Podcasts about take home points

We discuss the injuries sustained from smoke inhalation. Hosts: Sarah Fetterolf, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Smoke_Inhalation.mp3 Download Leave a Comment Tags: Environmental, Toxicology Show Notes Table of Contents 00:37 – Overview of Smoke Inhalation Injury 00:55 – Three Key Pathophysiologic Processes 01:41 – Physical Exam Findings to Watch For 02:12 – Airway Management and Early Intervention 03:23 – Carbon Monoxide Toxicity 04:24 – Workup and Initial Treatment of CO Poisoning 06:14 – Cyanide Toxicity 07:19 – Treatment Options for Cyanide Poisoning 09:12 – Take-Home Points and Clinical Pearls Physiological Effects of Smoke Inhalation: Thermal Injury: Direct upper airway damage from heated air or steam. Leads to swelling, inflammation, and possible airway obstruction. Chemical Irritation: Causes bronchospasm, mucus plugging, and inflammation in the lower airways. Increases capillary permeability, potentially causing pulmonary edema. Systemic Toxicity: Primarily involves carbon monoxide and cyanide poisoning.

We sit down with one of our toxicologists to discuss acetaminophen toxicity. Hosts: Marlis Gnirke, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acetaminophen_Toxicity.mp3 Download One Comment Tags: Toxicology Show Notes Table of Contents 0:35 – Hidden acetaminophen toxicity in OTC products 3:24 – Pharmacokinetics and toxicokinetics  6:06 – Clinical Course 9:22 – The antidote – NAC 11:02 – The Rumack-Matthew Nomogram  17:36 – Treatment protocols 22:34 – Monitoring and Lab Work 23:23 – Considerations when treating pediatric patients 23:57 – IV APAP overdose, fomepizole  25:42 – Take Home Points Acetaminophen vs. Tylenol: The importance of recognizing that acetaminophen is found in many products beyond Tylenol. Common medications containing acetaminophen, such as Excedrin, Fioricet, Percocet, Dayquil/Nyquil, and others. The risk of unintentional overdose due to combination products. Prevalence of Acetaminophen Toxicity:

We review Sexually Transmitted Infections and pertinent updates in diagnosis and management. Hosts: Avir Mitra, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Sexually_Transmitted_Infections_2_0.mp3 Download Leave a Comment Tags: gynecology, Infectious Diseases, Urology Show Notes Table of Contents (1:49) Chlamydia  (3:31) Gonorrhea (4:50) PID (6:14) Syphilis (8:08) Neurosyphilis  (9:13) Tertiary Syphilis (10:06) Trichomoniasis  (11:13) Herpes (12:49) HIV (14:10) PEP (15:13) Mycoplasma Genitalium  (18:00) Take Home Points Chlamydia: Prevalence: Most common STI. High percentage of asymptomatic cases (40% to 96%). Presentation: Urethritis, cervicitis, pelvic inflammatory disease (PID), prostatitis, proctitis, pharyngitis, arthritis. Importance of considering extra-genital sit...

PediPal goes on the road! Dan brings his microphone to Phoenix, AZ, for the 2024 Annual Assembly of Hospice and Palliative Medicine, ambushing unsuspecting guests with that classic PediPal question, "What are your take-home points?" Sarah, unable to attend the conference, shares her take-homes from home.Major thanks to AAHPM and all our enthusiastic participants: Tyler Badding, Gabe Daniels, Kelstan Ellis, Rachel Kentor, Jen Hwang, Matt McEvoy, Jennifer Salant, Alexis Santos, Meghna Singh, and Claire Slusarz, as well as #1 Fan Jared Rubenstein and #1 Fan Conrad Williams.

We are wrapping up the latest Lifecycle Nutrition Series on the podcast.In the past 7 episodes we've covered...- Nutrition for Preconception- Nutrition for Pregnancy- Nutrition for Postpartum/Breastfeeding- Infant Nutrition (0-6 months)- Baby Nutrition (6-12 months)- Toddler Nutrition (1~3 years)- Childhood, Adolescent, Teenage Nutrition (4~18 years)Dr. Susanna also shared her personal pregnancy and postpartum experience and tips to thrive in Episode #384.This week is a little wrap up and summary of the highlights from this series as well as the most important takeaways. Episode Highlights:The different nutritional needs that kids have compared to adultsThe importance of healthy relationships with food and nourishment during growth and developmentWhat Dr. Susanna learned and insights gained through the last ~2months of this seriesWhere supplements fit in (or not) at different lifecycle phasesAn exciting opportunity to optimize your health and nutritional status, regardless of where you are in your lifecycle!Links to some more good stuff- ALL NEW EAT MORE, WEIGH LESS PROGRAM - www.alter.health/eat-more-weigh-less- 1-on-1 Nutritional Analysis Package - www.alter.health/nutritional-analysis - Get the Alter Health weekly WFPB Meal Guides: www.alter.health/meal-guides- Work with us in the Thrive on Plants program: www.alter.health/thrive-on-plants

In part III, Adrian and Shaun put the "fun" in index funds by discussing the benefits and components of a written investment plan. These fiscally frugal wolves of Wall Street talk investing and provide 13 Take Home Points to empower you to improve your financial literacy. 

Dr. Monica Saxena JD, MD joins us to discuss the recent overturning of Roe v. Wade. How will this affect access to abortions, particularly for marginalized communities? What relevance does this ruling have to the role of the EM physician in caring for emergencies in pregnancy?  What role with the emergency department play in states that allow and don't allow abortions? What actions may we take for our patients, in the ED and outside the ED? Objectives   1. Explore the changing landscape of safe abortion access in the US 2. Learn how your practice in the emergency department may be affected by the decision to overturn Roe v. Wade, including implications for pregnancy related complaints that include terminataion of pregnancy as treatment (for both states where abortions remain legal and where they do not). 3. Learn what resources exist for you and your patients to navigate safe abortion access in the post-Roe era 4. Learn how you can help restore access to safe abortions    Take Home Points 1. The Supreme Court decision means that regulations or lack of regulation around abortion will be left up to the states. This creates a lot of variation as well as uncertainty.   2. Termination of pregnancy is the indicated medical procedure for many complications of pregnancy. In states where termination of pregnancy is banned after a certain amount of weeks or band altogether, the emergency physician may have to wait to intervene until  her patient is unstable or may have to transfer her.   3. EMTALA is a federal law which supersedes any state law, however it necessitates the stabilization of patients. In some interpretations, a woman with an emergency related to her pregnancy may have to be unstable prior to the physician intervening.   4. The legality around abortion is changing rapidly. The result is that medical decisions are sometimes being legislated in the emergency department. This is dangerous for patients and physicians.   5. These laws promote health equity and social injustice as they differentially affect states where there is a larger population of people of color and indigenous peoples.   6. Physicians interested in helping can do so in the following three ways: a) Advocate for a change with your national college. For us that is the American College of Emergency Physicians and the Society of Academic Emergency Medicine   b) familiarize yourself with what options your patients have and where they can turn to for resources. It may be possible to get training in medical abortion depending on where you live   c) states where abortion remains legal will see an Increasing volume of patients seeking termination of pregnancy. There may be scope to to set up innovative programs for medical termination in the emergency department   Resources Abortion providers near you: https://abortionfinder.org/  Teleabortions: https://mychoix.co/ Emergency Medicine and Reproductive Health in a Post-Row Landscape  Kelli L. Jarrell et al Monica Saxena: saxenam@stanford.edu   Guest Monica Saxena is an assistant professor of Emergency Medicine at Stanford School of Medicine. She is also a JD who has been involved in reproductive rights and women's health for more than a decade. Dr. Saxena initiated an ED protocol for elective termination of first trimester pregnancy in the ED.   Contributors: Payal Modi

Sila Bal, MD, MPH, continues her discussion with guest Elizabeth Shanika Esparaz, MD, in the second of a two-part episode of Pupil Pod's diabetic retinopathy series. In the previous episode, Drs. Bal and Esparaz broke down the risks associated with proliferative diabetic retinopathy (PDR). This episode dives into the take-home points and clinical applications from the Diabetic Retinopathy Study and other research, and Dr. Esparaz shares her approach to treating patients with high-risk PDR and clinically significant diabetic macular edema in her practice.

Shelley Kovar was in the same job in a small town in Michigan for 25 years when she began getting asked to help with social media marketing by local small business owners. Shelley didn't know a lot about Facebook, but she decided to say "yes!" and figure it out as she went. Her inspiring story proves you can branch out and try new things and you can be successful in any size community. Take-Home Points! Pay attention when multiple people start asking you for your advice or for you to do something for them, this means there's a need in the market and it means they believe you're good at it Even in a small town you can be an entrepreneur and grow a business. The key is to build the know, like, and trust factor. Nurture it. Look for a need and fill it. When you need to uplevel but you don't have teachers around you to help you grow, invest in yourself. Sign up for a course or class. You can't get to where you want to go if you don't have people around you to teach and push you to grow. Use discomfort to make you grow or light a fire under your bum. You ARE the company and you need to invest back in the company. Being around high-energy people will fill your cup up. Look at it as continuing education. Invest in yourself. Seek out positive podcasts, books, and mentors Work smarter, not harder (batch your posts, batch your cooking) You don't have to be everyone's perfect person, when you make a mistake, you're your biggest critic. Instead, use the discomfort of imperfection to light a fire =under your bum to make you grow. Don't be afraid of C+ work

Scripture: Jeremiah 18:1-11 (Message Version) Thoughts to consider: 1. If you want to move the heart of the nation, you need to move the hearts of the people. 2. We love to provide external solutions for internal problems, but this doesn't create lasting and sustainable change. Take-Home Points: 1. Listen to the prophets. 2. Learn humility and kindness toward others (especially those with whom you disagree). 3. Look for change inwardly before doing so outwardly. 4. Live as though the world you desire to create already has the capacity to exist within you.

A discussion with Drs. McNamara and Leifer on the essentials and beyond of debriefing Hosts: Brian Gilberti, MD Audrey Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Debriefing.mp3 Download Leave a Comment Tags: Resuscitation, Simulation Show Notes TAKE HOME POINTS Debriefing after a clinical case in the ED is a way to have an interprofessional, reflective conversation with a focus on improving for the next patient.  We can debrief routine cases, challenging cases, or even cases that go well. Follow a structure when leading a debrief. The prebrief sets ground rules and informs the team that the debrief is optional and will only take 3-5 minutes. Introduce names and roles Then give a one-liner about what happened in the case, followed by a plus/ delta: address  what went well and why, then how to improve Finally, wrap up with take home points Pitfalls to watch out for in clinical debriefing include: Avoid siloing or alienating any learners.  Learn from all your colleagues on your team- it's less about medicine and more about interprofessional and systems issues Don't pick on individual performance.  It's not about shaming- it's about improving patient care Avoid “guess what I'm thinking” questions; ask real questions Proceed with caution in order to dampen or avoid psychological trauma and second victim syndrome.  The learner may ask “was this my fault?”; we never want a learner to feel this way.  Ask, what systems supported or did not support you today?  Talk about what happened.  Avoid shame and blame. Have the right values and do it for the right reasons. ADDITIONAL TOOLS

This week we discuss the difficult to diagnose and high morbidity cauda equina syndrome. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_151_0_Final_Cut.m4a Download Leave a Comment Tags: Back Pain, Cauda Equina Show Notes Take Home Points Cauda equina syndrome is a rare emergency with devastating consequences Early recognition is paramount as the presence of bladder dysfunction portends bad functional outcomes The presence of bilateral lower extremity weakness or sensory changes should alert clinicians to the diagnosis. Saddle anesthesia (or change in sensation) and any bladder/bowel changes in function should also raise suspicion for the disorder MRI is the diagnostic modality of choice though CT myelogram can be performed if necessary Prompt surgical consultation is mandatory for all patients with cauda equina syndrome regardless of symptoms at presentation Read More EM Cases: Best Case Ever 11: Cauda Equina Syndrome OrthoBullets: Cauda Equina Syndrome Radiopaedia: Cauda Equina Syndrome Perron AD,

This week the podcast features a lecture from Dr. Frosso Admakos - Assistant Residency Director at Metropolitan Hospital in NYC https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_149_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, Pediatrics, Trauma Show Notes Take Home Points While peds traumas and severe traumas are uncommon, stay cool and collected – you've run many resuscitations in the past and resuscitating a kid is no different. You've got this When it comes to access, think 1, 2 IO. 2 shots at a peripheral line and if you don't get it, go to IO Tachycardia should be assumed to be compensated shock until proven otherwise. Don't write tachycardia off as anxiety Failed airway approach – place an 18 gauge catheter into the neck – hopefully through the cricothyroid membrane and bag through that. If you still have difficult getting an airway from above, consider a retrograde intubation over a wire Read More University of Maryland EM: Retrograde Intubation Read More

This episode reviews the highlights from the recent ACEP clinical policy on acute VTE management in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_148_0_Final_Cut.m4a Download Leave a Comment Tags: Deep Venous Thrombosis, DVT, PE, Pulmonary Embolism, VTE Show Notes Take Home Points The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing. Age-adjusted D-dimers are ready for use and it doesn't matter if your assay uses FEU (cutoff 500) or DDU (cutoff 250). For FEU use an upper limit of 10 X age and for DDU use an upper limit of 5 X age. For now, subsegmental PEs should continue to routinely be anticoagulated even in the absence of a DVT. Keep an eye out for more research on this area. Although outpatient management of select PE patients (using sPESI or Hestia criteria) may be standard practice, the evidence wasn't strong enough for ACEP to give it's support Patients with DVT can be started on a NOAC and discharged from the ED

This episode reviews the identification and management of patients with salicylate toxicity. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_147_0_Final_Cut.m4a Download 4 Comments Tags: Aspirin, Salicylate, Toxicology Show Notes Take Home Points Always consider salicylate toxicity: In patients with tachypnea, hyperpnea, AMS and clear lungs In the presence of an anion gap metabolic acidosis with a respiratory alkalosis Treat salicylate toxicity by alkalinizing the blood and urine to increase excretion Avoid intubation until absolutely necessary. If you do have to intubate, minimize apneic time and consider awake intubation and nake sure your ventilator settings match the patient's necessary high minute ventilation Think about chronic salicylate toxicity in unexplained altered mental status, tachypnea or metabolic acidosis in elderly Know indications for hemodialysis in salicylate toxic patients Read More REBEL EM: Salicylate Toxicity LITFL: Salic...

More pearls from our fantastic morning report series at Bellevue. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_146_0_Final_Cut.m4a Download Leave a Comment Tags: Endocarditis, Ludwig's Angina, Penetrating Neck Trauma Show Notes Take Home Points In patients with neck pain, consider Ludwig's angina particularly if they have any swelling, fever, truisms or respiratory difficulty. Consider early airway management and get your consultants involved early for operative management Endocarditis is a tricky diagnosis and will often be subtle. Any patient with a prosthetic valve and a fever has endocarditis until proven otherwise. Suspect it in any patient with fever and a murmur, get lots of cultures and remember that TEE is the gold standard but, TTE is highly specific Finally, penetrating neck trauma. Patients with hard signs – airway compromise, ongoing brisk bleeding, an expanding/pulsatile hematoma, neurologic compromise, shock or hematemesis should go directly to the OR and don't probe the wounds!

This week we dive into rhinosinusitis exploring the recommendations of who needs antibiotics and who doesn't. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_144_0_Final_Cut.m4a Download Leave a Comment Tags: Acute Bacterial Sinusitis, ENT, Sinusitis Show Notes Take Home Points Acute rhinosinusitis is a clinical diagnosis The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement. Read More Core EM: Acute Rhinosinusitis TheNNT.com: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults TheNNT.com: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Read More

This week we review the presentation, examination and diagnosis of testicular torsion. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_143_0_Final_Cut.m4a Download Leave a Comment Tags: Acute Scrotal Pain, Torsion, Urology Show Notes Take Home Points Consider the diagnosis of testicular torsion in all patients with acute testicular pain Testicular torsion is a surgical emergency that requires immediate urologic consultation to increase the rate of tissue salvage. History, physical examination and ultrasound are all flawed in making the diagnosis. The gold standard is surgical exploration Consider manual detorsion in patients where consultation will be delayed Show Notes Core EM: Testicular Torsion Ben-Israel T et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28:786-789. Sidler D et al. A 25-year review of the acute scrotum in children. S Afr Med J. 1997;87(12) 1696-8. PMID: Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID: Ban KM, Easter JS: Selected Urologic Problems; in Marx J...

This week we discuss more pearls from our morning report conference on APE, SAH and caustic ingestions. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_142_0_Final_Cut.m4a Download Leave a Comment Tags: APE, Cardiology, Caustic Ingestions, CHF, SAH, SCAPE, Subarachnoid Hemorrhage, Toxicology Show Notes Take Home Points In patients with APE, give high-dose nitro to decrease after load and preload quickly. 400-500 mcg/min for the first 4-5 minutes is my standard approach Consider DSI to facilitate pre-oxygenation. Ketamine is your go to drug here A NCHCT performed within 6 hours of symptom onset is extremely sensitive for ruling out SAH but, nothing is 100%. If you've got a high-risk patient, you should still consider LP Patients with caustic ingestions can have rapidly deteriorating airways. Prepare early and be ready to take over the airway at a moments notice Read More Core EM: Acute Pulmonary Edema EMCrit:

More pearls from our fantastic morning report series. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_134_0_Final_Cut.m4a Download 2 Comments Tags: ALL, Altered Mental Status, Hyperleukocytosis, Hyponatremia, Leukostasis Show Notes Take Home Points 1. When seeing patients with AMS, think of the 5 broad categories of pathologies – VS abnormalities, toxic-metabolic, infectious causes, CNS abnormalities and, lastly as a diagnosis of exclusion – psychiatric issues 2. In kids with AMS, think of zebra diagnoses and toxic ingestions and remember that primary psychosis is rare 3. Patients with ALL are susceptible to developing hyperleukocytosis. If the WBC is > 100K, think about getting hematology on the line to initiate chemo induction and leukopheresis 4. Always think about electrolyte disorders, particularly hypoNa in patients with global AMS. Remember to treat severe hypoNa w/ hypertonic saline and, to correct slowly as to avoid ODS Read More LITFL: HSV Encephalitis EM Cases: Episode 60 – Emergency Management of Hyponatremia

This week we dive in to the initial trauma assessment. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_133_0_Final_Cut.m4a Download Leave a Comment Tags: ABCDEs, Trauma Show Notes Take Home Points Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team Complete the primary survey (ABCDEs) and address immediate life threats Round out your assessment with a good medical history and remember to complete a comprehensive head-to-toe exam Read More Shlamovitz GZ, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007;50(1):25-33, 33.e1. PMID: 17391807 ER Cast: Gunshot to the Groin with Kenji Inaba EM:RAP: Do We Still Need The C-Collar? YouTube: Death of the Dinosaur: Debunking Trauma Myths by Dr. S.V. Mahadevan REBEL EM:

This week we dive into the rare but potentially fatal, and difficult to diagnose, air embolism. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_132_0_Final_Cut.m4a Download 2 Comments Tags: Air Embolism, Central Lines, Hyperbaric Oxygen Show Notes Take Home Points Air embolism is a rare but potentially fatal complication of central line placement and some surgical procedures and of course of as the result of barotrauma. Recognizing the signs and symptoms of air embolism can be tricky because it will look like any other ischemic process.  Consider air embolism if you have a patient that rapidly decompensates after placement of a central line, the most likely culprit for those of us in the ED. Treatment should focus on supportive cares.  Give supplemental O2, IV fluids and hemodynamic support and consider hyperbarics and cardiopulmonary bypass for the super sick patient. Show Notes Core EM: Air Embolism Blanc et al. Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation. Intensive Care Med. 2002; 28(5): 559-63. PMID 12029402

This week we explore the presentation, diagnosis and management of SBP. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_131_0_Final_Cut.m4a Download Leave a Comment Tags: Gastroenterology, Infectious Diseases, SBP Show Notes Take Home Points SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL) Read More Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen's Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205. REBEL EM: Spontaneous Bacterial Peritonitis EMRAP: C3 Live Paracentesis Video LITFL: Spontaneous Bacterial Peritoniti...

Another set of high-yield pearls coming out of our morning report conferences. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_130_0_Final_Cut.m4a Download Leave a Comment Tags: Babesiosis, Carbon Monoxide, Doxycycline, Myasthenia Gravis, Tick-Borne Illnesses Show Notes Take Home Points Non-specific viral syndromes are usually just that, a viral syndrome but, be cautious as a number of more serious ailments can present similarly. This includes tick borne illnesses, acute HIV and carbon monoxide Doxycycline is safe in kids. The dental staining seen with tetracycline is specific to that drug, not the class. If doxy is the best drug for the disease, use it. Lots of meds can lead to a myasthenia gravis exacerbation. Carefully review meds before prescribing for interactions Read More CDC: Research on Doxycycline and Tooth Staining Core EM: Episode 96.0 – Carbon Monoxide Poisoning Sinai EM: Succinycholine in Myasthenia Gravis

We welcome Meghan Spyres back to the podcast to discuss toxic alcohol ingestion diagnosis and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_129_0_Final_Cut.m4a Download Leave a Comment Tags: Ethylene Glycol, Fomepizole, Methanol, Toxic Alcohols, Toxicology Show Notes Take Home Points Suspect a toxic alcohol in any patient with a large osmol gap or a large anion gap metabolic acidosis and consider treating these patients empirically. Fomepizole is the critical antidote for toxic alcohol ingestions but, patients are likely going to require dialysis as well. Call your local poison control center if you suspect a toxic alcohol ingestion to help guide management. Read More LITFL: Toxic Alcohol Ingestion ER Cast: Mind the Gap: Anion Gap Acidosis FOAMCast: Episode 43 – Alcohols Read More

This week we talk about the subacute headache and the dangerous, can't miss diagnoses of cerebral venous thrombosis and IIH https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_127_0_Final_Cut.m4a Download Leave a Comment Tags: Cerebral Venous Sinus Thrombosis, Headache, Neurology Show Notes Take Home Points Keep IIH and CVST on the differential for patient's coming in with a subacute headache, particularly if they have visual or neuro symptoms. Consider an ocular ultrasound! It's quick, shockingly easy to do, and can help point you toward a diagnosis you may have otherwise overlooked.  I have made it my practice now to include a quick look in the physical exam of my patients with a concerning sounding headache or a headache with neurologic symptoms.  Consider IIH particularly in an overweight female of child bearing age with a subacute headache, but remember patients outside that demographic can have IIH as well. Consider CVST in a patient with a thrombophilic process like cancer, pregnancy or the use of OCPs or androgens or in a patient with a recent facial infection like sinusitis or cellulitis. Read More WikEM: Idiopathic Intracra...

This week we discuss the uncommon but must make diagnosis of flexor tenosynovitis https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_126_0_Final_Cut.m4a Download Leave a Comment Tags: Hand, Kanavel Signs, Orthopedics, Soft Tissue Infections Show Notes Take Home Points Think about flexor tenosynovitis in a patient with atraumatic finger pain.  They may have any combination of these signs: Tenderness along the course of the flexor tendon Symmetrical swelling of the finger – often called the sausage digit Pain on passive extension of the finger and Patient holds the finger in a flex position at rest for increased comfort Give antibiotics to cover staph, strep and possibly gram negatives. Get your surgeon to see the patient, while we can get the antibiotics started, these patients need admission and may require surgical intervention. Infographic

This week we discuss a quick case leading into the management of MALA. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_124_0_Final_Cut.m4a Download 2 Comments Tags: Metformin, Toxicology Show Notes Take Home Points In patients with shortness of breath and clear lungs, consider metabolic acidosis with respiratory alkalis as a potential cause Suspect MALA in any patient on metformin who presents with abdominal pain, nausea and vomiting and/or AMS Patients with MALA will have a low pH, a high-anion gap metabolic acidosis and high lactate levels Call your tox consultant to assist with management which will focus on fluid resuscitation with isotonic bicarbonate and dialysis Read More Bosse GM. Antidiabetics and Hypoglycemics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Accessed October 31, 2017 LITFL: Metformin-Associated Lactic Acidosis LITFL: Metfo...

This week we dive into a recent journal article questioning whether we should tap all ascites. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_123_0_Final_Cut.m4a Download Leave a Comment Tags: Albumin, Cirrhosis, Paracentesis, SBP, Spontaneous Bacterial Peritonitis Show Notes Take Home Points SBP is a difficult diagnosis to make clinically. While patients may have the triad of fever, abdominal pain and increasing ascites, they are far more likely to only have 1 or 2 of these symptoms In patients admitted to the hospital with ascites, consider performing a diagnostic paracentesis on all patients as limited literature shows an association with decreased mortality and, the procedure is simple and low risk Once you get the fluid, focus on the cell count: WBC > 500 or PMN > 250 should prompt treatment with a 3rd generation cephalosporin and albumin infusion Gaetano et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. Journal of Gastroenterology and Hepatology 2016. PMID: 26642977 Read More EMRAP: C3 Live Paracentesis Video

This week we discuss the tibio-femoral knee dislocation focusing on identification of the dangerous complications. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_122_0_Final_Cut.m4a Download Leave a Comment Tags: Knee Dislocation, Orthopedics, Popliteal Artery Show Notes Take Home Points Up to 50% of true knee dislocations will spontaneously reduce prior to arrival. Be suspicious of a dislocation in any patient who describes the joint moving out of place or if they have significant swelling, joint effusion or ecchymosis despite normal X-rays In all patients with suspected dislocation, perform a neurovascular exam immediately as popliteal artery injury is common. If they've got an absent DP or PT pulse, reduce immediately and get a CT angiogram as quickly as possible to assess for popliteal injuries If distal pulses are intact, you can either do ABIs and if normal, observe and repeat them or get a CTA. If the ABI is abnormal or the patient had an absent or decreased pulse at any point, get the CTA Read More OrthoBullets: Knee Dislocation Radiopaedia: Knee Dislocation EM: RAP: Obese Patient and Knee Dislocations

This week we dive into the diagnosis and management of pancreatitis in the ED https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_121_0_Final_Cut.m4a Download Leave a Comment Tags: Gastroenterology, GI, Pancreatitis Show Notes Ranson's Criteria for Pancreatitis-Associated Mortality (Rosen's) Take Home Points Pancreatitis is diagnosed by a combination of clinical features (epigastric pain with radiation to back, nausea/vomiting etc) and diagnostic tests (lipsae 3x normal, CT scan) A RUQ US should be performed looking for gallstones as this finding significantly alters management The focus of management is on supportive care. IV fluids, while central to therapy, should be given judiciously and titrated to end organ perfusion Patients will mild pancreatitis who are tolerating oral intake and can reliably follow up, can be discharged home

This week we discuss common bites, stings and envenomations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_120_0_Final_Cut.m4a Download Leave a Comment Tags: Bee Sting, Black Widow, Brown Recluse Spider, Hymenoptera Show Notes Take Home Points The most common bites and stings you will see are by bees and ants.  These can present as a local reaction, toxic reaction, anaphylaxis or delayed reaction.  For all of these, treat with local wound care and epinephrine for any systemic symptoms. The brown recluse spider is found in the Midwest and presents as local pain and swelling but carries the risk of a necrotic ulcer The black widow spider is found all around the US and presents with either localized or generalized muscle cramping, localized sweating and potentially tachycardia and hypertension.  Treatment is symptom management with analgesics and benzos. The bark scorpion usually presents with localized pain and swelling, but particularly in children, may present with a serious systemic presentation including jerking muscle movements, cranial nerve dysfunction, hypersalivation, ataxia and opsoclonus, which is the rapid, involuntary movement of the eyes in all directions. Treatment is supportive cares, but remember to call your poison center to ask about antivenin.

This week we review 4 articles discussed in our conference in the last month. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_119_0_Final_Cut.m4a Download Leave a Comment Tags: ACS, AMI, Cardiac Arrest, Cardiology, Oxygen, Pediatrics, POCUS, Syncope Show Notes Take Home Points Tachycardia in peds patients at discharge was associated with more revisits but not with more critical interventions. If your workup is reassuring, isolated tachycardia in and of itself shouldn't change your disposition. Supplemental O2 is not necessary in the management of AMI patients with an O2 sat > 90% and, may be harmful Until further study and prospective validation has been performed, we're not going to recommend embracing the Canadian decision instrument on predicting dysrhythmias after a syncopal event. Finally, our agreement on what cardiac standstill is isn't great. We need a unified definition going forward to teach our trainees and for the purposes of research. Read More Core EM: ED POCUS in OHCA –...

Part II of II on gallbladder disorders finishing up with acute cholangitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_118_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder, Gastroenterology, General Surgery, GI Show Notes Take Home Points Cholangitis is an acute bacterial infection of the bile ducts resulting from common bile duct obstruction and is potentially life-threatening (mortality 5-10%, acute bacterial infection of the bile ducts Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic. Look for RUQ tenderness with peritoneal signs and fever A normal ultrasound does not rule out acute cholangitis Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery) Read More Radiopaedia: Acute cholangitis Core EM: Cholangitis Read More

Part I of II on gallbladder pathology starting with cholecystitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_117_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder, Gastroenterology, General Surgery, GI Show Notes Take Home Points Acute cholecystitis is an inflammation of the gallbladder and is a clinical diagnosis. Imaging can be helpful but US and CT can both have false negatives. Lab tests are insensitive and non-specific and, as such, they can neither rule in or rule out the diagnosis. Treatment focuses on fluid resuscitation when indicated, supportive care, antibiotics and surgical consultation for cholecystectomy Although uncommon, be aware that patients can develop gangrene, necrosis and perforation as well as frank sepsis and require aggressive resuscitation Read More Core EM: Acute Cholecystitis Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen's Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205. Leschka S et al. Chapter 5.1: Acute abdominal pain: diagnostic strategies In: Schwartz DT: Emergen...

This week we sit down with toxicologist Meghan Spyres to talk about Wernicke's Encephalopathy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_115_0_Final_Cut.m4a Download Leave a Comment Tags: Alcohol Abuse, Thiamine, Toxicology, Wernicke's Encephalopathy Show Notes Take Home Points Consider the diagnosis in all patients with nutritional deficiencies, not just alcoholics. Look for ophthalmoplegia, ataxia and confusion in patients that have risk factors for thiamine deficiency. Don't think that it can't be Wernicke's because the triad isn't complete; any two of the components (dietary deficiency, oculomotor abnormalities, cerebellar dysfunction or altered mental status) makes the diagnosis. Treat Wernicke's with an initial dose of 500 mg of thiamine IV and admit for continued parenteral therapy. Read More LITFL: Thiamine Deficiency EMRAP: Remember to Take Your Vitamins ALiEM: Mythbusting the Banana Bag Read More

This week we discuss the initial approach to assessment of the alcohol intoxicated patient. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_114_0_Final_Cut.m4a Download One Comment Tags: Alcohol Intoxication, Chronic Alcoholism, Wernicke's Encephalopathy Show Notes Take Home Points Chronic drinkers and even just acutely intoxicated patients are at risk of many medical emergencies including life threatening trauma, infections, metabolic derangements and tox exposures.  Don't dismiss them as “just drunk” Undress these patients and perform a thorough head to toe examination, focusing on looking for e/o trauma and infection.  Get as much history as you can and be sure to ask about their drinking habits and etoh w/d hx to risk stratify them in your brain Always check FS glucose and replete glucose as needed.  Consider giving your chronic intoxicated patients thiamine injections semi-regularly to prevent WE, and look for e/o the triad in your patients as it can be easily overlooked and deadly if missed! Read More EM Docs: EM@3AM Alcohol Intoxication EM Updates: E...

This podcast takes a deep dive into the presentation, diagnosis and management of preeclampsia and eclampsia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_113_0_Final_Cut.m4a Download Leave a Comment Tags: Eclampsia, Hypertensive Disorders of Pregnancy, Obstetrics, Preeclampsia Show Notes Take Home Points Suspect preeclampsia in any pregnant women presenting with epigastric/RUQ pain, severe or persistent headache, visual disturbances, nausea or vomiting, shortness of breath, increased edema or weight gain Evaluate for preeclampsia by looking at the blood pressure, urine for protein and obtaining a panel to evaluate for HELLP syndrome Severe preeclampsia and eclampsia are treated with bolus and infusion of MgSO4 Emergency delivery is the “cure” for preeclampsia and eclampsia. Consult obstetrics early for an evaluation for delivery Don't forget to consider preeclampsia and eclampsia in the immediate postpartum period Read More Core EM: Preeclampsia and Eclampsia LITFL:

This week we discuss the presentation and management of herpes zoster. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_112_0_Final_Cut.m4a Download Leave a Comment Tags: Infectious Diseases, Varicella Show Notes Take Home Points Classically, herpes zoster will present with rash and pain in a dermatomal distribution Immunocompromised patients are at greater risk for significant complications of zoster, including visceral dissemination and zoster ophthalmicus Appropriate therapy includes antiviral therapy within 72 hours of onset of symptoms and analgesia for acute neuritis Disseminated zoster and zoster ophthalmicus threatening sight should be treated with IV antivirals Read More Emergency Medicine Ireland: Tasty Morsels of EM 073: FRCEM Varicella Life in the Fast Lane: Herpes zoster ophthalmicus Core EM: Herpes Zoster Read More

This week we dive into some advanced topics in RSI including patient positioning and pre-intubation resuscitation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_110_0_Final_Cut.m4a Download One Comment Show Notes Take Home Points Bed up head elevated position for intubation may reduce intubation related complications. Patients who are hypotensive or at risk of hypotension should be aggressively resuscitation prior to intubation with fluids and liberal use of pressors Shock patients would be intubated with decreased induction agent dose, preferably ketamine, and increased paralytic dose. Bed-Up-Head-Elevated Positioning Show Notes EMCrit: Podcast 104 – Laryngosocpe as a Murger Weapon (LAMW) Series – Hemodynamic Kills Life in the Fastlane: Intubation, hypotension and shock Core EM:

Should we intubate patients in cardiac arrest? We discuss this topic and some basics of running a good arrest. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_108_0_Final_Cut.m4a Download Leave a Comment Tags: Advanced Airway Management, Cardiac Arrest, Critical Care, Resuscitation Show Notes Take Home Points Intra-arrest intubation does not appear to improve outcomes. For most patients, support with BVM, or possibly an LMA, is adequate. Instead of securing an advanced airway, focus on the two things that clearly make a difference in outcomes – good compressions and defibirillation Good compressions should be fast and hard and you must minimize interruptions in compressions to minimize interruptions in perfusion Don't forget that a great resuscitation requires great preparation. Take whatever time you have to discuss with your team and assign roles. Read More Rebel EM: In-hospital Cardiac Arrest – The First 15 Minues Core EM: Proper Defibrillator Pad Placement + Dual Sequential Defibrillation

Prompted by the recent CAMEO trial publication on icatibant, we dive into angioedema with a focus on airway management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_107_0_Final_Cut.m4a Download Leave a Comment Tags: ACE Inhibitors, Allergy/Immunology, Angioedema, Icatibant Show Notes Take Home Points Airway management is paramount, expect a challenging intubation and consider controlling the airway early When controlling the airway, consider an awake approach and fiberoptics if available. Always be prepared for the can't intubate, can't oxygenate scenario with a double set up. If the patient has urticaria and pruritus, the process is likely histamine mediated and will respond to typical anaphylaxis treatment Finally, observe the patient for progression of swelling and don't forget to stop the inciting medication Read More Core EM: Angioedema EMCrit: Podcast 145 – Awake Intubation Lecture from SMACC ERCast: Angioedema

This week we drop into some of the nitty gritty on PSA including preparation and patient assessment as well as discuss some common pitfalls. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_106_0_Final_Cut.m4a Download Leave a Comment Tags: Pitfalls, Procedural Sedation, PSA Show Notes Take Home Points Always perform a full pre-PSA evaluation including an airway assessment. Time of last meal shouldn't delay your sedation based on the best available evidence. Always do a complete setup including consideration of different agents, dosage calculations, preparation of airway equipment and reversal agents. PSA serious adverse events are rare but you still must be prepared for them. Careful agent selection and dosing can help prevent issues but, know your outs. If apnea develops, do some basic maneuvers before you reach for the BVM or laryngoscope. Remember OOPS as in “oops, my patient went apneic.” Oxygen on, pull the mandible forward and sit the patient up. This fixes most issues Show Notes Core EM: Procedural Sedation and Analgesia Resources EM Updates:

This week we dive into some of the initial considerations in the resuscitation of major burn patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_101_0_Final_Cut.m4a Download Leave a Comment Tags: Carbon Monoxide, Cyanide, Major Burns, Trauma Show Notes Take Home Points Be prepared to intubate early, the patency of the airway can decline quickly and without warning. If there is any concern for burns to face/neck or smoke inhalation, consider taking control of the airway early. Review the rule of 9s and the parkland formula to direct your large volume fluid resus.  Remember the parkland formula directs you to use 4 mL x %TBSA x weight (kg).  Half in the first 8 hours and the second half over the next 16 hours.  Given the large volume here it's probably best to use LR or another balanced solution. Do a thorough trauma eval to make sure you don't miss any other injuries and be sure to watch for developing compartment syndrome And last, consider the need to treat for CO and/or cyanide poisoning.  Poor cardiac function, cardiac arrest or a high lactate can be clues to cyanide poisoning and just start 100% O2 while you wait for a co-ox, since CO tox is pretty likely.

This week we discuss 3 articles recently reviewed in our conference - LOV-ED study, Validation of Step-By-Step and Therapeutic Hypothermia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_99_0_Final_Cut.m4a Download Leave a Comment Tags: ARDS, Cardiac Arrest, Lung Protective Ventilation, Mechanical Ventilation, OHCA, Step-By-Step Protocol, Therapeutic Hypothermia, TTM Show Notes Take Home Points The step-by-step approach to managing febrile infants is a reliable decision instrument to identify patients at low risk for invasive bacterial infections. Caution in the group of patients 22-28 days of age. The LOV-ED study shows an association between employing a lung-protective ventilation strategy in the ED and decreased complications from mechanical ventilation. Best available evidence says that we should embrace this approach in the ED. Cooling to 33 degrees is no better than cooling to 36 degrees. However, shooting 36 degrees is more difficult than we may have thought. We have to continue to be vigilant about maintaining patients in the target temperature range and avoiding fever.

This week we discuss the rare but life-threatening methemoglobinemia with a focus on recognition and use of the antidote. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_97_0_Final_Cut.m4a Download 2 Comments Tags: Methemoglobin, Toxicology Show Notes Take Home Points MetHb –emia occurs as a results of various medications including amyl nitrite, dapsone, nitroprusside, phenazopyridine, sodium nitrite and topical anesthetics like benzocaine Patients will present with cyanosis, short of breath, fatigue, dizziness, weakness and ultimately CNS depression and death at higher concentrations. If you have a cyanotic/hypoxic patient that does not respond to supplemental oxygen, be concerned for MetHb and send a co-oximetry panel. If the level is 25% or the patient is symptomatic, you will treat with the antidote methylene blue given as a bolus of 1-2 mg/kg over 5 minutes And as always, make sure to call your local poison center to get your toxicologists involved. They can help with dosing, and they are also an important player of the public health component in cases such as these, to make sure this is an isolated incident and we don't have a repeat of the 11 blue men situation. Price DP. Chapter 127. Methemoglobin Inducers. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e New York,

This week we do a brief review on recognizing CO monoxide poisoning and expertly managing it. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_96_0_Final_Cut.m4a Download Leave a Comment Tags: CO, Inhaled Toxins, Toxicology Show Notes Take Home Points CO poisoning happens most often from common are accidental exposures from faulty home heaters, camp stoves and indoor use of gas powered generators, structure fires and intentional exposure like in suicide attempts. Patients with a mild exposure will present with symptoms like headache, nausea, vomiting, dizziness, vision blurring, palpitations, confusion or myalgias.  More severe exposures may produce Altered mental status. seizures, coma, dysrythmias, myocardial ischemia, metabolic acidosis, syncope and vital sign abnormalities including hypotension and, eventually, cardiac arrest. To help distinguish the vague symptoms of a patient who may have chronic exposure ask about things like whether symptoms improve in different environments or whether they have sick pets, as human viral illness generally don't affect our dogs and cats. If you're concerned about CO send a co-ox panel.  City dwellers may have a baseline carboxyhemoglobin of 1-2% and smokers around 6-10% but others should really have no carboxyhemoglobin. Treatment is supplemental O2 which can be stopped when symptoms improve.  For severe symptoms and for pregnant patients, consider hyperbarics to prevent long term sequelae and to protect the fetus.  As alway...

This week we discuss some of the many dialysis-related emergencies we frequently see in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_92_0_Final_Cut.m4a Download One Comment Tags: Dialysis, ESRD, Nephrology Show Notes Take Home Points On any dialysis patient, make sure to do a good assessment of their access site.  If it's a fistula, assess for a thrill, for any warmth/induration/erythema and make sure they have distal sensation and perfusion.  If it's a catheter, evaluate for any signs of infection—so warmth, erythema or discharge. Bleeding is a big concern. If the patient is bleeding from their access, start with direct pressure to the bleeding site, then move on to topical thrombotic agents and if needed throw a figure 8 stitch with a 5-0 proline on a non-cutting needle. Peritoneal dialysis patients are at risk for bacterial peritonitis.  In a PD patient that appears infected, get a peritoneal fluid sample and start antibiotics Dialysis patients are susceptible to dialysis disequilibrium syndrome which can present as altered mental status, focal neurological deficits or even frank coma or seizures after dialysis.  Make sure to consider a broad differential in these patients and start with a solute load such as an amp or two of D50 while starting your work up....

This week we dive into acute rhinosinusitis focusing on diagnosis and discussing the absence of utility for antibiotics in most patients. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_90_0_Final_Cut.m4a Download Leave a Comment Tags: ENT, Rhinosinusitis, Sinusitis, URI Show Notes Take Home Points Sinusitis is a clinical diagnosis. Patients typically present with purulent nasal discharge and facial pain or other URI symptoms. The vast majority of patients with acute rhino sinusitis will be viral in nature and will not benefit from antibiotics Patients with prolonged symptoms, more than 7-10 days, without improvement or continued fevers past 2-3 days should be considered for antibiotic treatment as should those who are immunocompromised. Show Notes Melio FR, Berge LR. Upper Respiratory Tract Infections, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen's Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 75: p 965-79. The NNT: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults The NNT: Antibiotics for Radiol...

This week we discuss the ED management of anterior and posterior epistaxis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_89_0_Final_Cut.m4a Download 3 Comments Tags: ENT, Epistaxis, Nose Bleeds, TXA Show Notes Take Home Points The first step is managing epistaxis is solid pressure.  This means holding a tight pinch just distal to the nasal bones and hold, without peaking, for at least 5 minutes.  This will stop a good deal of the bleeding. If you need to do more, start by soaking gauze in either oxymetazoline or epinephrine, mix in some lidocaine to help with anesthesia, pack the nare with that and add on some compression.  Hope fully this stops the bleeding enough that you can see a good bleeder and perform cautery. Third line of treatment would be to try some soaked gauze, but this time with TXA. Can't hurt to try! And then last resort is of course packing. Here make sure the patient is anesthetized with some lidocaine, lubricate the packing well and apply horizonally, no vertically as we are often tempted.