Listen Now

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the June 2023 Emergency Medicine Practice article, Hypertensive Emergencies: Guidelines and Best Practice Recommendations Epidemiology Etiology Differential diagnosis Prehospital care History and physical  Diagnostics Treatment Acute decompensated heart failure Acute ischemic stroke Acute coronary syndrome Intracerebral hemorrhage Subarachnoid hemorrhage Aortic dissection Hypertensive encephalopathy Severe pre-eclampsia and eclampsia Controversies Arterial line placement Beta blockers and cocaine Risk management caveats Summary

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the May 2023 Emergency Medicine Practice article on Emergency Department Management of Gastrointestinal Foreign Body Ingestion Epidemiology Etiology - types of ingestions Anatomy - common locations by age Food impaction Sharp objects Button batteries Magnets Colorectal foreign bodies Prehospital care History and Physical Imaging Expectant management Endoscopic removal Non-endoscopic techniques Body Packing Glucagon Gastric button batteries Summary

In this episode, Sam Ashoo, MD, talks with Rob Orman, MD, founder of Orman Physician Coaching, about longevity in emergency medicine.  Personal foundation  Regular check-ins Becoming an expert in…  Job stress Living beneath your means Recharging and shift work Bad outcomes Physician lounge Learning to say no Set a reminder More at Orman Physician Coaching 

Announcements:  The interactive Clinical Pathways have launched and they are available for free!  In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the March 2023 Emergency Medicine Practice article on Emergency Department Management of Infective Endocarditis-Associated Stroke Epidemiology Pathophysiology Populations at Risk Complications Intracranial hemorrhage Aneurysms Heart block Prehospital Care ED History and Examination Imaging Antibiotic Therapy Surgical Treatment Special Populations Summary

Announcements:    The interactive Clinical Pathways have launched and they are available for free!    —   In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the February 2023 Pediatric Emergency Medicine Practice article on Pediatric Electrolyte Emergencies: Recognition and Management in the Emergency Department   —   History   Point-of-care testing   I/O lines   Presentation, differential, and treatment of: Hyponatremia Hypernatremia Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia Hypomagnesemia Hypophosphatemia

Announcements:  The interactive Clinical Pathways have launched and they are available for free!  ___ In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2023 Pediatric Emergency Medicine Practice article on the Responsible and Safe Use of Opioids in Children and Adolescents in the Emergency Department DEA-X Waiver Repeal: The Mainstreaming Addiction Act The Medication Access and Training Expansion Act (MATE) FOAMed post Opioids in Children and Adolescents:  Introduction Epidemiology and Statistics  Medication safety at home Escalation of pain meds at home Naloxone prescriptions Medications in children Codeine Tramadol NSAIDs Local anesthetics and nerve blocks Intranasal meds: Ketamine and fentanyl Opioids and sedation Regional anesthesia Chronic pain

Announcements:  The interactive Clinical Pathways have launched and they are available for free!  —   In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2022 Emergency Medicine Practice article on the Management of Allergic Reactions and Anaphylaxis in the Emergency Department.    Intro The number of ED visits and hospitalizations Studies show up to 57% of anaphylactic reactions are not recognized, and epinephrine is not administered in up to 80% of cases.  Criteria 2006 Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN) WAO revised the criteria in 2020  Delphi group and Brown et al Pathophysiology   Epidemiology Most common causes in children and adults More than half of deaths from anaphylaxis occur within the first hour of symptom onset Prehospital Care Give epi, H1 blockers Mainstay = recognition ED Care Airway Epinephrine Decontamination H1 and H2 blockers Corticosteroids Biphasic reactions Glucagon Special Cases Alpha-gal Scombroid Kounis syndrome

Announcements:  1) The interactive Clinical Pathways have launched and they are available for free!  2) 2023 E/M coding guidelines are in effect. See the summary here.  ___   In this episode, Sam Ashoo, MD, interviews Ara Festekjian, MD, one of the authors of the November 2022 Pediatric Emergency Medicine Practice article on Pediatric Septic Shock in the Emergency Department   Introduction: How common is sepsis in kids and what is the mortality rate in the US?   Definitions Septic shock Sepsis associated organ dysfunction Sepsis-3 Compensated vs uncompensated shock   Etiology Neonate Central line and VP shunts Asplenia Immunocompromised children   Differential Diagnosis   Prehospital Care   ED Evaluation History Examination Septic shock + cardiogenic shock Warm vs cold shock Evolution of physical exam findings Diagnostics Labs Imaging Treatment IV/IO placement Fluid boluses Antibiotics  Pressors  Airway management  Special Populations Febrile neutropenia Newborns with septic shock Controversies Fluid volume Fluid type Antibiotic timing Corticosteroids

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2022 Evidence-Based Urgent Care article on Influenza in Urgent Care. Epidemiology Historical data Since COVID, tracking "influenza-like illness" has been complicated Influenza deaths and age Annual mortality  Outbreaks Transmission Classification Influenza A, B, and C Hemagglutinin and neuraminidase subgroups Antigenic drift and shift Pathophysiology Transmission Incubation  Secondary infection H3N2 Vaccines Egg-based, cell-based, and recombinant influenza vaccines CDC recommendations Patients aged >65 years Differential Diagnosis Complications   Testing When is it indicated?  What types of tests are available?  Testing in periods of low and high prevalence   Treatment High-risk conditions that suggest treatment  Antiviral medications  Oseltamivir: NNT and NNH Resistance patterns Billing and Coding

In this episode, Sam Ashoo, MD, interviews Prayag Mehta, MD, and Nikola Milanko, MD, two of the authors of the October 2022 Emergency Medicine Practice article on Angioedema in the Emergency Department   Pathophysiology: Non-pitting edema of respiratory or GI tract Histamine meditated, bradykinin mediated, or idiopathic Acquired, inherited, or idiopathic Do they present differently? (Urticaria, speed of onset) Histamine Mediated Most common form: 40%-70% Can be triggered by NSAIDs Can be induced by physical mechanism like cold, vibration Is rash a reliable method of distinguishing the types? Bradykinin Mediated May progress slowly Can be inherited or acquired Common triggers include ACE inhibitors and TPA Table 1 Differential Diagnosis   Prehospital Care Protect airway Epi, steroids, antihistamines Avoid CPAP ED History Figure 2: Distinguishing characteristics of histamine vs bradykinin mediated ED Exam Importance of repetitive exams Airway examination Laryngoscopy? Diagnostics Figure 6: Flow diagram of ED workup Labs Imaging Treatment Airway: Intubation Medication Special Populations Pediatric Pregnant/lactating patients Controversies TXA Disposition

In this episode, Sam Ashoo, MD, interviews Ami Shah, MD, MPH, and Don Walker, MD, about eye injuries in the pediatric population.    Why ocular injuries? Why did you pick this topic?   What kind of injuries are included and at what age are they most common?   Injury zones and terminology   Differential Diagnosis What should we keep in mind when we are confronted with an ocular injury? (Table 3) Prehospital Care What do our EMS colleagues need to keep in mind when transporting a child with an ocular injury? How can they help us in the ED? ED Evaluation History: What's important to know? Physical: Visual acuity and eye exam Diagnostics: Slit lamp, ocular pressure, US, CT, MRI Treatment Lid lacerations: Who repairs and when? Orbital fractures: What should we be looking for? Why is it different in children? When does repair typically occur? Corneal abrasions Corneal foreign body Chemical injuries: Irrigate with what and for how long? Traumatic hyphema: Treatment, disposition Traumatic iritis: Treatment, outcome Open globe injuries Retrobulbar hematoma - First 10 EM Special Populations Hemophilia, Von Willebrand disease Sickle cell and trait Neonates and infants Contact lenses Controversies and Cutting Edge Ketamine Tetanus NSAIDs, topical? Topical anesthetics Visual acuity apps

In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Rob Orman, MD, founder of Orman Physician Coaching, about career disillusionment. Career Disillusionment: What is it? How do we combat it? Should we combat it?  A frog in boiling water...  Burnout Two questions to ask yourself How coaching can help The advice trap A framework to explore your career and life goals More at Orman Physician Coaching. 

In this episode, Sam Ashoo, MD interviews Rawad Rayes, MD and Eva Tovar Hirashima, MD, MPH – two of the authors of the August 2022 PEMP article on Pediatric Firearm Injuries to the Extremity: Management in the Emergency Department. Episode Outline: How common are pediatric firearm injuries?  What is the most common location of these injuries?  Is there much literature published on this topic?   Epidemiology  What’s been the trend in pediatric firearm injuries over the past 10 years?  Do we have any idea how/why these are occurring (ie, accidental, intentional, etc) Terminology: For those unfamiliar with firearms (table 1) Ballistics: Mechanisms of damage.  Pre-hospital care Trauma center transport Prehospital hemorrhage control -- Combat application tourniquet, anything else?  ED Evaluation SIPA -- What is it and why use it?  Primary survey -- Tachycardia -> delayed cap refill -> hypotension in children?  Secondary Survey Diagnostic Studies:  Damage Control Resuscitation Wound Care -- Do we remove projectiles? Can they stay in?  Antibiotics  Joint Involvement Compartment Syndrome -- 3 As vs 6 Ps Rhabdomyolysis Controversies CTA for all injuries?  Hemostatic devices -- Any role for these in the ED? 

In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Andrew Phillips, MD, MEd, founder of EM Coach, about artificial intelligence and emergency medicine education. EM/Critical care practice - what’s that like?  EM Coach - what is it?  Artificial Intelligence - What is it and how does EM Coach use it?  The algorithm How did you create it?  What does it do?  The evidence behind it How and where to access EM Coach

In this episode, Sam Ashoo, MD interviews Lela Bachrach, MD, MS, Larissa Truschel, MD, MPH, and Makini Chisolm-Straker, MD, MPH - the authors of the July 2022 PEMP article on Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to human trafficking.  Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department  EMplify - Sept 2022 Episode Outline: Differential Diagnosis What is the differential diagnosis for this scenario in the ED? Are these diagnoses mutually exclusive ? EMS/Prehospital Care What role do EMS providers play in the recognition of trafficking? ED Evaluation What are common presentations/complaints that may represent trafficking? Examination: Privacy, use of a separate room, how do we accomplish this with minors? Ground rules: What does this mean? How do you state this in your practice? Do you find this dissuades patients form reporting? Technology: What if they are on the phone? History - HEADS-ED Physical examination - Findings that lead to suspicion, documentation best practices. Diagnostic Studies Imaging: Any role for this? Lab testing: STI, anything else? Screening tools: Trauma-informed care, PEARR tool Local laws differ by state. How do we handle this with patients? Does it dissuade reporting? "Rescuing mentality" and what that means in the ED Treatment  Medical Beyond medicines: Local services, national hotline Special Populations Diagnosis: What to chart?  National Human Trafficking Hotline 1-888-373-7888 https://humantraffickinghotline.org/

In this episode of EMplify: Conversation – Sam Ashoo, MD, and TR Eckler, MD, speak with John Roberts, MD, MPH, about his work with the International Medical Corps and his efforts in Ukraine. Topics include: What is the International Medical Corps (IMC) and what does it do? What has IMC been doing in the U.S.? What is involved in disaster response? What has IMC been doing in Ukraine? What are the conditions like in Ukraine now? How does bombing of civilian areas affect Ukraine and the IMC projects? How can we support IMC efforts? How can we volunteer with the IMC? How does IMC balance long-term efforts and short-term relief to prevent harm to communities? How has the war in Ukraine effected surrounding areas? What has been most frustrating and most rewarding for you in your work with IMC? How did you start your career in disaster medicine and how would someone interested in it follow your footsteps? Links IMC Website IMC Jobs Roster Positions Roster position - MD Roster position - Nurse  Roster position - Nurse Practitioner  Roster position - Midwife  Disaster Medicine The Nuts & Bolts of Global EM, free e-book

In this episode, Sam Ashoo, MD interviews Adam Sigal, MD and Stephanie Costa, MD - the authors of the August 2022 EMP article on Managing Acute Cardiac Valvular Emergencies in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to valvular emergencies.  Managing Acute Cardiac Valvular Emergencies in the Emergency Department EMplify - August 2022 Episode Outline: Why Valvular disease?  How common is it?  How often do we see it in the ED?  Which valves are we talking about?  Aortic Valve Disease Types and causes Mitral Valve Disease Types and causes Tricuspid and Pulmonic Disease Differential Diagnosis acute coronary syndromes (ACS) pulmonary embolism tamponade chronic obstructive pulmonary disease (COPD) pneumonia pneumothorax Prehospital Care Evaluation of chest pain History Shock  ED Evaluation History Aortic Stenosis Aortic Regurgitation Mitral Stenosis Mitral Regurgitation Physical exam findings  Diagnostic Testing  Labs ECG CXR Bedside US Formal ECHO Treatment Special Populations Prosthetic valves Pregnant patients See Episode Page

In this episode of EMplify, Sam Ashoo, MD reviews recent updates on the following topics: COVID-19 Public health emergency extended Cases increasing Medications and Vaccinations available Pharmacists prescribing COVID medications CDC COVID Therapeutics website HHS COVID Therapeutics Locator Monkeypox Cases increasing Vaccination Testing FOAMED post on Diagnosis and Treatment PPE Science Direct article on Monkeypox 3I Tool Medication Shortages Benzodiazepines FOAMED post on benzodiazepine equivalence American Society of Health System Pharmacists (ASHP) 988 Crisis Line Baby Formula Shortage

In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss meningococcal meningitis and the recent outbreak in Florida. Topics discussed include: Which vaccines are currently approved by the FDA and recommended by the CDC. The difference between the MEN ACWY vaccine and the meningococcal B vaccine. What the current recommendations are for those exposed. Challenges for healthcare providers treating patients who have been exposed or have symptoms. Further reading: Hogan AN, Brockman II CR, Santa Maria A. Emergency department management of adults with infectious meningitis and encephalitis. Emerg Med Pract. 2022 Apr;24(4):1-24. Epub 2022 Apr 2. PMID: 35315604. CDC Meningococcal Disease and Vaccination. As always, we value your feedback. Please take our listener survey. See the episode page for more details.

In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss high sensitivity troponin testing and clinical pathways. Topics discussed include:  Which troponin assay are you currently using and what are its limits of detection?  Do delta troponin results only count if they increase?  If the test result is indeterminate, then what? repeat in 1 hr (European standard), repeat in 3 hours (depending on chest pain onset), or just admit if the HEAR(T) score is high?  What does one negative troponin on presentation mean? No death in 30 days to 1 year but still missed MI? And more...  References Anand A, et al; HiSTORIC Investigators†. High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial. Circulation. 2021 Jun 8;143(23):2214-2224. doi: 10.1161/CIRCULATIONAHA.120.052380. Epub 2021 Mar 23. PMID: 33752439; PMCID: PMC8177493. Chapman AR, et al. Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary Syndrome. JAMA. 2017 Nov 21;318(19):1913-1924. doi: 10.1001/jama.2017.17488. Erratum in: JAMA. 2018 Mar 20;319(11):1168. Soerensen NA [corrected to Sorensen NA]. PMID: 29127948; PMCID: PMC5710293. Chenevier-Gobeaux C, et al. Multi-centre evaluation of recent troponin assays for the diagnosis of NSTEMI. Pract Lab Med. 2018 Feb 26;11:23-32. doi: 10.1016/j.plabm.2018.02.003. PMID: 30014015; PMCID: PMC6045566. Chiang CH, Chiang CH, Lee GH, Qian F, Chen SC, Lee CC. Time to Implement the European Society of Cardiology 0/1-Hour Algorithm. Ann Emerg Med. 2020 Nov;76(5):690-692. doi: 10.1016/j.annemergmed.2020.05.038. PMID: 33097132; PMCID: PMC7575504. McCarthy CP, Januzzi JL Jr. Increasingly Sensitive Troponin Assays: Is Perfect the Enemy of Good? J Am Heart Assoc. 2020 Dec;9(23):e019678. doi: 10.1161/JAHA.120.019678. Epub 2020 Nov 26. PMID: 33238785; PMCID: PMC7763764. Neumann JT, et al. Application of High-Sensitivity Troponin in Suspected Myocardial Infarction. N Engl J Med. 2019 Jun 27;380(26):2529-2540. doi: 10.1056/NEJMoa1803377. PMID: 31242362. Miller J, Cook B, Singh-Kucukarslan G, Tang A, Danagoulian S, Heath G, Khalifa Z, Levy P, Mahler SA, Mills N, McCord J. RACE-IT - Rapid Acute Coronary Syndrome Exclusion using the Beckman Coulter Access high-sensitivity cardiac troponin I: A stepped-wedge cluster randomized trial. Contemp Clin Trials Commun. 2021 Apr 23;22:100773. doi: 10.1016/j.conctc.2021.100773. PMID: 34013092; PMCID: PMC8114080.