Episodes

  • 00:28:10

    The Chest Pain Summit

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    A consensus summit with world experts and primary researchers focused on the question, “After a negative ED evaluation for ACS, is an expedited outpatient evaluation a safe alternative to admission?” Featuring Colin Kaide, MD, Mike Palacci, MD, Barbara Backus, MD, Erik Hess, MD, Ezra Amsterdam, MD, Douglas Van Fossen, MD, Rob Orman, MD, Mike Weinstock, MD, and Cam Berg, MD

  • 00:34:45

    Evidence Based Hyperkalemia Management

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    Hyperkalemia is one of, if not the most, common electrolyte abnormalities we see. But much of what we do in treatment is what someone told us to do when we were young learners. In this episode we debunk hyperkalemia myths and discuss an evidence based approach to management. For more great content check out

    https://www.hippoed.com/em/ercast/

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  • 00:33:38

    Las Vegas Mass Casualty: How one ED made order out of chaos

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    A first hand account of the emergency department response to the 2017 Las Vegas strip shooting that left 59 dead and over 800 wounded. Discussion of preparation with 20 minutes warning, how to keep patients flowing as they enter the hospital as well as once they’re in the treatment area, effective triage, critical steps to simultaneously resuscitating large numbers of trauma patients.

  • 00:31:16

    The Dying Asthmatic

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    Few patients are more challenging in the ED than the asthmatic in extremis who is recalcitrant to standard therapy. Asthma is different than other causes of severe respiratory distress. And there are different forms of asthma as well.

    Besides cricoid pressure, magnesium, and slowing down ventilations, how else might the provider try to reduce the consequences of breath stacking is this case?

    Weingart prefers noninvasive positive pressure ventilation to BVM early on in the management.

    In the rare cases of severe asthma with a ‘stone chest’ that is incredibly difficult to bag, you need to proceed to immediate RSI and get the tube in as quickly as possible. It’s the only way to safely provide the airway pressures you need.

    Prolonged bagging with high pressures carries the risk of gastric insufflation and aspiration.

    Failed attempts at intubation are especially risky in these patients. As their hypoxia worsens, they may get more acidotic, running a very real risk of cardiac arrest peri-intubation.

  • 00:22:21

    Why Epi Might (and might not) Work in Cardiac Arrest

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    The pendulum never seems to stop swinging when it comes to the efficacy of epinephrine in cardiac arrest.

    20-25 years ago, the push was to use escalating doses of epinephrine starting at 1 mg and increasing to 3 mg, then 5 mg, and continuing at 5 mg as needed. Some protocols started directly with 5 mg and continued with 5 mg thereafter. These protocols were based on early studies which suggested that higher doses of epi resulted in improved survival to hospital admission.

    Subsequent analyses, 5-10 years later, showed that many of the people who got high doses of epi were dying at the same rate, or perhaps even higher rate. Also, amongst the survivors, the neurologic outcome was worse.

    Over the past few years, a few studies have reported that epi, even in 1 mg doses, could be potentially harmful and not helpful.

    The most recent literature seems to be coming back to a middle zone whereby there probably is some benefit to epinephrine, but only if given in a certain time period. These studies suggest that epi is most beneficial if given in the first 15-20 minutes after cardiac arrest. Continued dosing of epi beyond the 20 minute mark (post cardiac arrest) seems to produce more rapid deterioration and is not supported by the literature.

  • 00:22:45

    Mind of an Addict

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    Our guest today is Joe Polish. Unlike most guests on this show, Joe is not involved in medicine- heis one of the best known marketing minds on the planet. He is the creator of the Genius Network which is the place high level entrepreneurs go to get their next big breakthrough with access to connection, contribution, and collaboration. Joe is also a best selling author and renown podcaster with I Love Marketing, genius network, Rich Cleanerand 10x Talk. But none of those things are why Joe is on the show today. Joe is also an addict, but deeper than that, he’s turning his experience with addiction into a force for change with Genius Recovery and Artists for Addicts.

    In this episode

    Open Letter to Anyone Struggling with Addiction Joe's story of addiction and how he's dealt with it on the path to recovery The roots of addiction, why punishing addicts doesn't work and what we can do instead Sex addiction and connection The Craving Brain: Why addiction may not be a choice and what we need to understand about it How to bring more compassion and empathy to addicts and help them recover Gabor Mate:"Not why the addiction, but why the pain?" Be transformational, not transactional
  • 00:44:11

    ZDoggMD

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    Zubin Damania (ZDoggMD) is an internist and founder of Turntable Health, an innovative healthcare startup that was part of an urban revitalization movement in Las Vegas. During a decade-long hospitalist career at Stanford, he experienced our dysfunctional health care system firsthand leading to burnout and depression. He created videos under the pseudonym ZDoggMD as an outlet to find his voice. This launched a grassroots movement — half a billion youtube views and a passionate tribe dedicated to improving health care for everyone.

    ERcast 2.0 Launches May 1

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    In this interview we cover a wide range of topics including

    Underwear How ZDogg went from hospitalist to rapper to Medicine 3.0evanaglist Meditation The Mind Illuminated The roots of anxiety Mental preparation before giving a talk ZDogg's response to criticism, antipathy, and negative feedback from the anti-vaccine movement Nurse practitioners

    A Smattering of Performance Improvement, Stress Management, and Wellness Episodes

    Finding the Joyin Your Job Performance Coach Jason Brooks Making Order Out of Chaos How to Not Freak Out When Consultants Give Bad Advice Beating Stress and the Hot Offload Mastering the Storm Full Video Interview Below

    https://www.youtube.com/watch?v=bujZmXEtuHA

    My Favorite Zdogg Song

    https://www.youtube.com/watch?v=NAlnRHicgWs

  • 00:12:12

    C Diff Treatment Changes

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    A few weeks ago, a post on Clay Smith’s Journal Feedabout the new IDSA C diff guidelines caught my attention (specifically, that metronidazole is no longer recommended as first line therapy). Whuut? I tweeted this and @medquestioningtweeted back, "Need to dig to see why they dropped metro in the bucket." Yes, @medquestioning, my thoughts exactly.

    Mentioned in this episode ERcast 2.0launches May 1, 2018 To sign up for the new site and 1 year of free CME, click here Essentials of Emergency Medicineis just around the corner. If you can't make it to Vegas, the digital live stream is pretty sweet. New IDSA C Diff Guideline Treatment Recommendations

    Initial Episode, Non Severe (WBC ≤ 15k, creatinine < 1.5)

    First Line

    Vancomycin 125 mg PO QID for 10 days Fidaxomicin 200mg PO BID for 10 days

    Second line

    Metronidazole 500mg TID PO for 10 days

    Initial Episode, Severe (WBC >15k, creatinine >1.5)

    Vancomycin 125 mg PO QID for 10 days Fidaxomicin 200mg PO BID for 10 days

    Initial Episode, Fulminant (Hypotension or shock, ileus, megacolon)

    Vancomycin 500 mg 4 times per day by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present

    First Recurrence

    • Vancomycin 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode, OR

    • Use a prolonged tapered and pulsed vancomycin regimen if a standard regimen was used for the initial episode (eg, 125 mg 4 times per day for 10–14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2–8 weeks), OR

    • Fidaxomicin 200 mg given twice daily for 10 days if Vancomycin was used for the initial episode

    Photo Credit Photo by Gabor Monori on Unsplash

    The Guidelines

    McDonald, L. Clifford, et al. "Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)." Clinical Infectious Diseases66.7 (2018): e1-e48. PMID:29462280

    Original Studies

    Teasley, DavidG, et al. "Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis." The Lancet322.8358 (1983): 1043-1046. PMID:6138597 Wenisch, C., et al. "Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile—associated diarrhea." Clinical infectious diseases22.5 (1996): 813-818. PMID:8722937 New Evidence Favoring Vancomycin Zar, Fred A., et al. "A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile–associated diarrhea, stratified by disease severity." Clinical Infectious Diseases45.3 (2007): 302-307. PMID:17599306 Johnson, Stuart, et al. "Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials." Clinical Infectious Diseases 59.3 (2014): 345-354. PMID: 24799326

    CDC C. Diff Statistics

    New York Times article on the association of the rise of new sweeteners and the rise of C. diff.

    The Germs That Love Diet Soda

  • 00:15:31

    Pseudoseizures (PNES)

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    Walker Foland is an emergency physician practicing in Michigan and in this episode breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.

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    Are patients with PNES ‘faking it’? PNES is a conversion disorder: an unconscious manifestation of psychological trauma. Walker treats PNES patients with haloperidol or olanzapine with the thinking that this is psychological, not true epilepsy PNES is not ‘faking it’ or lying Challenges Patients with PNES may also have true epileptic seizures Diagnosing PNES, or separating it from epilepsy, may take video EEG monitoring, a neurologist, and sometimes prolonged periods of time to figure things out How to tell the difference between an grand mal epileptic seizure vs PNES vs faking it?

    PNES

    Seizures related to a specific stimulus (sound foods, body movement) Frequency and amplitude of concussions: same frequency through the seizure with varying amplitude. Maintenance of consciousness and may have some of the below may guard the face with passive hand drop resist eyelid opening visual fixation on a mirror Whit Fisher, Dr Procedurettes, squirts water in the face of patients where there is thought of PNES. If they grimace, probably not an epileptic seizure.

    Faking Seizures

    Talking Purposeful movement Avoids injury May use convulsions as a way of harming staff Intermittently awake and vocal during the episode

    Epileptic seizure

    Convulsive frequency decreases, amplitude increases as seizure progresses No response to pain Allow passive eye opening

    A 2010 article from the Journal of Neurology Neurosurgery and Psychiatry broke down the evidence of what other elements can help distinguish PNES from epileptic seizures.

    Duration over 2 minutes suggests PNES, but we’ve all seen epileptic seizures last for a long time, status, and some PNES can be super short Happens in sleep. Evidence suggests that if the event happens in sleep, that is probably episode. PNES episodes happen when awake Fluctuating course such as a pause in the rhytmic movement, epileptic seizures usually don’t pause and then restart, a pause favors PNES Flailing. You’d think the flailing patient has PNES for sure because epilepsy doesn’t flail, but it does! Flailing is much more common in PNES, but not so much so that it’s a clear distinguishing factor Urinary incontinence, more common in epilepsy, but does happen in PNES. Post-ictal recovery period. Surely, this is the sine qua non of epilepsy. It is way way more common following generalized epileptic seizures but happens in around 15% of PNES. The sterterous breathing (noisy, labored) that we see after generalized tonic clonic epileptic seizures suggests epilepsy and is not a characteristic of PNES Walker’s take home points PNES patients aren’t ‘faking it’ This is a real disorder, it's just not epilepsy

    References

    Chen, David K., and W. Curt LaFrance Jr. "Diagnosis and treatment of nonepileptic seizures." CONTINUUM: Lifelong Learning in Neurology 22.1, Epilepsy (2016): 116-131. PMID:26844733

    Avbersek, Andreja, and Sanjay Sisodiya. "Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?." Journal of Neurology, Neurosurgery & Psychiatry 81.7 (2010): 719-725.Full Text PMID:20581136

    Shen, Wayne, Elizabeth S. Bowman, and Omkar N. Markand. "Presenting the diagnosis of pseudoseizure." Neurology 40.5 (1990): 756-756. Full Text PMID:2330101

  • 00:22:25

    What Canada Can Teach Us About CAT Scans

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    Joe Habbousche is the CEO of MDCalc, the world's most used online medical calculator. Chances are, you've used it yourself. Joe is a passionate advocate for the practice of evidence based medicine and the proper use of clinical decision tools. In this episode, we dissect one of his favorites: the Canadian CT Head Injury/Trauma Rule

    Canadian CT Head Injury Rule Derived and validated in a large patient population Overall 8% of patients had positive CTs, but only 1.5% required intervention Two sets of criteria

    High Risk/Major Criteria

    Designed to capture patients that went on to require intervention.

    Medium Risk/Minor Criteria

    Added on to the high risk criteria to capture those with clinically important brain injury- CT findings that require admission or observation Who does this not apply to? Patients on blood thinners/bleeding disorder Under 16 years old Seizure after trauma No clear history of trauma Obvious penetrating skull injury or obvious depressed fracture Acute focal neurological deficit Unstable vital signs associated with major trauma Returned for reassessment of the same head injury This is a one directional rule Designed to be sensitive but not necessarily specific This decision rule was designed because when CT imaging is done in all comers with head injury, it has very low yield The CT Head Injury/Trauma rule asks, "Can I carve out a cohort of patients who we know will not have a need for this test." If you fall in this group (the cohort that the rule says doesn't need the test), then you don't need the test Here's the one directional part: If you fall outside that group, the group the rule says does not need the test....the rule DOES NOT COMMENT. It is not studying anyone outside the group that has been deemed safe to not have the test done Canadian CT Head Rule

    Applies to this group of patients

    Blunt trauma to the head resulting in witnessed loss of consciousness Definite amnesia or witnessed disorientation Initial emergency department GCS score of 13 or greater as determined by the treating physician Injury within the past 24 h

    High Risk Criteria: Rules out need for neurosurgical intervention

    Fails rule with any of the following

    GCS
  • 00:43:39

    Winter 2018 Journal Club

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    In the edition of the Ercast journal club

    thrombectomy in pts with delayed stroke presentation shows promise beware behavioral changes after procedural sedation kids with isolated linear skull fractures have a good short term prognosis procalcitonin may help decrease abx use in respiratory infections steroids in mild sore throat help... a little

    Registration for ConCert (the big board recertification exam we take once a decade) has opened. If this is your year to take the exam, there's only one place to go for board review.

    The DAWN Trial

    Nogueira, Raul G., et al. "Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct." New England Journal of Medicine 378.1 (2017). PMID:29129157 What happens when thrombectomy is done when last normal was over 6 hours ago? 206 patients with occlusion of the intracranial internal carotid artery, middle cerebral artery, or both these were patients excluded from TPA because of time from onset or they had persistent occlusion despite TPA Pts had to get either perfusion CT or diffusion weighted MRI to see if there was salvageable brain (there had to be) 107 got thrombectomy and 99 didn't. 90 day functional independence: 49% thombectomy vs 13 % controls No significant difference in symptomatic intracranial hemorrhage or 90 day mortality Trial stopped early because of superiority of thrombectomy Majority of patients were wake up strokes, a group we've had pretty much nothing to offer previously Industry sponsored, many conflicts of interest Rob's take-This trial uses salvageable brain as a determinant of treatment which makes sense as these are the patents who may actually benefit from reperfusion. This purports to speak for the patient 6-24 hours, but from what I can tell, treatment was heavily skewed toward those with time from last normal 16 hours and under, so it doesn't really tell us much about 24 hours. I will be consulting stroke centers with this patient cohort. Adam's take- Impressive. I like that this is tissue based, not time based.

    Skull Fractures in Kids

    Bressan, Silvia, et al. "A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children." Annals of emergency medicine (2017). PMID: 29174834 Are pediatric patients with isolated skull fractures at increased risk for short term adverse events? Pool of 21 studies, over 6,000 kids with isolated skull fractures. One required emergency neurosurgery, none died. All kids had CT scan or MRI to exclude intracranial injury 6 out of 570 had bleeding on a second scan and zero had surgery. The incidence of delayed hemorrhage is super low and even those with bleeding didn't need an intervention. Unless there is a change, you don't need to rescan. Author take home: "Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns." Rob's take-An otherwise well appearing child with isolated skull fracture has an excellent short term neurosurgical prognosis and probably don't need hospitalization based on the skull fracture alone Adam's take-Open and shut case. One kid out of over 6,000 is pretty good odds and that one patient got meningeal repair.

    Procalcitonin is dead. Long live procalcitonin

    Schuetz, Philipp, et al. "Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis." The Lancet Infectious Diseases 18.1 (2018): 95-107. PMID: 29037960 Over 6,000 patients with respiratory infections Decision to give antibiotics based on procalcitioin level Primary endpoints: Mortality, treatment failure Secondary endpoints: Antibiotic use No significant difference in death, treatment failure, ICU length of stay Antitiocis initiated 86% controls, 70% procalcitonin guided and shorter duration of abx using procalcitonin as the guide Fewer Abx side effects with procalcitonin guided therapy Adam's take-This is not a lifesaving study, this is a safety study. The point is, can you safely withhold antibiotics from people? This study says you can, based on procalc level in a patient with respiratory infection. The scenario I envision is someone with CHF, COPD, fever, and coughing. If the procalc is low, I don't have to add a horrendous quinolone to your 25 other meds, you can take tessalon perles and do better. I'm going to keep one more abx prescription out of the pool and it's not going to harm the patient. This is a noniferiory trial to me. Prescribing fewer antibiotics is a worthwhile goal to me. We know that using procalcitonin for that purpose works and this study says it is safe.

    Steroids for sore throat

    Little, Paul, et al. "Effect of oral Dexamethasone without immediate antibiotics vs placebo on acute sore throats in adults: a randomized clinical trial." JAMA 317.15 (2017): 1535-1543. PMID: 28418482 RCT of 576 adults with sore throat not requiring immediate abx. Treated with either steroid or placebo Most afebrile and did not have pus on tonsils Results: Symptoms better at 48 hours (but not 24) with dexamethasone Rob's take- Set the expecation that it will take 48 hours to start feeling better if giving steroids. That being said, I don't think that steroids are worth it in most mild sore throat patients. NSAIDS, tea, and time Adam's take- A cofounder for me was that 14% of the dexamethasone and 19% of no dex group had strep, a confounder I don't like. Steroids probably work a little, they're probably safe, but they're not amazing

    The Brain Does Not Love Ketamine as Much as You Do

    Pearce, Jean I., et al. "Behavioral Changes in Children After Emergency Department Procedural Sedation." Academic Emergency Medicine (2017). PMID: 28992364 82 kids received ketamine for procedures in the ED Most had forearm fracutres Most had analgesia before procedure 22% with negative behaviors changes after discharge. Anxiety, aggression, withdrawal, sleep anxiety, separation anxiety Higher odd of this happening in kids anxious before procedure, nonwhite Rob's take- ketamine is an excellent drug, but can have lasting effects. Also, it's not totally benign, one patient had over 30 seconds of apnea. Still one of our best options, but discuss with parents the post discharge behavioral changes that might occur Adam's take- I don't think this is a study about ketamine at all. This says nothing about ketamine, this talks about procedural sedation. There is a long history of research about general anesthesia that shows a similar pattern- post op kids have behoaboiral disturbance a week after and the kids who come into the OR have worse outcomes, and if you treat the anxiety before the procedure, they have better outcomes.This could have been propofol nitrous, whatever. The kids who start out anxious pre-procduere have a much higher incidence of behavioral disturbance post procedure.In my opinion, this study shows that anxious kids are more likely to be disrupted by this experience than non-anxious kids. I am going to give a lot more versed. Maybe this is the versed indication that works with ketamine.
  • 00:28:57

    Why Doctors Get Sued for Missed MI

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    Amal Mattu gives his thoughts on why we actually get sued for missed MI. Is it the patient who has an impeccable workup with shared decision making? Or are there other factors/patient characteristics that commonly show up in lawsuits?

    In part 2, we talk with Mike Weinstock about criticism of his paper How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician?

    Episode contents

    Frontmatter

    ERcast is now part of the Hippo Education family Early bird discount for Essentials of Emergency Medicine ends soon

    Part one. Amal Mattu on lawsuits for missed myocardial infarction

    Do we mitigate medico-legal risk if we use a validated decision instrument or pathway? Amal feels that we do. You are applying validated literature to your practice. Problems arise when the score, HEART for example, is miscalculated or guessed at. If you're going to use a protocol or score, be sure you're using it correctly What are the things that Amal sees as common factors that lead to 'missed MI' lawsuits? Misread EKGs Young women presenting with atypical symptoms (atypical chest pain, shortness of breath, fatigue) Young patients Upper abdominal pain, especially without abdominal tenderness Diagnosing a patent with 'reflux' when the patient was actually having an acute coronary syndrome. Inferior MIs in particular may masquerade as reflux symptoms or the patient with ischemia may have concomitant (true) reflux. In 2015, Amal discussed his pathway for evaluating ED chest pain patients. Here is the protocol

    Part two. Mike Weinstock on risk of CRACE (Clinically Relevant Adverse Cardiac Event), criticism of How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician?

    Original Episode air date October 30, 2017 We think we protect patients by admitting them to the hospital, but looking at the numbers, that might not be the case. The criticism of Mike’s paper that teased out the risk of CRACE in patients with non-ischemic interpretable EKGs and negative troponins, was that all patients were evaluated in the hospital. Did hospitalization confer some unmeasured benefit? Can we extrapolate that risk of CRACE in patients who have been hospitalized applies to discharged patients with the same profile? This is an ongoing debate, but the data is some of the best we have and can still inform discussions with patients. We don't sent patients home and tell them they have no disease, we send them home with a plan for continued evaluation.

    How does Mike use this information?

    If the ED workup shows a non-ischemic EKG and there are two negative serial troponins, he presents the option of an outpatient workup. A caveat to this is that access to rapid outpatient evaluation must be readily available. He advises the patient that the possibility of a CRACE is one in several thousand and, while being hospitalized may seem like the safest course of action, hospitalization itself is not without risk. The Weinstock Credo: Don’t practice defensive medicine. Document “defensibly” References

    Singh, Swarnjit, et al. "The contribution of gastroesophageal reflux to chest pain in patients with coronary artery disease." Annals of internal medicine 117.10 (1992): 824-830. PMID: 1416557

    Dobrzycki, Slawomir, et al. "Does gastro-esophageal reflux provoke the myocardial ischemia in patients with CAD?." International journal of cardiology 104.1 (2005): 67-72. PMID: 16137512

    Pope, J. Hector, et al. "Missed diagnoses of acute cardiac ischemia in the emergency department." New England Journal of Medicine 342.16 (2000): 1163-1170. PMID: 10770981

  • 00:25:43

    Haloperidol for Analgesia

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    One of the stress points when a patient taking chronic opioids presents with acute pain is that we feel we have little to offer them. Are more opioids the answer? That's often what happens, but might not be the best next step. In this episode, Reuben Strayer presents the argument in favor of haloperidol for analgesia and why more opioids can do more harm than good.

    Episode Guide

    In the introduction, preview of a project we're working on for Essentials of Emergency Medicine (May 15-17).

    Opioid induced hyperalgesia: compared to those not taking opioids, patients on chronic opioids may have a more unpleasant experience when exposed to painful stimuli. In other words, they are more sensitive pain. The meds used to treat pain, actually worsen pain.

    A patient who uses chronic opioids will have marginal gains in analgesia with escalating doses while getting closer to potentially lethal adverse effects.

    Haloperidol is an analgesic option for patients taking chronic opioids.

    Reuben's strategy for using haloperidol for analgesia in chronic opioid patients: 10 mg IM haloperidol if there is no IV, 5 mg IV if they have a line. If they don't fall asleep shortly after (or have improvement of pain) he repeats the dose. If that doesn’t work, he uses analgesic dose ketamine.

    For analgesic dose ketamine in these patients, Reuben uses 30 mg IV. This may cross over into the 'recreational' or 'partial dissociation' dose where the patient can have disturbing psycho-perceptual effects. He has found that the pretreatment with haloperidol leads to less distress from these psycho-perceptual effects. For more information on ketamine dosing, see Reuben's post on the Ketamine Brain Continuum.

    Haloperidol and the prolonged QTc: Butyrophenones (of which haloperidol is one) are known to prolong the QTc. Should we get an EKG prior to giving haloperidol to see if the QTc is already prolonged? Reuben feels that the negative effects of butyrophenone QTc prolongation are overblown and does not routinely get an EKG prior to giving haloperidol. This includes initial and subsequent doses. Take that with a grain of salt because there are many docs who do get an EKG before the first or second dose of haloperidol, especially if there is a known QTc prolonging drug on the patient's med list (like methadone). Some hospitals even have policies that before a second dose is given, there is a hard stop for EKG and QTc check.

    Check out Reuben's blog Emergency Medicine Updates and follow him on Twitter

    References

    Opioid Hyperalgesia

    Marion Lee, M., et al. "A comprehensive review of opioid-induced hyperalgesia." Pain physician 14 (2011): 145-161 Full text link. PMID: 21412369 Hooten, W. Michael, et al. "Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering." Pain Medicine 11.11 (2010): 1587-1598 Full text link. PMID: 21029354

    Droperidol for analgesia

    Richards, John R., et al. "Droperidol analgesia for opioid-tolerant patients." Journal of Emergency Medicine 41.4 (2011): 389-396. PMID: 20832967 Amery, W. K., et al. "Peroral management of chronic pain by means of bezitramide (R 4845), a long-acting analgesic, and droperidol (R 4749), a neuroleptic. A multicentric pilot-study." Arzneimittel-Forschung 21.6 (1971): 868. PMID: 5109279 Admiraal, P. V., H. Knape, and C. Zegveld. "EXPERIENCE WITH BEZITRAMIDE AND DROPERIDOL EN THE TREATMENT OF SEVERE CHRONIC PAIN." British journal of anaesthesia 44.11 (1972): 1191-1196. PMID: 4119073

    Early studies on Haloperidol for analgesia

    Maltbie, A. A., et al. "Analgesia and haloperidol: a hypothesis." The Journal of clinical psychiatry 40.7 (1979): 323-326. PMID: 222741 Cavenar, Jo, and A. A. Maltbie. "The analgesic properties of haloperidol." US Navy Med 67 (1976): 10. Cavenar, Jesse O., and Allan A. Maltebie. "Another indication for haloperidol." Psychosomatics 17.3 (1976): 128-130.

    Haloperidol for pain

    Seidel, Stefan, et al. "Antipsychotics for acute and chronic pain in adults." Cochrane Database Syst Rev 4 (2008). PMID: 18843669 Ramirez, R., et al. “Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.” The American journal of emergency medicine (2017). PMID:28320545 Reviewed in this ERCast episode Salpeter, Shelley R., Jacob S. Buckley, and Eduardo Bruera. "The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia." Journal of palliative medicine 16.6 (2013): 616-622. PMID: 23556990 Afzalimoghaddam, Mohammad, et al. "Midazolam Plus Haloperidol as Adjuvant Analgesics to Morphine in Opium Dependent Patients: A Randomized Clinical Trial." Current drug abuse reviews 9.2 (2016): 142-147. PMID: 28059034
  • 00:35:13

    When Consultants Give Bad Advice

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    Sam Ashoo is an ED doc practicing in Tallahassee, Florida. He has been an ED director, coding and billing chief medical officer, international educator, and runs the Admin EM blog. That blog name might sound nerdy (and it is) but his short write ups on common clinical problems are famously high yield.

    In this episode, Sam gives his strategies on what to do when the consultant on the other end of the phone call is giving questionable advice.

    Before jumping in to the episode, take a few minutes for the ERCast listener survey.The survey lets me know who you are, what you do, and what you need when it comes to medical education. Thanks in advance.

    Discussion topics

    Are you disagreeing with your consultant or is the information you are being given simply wrong? Why determining the root cause of the bad advice can help lead to resolution of conflict Should you apologize for bothering a consultant when you call them? What to do when a consultant is dismissive of your concerns about a patient Factors that may lead to questionable advice from a consultant Bad advice is usually not malicious (even though it may feel that way) Be aware of downstream effects of negative interactions with consultants

    Bonus Content

    What follows is a summary of a conversation with Dr. Jim Adams, Chairman Northwestern University Emergency Medicine. He is a master of conflict management, resolution, and prevention

    How to insulate ourselves from the stress of conflict with consultants

    Get to know them personally. Build social capital and friendships. We underestimate the power of social connection to prevent negative interactions. Slow down before you make the call and think about why you're calling. Know your needs and know your ask. (example of rambling vs focused). Don't give your consultant an order, call with a specific need. Speak at a measured pace. While you may think you sound calm and friendly, it's possible that what's heard on the other end of the line is pressured, pushing, and curt. Trainees and new attendings are especially vulnerable to this. It's not a mystery why this happens-your work environment is the perfect setup for the opposite of a calm phone presence. At baseline, the ED is high pressure and there are myriad demands for your time and attention. When you sound pressured, the person on the other end of the call feels pressured, then they match your tone... and then YOU think that THEY are the problem! Consider reciprocity when dealing with an irritated consultant. If you're irritated, they're irritated. It's infectious. If you choose to be happy and express appreciation for the consultants advice or coming in, that changes the dynamic. If you lead with irritation when they come into the ED to evaluate a patient, what do you think is going to happen 9 times out of 10? Your consultant will be more irritated! When you get a hard time on the phone, your brainstem screams "threat, aggression!" You start to get angry and want out of the conversation. That is a primitive conversation. Your emotion is now driving you. Take some reset breaths, try combat breathing, recognize and be in control of the emotional response At the end of the conversation, show appreciation for the consultant's expertise. If it's a surgeon, Jim says, "It looks like this patient needs your hands." If it's an internist, he might say, "It looks like this patient needs your time and wisdom." That may sound lame/dorky/fake/etc but you are doing two things: expressing gratitude and making them feel needed. Feeling needed is irresistible for doctors (or pretty much any human) - it makes them feel good about their jobs. Even if they're tired and cranky, making someone feel needed and valued leads to better interpersonal results. In any conflict, there is a moment when you should stop listening to what they're saying and focus instead on why they're saying it. Often a consultant that is giving you a hard time or is dismissive may not be in position to help you at this moment (they might busy, tired). you may also have a consultant who acts like a bully and tries to dominate you in a conversation. They may in fact just be a bully, but sometimes it's a case that where they have nothing to offer the patient. When a person is not giving you answers that are not acceptable, find the things that you'd agree on that are acceptable. When there is a negative interaction, let your department chair know. On investigation, what's often uncovered is burnout, depression, substance abuse, going through a divorce, etc. Of course, some people have grown accustomed to exhibiting rude behavior and it has nothing to do with other life circumstances.

    The Case

    You are seeing a patient with a VP shunt who is having repeated seizures. They are followed by a neurosurgeon for all of their neurologic related needs (the family called the neurosurgeon who recommended they come see you). After a workup in the emergency department, it's still not clear why the patient is having seizures.

    You call the neurosurgeon and the response is something like this, "Why are you calling me? This patient doesn't need surgery. Do you understand what I do? I am a neurosurgeon, that means I do brain surgery. This patient doesn't need that."

    You reply, "I understand that, but you recommended the patient come to the ED, they are your patient and have complex brain hardware so I thought you'd like to know what's going on and we could discuss treatment options."

    "I'm not sure why you can't understand what a neurosurgeon does. Are you a doctor..."

    If the consultant has a truly pathologic personality, there's no magic fix or workaround. Just don't take their derision toward you personally. You'll find that they are exhibiting the same behavior in every part of their life. There are other paths you can take besides wanting to smash the phone into the desk in a fit of rage. Your primitive brain is exploding right now, begging to go full caveman here. Take a breath, stay calm and measured and use the technique of BLEND and REDIRECT Blend - restate what you do agree on and Redirect- see if you can align with them to help the patient. Blend "I think we can agree this is a really complex patient. There's nothing suggesting they need acute surgery." Redirect "But they're having this problem and I need some guidance on how to best help this patient and family." You are blending with what they're saying and redirecting them toward your need and seeing if they can help provide a solution. The solid

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  • 00:32:58

    Anorexia Nervosa may not scare you but it should

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    Vicky Vella is an emergency physician practicing in the United Kingdom with a special interest and expertise in eating disorders. In December of last year, Vicky had a guest post on the St Emlyn’s blog about the MARSIPAN Guidelines. Never heard of them? Neither had pretty much anybody. MARSIPAN is an acronym for Management of Really Sick Patients with Anorexia Nervosa.

    Anorexia is often viewed as a chronic condition that doesn't really warrant emergency care, but that's not the case. Mortality with anorexia nervosa is high (on the order of 10-20%) and patients can present, as MARSIPAN suggests, really sick.

    Consider an eating disorder/anorexia in patients presenting with Self Harm. Up to 70% of patients with anorexia will self harm Diabetic Ketoacidosis. In the UK around half of 15-25 year olds with type 1 diabetes will withhold insulin to try and lose weight. Not all of them will have an eating disorder, but many will Vasovagal syncope. We often ask if a patient had breakfast or enough to drink today, but there may be an underlying eating disorder What question(s) to ask Vicky starts with, "What's your relationship with food?" "Do you eat regular meals?" The patient may not disclose that there's a problem. Information may come from a family member Who has anorexia nervosa Highest risk is 13-17 yo age group, both male and female Can actually affect all ages, races, genders What's the difference between anorexia nervosa and someone who just doesn't eat much? Anorexia is a mental illness. Sometjing the person doesn't have much control over Less of a desire to be thin than a fear of being obese Guilt associated with eating May restrict intake, exercise to burn off consumed calories Often mood swings, social isolation, can become aggressive toward family

    DSM 5 Criteria

    Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Red Flags in the Anorexia Workup (from the MARSIPAN Guidelines)

    BMI

    low risk 15–17.5 medium risk 13–15 high risk
  • 00:17:06

    Cellulitis

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    Recorded at Essentials of Emergency Medicine 2017, Greg Moran, MD reviews current thinking on cellulitis diagnosis and management. Greg is a professor of emergency medicine at Olive View-UCLA medical center who, in addition to emergency medicine, is fellowship trained in infectious disease and has over 100 publications in journals including: New England Journal of Medicine, British Medical journal, JAMA, Lancet, and Annals of Emergency Medicine. Greg is a thought leader in the field of emergency infectious disease and a super nice guy. In this segment, Greg covers: a common cellulitis mimic; admit vs discharge of patients with cellulitis; what bugs cause cellulitis and, taking that into account, what antibiotic should I use- double coverage, single coverage?

    The great cellulitis mimic: Stasis Dermatitis Similar in appearance to cellulitis Often bilateral (where cellulitis is usually unilateral) Risk factors include venous stasis, lymphedema Fluid goes into the interstitial space -> into the dermis -> and then causes superficial redness and irritation

    Treatment

    Many recommendations out there, many of them consensus, opinion or based on weak data Elevation Compression if the patient can tolerate it Wet dressings if there is crusting and exudative eczema Topical steroids (medium to high potency) such as triamcinolone, fluocinonide, fluticasone ointments If you think there could be infection at play, consider a short course of oral antibiotics (also consider topical if there’s a break in the skin or part of the leg is looking particularly red and angry) Admit or go home? Inpatient mortality for cellulite is low (somewhere in the low single digits percent) No validated decision instruments regarding admission or discharge 2014 study Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients With Uncomplicated Cellulitis found that fever, chronic leg ulcers, edema, lymphedema, cellulitis at a wound site or recurrent in the same area were risk factors for outpatient treatment failure Does this mean that patients with these risk factors need mandatory admission? It doesn’t, but it gives an inkling of who might do poorly or at least fail outpatient antibiotics Bottom line: no clear consensus on who can be discharged but low inpatient mortality suggests we may be over-admitting A nice review of the admit or discharge cellulitis question can be found here Single or double antibiotic coverage

    Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis. JAMA May 2017 PMID:28535235

    500 patients with cellulitis Treated cephalexin alone or cephalexin plus TMP/Sulfa No significant difference in outcome

    Comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 2013 PMID:23457080

    150 patients with cellulitis Treated cephalexin alone or cephalexin plus TMP/Sulfa No significant difference in outcome

    Bottom line: In uncomplicated cellulitis without abscess or significant co-morbidities, current evidence suggests no advantage of adding TMP/Sulfa to cephalexin

    Check out Essentials of Emergency Medicine. Well, I guess if you're against fun education and hate puppies, then disregard that recommendation. References Weng, Qing Yu, et al. "Costs and consequences associated with misdiagnosed lower extremity cellulitis." Jama dermatology 153.2 (2017): 141-146. PMID:27806170 Weiss, Stefan C., et al. "A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis." Journal of drugs in dermatology: JDD 4.3 (2005): 339-345. PMID:15898290 Talan, David A., et al. "Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection." Western Journal of Emergency Medicine 16.1 (2015): 89. PMID:25671016 Peterson, Daniel, et al. "Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis." Academic Emergency Medicine21.5 (2014): 526-531. PMID:24842503 Khachatryan, Alexandra, et al. "Skin and Skin Structure Infections in the Emergency Department: Who Gets Admitted?." Academic Emergency Medicine 21 (2014): S50. Abstract from 2014 SAEM Carratala, J., et al. "Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis." European Journal of Clinical Microbiology and Infectious Diseases 22.3 (2003): 151-157. PMID:12649712 Pallin, Daniel J., et al. "Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial." Clinical infectious diseases 56.12 (2013): 1754-1762. PMID:23457080 Moran, Gregory J., et al. "Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial." Jama 317.20 (2017): 2088-2096. PMID:28535235 Original Kings of County Analysis of Admit or Discharge Cellulitis