Episode 21: You’re Not Alone

In this mini-episode, I talk a bit about an incredibly interesting and important article published recently in the New York Times regarding resident suicide and depression.  The bottom line: If you feel like you need help, you’re not alone.  

Check this sobering article out here

Two quick announcements:

1.  Are you interested in helping write for or participate in the EM Res Podcast and blog?  I am looking to expand the blog and podcast, and I’d love for you to help.  Have an idea for a blog post?  A series?  Podcast ideas?  email me at bobstuntzmd@gmail.com, and let me know what you think.  Residents and educators welcome.  

2. Thanks to everyone who has joined the EM Res Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  It gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  Feel free to post items, comment, and share.  

Now, onto the episode:

Episode 20: COPD Part 2

Episode 20 is Part 2 of Dr. Kochert’s lecture on COPD.  In Part 2, Dr. Kochert discusses the tough question regarding antibiotics in COPD exacerbations, smoking cessation in the ED, and finishes with a Q/A discussing some of the finer points of the lecture and managing COPD patients.  Thanks again to Dr. Kochert for allowing me to post his lecture.  Making a great lecture like this takes a bunch of work, and he gives a great comprehensive review.  

Here is the final summary for the whole COPD talk:

  1. Titrate oxygen on patients with COPD exacerbations to achieve saturations of 88-92%.  Want a more detailed discussion with references?  Check this out
  2. Steroids should be given for all patients with COPD exacerbations.  Prednisone 40 mg PO x 5 days seems to be a reasonable dose.  
  3. Have a low threshold for non-invasive positive pressure ventilation (NIPPV).  It has been shown to reduce mortality and intubation rates.  jump on it early.  Again, as discussed in Episode 19, there has not been any great evidence to show CPAP or BiPAP is better.  Talk with your friendly neighborhood respiratory therapist and see what the standard is at your shop.  
  4. The evidence for antibiotics is not totally clear, but, based on available evidence, give antibiotics to:
    • Patients admitted for COPD exacerbation (especially intubated patients)
    • Outpatients with purulent sputum
  5. Discuss smoking cessation in the ED.  This is a teachable moment.  As Dr. Kochert said, peri-intubation may not be the best time, but otherwise this can definitely impact patients in a positive way.  

Two Reminders:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. Below you will find the III/Asynchronous Learning Quiz for Episodes 19/20.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  

Remember, if you have feedback, or questions for me or Dr. Kochert, I want to hear from you!

Email: bobstuntzmd@gmail.com

Twitter: @BobStuntz

Google+

References

  1. GOLD: http://www.goldcopd.org
  2. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD): http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764.pub2/abstract
  3. New, A.  Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient.  Emerg Med J. 2006 February; 23(2): 144–146.

  4. Austin MA et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. BMJ 2010 Oct 18; 341:c5462.

  5. Quon BS, Gan WQ and Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and meta-analysis. Chest. 2008; 133:756–66.

  6. Leuppi JD et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: The REDUCE randomized clinical trial. JAMA 2013;309:2223. [PMID: 23695200]

  7. Nouira S, Marghli S, Belghith M, Besbes L, Elatrous S, Abroug F.  Once daily oral ofloxacin in chronic obstructive pulmonary disease exacerbation requiring mechanical ventilation: a randomised placebo-controlled trial.  Lancet. 2001 Dec 15;358(9298):2020-5.

  8. Miravitlles M, Moragas A, Hernández S, Bayona C, Llor C.  Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment?  Chest. 2013 Nov;144(5):1571-7. doi: 10.1378/chest.13-0518.

  9. http://www.acep.org/Clinical—-Practice-Management/Smoking-Cessation/

  10. Prochazka A, Koziol-McLain J, Tomlinson D, Lowenstein SR.  Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs.  Acad Emerg Med. 1995 Mar;2(3):211-6.

  11. Katz DA, Vander Weg MW, Holman J, Nugent A, Baker L, Johnson S, Hillis SL, Titler M.  The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling.  Acad Emerg Med. 2012 Apr;19(4):409-20. doi: 10.1111/j.1553-2712.2012.01331.x.

Enjoy the podcast!


Get the OK from your PD?  Get Asynchronous Learning credit for listening!

Are You Ready for Some…C Spine protection?

It is that great time of year.  Sure the kids are going back to school, but more importantly, football is back.  And with that, your ED may soon be filled with folks on backboards wearing full football attire, taped down for c-spine protection.  How do you get their helmet and those pesky shoulder pads off while maintaining c-spine precautions?  Check out the video below, which does a great job demonstrating how to do just that.  The video is courtesy of Dr. A.J. Monseau.  Dr. Monseau is the Assistant Program Director at the West Virginia University Emergency Medicine Residency, and a sports medicine specialist.  A few of the WVUEM residents show us how it is done. Make sure you are following them on Twitter:

Dr. Monseau: @EMedSportsDoc

WVUEM: @WVUEmergencyMed

Definitely give Dr. Monseau’s YouTube page a view as well - he has some great splinting videos.  

Also, please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

Episode 19: COPD Part 1

In Episode 19, Dr. Erik Kochert returns to the podcast to give a great talk on COPD.  There was so much good stuff, I decided to split this into two podcast episodes.  In Part 1, Dr. Kochert talks about GOLD, oxygen titration, inhaled therapies, steroids and NIPPV.  

The full write up and show notes will be posted with episode 2 next week.  Also, if you are interested, our III/Asynchronous Learning quiz will be posted with Part 2 as well.  In the meantime, you can find the reference for the article regarding oxygen titration and my thoughts on that here.

Two announcements/reminders:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. I am going to be offering quizzes at the end of each podcast I do (For this COPD discussion, it will be posted along with Part 2 next week).  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  As usual, Academic life in Emergency Medicine has led the way with this (check it out here), and I hope this is something that catches on with other blogs and podcasts.

Enjoy the podcast!



Episode 18: GI Toxicology

In Episode 18, we take a look at the ingestions and insertions - both accidental and not - that make their way into the GI tracts of your patients.  This is by no means a comprehensive review of all things toxicology that can affect the GI system.  Rather, we focus on ingestions, foreign bodies, and whether or not GI decontamination actually helps.  

Two announcements:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. I am going to be offering quizzes at the end of each podcast I do.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  As usual, Academic life in Emergency Medicine has led the way with this (check it out here), and I hope this is something that catches on with other blogs and podcasts.  

Check out the podcast below, the show notes that follow, and if you can get credit, the quiz is at the bottom of the page!  


Download the show notes here

Case 1: Caustic ingestion - alkali or acidic ingestion (Images from Reference 3)

  1. Epidemiology
    • Kids: Usually accidental and smaller amounts, more upper injury
    • Adults: Usually intention, more severe
  2. Types
    • Acidic: Coagulation necrosis, usually limited superficial injury, pain limits ingestion
      • Studies suggest acid ingestion may have worse outcome overall
      • Tend to affect stomach more vs esophagus
    • Alkali: Liquefactive necrosis, delayed/continued injury, 
      • Usually more viscous preparations
      • More esophageal injury
    • If you can obtain the material ingested, look at contents or check pH 
  3. Management
    • Airway: Intubate early for signs of airway compromise
    • Skilled intubator
    • Have backups and surgical airway ready
    • Imaging: CXR/AXR to evaluate for pneumomedastinum or pneumoperitoneum
    • Give IV fluids if needed.  If delayed and high suspicion for perforation/mediastinitis, treat as sepsis (fluids, antibiotics)
    • Decontamination: DON’T
      • Never induce emesis
      • NG/OG tubes contraindicated initially
      • charcoal of no benefit, and risk aspiration
    • Steroids: Thought to decrease inflammation and thus stricture formation
      • Stricture formation largely depends on initial injury grading (more on that later)
      • Current research suggests likely no benefit
    • Proton pump inhibitors: Thought to decrease acid damage in stomach
      • Few studies with mixed results
      • Talk to your local GI specialist
    • Antibiotics
      • Yes if patient on steroids or immunocompromised and suspect significant injury/ingestion
      • Yes if suspect high grade injury/significant ingestion
      • Yes if toxic/septic, or evidence of perforation/mediastinitis/pneumoperitoneum/peritonitis
      • Otherwise, no
    • Endoscopy
      • Want done within 24 hours
      • Grading of injury
        • 0, 1, 2A: Good prognosis
        • 2B, 3A and 3B: Bad prognosis
    • Consultation
      • GI for endoscopy
      • May need CT surgery for esophagectomy or more intensive therapy if severe or evidence of perforation
      • May need general surgery is gastric perforation
      • Psychiatry if intentional
      • Consider child abuse/neglect



Case 2: Billy swallowed something

  1. Epidemiology
    • Kids: usually accidental
    • Adults: usually intentional
  2. Management
    • Airway: Look for signs of airway compromise (stridor, drooling, respiratory distress)
    • Imaging
      • AP/Lateral Plain films to start
        • Esophagus: Face on AP
        • Trachea: face on lateral
        • Kids: T6/cricopharyngeus
        • Adults: Lower esophageal sphincter
      • If respiratory concern in kids with a non radioopaque foreign body (hot dog), consider plain films in lateral position, look for hyperinflation (ball valve physiology) - but that’s another episode
      • If negative and concerning or unknown ingestion, consider CT
    • Removal, or let it pass?
      • Most things: Let it pass
      • Indications for urgent removal:
        • Sharp objects or very long objects (> 2 inches/5 cm)
        • Magnets
        • Disc battery in esophagus
        • Inability to swallow or handle secretions
        • Toxic
      • Button batteries
        • Remove if in the esophagus
        • If in the stomach or farther, re-image in the next 3-4 days


Case 3: Packers and stuffers

  1. Stuffers: Running from the police, and they ingest a substance to avoid detection
    • Treat the toxidrome
    • Expected management based on what they ingested
  2. Packers: Intentional and methodical concealment of smuggled substances
    • Most commonly opioids and cocaine
    • Evaluation: Sick or not sick
      • If not sick/asymptomatic, packing likely intact
      • Otherwise, look for toxidrome
    • Imaging
      • XR: initial imaging, especially if concern for perforation
      • CT: If high suspicion or to guide clearance/surgical management/approach
    • Management
      • Treat toxidrome if present
      • Whole bowel irrigation (WBI) with PEG
      • If obstruction/perforation or symptomatic, surgical consult
      • Disposition: admit for WBI

Check out this interesting article regarding suspected body packers and the role of the police in these patients



So what about Decontamination?

  1. Ipecac: NO
  2. Gastric levage: NO
  3. Cathartics: NO
  4. Single dose charcoal
    • Minimal evidence this works at all
    • If you do it, do it within an hour of ingestion
    • No definite evidence of outcome improvement
  5. Multi-dose activated charcoal (MDAC)
    • Consider if life threatening ingestion of carbamazepine, dapsone, phenobarbitol, quinine or theophylline
  6. Whole bowel irrigation:
    • If iron, lead, zinc, or body packing, may help
    • Consider for sustained release or enteric coated drugs
    • Avoid if perforation, obstruction, hemodynamic instability, or otherwise toxic
  7. Sodium polystyrene sulfonate (SPS - kayexalate)
    • Used in Lithium ingestion to prevent absorption and increase excretion
    • Side effects: hypokalemia, GI necrosis
    • No definite clinical outcome improvement

References

  1. Brent, J et. al.  Critical Care Toxicology.  2005.  Elsivier Mosby.  
  2. Up To Date: Caustic Esophageal Injury in Adults, updated 9/11/13.
  3. Lupa, M et. al.  Update on the diagnosis and treatment of caustic ingestion.  Ochsner J. 2009 Summer; 9(2): 54–59. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096249/)
  4. Contini, S. and Scarpignato, C.  Caustic injury of the upper gastrointestinal tract: A comprehensive review.  World J. Gatroenterol.  2013 July 7; 19(25): 3918-3930.  
  5. Abaskharoun, R et. al.  Nonsurgical management of severe esophageal and gastric injury following alkali ingestion.  Can J Gastroeneterol.  2007 November 11; 21(11): 757-760.  
  6. Up To Date: Foreign bodies of the esophagus and gastrointestinal tract in children, updated 12/30/13. 
  7. Albertson, TE et. al.  Gastrointestinal decontamination in the acutely poisoned patient.  Int J of Emergency Medicine.  2011, 4(65).  

Talk to your program director and if they approve, take the test below to help you count this podcast and blog post towards asynchronous learning!

Episode 17: Important Topics in Emergency Ophthalmology

In this episode of the EM Res Podcast, we welcome back Dan Kaminstein, MD.  Dr. Kaminstein is our director of the section of International Medicine in the Emergency Department at Wellspan York Hospital, and a guru of ultrasound.  Dan got in touch with an old residency pal, Dr. Emory Patterson from Athens, GA to talk about all things Emergency Ophthalmology.  Lots of great leaning points and practical tips to be had.  Some of the highlights from the discussion:

  • You must know three things when you call the ophthalmologist: visual acuity, pupils, and pressure.

  • If you can’t get a visual acuity, have them count fingers, then identify hand movement, and if all else fails, ask about light perception.

  • If the patient has a detached retina - whether mac on or off - call the ophthalmologist.
  • If you are going to dilate, use a shorter acting agent, such as 2.5% phenylephrine and 1% tropicamide,
  • There are few, if any, conditions you will diagnose in the ED that require acute topical steroids when it comes to eye complaints.  You don’t need to prescribe them in the ED for the most part, and if you need to, you should at least talk with an ophthalmologist
  • When it comes to retrobulbar hematoma - know the pressure.  Just because they have one does not mean it is causing elevated pressure, which is why you do the lateral canthotomy.  
  • Dilute proparicaine is probably not ready for primetime.  Make sure you are talking to your local ophthalmologist about stuff like this before jumping on a small amount of data.  
  • When it comes to ocular exposure to alkali or acid, anything you can flush with is better than acid or alkali.  Normal saline is fine.  So is tap water.