emergency medicine

The Five Canons of Levitan - Difficult Airway Part 3

Canon - a general law, rule, principle, or criterion by which something is judged

No one has changed the face of how we approach difficult airway more than Rich Levitan, MD.  In this episode I review five of Rich's most important contributions to how we approach emergent intubations.  These are techniques you can take to the department tomorrow to improve your view, increase your success, and save your patient's life! 

 
Click here to follow Dr. Levitan on twitter.

Click here to follow Dr. Levitan on twitter.

Levitan's best bougie techniques (includes Shaka, Kiwi and Ducanto)!

Levitan's best bougie techniques (includes Shaka, Kiwi and Ducanto)!

Child Abuse

It is hard to put into words or even imagine the concept of someone intentionally hurting a child, but it happens more frequently than we'd like to believe.  In this episode, I had the privilege of discussing some of the cornerstone exam findings and history flags for occult abuse with Marci Donaruma-Kowh, MD a child abuse expert from the Baylor College of Medicine ~ Texas Children's Hospital.  This episode will change the lens you view your pediatric patients through; even with those who have what appears to be the most mundane of injuries.  Unfortunately, abuse is not always overt and Dr. Donaruma is an expert in identifying the subtleties of this diagnosis, nailing the perpetrator, and making sure they go away for a long-long time...

If you know of a child that is being abused call the police now.  If you would like to refer a case and you are in the Houston area please click here: Children's Assessment Center.

Asthma and the Vent

                                                              TOP  =  AUTO PEEP        BOTTOM  =  NORMAL FLOW

                                                              TOP  =  AUTO PEEP        BOTTOM  =  NORMAL FLOW

Set the Vent in SIMV at 7cc/kg and an I:E ratio of 1:4/1:5 and check a blood gas!
— Andrew Sloas, DO, RDMS, FAAEM

iTunes Link

Wow!  We've made it to the end of three episodes on asthma.  We've covered everything from diagnosis to treatment and everything in between.  We now know how to best educate our patients to empower them to treat their disease at home and prevent recitivism! 

Tune in this episode for the specifics on how to use a Peak Flow Meter, Bi-Pap, EtCO2 and of course how to set-up the ventilator in a way to maximize support and minimize chances of injury in your asthmatics. 

EM Crit - Infamous Awake Sedated Video

EM Crit - Dominating the Vent Part 1

EM Crit - Dominating the Vent Part 2

Asthma Andrews Style - What's the best oral steroid you ask?

What's the best oral steroid to treat acute asthma exacerbations you may ask? Well, we're here to answer that for you.  Please welcome Dr. Annie Andrews, MD, MSCR who has written all the articles you will find listed below on just that subject.  In this podcast we will prove that dexamethasone is not only the most cost effective steroid to prescribe in asthma exacerbations, decreases recidivism, and has the best compliance rates, but it tastes great too! 

http://www.paramedictorn.org/trauma-care.html

Andrews AL, Simpson AN. Dexamethasone may be a viable alternative to

prednisone/prednisolone for the treatment of acute asthma exacerbation in the

paediatric emergency department. Evid Based Med. 2014 Jun 10. pii:

ebmed-2014-110006. doi: 10.1136/eb-2014-110006. [Epub ahead of print] PubMed

PMID: 24919976.

Andrews AL, Wong KA, Heine D, Scott Russell W. A cost-effectiveness analysis

of dexamethasone versus prednisone in pediatric acute asthma exacerbations. Acad

Emerg Med. 2012 Aug;19(8):943-8. doi: 10.1111/j.1553-2712.2012.01418.x. Epub 2012

Jul 31. PubMed PMID: 22849379.

Andrews AL, Teufel RJ, 2nd, Basco WT, Jr., Simpson KN. A Cost-Effectiveness Analysis of Inhaled Corticosteroid Delivery for Children with Asthma in the Emergency Department. Journal of Pediatrics. 2012 Nov;161(5):903-907

Keeney GE, Gray MP, Morrison AK, Levas MN, Kessler EA, Hill GD, Gorelick MH, Jackson JL. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9. doi: 10.1542/peds.2013-2273. Epub 2014 Feb 10. Review. PubMed PMID: 24515516; PubMed Central PMCID: PMC3934336.

Podcast 25 ~ Asthma and Steroids

Thin Kids, Gallbladders Too

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Now I've got your mind palatable to the fact that young thin kids can get cholecystitis too, lets figure out how to weed those kids out from the hundreds of gastroenteritis that you're still going to see each week.  On this episode we'll explore which labs and rads get you to the place you want to be.... not just a disposition, but the correct disposition.  Dr. Doug Fishman is back to get you on the right track to making the right diagnosis!

Podcast 21 ~ Pediatric Cholecystitis 2

Great Pedi Gallbladders of Fire

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You may think that Miley Cyrus' on-stage theatrics was the most shocking thing to happen in 2013, but au contraire mon frère.  Hold on tight, because the most outrageous thing you've heard between stanzas of "Auld Lang Syn" is that kid's are getting gallbladder disease.  This is especially frequent in the good ole US of A where we have mid-morning cheese burgers for a snack.  Shocking I know.  In this episode Pediatric Gastroenterologist Dr. Doug Fishman, from the Texas Children's Hospital, is going to go through the In-N-Outs of pediatric cholecystitis.  Not that In-N-Out is in anyway responsible for pediatric gallstones...they make a tasty burger....try the double-meat animal style...it's fantastic....

Thanks to Doug Fishman, MD.  Director, Gastrointestinal Endoscopy

Texas Children's Hospital

Associate Professor of Pediatrics

Please visit his website devoted to education and treatment of Celiac Disease below

Check out the Celiac Universe Here

Park that Shoulder in Place - Shoulder Reductions & One Hip

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FinaltentcardYellowstone.pdf

How many times have you been involved in an adult or pediatric shoulder reduction that you just can't relocate.  Very frustrating, but here's your solution: Dr. Jay Park has invented a method that allows you to reduce a shoulder without sedation (RNs love that) and without any pain to your patient (Press Ganey scores will rise faster than your salary).  Listen up, this defines cool!

Jay Park, MD

Contact Jay For Website Design:  http://jayparkmd.com

Dr. Park is involved in numerous medical missions, if you would like to contact Dr. Park to see how you can get involved or make a donation email him at:  jayparkmd@yahoo.com

Shoulder Dislocation Video

Hip Dislocation Video

Levitan Airway

Contact CEME.org (1-800-651-2363 ext. 1312) for enrollment.

http://www.airwaycam.com/custom-intubation-training.html

info@airwaycam.com  

877-EPIGLOTTIS

fax: 610-341-1866

2 - Red Eyes

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Red eyes usually come in pairs and so do podcasts on the subject.  In part two of the red eye disorders we discuss the non-threatening maladies that can turn into eye threatening disorders if missed.  Sit back and relax and let dear ole' dad tell you one more time why it's going to be OK...If you listen to him.  Otherwise you may get spanked.  I'm serious he spanked me a lot for not listening.  Call CPS; there's still a chance for me....

Eye Show Notes

Dr. Shenoi's Emergency Preparedness Book

PEM ED Podcast iTunes Link

Podcast 18 ~ The Non-Threatening Red Eye

The Eyes Have It..... Or At Least The Red Eyes Do

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Harold Andrew Sloas Jr, DO, CAPT, USN-R is a board certified ophthalmologist (and my dad).  He had a competition with his son Harold Andrew Sloas III, DO, RDMS, FAAEM to see who could get get more letters behind their name. As it turns out none of those letters have any bearing on what we'll be talking about today. 

You're in for a real treat because I got to sit down with dear ole' dad and talk about some red eye disorders.  We explore all the threatening causes of the red eye on this podcast and move into the non-threatening red eye disorders on the next episode.  You need to know something about both so you can distinguish between the two.  Pull out your Kleenex and dry your eyes; you're going to need to see this. 

Eye Show Notes

iTunes Link

Podcast 17 ~ The Threatening Red Eye

Pediatric Concussion

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I have had the opportunity to work with some truly amazing people in my life and Dr. Matt Bayes, sports medicine physician extraordinaire, is no exception.  Dr. Bayes is the only person I have known to successfully ask about a “code red” and somehow avoid receiving one.  Dr. Bayes now resides in St. Louis, Missouri (Bayes from The Lou) and has been part of the sports medicine team that delivers care to the St Louis Cardinals.   On this episode Dr. Bayes takes me through the intricacies of diagnosing and managing a pediatric concussion from the ER perspective. Hold on to your head because you’re about to get knocked out....Smokey

ARTICLES:

Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170.

William R. Mower, MD.  What Rules Should Guide Imaging Decisions in Injured Children?  Medscape.  Posted: 02/23/2010. http://www.medscape.com/viewarticle/717110

Evaluating Minor Head Injury - Sports Medicine Update

Pediatrics - Sports Related Concussions and Management

Pediatrics - Emergency Department Visits for Concussion in Young Athletes

Misconceptions Common With Pediatric Concussions

José Álvarez-Sabín, MD; Antoni Turon; Manuel Lozano-Sánchez; José Vázquez, MD; Agustí Codina, MD Delayed Posttraumatic Hemorrhage "Spät-Apoplexie"Stroke. 1995;26:1531-1535doi: 10.1161/01.STR.26.9.1531

SCAT 2 iPhone App

Dr Matt Bayes Contact Info:  

12855 North Forty Drive

Suite 380

St Louis, MO 63141

Ph: 314-434-7784

Fax: 314-434-4775

www.bluetailmedicalgroup.com

iTunes Link

Podcast 16 ~ Pediatric Concussion

Calcium Channel Blockers, Beta Blockers and Undifferentiated Hypotension....OH MY!

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One of the most sphincter tightening overdoses to deal with in adults and pediatrics is the CCB overdose.  In this podcast I cover all the treatments that work, don't work, and you would think should work to give you a recipe for success.  Hold on to your insulin; it's not just for diabetics and critically ill patients anymore.  Intralipids???  How the heck does that help???  Well you need to tune in to find out......

CCB/BB/Undifferentiated Show Notes

CCB/BB PDA Companion

Hypotension Slide

Pediatric ECG Basics ~ Part 2

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Our resident cardiologist Dr. Buck Kyle completes the second part of his lecture series on pediatric ECG reading.  This time we get into the most common cardiac disease processes that occur in the pediatric population.  What’s black and white and read all over??? OK, yes the newspaper, but ECGs are too....don’t steal my punch lines.....

Pediatric (and some adult) ECG Basics

Cards Logo.png

The Squiggly Line Rule: The more squiggly lines in the outline/border lines of a state, the cooler/more fun it is to live in that state. In, for example, the state of California, the squiggly lines are found on the coastline adjacent to the pacific ocean ~ Urban Dictionary

It also happens to be true that if you are an electrocardiogramophile than the more abundant the squigglies, the more stimulating and salacious the ECG is to read (and you probably have eroticism issues).  While it is also true that if you do not find electrocardiogram interruption to be lascivious than you probably find it to be frustrating (and you may have ECG performance issues).  Either way, have I got a tonic for you.  It cures all of the above (except the obvious sexual innuendo problems, you need to see a therapist for that soon). 

In this episode, we start a two part series on the basics of pediatric ECG interruption with Dr. Buck Kyle, pediatric cardiologist and electrocardiogram aficionado.  Sit back and relax as Dr. Kyle makes everything clear and really...see the therapist soon......

Penis Talk ~ With Your Hosts Sloas and Stroup

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 The finale in the Urology trilogy.  In this episode Dr. Sean Stroup, CDR, USN, MC and I wrap-it-up with a series of "down-there" complaints (down-there does not imply that this episode is about Australians with grievances) with the most sensitive of subjects to any male patient, penile complaints, worries about the willie, persevering about the pee pee, jargon about the junk, etc.  Hold on to your hats....

The Disclaimer hasn't changed: if you think jokes about "shrinkage" are funny than please listen to the podcast, but if you find those offensive then skip this episode and I wish you all the best in your attempt to make it through your career without encountering another penis...again....ever.

iTunes Link

Podcast 12 - Penis Talk ~ With Your Hosts Sloas and Stroup

Urology Part 2 ~ The Painless Scroti

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"Amigo, the only thing in this world that gives orders is balls. Balls. You got that?" ~  Scarface 1983

Every man is attached to their nuts.  In this episode CDR Sean Stroup, MD USN and I continue to discuss non painful ballular complaints.  You make think your safe with a non-painful swollen scrotum, but oh contraire mon frere, you can lose a nut that way too.  A guy just can't get a break....

The Disclaimer from the last episode still applies: if you think jokes about old man balls are funny then please proceed to listen to this podcast, but if you find those offensive then skip this episode and look into non-urologic career paths.  However, if you do listen to this podcast then the ball you save could be your own....

iTunes Link

Podcast 11 - Urology Part 2 ~ The Painless Scroti

Urological Complaints Part 1 - The Painful Scrotum

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"Rub your balls, squeeze your balls so you don't get cancer"  ~  Tom Green

Few things cause more pain for the patient and fear in the practitioner than scrotal discomfort in a child.  I sat down with my good friend and pee-pee doctor CDR Sean Stroup, MD USN at the National Naval Medical Center in sunny, beautiful, oh how I miss it: San Diego, to discuss painful ballular complaints.  Dr. Stroup is a fellowship trained urologist practicing on the west coast and sees a ton of children at the Naval Medical Center.  Disclaimer:  If you are offended by jokes about pee-pee, the scroti, or not wearing appropriate underwear than it is probably best to skip this episode.  No testicles were injured or neutered in the production of this podcast. 

iTunes Link

Podcast 10 - Urological Complaints Part 1: The Painful Scrotum

Ketofol & Shah

I had the privilege to sit down with one of Canada’s finest, Dr. Amit Shah, and discuss his blinded randomized prospective study concerning one of my favorite procedural medications: Ketofol.

This is the evidence based follow-up to my last (more opinion based) podcast on “Sedation and Ketofol.”  The chocolate in my peanut butter.......

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Shah A, Mosdossy G, McLeod S, Lehnhar, Peddle M, Rieder M. A blinded randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425 33.e2. Epub 2010 Oct 13. PubMedPMID: 20947210

iTunes Link

Podcast 9 - Ketofol and Shah

Sedation and Ketofol

There are a lot of ways to sedate, but I would like to provide you with a philosophy and the methodology to put together the safest possible sedation package. 

Please stay tuned for my next episode in which I get a chance to interview Dr. Amit Shah the lead author on the game-changing Ketofol article listed below.

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Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded,randomized controlled trial to evaluate ketamine/propofol versus ketamine alonefor procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425-33.e2.Epub 2010 Oct 13. PubMed PMID: 20947210

Sedation Show Notes

iTunes Link

Podcast 8 - Sedation and Ketofol

Pediatric Airway - The Advanced Course

This is the second part of a two part series in pediatric airway management.  Here we focus on how to use the "Airway Algorithm" that we have created and how to manage the more difficult airways we encounter in the emergency department.  The "Airway Algorithm" is designed to be used in both adults and children. 

 Mac Friendly Airway Algorithm

iTunes Link

Reference: The Difficult Airway Course: Emergency™ (http://www.theairwaysite.com) and from Walls RM and Murphy MF: Manual of Emergency Airway Management, 4th Edition, Philadelphia, Lippincott, Williams and Wilkins, 2012.

Podcast 7 - Pediatric Airway The Advanced Course

Pediatric Airway 101

“Airway is the reason that many go into emergency medicine…”

-  Jaime McCarthy MD,  UT Health Sciences Center at Houston EM Director

One of the many things that we do better than anyone in the business is obtain the emergent airway.  Unlike our colleagues in other disciplines, we do not have the luxury of planning our airway approach on the golf course the evening before; we meet patients on their worst day.  Even though we would often prefer it, we do not have the option to reschedule our intubations. 

Smashed, bloody, distorted, edematous, airways secondary to trauma, anaphylaxis and GI bleeds are the things that we deal with routinely with nary a complaint or even a hither for a better look than what were given.  We often feel lucky to get any type of view that resembles normal laryngeal anatomy.  Personally, if I knew that I would need to be intubated today, that my airway would be bloody and edematous, and there was only time for one person to take a shot at placing the tube, then I would pray to God that the last face I see before the Roc and Etomidate push me asunder is the familiar grill of one of my EM colleagues.  Who better to bet all my chips on then someone who deals with the hardest airways on the face of the planet as part of their daily routine?  The general EM provider can not only get that airway, but is so relaxed about it that they will casually check on the patient in the next bed before and after the intubation.   That’s the confidence I’m looking for when it comes to the fast paced life and death world of emergency airway.

Whether it is pediatric or adult emergency medicine, the most important thing that we do as “emergentologists and resusitologists” is control the airway.   

iTunes Link

 Mac Friendly Airway Algorithm

Podcast 6 - Pediatric Airway 101