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EM Quick Hits 5 Ludwig’s Angina, Transient Monocular Vision Loss, D-dimer for PE Workup in Pregnancy, Pediatric Nasal Foreign Bodies, Trimethoprim Drug Interactions, Airway Management in Cardiac Arrest

In this EM Quick Hits Podcast: Ludwig's Angina Emergency Management - Approach, Airway, Imaging, Transient Monocular Vision Loss (TMVL), D-dimer in the Work-up of Pulmonary Embolism in Pregnancy, Management of Pediatric Nasal Foreign Bodies: Tips and Tricks, Sulfamethoxazole-Trimethoprim Drug Interactions and Airway Options in Cardiac Arrest - LMA for all?...

BCE 74 Coding in the Scanner

In anticipation of EM Cases Episode 113 Diagnosis an Workup of Pulmonary Embolism with Dr. Kerstin DeWit and Dr. Eddy Lang, we have Dr. Peter Reardon telling us his Best Case Ever (Coding in the Scanner) of a young woman who presents with a seizure followed by hemodynamic instability, who codes while in the CT scanner...

Best Case Ever 46 – Chris Nickson on Hickam’s Dictum

EM Cases Best Case Ever - Chris Nickson on Hickam's Dictum. Usually we use the heuristic of Occam's razor to help us arrive at one diagnosis that makes sense of all the data points that a particular patient presents to us. However sometimes it's not so straight forward and we need to think about multiple diagnoses that explain a patient's condition - Hickam's Dictum. Dr. Chris Nickson, the brains behind the Life in the Fast Lane blog tells his Best Case Ever from the SMACC Conference in Dublin, in which a patient thrombolysed for massive pulmonary embolism suffers a cardiac arrest, and the thought process he went through to discover the surprising complicating diagnoses that ensue...

Episode 69 Obesity Emergency Management

Current estimates of the prevalence of obesity are that a quarter of adult Canadians and one third of Americans are considered obese with approximately 3% being morbidly obese. With the proportion of patients with a BMI>30 growing every year, you’re likely to manage at least one obese patient on every ED shift. Obese patients are at high risk of developing a host of medical complications including diabetes, hypertension, coronary artery disease, peripheral vascular disease, biliary disease, sleep apnea, cardiomyopathy, pulmonary embolism and depression, and are less likely compared to non-obese adults to receive timely care in the ED. Not only are these patients at higher risk for morbidity and mortality, but obesity emergency management is complicated by the patient’s altered cardiopulmonary physiology and drug metabolism. This can make their acute management much more challenging and dangerous. To help us gain a deeper understanding of the challenges of managing obese patients and elucidate a number of important differences as well as practical approaches to obesity emergency management, we welcome Dr. Andrew Sloas, the founder and creator of the fantastic pediatric EM podcast PEM ED, Dr. Richard Levitan, a world-famous airway management educator and innovator and Dr. David Barbic a prominent Canadian researcher in obesity in emergency medicine from University of British Columbia....

Episode 68 Emergency Management of Sickle Cell Disease

A recent needs assessment completed in Toronto found that Emergency providers are undereducated when it comes to the Emergency Management of Sickle Cell Disease. This became brutally apparent to me personally, while I was researching this topic. It turns out that we’re not so great at managing these patients. Why does this matter? These are high risk patients. In fact, Sickle Cell patients are at increased risk for a whole slew of life threatening problems. One of the many reasons they are vulnerable is because people with Sickle Cell disease are functionally asplenic, so they’re more likely to suffer from serious bacterial infections like meningitis, osteomyelitis and septic arthritis. For a variety of reasons they’re also more likely than the general population to suffer from cholycystitis, priapism, leg ulcers, avascular necrosis of the hip, stroke, acute coronary syndromes, pulmonary embolism, acute renal failure, retinopathy, and even sudden exertional death. And often the presentations of some of these conditions are less typical than usual. Those of you who have been practicing long enough, know that patients with Sickle Cell Disease can sometimes present a challenge when it comes to pain management, as it’s often difficult to discern whether they’re malingering or not. It turns out that we’ve probably been under-treating Sickle Cell pain crisis pain and over-diagnosing patients as malingerers. Then there are the sometimes elusive Sickle Cell specific catastrophes that we need to be able to pick up in the ED to prevent morbidity, like Aplastic Crisis for example, where prompt recognition and swift treatment are paramount. A benign looking trivial traumatic eye injury can lead to vision threatening hyphema in Sickle Cell patients and can be easy to miss. In this episode, with the help of Dr. Richard Ward, Toronto hematologist and Sickle Cell expert, and Dr. John Foote, the Residency Program Director for the CCFP(EM) program at the University of Toronto, we’ll deliver the key concepts, pearls and pitfalls in recognizing some important sickle cell emergencies, managing pain crises, the best fluid management, appropriate use of supplemental oxygen therapy, rational use of transfusions and more...

Journal Jam 1: Age Adjusted D-dimer with Jeff Kline and Jonathan Kirschner

In this first ever episode of the Journal Jam podcast, a collaboration between EM Cases, Academic Life in EM and The Annals of Emergency Medicine's Global Emergency Medicine Journal Club, Teresa Chan and I, along with Jeff Kline, Jonathan Kirschner, Anand Swaminathan, Salim Rezaie and Sam Shaikh from ALiEM, discuss the potential for Age Adjusted D-dimer to rule out pulmonary embolism in low risk patients over the age of 50. We discuss 4 key questions about the ADJUST-PE Study from JAMA in March 2014 including: Would you order a CTPA on a 60 year old woman with an age adjusted D-dimer of 590 ng/L? The problem until now has been that the older the patient, the more likely the D-dimer is to be positive whether they have a PE or not, so many of us have thrown the D-dimer out the window in older patients and go straight to CTPA, even in low risk patients. If you are a risk averse doc, this strategy will lead to over-utilization of resources, huge costs, length of stay, radiation effects etc; and if you’re not so risk averse, then you might decide not to work up the low risk older patient at all and miss clinically important PEs. expert peer reviewFor all the questions discussed on this podcast, the original Google Hangout interview from which this podcast was based, and the crowd sourced opinions from around world, visit the ALiEM website. Many thanks to all the talented people who made this podcast possible. Together, we're smarter!

Episode 44 – Whistler Update in Emergency Medicine Conference 2014

In this episode on Whistler's Update in Emergency Medicine Conference 2014 Highlights we have... Chapter 1 with David Carr on his approach to Shock, including the RUSH protocol, followed by a discussion on Thrombolysis for Submassive Pulmonary Embolism.... Then in Chapter 2 Lisa Thurgur presents a series of Toxicology Cases packed with pearls, pitfalls and surprises and reviews the use of Lipid Emulsion Therapy in toxicology....Finally in Chapter 3 Joel Yaphe reviews the most important articles from 2013 including the Targeted Temperature Managment post-arrest paper, the use of Tranexamic Acid for epistaxis, return to play concussion guidelines and clinical decision rules for subarachnoid hemorrhage. Another Whistler's Update in Emergency Medicine Conference to remember.......

Best Case Ever 22: Nonconvulsive Status Epilepticus (NCSE)

In the first of our series on Best Case Ever of 'Carr's Cases' we have, the legend himself, Dr. David Carr. This series will run on the theme of interesting diagnoses that we don't think of too often, but that are not as rare as we might think and can make a significant difference to your patient's outcome if you pick up on them early - and maybe even make you look as smart as David! Dr. Carr will be highlighted in our upcoming episode on Whistler's Update in EM Conference highlights 2014 when he will be speaking about his approach to the shocky patient as well as the controversial management of submassive pulmonary embolism. He will be featured along with Dr. Lisa Thurgur speaking about lipid emulsion therapy and other toxicologic goodies and Joel Yaphe will give us his take on the best of the EM literature from 2013 including the TTM trial, tranexamic acid for epistaxis, return to sport after concussion guidelines and more. Please go to the 'Next Time on EM Cases' page to submit your question about these topics.

Best Case Ever 8: Acute Dyspnea

Acute Dyspnea has a wide differential diagnosis from Metabolic Acidosis to Medically Unexplained Dyspnea. As a bonus to Episode 21 on Pulmonary Embolism and Acute Dyspnea, Dr. John Foote the CCFP(EM) residency program director at the University of Toronto presents his Best Case Ever related to an Acute Dyspnea presentation. In the related episode on Pulmonary Embolism we havet, with Dr. Foote, the triumphant return of Dr. Anil Chopra, the Head of the Divisions of Emergency Medicine at University of Toronto . We kick it off with Dr. Foote’s approach to undifferentiated acute dyspnea and explanation of Medically Unexplained Dyspea (‘MUD’) and go on to discuss how best to develop a clinical pretest probability for the diagnosis of pulmonary embolism using risk factors, the value of the PERC rule, Well’s criteria and how clinical gestalt plays into pretest probability. Dr. Chopra tells about the appropriate use of D-dimer to improve our diagnostic accuracy without leading to over-investigation and unwarranted anticoagulation. We then discuss the value of V/Q scan in the workup of PE, and the pitfalls of CT angiography. A discussion of anticoagulation choices follows and the controversies around thrombolysis for submassive PE closes the podcast. [wpfilebase tag=file id=384 tpl=emc-play /] [wpfilebase tag=file id=385 tpl=emc-mp3 /]

ECG Cases 27 Pericarditis – Diagnosis of Exclusion

Jesse McLaren guides us through 9 cases and explains how pericarditis is a diagnosis of exclusion through 3 simple steps: 1. Exclude more serious causes of chest pain, eg wraparound LAD occlusion, inferior OMI 2. Exclude complications of pericarditis, eg myocarditis, large pericardial effusion 3. Exclude normal variant ST elevation presenting with benign chest pain on this month's ECG Cases blog...

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