHA, and CDC studies. She is a founding Board member of Addiction Medicine, now recognized as a new specialty, subspecialty by the American Board of Medical Specialties. Lewis Nelson, MD, is Professor and Chair of the Department of Emergency Medicine and Chief of the Division of Medical Toxicology at Rutgers New Jersey Medical School in Newark, NJ. He is a member of the Board of Directors of the American Board of Emergency Medicine and a Past-President of the American College of Medical Toxicology. He is actively involved with several governmental and professional organizations and is an editor of Goldfrank’s Toxicologic Emergencies. His areas of specific interest include consequences of opioids, pain management, and emerging drugs of abuse.

Do we see code 1 transport to hospital as a clinical intervention? Like any intervention, there are potential risks and benefits. Is there a benefit in getting to hospital a few minutes faster when 19 million responses in the US have shown us that the risk is immense? Is it worth risking our own lives and that of the patient? Reference Watanabe et al. Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data https://www.annemergmed.com/article/S0196-0644(18)31325-8/fulltext   Maguire et al. Occupational injury risk among Australian paramedics: an analysis of national data https://www.mja.com.au/journal/2014/200/8/occupational-injury-risk-among-australian-paramedics-analysis-national-data

Es geht weiter. Der Einsatz ist erst vorbei, wenn er vorbei ist … Wenn euch unser Podcast gefällt, dann gebt uns eine gute Rezension bei iTunes oder schreibt einen freundlichen Kommentar auf unserer Homepage. Anregung und Kritik am besten direkt an Mail@RettungsdienstFm.de Quellen: Open access-Artikel zur Präoxygenierung: https://www.annemergmed.com/article/S0196-0644(11)01667-2/fulltext Übersicht Delayed sequence Intubation: Lagerung des Kopfes … „Notfall „Notfallnarkose“ Teil 2“ weiterlesen Der Beitrag Notfall „Notfallnarkose“ Teil 2 erschien zuerst auf Rettungsdienst FM.

In this episode of Critical Matters, we discuss the role of noninvasive ventilation and high-flow oxygen nasal cannula in respiratory failure. Our guest, Dr. Pratik Doshi, is an academic intensivist and emergency medicine physician at the University of Texas Health Science Center in Houston, Texas. Dr. Doshi is the lead author and investigator of a recently published multicenter randomized clinical trial evaluating this topic. Additional Resources: Official ERS / ATS Guidelines for non-invasive ventilation (NIV): https://www.ncbi.nlm.nih.gov/pubmed/28860265 High-velocity nasal insufflation in the treatment of respiratory failure: A randomized clinical trial by Doshi P et al: http://www.annemergmed.com/article/S0196-0644(17)31968-6/fulltext Books Mentioned in This Episode: The Alchemist: https://www.amazon.com/Alchemist-Paulo-Coelho-ebook/dp/B00U6SFUSS/ref=sr_1_1?ie=UTF8&qid=1523055572&sr=8-1&keywords=the+alchemist

Jordan discusses critical elements of intubation and the different forms of intubation. From rookie to veteran, medicine is a dynamic art that is always changing. This podcast looks at current evidence based practice for intubation. Setting up for success is the goal!Studies Referenced:https://www.annemergmed.com/article/S0196-0644110(16)67-2/fulltexthttps://www.jem-journal.com/article/S0736-4679(17)31171-X/abstracthttps://www.sscor.com/suction-assisted-laryngoscopy-and-airway-decontamination-salad.htmlMusic: One Destination, Two Journeys by Alexander Nakarada l https://www.serpentsoundstudios.com. Music promoted by https://free-stock-music.com Attribution 4.0 International (CC BY 4.0) https:creativecommons.org/licenses/by/4.0/

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management. Nachi: With no gold standard diagnostic test and with complications ranging from simple ectopic beats to fulminant cardiac failure and death, this isn’t an episode you’ll want to miss. Jeff: Before we begin, let me give a quick shout out to our incredible group of authors from New York -- Dr. Eric Morley, Dr. Bryan English, and Dr. David Cohen of Stony Brook Medicine and Dr. William Paolo, residency program director at SUNY Upstate. I should also mention their peer reviewers Drs. Jennifer Maccagnano and Ashley Norse of the NY institute of technology college of osteopathic medicine and UF Health Jacksonville, respectively. Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST. Jeff: Clearly a large undertaking for a difficult topic to come up with solid evidence based recommendations. Nachi: For sure. Let’s begin with some epidemiology, which is admittedly quite difficult without universally accepted diagnostic criteria. Jeff: As you likely know, despite advances in motor vehicle safety, trauma remains a leading cause of death for young adults. In the US alone, each year, there are about 900,000 cases of cardiac injury secondary to trauma. Most of these occur in the setting of vehicular trauma. Nachi: And keep in mind, that those injuries don’t occur in isolation as 70-80% of patients with blunt cardiac injury sustain other injuries. This idea of concomitant trauma will be a major theme in today’s episode. Jeff: It certainly will. But before we get there, we have some more definitions to review - cardiac concussion and contusion, both of which were defined in a 1989 study. In this study, cardiac concussion was defined as an elevated CKMB with a normal echo, while a cardiac contusion was defined as an elevated CKMB and abnormal echo. Nachi: Much to my surprise, though, abnormal echo and elevated ck-mb have not been shown to be predictive of adverse outcomes, but conduction abnormalities on ekgs have been predictive of development of serious dysrhythmia Jeff: More on complications in a bit, but first, returning to the idea of concomitant injuries, in one autopsy study of nearly 1600 patients with blunt trauma - cardiac injuries were reported in 11.9% of cases and contributed to the death of 45.2% of those patients. Nachi: Looking more broadly at the data, according to one retrospective review, blunt cardiac injury may carry a mortality of up to 44%. Jeff: That’s scary high, though I guess not terribly surprising, given that we are discussing heart injuries due to major trauma... Nachi: The force may be direct or indirect, involve rapid deceleration, be bidirectional, compressive, concussive, or even involve a combination of these. In general, the right ventricle is the most frequently injured area due to the proximity to the chest wall. Jeff: Perfect, so that's enough background, let’s talk differential. As you likely expected, the differential is broad and includes cardiovascular injuries, pulmonary injuries, and other mediastinal injuries like pneumomediastinum and esophageal injuries. Nachi: Among the most devastating injuries on the differential is cardiac wall rupture, which not surprisingly has an extremely high mortality rate. In terms of location of rupture, both ventricles are far more likely to rupture than the atria with the right atria being more likely to rupture than the left atria. Atrial ruptures are more survivable, whereas complete free wall rupture is nearly universally fatal. Jeff: Septal injuries are also on the ddx. Septal injuries occur immediately, either from direct impact or when the heart becomes compressed between the sternum and the spine. Delayed rupture can occur secondary to an inflammatory reaction. This is more likely in patients with a prior healed or repaired septal defects. Nachi: Valvular injuries, like septal injuries, are rare. Left sided valvular damage is more common and carries a higher mortality risk. In order, the aortic valve is more commonly injured followed by the mitral valve then tricuspid valve, and finally the pulmonic valve. Remember that valvular damage can be due to papillary muscle rupture or damage to the chordae tendineae. Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. Jeff: Next on the ddx are coronary artery injuries, which include lacerations, dissections, aneurysms, thrombosis, and even MI secondary to increased sympathetic activity and platelet activity after trauma. In one review, dissection was the most commonly uncovered pathology, occurring 71% of the time, followed by thrombosis, which occured only 7% of the time. The LAD is the most commonly injured artery followed by the RCA. Nachi: Pericardial injury, including pericarditis, effusion, tamponade, and rarely rupture, is also certainly on the differential. Jeff: In terms of dysrhythmias, sinus tachycardia is the most common dysrhythmia, with other rhythms, including PVC / PAC / and afib being found only 1-6% of the time. Nachi: And while conduction blocks are rare, a RBBB is the most commonly noted, followed by a 1st degree AVB. Jeff: Though also rare, commotio cordis deserves it’s own section as its the second most common cause of death in athletes < 18 who are victims of blunt trauma. Though only studied in swine models, it’s hypothesized that the impact to the chest wall during T-wave upstroke can precipitate v-fib. Nachi: Aortic root injuries usually occur at the insertion of the ligamentum arteriosum and isthmus. Such injuries typically result in aortic insufficiency. Jeff: And the last pathology on the differential requiring special attention is a myocardial contusion. Again, no standard definition exists, with some diagnostic criteria including simply chest pain and increasing cardiac enzymes, and others including cardiac dysfunction, ecg abnormalities, wall motion abnormalities, and an elevation of cardiac enzymes. Nachi: Certainly a pretty broad differential… before moving on to the work up, Jeff why don’t you get us started with prehospital care? Jeff: Prehospital management should focus on rapid identification and stabilization of life threatening injuries with expeditious transport as longer prehospital times have been associated with increased mortality in trauma. Immediate transport to a Level I trauma center should be the highest priority for those with suspected blunt cardiac injury. Nachi: In terms of who specifically should be transporting the patient, a Cochrane review evaluated the utility of ALS vs BLS transport in trauma. There is reasonably good data to support BLS over ALS, even when controlling for trauma severity. Moreover, when airway management is needed, advanced airway techniques by ALS crews were associated with decreased odds of survival. Regardless of who is there, the message is the same: focus not on interventions, but instead on rapid transport. Jeff: And if it does happen to be an ALS transport crew, without delaying transport, pain management with fentanyl is both safe and reasonable and preferred over morphine. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. Nachi: And if the prehospital team is lucky enough, or maybe unlucky enough, i don’t know, to have a credentialed provider who can perform ultrasound for those suspected of having a blunt cardiac injury, the general prehospital data on ultrasound is sparse. As of now, it’s difficult to conclude if prehospital US improves care for trauma patients. Jeff: Interestingly, the system I work in has prehospital physicians, who do carry US, but I can’t think of a major trauma where ultrasound changed any of the decisions we made. Nachi: Right, and I think that just reinforces the main point here: there may be a role, we just don’t have the data to support it at this time. Jeff: Great, let’s move onto ED care, beginning with the H&P. Nachi: On history, make sure to elucidate if there is any chest pain, and if it’s onset was before or after the traumatic event. In addition, make sure to ask about dyspnea, fatigue, palpitations, and lightheadedness. Jeff: And don’t forget to get the crash details from the EMS crew before they depart! As a side note, for anyone taking oral boards in a few months, don’t forget to ask the EMS crew for the details!!! Nachi: A definite must for oral boards and for your clinical practice. Jeff: In terms of the physical, tachycardia is the most common abnormality in blunt cardiac injury. In those with severe injury, you may note refractory hypotension secondary to cardiogenic shock. But don’t be reassured by normal vitals, especially in the young, who may be compensating well despite being quite ill. Nachi: Fully undress the patient to appropriately inspect and percuss the chest wall - looking for signs of previous cardiac surgeries or pacemaker placement, as well as to auscultate for new murmurs which may be a sign of valvular injury. Jeff: Similarly, as concomitant injuries are common, inspect the abdomen, looking for ecchymosis patterns, which often accompany blunt cardiac injury. Nachi: Pretty standard stuff. Let’s move on to diagnostic testing. Jeff: Lab testing should include a CBC, BMP, coags, troponin, lactate, and T&S. In one retrospective analysis, an elevated troponin and a lactate over 2.5 were predictors of mortality. Nachi: Additionally, in patients with chest trauma, a troponin > 1.05 was associated with a greater risk for dysrhythmias and LV dysfunction. Jeff: And it likely goes without saying, but an EKG is a must on all trauma patients with suspicion for blunt cardiac injury in accordance with the EAST guidelines. New EKG findings requires admission for monitoring. Unfortunately, on the flip side, an ECG cannot be used to rule out blunt cardiac injury. Nachi: Diving a bit deeper into the data, in a prospective study of 333 patients with blunt thoracic trauma, serial EKG and troponins at 0, 4, and 8 hours post injury had a sensitivity and specificity of 100% and 71%, respectively. However, of those with abnormal findings, all but one had them on initial testing, leading to a negative predictive value of 98%. Jeff: Well that’s an impressive NPV and has huge implications, especially in the era of heavily monitored lengths of stay... Nachi: Definitely. In terms of radiography, a chest x-ray should be obtained as rib fractures, hemopneumothorax, and mediastinal free air are all things you wouldn't want to miss and are also associated with blunt cardiac injury. Jeff: Keep in mind, however, that the chest x-ray should not be seen as a test for pericardial fluid as up to 200 mL of fluid can be contained in the pericardial space and remain undetectable by chest radiograph. Nachi: Which is why you’ll have to turn to our good friend the ultrasound, for more useful data. The data is strong that in the hands of trained Emergency Clinicians, when parasternal, apical, and subcostal views are obtained, US has an accuracy of 97.5% for pericardial effusion. Jeff: Not only is US accurate, it’s also quick. In one RCT, the FAST exam reduced the time from arrival in the ED to operative care by 64% in the setting of trauma. Nachi: That’s impressive -- for expediting patient care and for managing ED flow. Jeff: Exactly. The authors do note however that hemopericardium is a rare finding, so, while not the focus of this article, the real utility of the FAST exam may be in its expanded form, the eFAST, in which a rapid bedside ultrasonographic lung exam for pneumothorax is included, as this can lead to immediate changes in management. Nachi: And assuming you do your FAST or eFAST and have no management changing findings, CT will often be your next test. Jeff: Yeah, EKG-gated multidetector CT can easily diagnose myocardial rupture, pneumopericardium, pericardial rupture, hemopericardium, coronary artery insult, ventricular septal defects and even valvular dysfunction. Unfortunately, CT does not perform well for the evaluation of myocardial contusions. Nachi: This is all well and good, and certainly accurate, but let’s not forget that hemodynamically unstable trauma patients, like those with myocardial rupture, need to be in the operating room, not the CT scanner. Jeff: An important point that should not be understated. Nachi: And the last major testing modality to discuss is the echocardiogram. Jeff: The echo is a fantastic test for detecting focal cardiac dysfunction often see with cardiac contusions, hemopericardium, and valve disruption. Nachi: And it’s worth noting that transthoracic is enough, as transesophageal, despite the better images, hasn’t been shown to change management. TEE should be saved for those in whom a optimal TTE study isn’t feasible. Jeff: Great point. And one last quick note on echo: in terms of guidelines, the EAST guidelines from 2012 specifically recommend an echo in hemodynamically unstable patients or those with a persistent new dysrhythmia without other sources of ongoing hemorrhage or neurologic etiology of instability. Nachi: Perfect, so that wraps up testing and imaging for our blunt cardiac injury patient. Let’s move on to treatment. Jeff: In terms of initial resuscitation, there is an ever increasing body of literature to support blood transfusion over crystalloid in patients requiring volume expansion in trauma. There are no specific guidelines for transfusion in the setting of blunt cardiac injury, so stick to your standard trauma protocols. Nachi: It is worth noting, though, that there is literature outside of trauma for those with pericardial effusions, suggesting that those with a SBP < 100 have substantial benefit from volume expansion. So keep this in mind if your clinical suspicion is high and your trauma patient has a soft but not truly shocky blood pressure. Jeff: Operative management, specifically ED thoracotomy is a heavily debated topic, and it’s next on our list to discuss. Nachi: The 2015 EAST guidelines conditionally recommend ED thoracotomy for moribund patients with signs of life. The Western Trauma Association broadens the ED thoracotomy window a bit to include anyone with no signs of life but less than 10 minutes of CPR. The latter also recommend ED thoracotomy in those with refractory shock. Jeff: Though few studies exist on the topic, in one study of 187 patients, cardiac motion on US was 100% sensitive for predicting survivors. Nachi: Not great data, but it does support one's decision to stop any further work up should there be no cardiac activity, which is important, because the decision to pursue an ED thoracotomy is not an easy one. Jeff: And lastly, emergent pericardiocentesis may be another option in an unstable patient when definitive operative management is not possible. But do note that pericardiocentesis is only a temporizing measure, and not definitive for cardiac tamponade. Nachi: Treatment for dysrhythmias is standard, treat in accordance with standard ACLS protocols, as formal randomized trials on prophylaxis and treatment in the setting of blunt cardiac injury do not exist. Jeff: Seems reasonable enough. And in the very rare setting of an MI after blunt cardiac injury, you should involve cardiology, cardiothoracic surgery, and trauma to help make important management decisions. Data is, again, lacking, but the patient likely needs percutaneous angiography for appropriate diagnosis and potentially further intervention. Definitely hold off on ASA and likely nitroglycerin, at least until significant bleeding has been ruled out. Nachi: Yup, no style points for giving aspirin to a bleeding trauma patient. Speaking of medications, the last treatment modality to discuss here is pain control. Pain management is essential with chest injuries, as appropriate pain management has been shown to reduce mortality in pulmonary related complications. Jeff: And in line with every acute pain consult note I’ve ever come across, a multimodal approach utilizing opioids and nonopioids is recommended. Nachi: Perfect, so that sums up treatment, next we have one special circumstance to discuss: sternal fractures. Cardiac contusions are found in 1.8-2.4% of patients with sternal fractures, almost all of which were seen on CT and not XR according to the NEXUS chest CT study. Of these patients, only 2 deaths occured, both due to cardiac causes.  Thus, in patients with isolated sternal fractures, negative trops, ekg, and negative cxr - the patient can likely be discharged from the ED, as long as their pain is well-controlled. Jeff: And let’s talk controversies for this issue. We only have one to discuss: MRI. Nachi: The fact that MRI produces awesome images is not controversial, see figure 3. It’s role, however, is. In accordance with EAST guidelines, MRI may be most useful in differentiating acute ischemia from blunt cardiac injury in those with abnormal ECGs, elevated enzymes, or abnormal echos. It’s use in the hyperacute evaluation, however, is limited, in large part owing to the length of time required to complete an MRI Jeff: What a time to be alive that we even have to say that MRIs may not have a hyperacute role in trauma - absolutely crazy... Nachi: Moving on to disposition: any patient with aortic, pericardial, or myocardial injury and hemodynamic instability needs operative evaluation and likely intervention, so do not hesitate to get the consults coming or the helicopter in the air should such a patient arrive at your non-trauma center. Jeff: And in those that are hemodynamically stable, with either a positive ECG or a positive trop, they should be monitored on telemetry. There is no clear answer as to how long, but numerous studies suggest a 24 hour period of observation is sufficient. For those with persistent ekg abnormalities or rising trops - this is precisely when you will want to pursue echocardiography. Nachi: And if there are positive EKG findings AND a rising trop, they should be admitted to a step down unit or ICU as well -- as ⅔ of them will develop myocardial dysfunction. Similarly, those with hemodynamic instability but no active traumatic bleeding source - they too should be admitted to the ICU for a STAT echo and serial enzymes. Jeff: But in the vast majority of patients, those that are hemodynamically stable with negative serial EKGs and serial tropinins, they can effectively be ruled out for significant BCI after an 8 hour ED observation period, as we mentioned earlier with a sensitivity approaching 100%! Nachi: Though there are, of course, exceptions to this rule, like those with low physiologic reserve, mobility or functional issues, or complex social situations, which may need to be assessed on a more case-by-case basis. Jeff: Let’s wrap up this episode with some key points and clinical pearls. Cardiac wall rupture is the most devastating form of Blunt Cardiac Injury. The sealing of a ruptured wall may lead to a pseudoaneurysm and delayed tamponade. Trauma to the coronary arteries may lead to a myocardial infarction. The left anterior descending artery is most commonly affected. The most common arrhythmia associated with blunt cardiac injury is sinus tachycardia. RBBB is the most commonly associated conduction block. Commotio cordis is the second most common cause of death in athletes under the age of 18. Early defibrillation is linked to better outcomes. Antiplatelet agents like aspirin should be avoided in blunt cardiac injury until significant hemorrhage has been ruled out. An EKG should be obtained in all patients with suspected blunt cardiac injury. However, an EKG alone does not rule out blunt cardiac injury. Serial EKG and serial troponin testing at hours 0, 4, and 8 have a sensitivity approaching 100% for blunt cardiac injury. An elevated lactate level or troponin is associated with increased mortality in blunt cardiac injury. Perform a FAST exam to assess for pericardial effusions. FAST exams are associated with a significant reduction in transfer time to an operating room. Obtain a chest X-ray in all patients in whom you have concern for blunt cardiac injury. Note that the pericardium is poorly compliant and pericardial fluid might not be detected on chest X-ray. Transesophageal echocardiogram should be considered when an optimal transthoracic study cannot be achieved. CT is used routinely in evaluating blunt chest trauma but know that it does not evaluate cardiac contusions well. In acute evaluation, MRI is generally a less useful imaging modality given the long imaging time. There is evidence to suggest that a patient with an isolated sternal fracture and negative biomarkers and negative EKG findings can be safely discharged from the ED if pain is well-controlled. Trauma to the aorta, pericardium, or myocardium is associated with severe hemodynamic instability. These patients need surgical evaluation emergently. Hemodynamically stable patients with a positive troponin test or with new EKG abnormalities should be observed for cardiac monitoring. Nachi: So that wraps up Episode 26 on Blunt Cardiac Injury! Jeff: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Nachi: It’s also worth mentioning for current subscribers that the website has recently undergone a major rehaul and update. The new site is easier to use on mobile browsers, has better search functionality, mobile-friendly CME testing, and quick access to the digest and podcast. Jeff: And as those of us in the north east say goodbye to the snow for the year, it’s time to start thinking about the summer and maybe start planning for the Clinical Decision Making conference in sunny Ponta Vedra Beach, Fl. The conference will run from June 27th to June 30th this year with a pre-conference workshop on June 26th. Nachi: And the address for this month’s credit is ebmedicine.net/E0319, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 7.* Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-S306. (Guideline) 22.* Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57-70. (Review article) 23.* El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008;35(2):127-133. (Review article) 27.* Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012;30(4):545-555. (Review article) 34.* Berk WA. ECG findings in nonpenetrating chest trauma: a review. J Emerg Med. 1987;5(3):209-215. (Review article) 64.* Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54(1):45-50. (Prospective; 333 patients) 73.* Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. (Randomized controlled trial; 262 patients)

The following is a short list of salient points related to the podcast and the corresponding source literature. As always, read the source literature and critically appraise it for yourself. Take none of the following as a substitution for local protocol or procedure. 2018 NAEMSP Spinal Immobilization paper https://naemsp.org/resources/position-statements/spinal-immobilization/ Securing a patient to the stretcher mattress significantly reduces lateral motion: Am J Emerg Med. 2016 Apr;34(4):717-21. doi: 10.1016/j.ajem.2015.12.078. Epub 2015 Dec 30. C-Collar limits visible external motion in the intact spine, but not internal motion in the unstable injured spine: Horodyski M, DiPaola CP, Conrad BP, Rechtine GR 2nd. Cervical collars are insufficient for immobilizing an unstable cervical spine injury. J Emerg Med. 2011 Nov;41(5):513-9. doi: 10.1016/j.jemermed.2011.02.001. Epub 2011 Mar 12. PubMed PMID: 21397431. C-Collar increases ICP: Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996 Nov;27(9):647-9. PubMed PMID: 9039362. C-Collar causes distraction of unstable C-spine: Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010 Aug;69(2):447-50. doi:10.1097/TA.0b013e3181be785a. PubMed PMID: 20093981. Lador R, Ben-Galim P, Hipp JA. Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. J Trauma. 2011 Jan;70(1):247-50; discussion 250-1. doi: 10.1097/TA.0b013e3181fd0ebf. PubMed PMID: 21217496. Spinal immobilization negatively impacts the physical exam: March J et al. Changes In Physical Examination Caused by Use of Spinal Immobilization. Prehosp Emerg Care 2002; 6(4): 421 – 4. PMID: 12385610 Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994 Jan;23(1):48-51. PubMed PMID: 8273958. Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8. PubMed PMID: 8782022. Even Manual In Line Stabilization alone increased difficulty during intubation and increases forces applied to the neck: 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. PubMed PMID: 19396507. 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. PubMed PMID: 19104166. Spinal immobilization makes it harder to breath and decreases forced expiratory volume: “...produce a significantly restrictive effect on pulmonary function in the healthy, nonsmoking man.” Chan, D., Goldberg, R., Tascone, A., Harmon, S., & Chan, L. (1994). The effect of spinal immobilization on healthy volunteers. Annals of Emergency Medicine, 23(1), 48–51. https://doi.org/10.1016/S0196-0644(94)70007-9 Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkisson A. Respiratory effects of spinal immobilization in children. Ann Emerg Med. 1991 Sep;20(9):1017-9. PubMed PMID: 1877767. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999 Oct-Dec;3(4):347-52. PubMed PMID: 10534038. Prehospital providers can effectively apply selective immobilization criteria without causing harm: Domeier, R. M., Frederiksen, S. M., & Welch, K. (2005). Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Annals of Emergency Medicine, 46(2), 123–131. https://doi.org/10.1016/j.annemergmed.2005.02.004 Out of 32,000 trauma encounters, a prehospital clearance protocol resulted in ONE patient with an unstable injury that was not immobilized. This patient injured her back one week prior, required fixation, but had no neurological injury: Burton, J.H., Dunn, M.G., Harmon, N.R., Hermanson, T.A., and Bradshaw, J.R. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006; 61: 161–167 Ambulatory patients self extricating with a cervical collar results in less cervical spine motion than with the use of a backboard: Shafer, J. S., & Naunheim, R. S. (2009). Cervical Spine Motion During Extrication: A Pilot Study. Western Journal of Emergency Medicine, 10(2), 74–78. https://doi.org/10.1016/j.jemermed.2012.02.082 Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7. doi:10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15. PubMed PMID: 23079144 Lift and slide technique is superior to log roll: Boissy, P., Shrier, I., Brière, S. et al. Effectiveness of cervical spine stabilization techniques. Clin J Sport Med. 2011; 21: 80–88 Despite there not being any randomized control trials evaluating spinal immobilization, patients transferred to hospitals immobilized have more disability than those transported without immobilization: Hauswald, M., Ong, G., Tandberg, D., and Omar, Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998; 5: 214–219 “Mechanism of injury does not affect the ability of clinical criteria to predict spinal injury” Domeier, R.M., Evans, R.W., Swor, R.A. et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury.Prehosp Emerg Care. 1999; 3: 332–337 Spinal immobilization in penetrating trauma is associated with an increased risk of death: Vanderlan, W.B., Tew, B.E., and McSwain, N.E. Jr. Increased risk of death with cervical spine immobilisation in penetrating cervical trauma. Injury. 2009; 40: 880–88 Stuke, L.E., Pons, P.T., Guy, J.S., Chapleau, W.P., Butler, F.K., and McSwain, N.E.Prehospital spine immobilization for penetrating trauma-review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011; 71: 763–769 “The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.” Haut, E.R., Kalish, B.T., Efron, D.T. et al. Spine immobilization in penetrating trauma: more harm than good?. J Trauma. 2010; 68: 115–121 Vanderlan WB, Tew BE, Seguin CY, Mata MM, Yang JJ, Horst HM, Obeid FN, McSwain NE. Neurologic sequelae of penetrating cervical trauma. Spine (Phila Pa 1976). 2009 Nov 15;34(24):2646-53. doi: 10.1097/BRS.0b013e3181bd9df1. PubMed PMID: 19881402. Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Haut ER. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg. 2018 May;84(5):736-744. doi:10.1097/TA.0000000000001764. PubMed PMID: 29283970. Use of LSB can cause sufficient pressure to create pressure ulcers in a short period of time: Cordell W:H, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 Jul;26(1):31-6. PubMed PMID: 7793717. The natural progression of some C-spine injuries is to get worse, sometimes because we force them into immobilization devices, sometimes because of hypotension, vascular injury, or hypoxia, but surprisingly not because of EMS providers… Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ. The cause of neurologic deterioration after acute cervical spinal cord injury. Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6. PubMed PMID: 11224879. Reports of asymptomatic but clinically important spine injuries are, at best, dubious: McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cervical spine fracture: case report and review of the literature. J Trauma. 1990 May;30(5):623-6. Review. PubMed PMID: 2188001. Bresler MJ, Rich GH. Occult cervical spine fracture in an ambulatory patients. Ann Emerg Med. 1982 Aug;11(8):440-2. PubMed PMID: 7103163.

In this episode, we're graced by the presence of Airway Jedi Dr. Jeff Jarvis. We discuss a novel approach to the standardization of airway management in order to prevent peri-intubation hypoxia and valuable insight into the organizational culture required to make it successful. Link to Dr. Jarvis' paper "Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia": (Note, at the time of publishing, this article was open-access). https://www.annemergmed.com/article/S0196-0644(18)30071-4/abstract Link to the FOAMfrat Q&A with Dr. Jarvis: https://www.foamfrat.com/single-post/2018/09/29/Why-Do-You-QA-w-Jeff-Jarvis Link to "EMS Intubation Improves with King Vision Video Laryngoscopy" (Non-open access) https://www.tandfonline.com/doi/abs/10.3109/10903127.2015.1005259 Williamson County EMS YouTube Channel: https://www.youtube.com/channel/UCkMY9plbu_4aTUuSXXm46gg  

Today’s show is all about the changes in how we approach intubation in EMS. Dr. Jeff Jarvis will relate how he got interested in the topic of airway management and specifically the process of delayed sequence intubation. Dr. Jarvis is the EMS medical director for Williamson County Texas EMS. He will present data from the recent Annals of Emergency Medicine paper his group authored on the topic. MCHD quality lead, Kevin Crocker, will present our data following DSI Implementation in Montgomery County. Weingart Emcrit podcast and Annals of EM article https://emcrit.org/dsi/ http://dx.doi.org/10.1016/j.annemergmed.2014.09.025 Jarvis Annals paper http://www.annemergmed.com/article/S0196-0644(18)30071-4/abstract Wilco EMS: https://www.wilco.org/Departments/EMS 2017 SOCs DSI protocol DSI checklist for both WCEMS and Marble Falls Area EMS

When reporter Brenna Farrell was a new mom, her son gave her and her husband a scare -- prompting them to call Poison Control. For Brenna, the experience was so odd, and oddly comforting, that she decided to dive into the birth story of this invisible network of poison experts, and try to understand the evolving relationship we humans have with our poisonous planet. As we learn about how poison control has changed over the years, we end up wondering what a place devoted to data and human connection can tell us about ourselves in this cultural moment of anxiety and information-overload. Call the national Poison Help Hotline at 1-800-222-1222 or text POISON to 797979 to save the number in your phone. This episode was reported by Brenna Farrell and was produced by Annie McEwen. Special thanks to Wendy Blair Stephan, Whitney Pennington, Richard Dart, Marian Moser Jones, and Nathalie Wheaton. Thanks also to Lewis Goldfrank, Robert Hoffman, Steven Marcus, Toby Litovitz, James O'Donnell, and Joseph Botticelli.   Support Radiolab today at Radiolab.org/donate.   Further Reading:  The Poisoner's Handbook, by Deborah Blum The Poison Squad, by Deborah Blum Illinois Poison Center’s latest “A Day in the Life of a Poison Center” post You can find out more about the country’s 55 poison centers at the American Association of Poison Control Centers, including a snapshot of the latest available from the National Poison Data System (2106):  "Poison Politics: A Contentious History of Consumer Protection Against Dangerous Household Chemicals in the United States," by Marian Moser Jones:  2011 article from The Annals of Emergency Medicine: "The Secret Life of America's Poison Centers," Richard Dart  A 1954 article from Edward Press -- one of the key figures in creating a formalized poison control system in Chicago in the early 1950s, Press and Gdalman are credited with starting the first poison control center in the US in 1953 in Chicago: "A Poisoning Control Program" Edward Press and Robert B Mellins 

Podcast sobre abordagem do adulto que procura o serviço de emergência após a primeira crise convulsiva da vida. Referências: http://www.annemergmed.com/article/S0196-0644(14)00080-8/abstract https://www.aan.com/Guidelines/home/GetGuidelineContent/688 https://jamanetwork.com/journals/jama/article-abstract/2594724?redirect=true

We review select articles from 2017 that are important or that got people talking including: Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017;358:j3887. Barniol et al.Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. 2018;71(1):125-131.e1 Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. Hu et al  Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med. 2017 Sep 1. S0196-0644(17)31376-8 Clattenburg et al Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018;122:65-68. Hinson JS et al. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Ann Emerg Med. 2017 Healey CD et al. Asymptomatic cervical spine fractures: Current guidelines can fail older patients. J Trauma Acute Care Surg. 2017;83(1):119-125. Crowell et al. Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology. Acad Emerg Med. 2017;24(9):1072-1079. Talan et al. Subgroup Analysis of Antibiotic Treatment for Skin Abscesses. Ann Emerg Med. 2018;71(1):21-30.  

Discussion with Dr. Friedman on his piece in the Annals of Emergency Medicine.http://www.annemergmed.com/article/S0196-0644(17)30476-6/abstract Dr. Friedman is a resident in Emergency Medicine at the Beth Israel Deaconess Medical Center. His research investigates the industrial organization of the unscheduled care system (primary care clinics, urgent care and retail clinics, and emergency departments), access to care and insurance, and financial integration of population health into the medical system. http://www.abfriedman.com

Author: Aaron Lessen M.D. Educational Pearls: Regularly a patient’s creatinine level is an important factor in determining whether a patient will receive IV contrast with a CT because it is thought that contrast can harm the kidneys and could worsen underlying kidney disease. A recent retrospective study compared the rates of worsening kidney problems between patients who received a CT scan with contrast, a CT without contrast, and no CT. The study even included patients with creatinines of up to 4 before excluding patients. The study suggested that there is no difference in the rate of worsening kidney problems between the three groups. References: http://www.annemergmed.com/article/S0196-0644(16)31388-9/fulltext

This episode has you covered from the top of your head to the tips of your lucky socks. Ben and Don dig into some 1980's culture and shoot forward into the food on the future, and then back again. It's a food (and pet) safety grab bag covering pineapple safety, hand sizes and hand sanitizers, safe raw cookie dough, rats, turtles, milk from camels, microgreens and toilet history. Here are some links so you can follow along at home. * [Socks](https://www.amazon.com/s/?ie=UTF8&keywords=socks&tag=googhydr-20&index=aps&hvadid=172784669649&hvpos=1t3&hvnetw=g&hvrand=15289779452546695849&hvpone=&hvptwo=&hvqmt=e&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9003676&hvtargid=kwd-19345770&ref=pd_sl_6e22knv3yz_e) * [Miami Vice](https://en.wikipedia.org/wiki/Miami_Vice) * [eero - WiFi](https://eero.com/) * [Dippin' Dots](https://en.wikipedia.org/wiki/Dippin'_Dots) * [Sean Spicer's Dippin' Dots Tweets Put Press Secretary On The Spot : NPR](http://www.npr.org/2017/01/23/511278562/dippin-dots-beef-puts-white-house-press-secretary-on-the-spot) * [Dippin' Dots open lettr](https://www.dippindots.com/news/2017/01/Open-Letter-to-Sean-Spicer.html) * [Say Anything... ](https://en.wikipedia.org/wiki/Say_Anything...) * [Ill Communication by Beastie Boys on Apple Music](https://itunes.apple.com/us/album/sure-shot/id724771323?i=724771816) * [Pod Save America](https://getcrookedmedia.com/here-have-a-podcast-78ee56b5a323#.neujn6xky) * [sciencecafes.org](http://www.sciencecafes.org/) * [Science Cafe: You cannot B. cereus: Microbial food safety in the modern world](http://naturalsciences.org/calendar/event/science-cafe-you-cannot-b-cereus-microbial-food-safety-in-the-modern-world/) * [Lunds & Byerlys Pulls 'Fresh-Cut Cored Pineapple' after Voluntary Recall | KSTP.com](http://kstp.com/news/lunds-and-byerlys-recalls-pineapple-listeria-risk-no-illnesses/4376206/) * [Growth Potential of Listeria Monocytogenes and Staphylococcus Aureus on Fresh-Cut Tropical Fruits](http://onlinelibrary.wiley.com/doi/10.1111/1750-3841.13089/abstract) * [USDA Scientists Have Been Put On Lockdown Under Trump](https://www.buzzfeed.com/dinograndoni/trump-usda?utm_term=.we0GMyOvZ#.jdxNq6PR8) * [You Aren't Using Enough Hand Sanitizer](http://www.acsh.org/news/2017/01/10/you-arent-using-enough-hand-sanitizer-10717) * [Hand coverage by alcohol-based handrub varies: Volume and hand size matter](http://www.ajicjournal.org/article/S0196-6553(16)30690-3/abstract) * [Gorge On Cookie Dough In All Its Forms At This NYC Eatery](http://www.konbini.com/us/lifestyle/gorge-on-raw-cookie-dough-cookie-do-nyc/) * [Spaceballs (1987)](http://www.imdb.com/title/tt0094012/) * [Not Even Scientists Can Easily Explain P-values](http://fivethirtyeight.com/features/not-even-scientists-can-easily-explain-p-values/) * [CDC: Pet rats linked to virus outbreak](http://www.ksat.com/health/cdc-pet-rats-linked-to-virus-outbreak) * [FDA Bets It Will Escape Coming Political Hurricane, Targets Raw Camel Milk](http://www.davidgumpert.com/3010-2) * [FDA Compliance & Enforcement on Salmonella and Turtle Safety](http://www.fda.gov/AnimalVeterinary/GuidanceComplianceEnforcement/ComplianceEnforcement/ucm090573.htm) [NC rule on pet turtles](http://cph.publichealth.nc.gov/Rules/EpiHealth/10A-NCAC-41A-.0302.pdf) * [The History of 'Toilet' on Merriam-Webster](https://www.merriam-webster.com/words-at-play/word-history-of-toilet) * [Microgreens, Elevator, This Old House](https://www.thisoldhouse.com/watch/ask-toh-microgreens-elevator)

Congratulations to Dr. Vijay Kannan (current chief resident), Dr. Nicole Hodgson (current chief resident), Dr. Andrew Lau (current senior resident), and Dr. Frank LoVecchio (Vice Chairmen for Research), on their recent publication entitled Geolocalization of Influenza Outbreak Within an Acute Care Population: A Layered-Surveillance Approach. Quoting from the conclusion in the abstract, "Our layered-surveillance approach was effective in localizing a cluster of influenza A outbreak. This region may house a high-yield target population for public health intervention. Further collaborative efforts will be made between our hospital and the Maricopa County Department of Public Health to perform a series of community vaccination events before the next influenza season. We hope these efforts will ultimately serve to reduce the burden of this disease on our patient population, and that this system will serve as a framework for future investigations locating at-risk populations." Read the full article here: http://www.annemergmed.com/article/S0196-0644(16)30405-X/abstract Listen to Dr. Kannan describe the paper in his own words! Please note the views and opinions expressed in this recording do not represent the position of Maricopa Integrated Health System or any other institution or party.

Study: http://www.ajicjournal.org/article/S0196-6553(14)01328-5/abstract Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines In this podcast Barrie Tyner speaks with Infection Prevention and Control researcher and Health Protection lecture Maura Smiddy from UCC, Ireland. She is the lead author on a systematic review on health care workers’ compliance with hand hygiene guidelines guide. The study was published in the American Journal of Infection Control December 2015 breaks ground by taking a qualitative approach to tease out the barriers and influences to optimal compliance. Also in the podcast Maura talks about the upcoming Safe Patient Care conference which this year will have a strong focus on healthcare workers involved in the delivery of patient care in residential and long term settings. This years conference is at the Brookfield Health Science Building 1st & 2nd Sep 2016 Links to information mentioned in the podcast: Safe Patient Care conference 2016: https://goo.gl/MdiLDM Registration: Jennifer Coughlan / jennifer.coughlan@ucc.ie Conference twitter: https://twitter.com/SPC2016Cork #SafePatientCare Maura Smiddy featured in the Infection Control Today: http://goo.gl/BgdApU WHO multimodal hand hygiene improvement strategy: http://apps.who.int/iris/handle/10665/70030

For June we have a look at papers covering CT head imaging in delayed trauma presentations, risk stratifying TIAs, early administration of fluids in severe sepsis and most importantly the utility of a biro in a surgical airway....... Make sure you go and have a look at the papers yourself to see what the evidence means to you. References Validation of ABCD2 scores ascertained by referring clinicians: a retrospective transient ischaemic attack clinic cohort study. Dutta D. Emerg Med J. 2016 Apr 7. pii: emermed-2015-205519. doi: 10.1136/emermed-2015-205519. [Epub ahead of print] Bystander cricothyrotomy with ballpoint pen: a fresh cadaveric feasibility study. Kisser U. Emerg Med J. 2016 Apr 19. pii: emermed-2015-205659. doi: 10.1136/emermed-2015-205659. [Epub ahead of print] Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Leisman D. Ann Emerg Med. 2016 Apr 14. pii: S0196-0644(16)00148-7. doi: 10.1016/j.annemergmed.2016.02.044. [Epub ahead of print] CT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study. Marincowitz C. Emerg Med J. 2016 Apr 13. pii: emermed-2015-205370. doi: 10.1136/emermed-2015-205370. [Epub ahead of print]

Ep #21 Ketamine Induced Rapid Sequence Intubation with Faizan H. Arshad, MD @emscritcare Happy #EMSWeek #EMSStrong #EMSNation   SKEPTIC = Safety & Efficacy of Ketamine in Emergent Prehospital Tracheal Intubation – a Case Series   Brand new paper from Sydney HEMS on Ketamine and Shock Index in Annals of EM! http://www.annemergmed.com/article/S0196-0644(16)30002-6/abstract   Additional References: Carlson JN, Karns C, Mann NC, et al. Procedures performed by emergency medical services in the united states.Prehosp Emerg Care. 2015. Jacobs PE, Grabinsky A. Advances in prehospital airway management.International Journal of Critical Illness & Injury Science. 2014;4:57-64. Prekker ME, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea TD. The process of prehospital airway management: Challenges and solutions during paramedic endotracheal intubation.Crit Care Med. 2014;42:1372-1378. Wang HE, Kupas DF, Greenwood MJ, et al. An algorithmic approach to prehospital airway management.Prehospital Emergency Care. 2005;9:145-155. Mace SE. Challenges and advances in intubation: Airway evaluation and controversies with intubation.Emerg Med Clin North Am. 2008;26:977-1000. Combes X, Jabre P, Jbeili C, et al. Prehospital standardization of medical airway management: Incidence and risk factors of difficult airway.Acad Emerg Med. 2006;13:828-834. Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity. Br J Anaesth. 1996;76:663-667. Jackson APF, Dhadphale PR, callaghan ML, Alseri S. Haemodynamic studies during induction of anaesthesia for open-heart surgery using diazepam and ketamine. Br J Anaesth. 1978;50:375-378. Price B, Arthur AO, Brunko M, et al. Hemodynamic consequences of ketamine vs etomidate for endotracheal intubation in the air medical setting. Am J Emerg Med. 2013;31:1124-1132. Scherzer D, Leder M, Tobias JD. Pro-Con Debate: Etomidate or Ketamine for Rapid Sequence Intubation in Pediatric Patients. J Pediatr Pharmacol Ther. 2012;17:142-149. Bruder Eric A, Ball Ian M, Ridi S, Pickett W, Hohl C. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients.Cochrane Database of Systematic Reviews. 2015 Thompson Bastin ML, Baker SN, Weant KA. Effects of Etomidate on Adrenal Suppression: A Review of Intubated Septic Patients.Hospital Pharmacy. 2014;49:177-183. Arnold C. The promise and perils of ketamine research Ketamine began its life as an anaesthetic , but has enjoyed a recent renaissance as a potential. Lancet Neurol. 2013;12:940-941. Craven R. Ketamine. Anaesthesia. 2007;62:48-53. Perkins ZB, Gunning M, Crilly J, Lockey D, O’Brien B. The haemodynamic response to pre-hospital RSI in injured patients. Injury. 2013;44:618-623. Aroni F, Iacovidou N, Dontas I, Pourzitaki C, Xanthos T. Pharmacological Aspects and Potential New Clinical Applications of Ketamine: Reevaluation of an Old Drug. J Clin Pharmacol. 2009;49:957-964. Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation.J Emerg Med. 2010;38:622-631. Kohrs R, Durieux ME. Ketamine. Anesth Analg. 1998;87:1186-1193. Moy RJ, Clerc S Le. Trends in Anaesthesia and Critical Care Ketamine in prehospital analgesia and anaesthesia. Trends Anaesth Crit Care. 2011;1:243-245. Reich DL, Silvay G. Ketamine: an update on the first twenty-five years of clinical experience. Can J Anaesth. 1989;36(2):186-197. Porter K. Ketamine in prehospital care. Emerg Med J. 2004;21:351-354. Svenson JE, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007;25:977-980. Johansson J, Sjöberg J, Nordgren M, Sandström E, Sjöberg F, Zetterström H. Prehospital analgesia using nasal administration of S-ketamine--a case series. Scand J Trauma Resusc Emerg Med. 2013;21:38. Filanovsky Y, Miller P, Kao J. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. Can J Emerg Med. 2010;12:154-201. Himmelseher S, Durieux ME. Revising a Dogma: Ketamine for Patients with Neurological Injury? Anesth Analg. 2005;101:524-534. Kropf J a., Grossman MD, Genzlinger M a., Stoltzfus J, Stehly CD. 328 Ketamine versus Etomidate for Rapid Sequence Intubation in Traumatically Injured Patients: An Exploratory Study. Ann Emerg Med. 2012;60:S117. Angus DC, van dP. Severe sepsis and septic shock.N Engl J Med. 2013;369:840-851. Jabre P, Avenel A, Combes X, et al. Morbidity related to emergency endotracheal intubation-A substudy of the KETAmine SEDation trial. Resuscitation. 2011;82:517-522. Shafi S, Gentilello L. Pre-Hospital Endotracheal Intubation and Positive Pressure Ventilation Is Associated with Hypotension and Decreased Survival in Hypovolemic Trauma Patients: An Analysis of the National Trauma Data Bank. The Journal of Trauma: Injury, Infection, and Critical Care. 2005;59:1140–1147. Seymour CW, Band RA, Cooke CR, et al. Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study.J Crit Care. 2010;25:553-562. Williams E, Arthur a., Price B, Banister NJ, Goodloe JM, Thomas SH. 175 Ketamine versus Etomidate for Use in Helicopter Emergency Medical Services Endotracheal Intubation. Ann Emerg Med. 2012;60:S63-S64 Bruns, B, Gentilello, L, Elliott, A, Shafi, S. Prehospital Hypotension Redefined. The Journal of Trauma: Injury, Infection, and Critical Care. 2008;65:1217–1221. Seymour, CW, Cooke, CR, Heckbert, SR, et al. Prehospital Systolic Blood Pressure Thresholds: A Community-based Outcomes Study. Acad Emerg Med Academic Emergency Medicine. 2013;20:597–604. Kristensen AKB, Holler JG, Mikkelsen S, Hallas J, Lassen A. Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study.Critical Care. 2015;1:158. Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84:1500-1504. Salt PJ, Baranes PK, Beswick FJ. Inhibition of neuronal and extraneuronal uptake of noradrenaline by ketamine in the isolated perfused rat heart. Br J Anaesth. 1979;51:835-838. Sprung J, Schuetz SM, Stewart RW, Moravec CS. Effects of Ketamine on the Contractility of Failing and Nonfailing Human Heart Muscles in Vitro. Surv Anesthesiol. 1999;43:230-231. Kunst G, Martin E, Graf BM, Hagl S, Vahl CF. Actions of Ketamine and Its Isomers on Contractility and Calcium Transients in Human Myocardium. Anesthesiology. 1999;90:1363-1371. Lundy PM, Lockwood PA, Thompson G, Frew R. Differential Effects of Ketamine Isomers on Neuronal and Extraneuronal Catecholamine Uptake Mechanisms. Anesthesiology. 1986;64:359-363. Selde W. Push dose epinephrine. A temporizing measure for drugs that have the side-effect of hypotension.JEMS. 2014;39:62-63.   Sponsored by @PerfectCPR Apple Watch App with Audio and Haptic Feedback to Optimize Cardiac Arrest Training and Improve Quality of CPR Delivery PerfectCPR.com     Query us on Twitter: www.twitter.com/EMS_Nation Like us on Facebook: www.facebook.com/prehospitalnation   Wishing Everyone a safe tour! ~Faizan H. Arshad, MD @emscritcare www.emsnation.org  

Hosted by Dr. Brian Hayes, Drs. Kevin Scott and Mira Mamtani, authors of 'Integration of Social Media in Emergency Medicine Residency Curriculum', join Drs. Stella Yiu, Michael Gisondi and Seth Trueger to discuss the importance of how social media is being used in the EM educational curriculum. Read the Perspective Article here: http://www.annemergmed.com/article/S0196-0644(14)00489-2/pdf Read more here: http://www.aliem.com/2014/social-media-in-the-em-curriculum-annals-em-resident-perspective-article/ Watch the hangout here: https://www.youtube.com/watch?v=kyeTj7SXzCI

BLS CPAP / JEMS: http://www.jems.com/articles/print/volume-38/issue-11/patient-care/argument-bls-cpap.html   Optimizing Preoxygenation, Delayed Sequence Intubation: Must read: http://emcrit.org/preoxygenation Paper in Annals @emcrit @mdaware: http://www.annemergmed.com/article/S0196-0644(14)01365-1/abstract LITFL DSI: http://lifeinthefastlane.com/ccc/delayed-sequence-intubation/     Follow us on Twitter: www.twitter.com/EMS_Nation Like us on Facebook: www.facebook.com/prehospitalnation   Wishing Everyone a safe tour! ~Faizan H. Arshad, MD www.emsnation.org

In this episode we talk to Dr. Kathryn Weibrecht about a US case of mustard exposure and how to identify and treat these cases. MMWR case series can be found here and a link to the case in Annals can be found here. Contributors include Matthew Zuckerman and Kat Weibrecht.