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Episode 67 Pediatric Pain Management
Pain is the most common reason for seeking health care. It accounts for 80% of ED visits. The WHO has declared that “optimal pain treatment is a human right”. As has been shown in multiple ED-based Pediatric pain management studies, Pediatric pain is all too often under-estimated and under-treated. Why does this matter? Under-estimating and under-treating pediatric pain may have not only short term detrimental effects but life-long detrimental effects as well; not to mention, screaming miserable children disturbing other patients in your ED and complaints to the hospital from parents. Whether it’s venipuncture, laceration repair, belly pain or reduction of a fracture we need to have the skills and knowledge to optimize efficient and effective pain management in all the kids we see in the ED. What are the indications for intranasal fentanyl? intranasal ketamine? Why should codeine be contra-indicated in children? How do triage-initaited pain protocols improve pediatric pain management? Which are most effective skin analgesics for venipuncture? To help you make these important pediatric pain management decisions, in this podcast we have one of the most prominent North American researchers and experts in Emergency Pediatric pain management, Dr. Samina Ali and not only the chief of McMaster Children’s ED but also the head of the division of Pediatric EM at McMaster University, Dr. Anthony Crocco.
Best Case Ever 37 Neonatal Lazy Feeder
On this EM Cases Best Case Ever Dr. Anthony Crocco, the Head and the Division Head of Pediatric EM at McMaster University and Medical Director of Pediatric Emergency Medicine at Hamilton Health Sciences Hosptial, discusses an approach to the neonatal lazy feeder and why we should abandon the use of codeine in pediatrics as well as in breastfeeding mothers. The approach to the neonatal lazy feeder should be considered as an approach to altered level of awareness with a wide differential diagnosis, and there is one question that should always be asked of the neontal lazy feeder....
Episode 66 Backboard and Collar Nightmares from Emergency Medicine Update Conference
In the first of our series on Highlights from North York General's Emergency Medicine Update Conference, Dr. Kylie Boothdiscusses Backboard and Collar Nightmares. The idea that backboards and c-spine collars prevent spinal cord injuries came from level 3 evidence in the 1960's and there has never been an RCT to prove this theory. In fact a Cochrane review on the topic in 2007 concluded that "the effect of pre-hospital spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain" and that "the possibility that immobilisation may increase mortality and morbidity cannot be excluded". There have subsequently been several observational studies that describe increased morbidity and mortality associated with backboard and collars in a subset of patients. Dr. Booth argues that the time has long past that a major paradigm shift needs to occur toward a safer more rational use of backboards and collars in our trauma patients.
Best Case Ever 36 Tracheo-innominate Fistula
In this Best Case Ever with Dr. Scott Weingart, the brains behind EMcrit.org, we hear the devastating story of a tracheostomy gone bad. Dr. Weingart shares with us what he has learned about how to manage massive hemoptysis in tracheostomy patients, and in particlar, a step-wise approach to managing a tracheo-innominate fistula. We discuss the balance between providing maximal aggrressive critical care while maintaining a deep respect for the risks associated with the procedures we perform. Recorded at North York General's EM Update Conference 2015.
Episode 65 – IV Iron for Anemia in Emergency Medicine
For years we’ve been transfusing red cells in the ED to patients who don’t actually need them. A study looking at trends in transfusion practice in the ED found that about 1/3 of transfusions given were deemed totally inappropriate. As we explained in previous EM Cases episodes, there have been a whole slew of articles in the literature over the years that have shown that morbidity and mortality outcomes with lower hemoglobin thresholds, like 70g/L for transfusing ICU patients (TRICC trial), patients in septic shock (TRISS trial), and patients with GI bleeds are similar to outcomes with traditional higher hemoglobin thresholds of 90 or 100g/L. We’re simply transfusing blood way too much! The American Association of Blood Banks in conjunction with the American Board of Internal Medicine’s Choosing Wisely campaign, as one of its 5 statements on overuse of procedures, stated, “don’t transfuse iron deficiency without hemodynamic instability”. So, in this episode with the help of Transfusion specialist, researcher and co-author of the American Association of Blood Banks transfusion guidelines Dr. Jeannie Callum, Transfusion specialist and researcher Dr. Yulia Lin, and 'the walking encyclopedia of EM' Dr. Walter Himmel, we give you an understanding of why it’s important to avoid red cell transfusions in certain situations, why IV iron is sometimes a better option in a significant subset of anemic patients in the ED, and the practicalities of exactly how to administer IV iron.
Journal Jam 3 – Ultrasound vs CT for Renal Colic
In this Journal Jam we have Dr. Michelle Lin from Academic Life in EM interviewing two authors, Dr. Rebecca Smith‑Bindman, a radiologist, and Dr. Ralph Wang an EM physician both from USCF on their article “Ultrasonography versus Computed Tomography for suspected Nephrolithiasis” published in the New England Journal of Medicine in 2014. There is currently a wide practice variation in the imaging work-up of the patient who presents to the ED with a high suspicion for renal colic. On the one extreme, some EM physicians use CT to screen all patients who present with renal colic, while on the other extreme, other EM physicians do not use any imaging on any patient who has had previous imaging. The role of POCUS and radiology department ultrasound as an alternative to CT in the work up of renal colic has not been clearly defined in the ED setting. This study was a pragmatic multi-centre randomized control trial of patients in whom the primary diagnostic concern was renal colic, that tried to answer the question: is there a significant difference in the serious missed diagnosis rate, serious adverse events rate, pain, return visits, admissions to hospital, radiation dose and diagnostic accuracy if the EM provider chose POCUS, radiology department ultrasound or CT for their initial imaging modality of choice. This Journal Jam is peer review by EMNerd's Rory Spiegel. [wpfilebase tag=file id=618 tpl=emc-play /] [wpfilebase tag=file id=619 tpl=emc-mp3 /]
