Foamcast - Emergency Medicine Core Content

We cover a post by Dr. Rory Spiegel, EMNerd: The Case of Differing Perspectives, on the results of the ATACH-2 trial on blood pressure control in intracranial hemorrhage (ICH). This study sought to determine the safety and efficacy of the Population: adults (>18 y/o) with ICH on CT scan, GCS ≥ 5 and

Just in time for the new interns, we answer the most common question asked of us - our favorite resources to use on shift. Free Open Access Medical Education (FOAM) exists in forms that are suitable for self-study or function as resources and those that are easy to use resources to consult on shift, Just In Time (JIT) Resources. We review our favorite FOAM JIT resources.

We cover a Scancrit post on the Back Up Head Elevated (BUHE) intubation position.  This post details a multicenter retrospective observational study by Khandelwal et al in Anesthesia & Analgesia.  Intubating with the head elevated (ear to sternal notch) and the back of the bed up reduces complications. We delve into core content on the esophagus using Rosen’s (8th ed) Chapter 71 and Chapter 77 in Tintinalli (8th ed). We discuss dysphagia, food impaction, and esophagitis. Thanks for listening! JEremy Faust and Lauren WEstafer

ITUNES OR LISTEN HERE We cover pearls from smaccDUB (Social Media and Critical Care Conference in Dublin, Ireland), Day 3. We are here thanks to the Rosh Review. Dr. Scott Weingart - "Post-Intubation Sedation" Analgesia first. Try a hydromorphone 1mg push while you're waiting for the fentanyl drip. The endotracheal tube is uncomfortable. Minimize sedation. There's this principle: eCASH: early Comfort using Analgesia, minimal Sedatives and maximal Humane care [1].  Sedation: go for dexmedetomidine if you have it (but it's expensive) or propofol. This is supported by the Society of Critical Care Medicine (SCCM) Pain, Agitation, and Delirium guidelines [2]. Be careful with rocuronium.  The long duration of rocuronium means that you can't assess for pain or discomfort so you must be responsible and get these Dr. David Carr - "The Aorta Will #!&?% You Up" Dr. Kathleen Thomas - "Oh Sh**! They’re bombing the hospital!" We should not need a website entitled STOPBOMBINGHOSPITALS.ORG but, unfortunately, over th

#smaccDUB day 2 Dr. Reuben Strayer - “Disruption, Danger, and Droperidol: Emergency Management of the Agitated Patient."   Dr. Strayer presented a brilliant talk on dealing with the quintessential Emergency Medicine patient - the undifferentiated acutely agitated patient. These patients are high risk and require emergent stabilization and resuscitation. Dr. Haney Mallemat - "The PEA Paradox" The typical way we think about PEA, the "H's and T's," is overly complicated. Further, we are horrendous at pulse palpation (see this for more), and so what we think is PEA may not actually be PEA.  Dr. Mallemat proposed QRS duration as one way to think about PEA, although this has limitations. Dr. Michele Dominico - "How Usual Resuscitative Maneuvers Can Kill Paediatric Cardiac Patients" Interventions we jump to in sick patients - oxygenation, ventilation, vasopressors - these can kill pediatric patients with cardiac pathology. She gave examples of some high yield pearls in these already terrifying patients. EM Literatur

We are at SMACC in Dublin - thanks to the Rosh Review, an excellent board review question bank. Here are some of our favorite pearls. Do We Make Saves? Dr. Mervyn Singer "Is Survival Predetermined in the Critically  Ill?" Many critical care studies are negative, but in some cases this may be because critically ill patients don't have a uniform prognosis. Dr. Singer argues that some people may be "destined to die" and some may be "destined to live."  So, it's not really us "saving the patient", it's just the math playing out. Interventions may be harmful or futile in one group but beneficial in the other.  For example, Dr. Singer references the CORTICUS trial of steroids in septic shock. This was a negative trial.  Dr. Singer asserts that some evidence (of not great quality), purports that the sickest patients could benefit from steroids, while this same intervention could be deleterious in the healthier ones. Problem: many of the studies that go back and re-analyze these groups looking at the sickest or leas

We cover this short video from EMRAP on lateral canthotomies.  This is one of those rare procedures that is vision saving; hence, it is worthy of frequent review. Then, we delve into core content on orbital fractures, hyphemas, and ocular burns using Tintinalli and Rosen's Emergency Medicine as a guide. Show notes and references at foamcast.org Thanks for listening! Jeremy Faust and Lauren Westafer

We review the FOAM video by Dr. Anna Pickens of EMin5.com on "Special Seizures" including hyponatremia, isoniazid toxcitiy, alcohol withdrawal, and eclampsia. Then we review core content on seizures using Rosen's Emergency Medicine and Tintinalli's Emergency Medicine: A Comprehensive Review. Thanks for listening! Jeremy Faust and Lauren Westafer

ALTE is out and BRUE is in. We review the American Academy of Pediatrics guideline on Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants 

We cover a post by Dr. Seth Trueger (@MDaware) on false positives in the urine drug screen and review limitations of this test.  Then we review some toxicology, including toxicity associated with cocaine and PCP using Rosen's Emergency Medicine (8e) and Tintinalli's (8e) as a guide. Thanks for listening! Lauren Westafer and Jeremy Faust

In this episode we cover a post from Dr. Smith's ECG blog investigating ways to read ischemia on a ventricular paced ECG:  A Patient with Ischemic symptoms and a Biventricular Pacemaker. Then we delve into core content on the Sgarbossa/modified Sgarbossa criteria as well as pacers and implantable defibrillators and their complications. Thanks for listening! Jeremy Faust and Lauren Westafer

We cover a podcast from HEFT EMcast  demonstrating that needle decompression at the 2nd intercostal space at the midclavicular line (2ICS MCL) is likely to fail.  They review a systematic review and meta-analysis by Laan et al in 2015 that suggests the fifth intercostal space at the anterior axillary line (5ICS AAL) is less likely to fail. Then we delve into core content on pneumothoraces and empyemas using Tintinalli and Rosen's Emergency Medicine as a guide. Thanks for listening, Jeremy Faust and Lauren Westafer

We cover a post from Life in the Fast Lane Research and Reviews (LITFL R&R) #121  featuring a section on the new American Gastroenterology Association (AGA) guidelines on diverticulitis. The game changer?  Antibiotics aren't a requirement in select patients with uncomplicated acute diverticulitis. Then we delve into core content on diverticulosis, diverticulitis, and clostridium difficile using Rosen's Emergency Medicine (8e) and Tintinalli: A Comprehensive Review (7e). Show notes at FOAMcast.org Thanks for listening! Jeremy Faust and Lauren Westafer

We bring you breaking news on the updated sepsis definition from the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine. SIRS and Severe Sepsis?   Out. qSOFA (HAT - Hypotension, AMS, Tachypnea)?  In. Septic Shock?  Sepsis + Vasopressors needed to maintain MAP >65 mmHg + Lactate >2 mmol/L (*after adequate fluids)    

We cover the Skeptic's Guide to Emergency Medicine Episode 144, "That Smell of Isopropyl Alcohol for Nausea in the Emergency Department." This podcast reviews an article by Beadle et al, an RCT on the use of inhalational isopropyl alcohol for nausea. Then we delve into core content on vertigo using Rosen’s Medicine (8e) and Tintinalli’s Emergency Medicine: A Comprehensive Study Guide  (7e) on all things toxic alcohols   Thanks for listening!Jeremy Faust and Lauren Westafer

We cover an EMcrit episode on Semantics of End of Life Discussions with Dr. Ashley Shreves as well as pearls from another favorite episode with her, Episode 93 - Critical Care Palliation.  We can't do these episodes justice summarizing them so listen to them. Key Pearls on moving away from "DNAR" and moving towards "AND" - Allow Natural Death, how to have the conversation, and with whom to have the end of life discussion. Then we delve into core content on vertigo using Rosen’s Medicine (8e) electronic chapter, "End of Life,"  and Tintinalli’s Emergency Medicine: A Comprehensive Study Guide  (7e) Chapter 297 “Death and Dying.” Thanks for listening!Jeremy Faust and Lauren Westafer

We cover two bits of FOAM,Emergency Medicine Literature of Note - Dr. Ryan Radecki - on the use of meclizine for vertigo and EMcrit - Dr. Scott Weingart on the HiNTs exam. Then we delve into some of the problems with the HiNTs exam including it can only be performed on patients with continuous vertigo and that external validity is a major issue with HiNTs. Then, we delve into core content on vertigo using Rosen’s Medicine (8e) Chapter 19,  and Tintinalli’s Emergency Medicine: A Comprehensive Study Guide  (7e) Chapter 164 “Vertigo and Dizziness." Thanks for listening! Jeremy Faust and Lauren Westafer

In this special episode we review some of the top items of 2015* David Newman: Opioids for back pain - falling out of favor. Risk stratifying (and testing) low risk chest pain. Haney Mallemat: Peripheral vasopressors may be ready for prime time FAST guided resuscitative thoracotomy (No cardiac activity and no effusion? No thoracotomy). Movement towards less volume in sepsis (ex: in PROMISE trial average patient got 6L over 72 h) Michelle Lin Merging of FOAM with traditional journals  Merging of FOAM resources into conglomerates More medical education FOAM (ex: ICEnet, EMin5) Rob Orman Same as Haney (peripheral vasopressors + FAST in resuscitative thoracotomy) Sexual intercourse 3-4 times per week may aid in expulsion of distal kidney stones. Thanks for listening! Jeremy Faust and Lauren Westafer *Chosen by people smarter than we are. (nb: Lauren initially wrote "smarter than us," but I fixed it. You're welcome, universe. -JF)

In this episode we cover The Skeptic's Guide to Emergency Medicine Episode on Regional Anesthesia for hip and femoral neck fractures. Then we delve into core content on Rosen's and Tintinalli (Rosenalli) on core content pearls on compartment syndrome. Thanks for listening! Jeremy and Lauren

We cover Dr. Rory Spiegel's blog EMNERD, covering an article in Chest 2015 by Pivetta et al, discussing the ways lung ultrasound (US) may be far more helpful than the brain natriuretic peptide (BNP) in determining heart failure in the dyspneic patient.  Then we delve into likelihood ratios and show notes can be found at FOAMCAST.org Bottom Line, LR of 1 is useless. It doesn't change the likelihood of using the disease. + LR >5 is good, + LR of 10 means that a test is useful and, if positive, patient most likely had the disease - LR 0.2 is ok but a - LR of 0.1 is much more helpful. Using a Fagan nomogran, one can understand how various likelihood ratios (and tests with their known LRs) may affect the post-test probability (i.e. the likelihood the patient has the disease). The utility of tests also depends on the pretest probability.